An Act to amend titles XVIII and XIX of the Social Security Act to provide payment for rural health clinic services, and for other purposes.
PL 95-210 (H.R.8422), enacted 12/13/1977

PUBLIC LAW 95-210—DEC. 13, 1977 
91 STAT. 1485 
Public Law 95-210 
95th Congress 
An Act 
To amend titles XVIII and XIX of the Social Security Act to provide paymt'nt 
for rural health clinic services, and for other purposes. 
Be it enacted hy the Senate and House of Representatives of the 
United States of America in Congress assembled, 
MEDICARE AMENDMENTS 
Dec. 13, 1977 
[H.R. 8422] 
Social Security 
Act, 
amendment. 
42 use 1395/. 
Supra. 
SECTION 1. (a) Section 1832(a) of the Social Security Act is 42 USC1395k 
amended— 
(1) by striking out "paragraph (2) (B)" in paragraph (1) and 
inserting in lieu thereof "subparagraphs (B) and (D) of para-
graph (2)"; and 
(2) by striking out the period at the end of paragraph (2) (C) 
and inserting in lieu thereof "; and" and by adding the following 
new subparagraph at the end of paragraph (2),: 
" (D) rural health clinic services." 
(b) Section 1833(a) of such Act is amended— 
(1) by striking out "and" at the end of paragraph (1); 
(2) by inserting "(except those services described in subpara-
graph (D) of section 1832(a)(2))" in paragraph (2) after 
"1832(a)(2)"; 
(3) by striking out the period at the end of paragraph (2) and 
inserting in lieu thereof ", and"; and 
(4) by inserting the following new paragraph after paragraph 
"(3) in the case of services described in section 1832(a) (2) (D), 
80 percent of costs which are reasonable and related to the cost of 
furnishing such services or on such other tests of reasonableness as 
the Secretary may prescribe in regulations, including those author-
ized under section 1861 (v) (1) (A)." 
(c) The Secretary of Health, Education, and Welfare (hereinafter 
in this Act referred to as the "Secretary") shall conduct a study of the 
feasibility and desirability of imposing a copayment for each visit to 
a rural health clinic for rural health clinic services under part B of 
title XVIII of the Social Security Act, instead of the deductible and 
coinsurance amounts otherwise required under section 1833 of such Act 
with respect to the provision of such services. The Secretary shall 
report to the appropriate committees of Congress, not later than one 
year after the date of enactment of this Act, on such study and on any 
recommendations he may have for changes in the provisions of part B 
of title XVIII of the Social Security Act to reflect the findings of such 
study. 
(d) Section 1861 of such Act is amended by adding at the end thereof 
the following new subsection: 
"Rural Health Clinic Services 
" (aa) (1) The term 'rural health clinic services' means— 
"(A) physicians' services and such services and supplies as are 
covered under section 1861 (s) (2) (A) if furnished as an incident 
to a physician's professional service, 
42 u s e 1395x. 
Study. 
42 u s e 1395/ 
note. 
42 u s e 1395J. 
Supra. 
Report to 
congressional 
committees. 
Definitions. 
42 u s e 1395x. 
91 STAT. 14S6 
PUBLIC LAW 95-210—DEC. 13, 1977 
"(B) such services furnished by a physician assistant or by a 
nurse practitioner and such services and supplies furnished as an 
incident to his service as would otherwise be covered if furnished 
by a physician or as an incident to a physician's service, and 
"(C) in the case of a rural health clinic located in an area in 
which there exists a shortage of home health agencies, part-time 
or intermittent nursing care and related medical supplies (other 
than drugs and biologicals) furnished by a registered professional 
nurse or licensed practical nurse to a homebound individual under 
a written plan of treatment (i) established and periodically 
reviewed by a physician described in paragraph (2) (B), or (ii) 
established by a nurse practitioner or physician assistant and 
periodically reviewed and approved by a physician described in 
paragraph (2) (B), 
when furnished to an individual as an outpatient of a rural health 
clinic. 
"(2) The term 'rural health clinic' means a facility which— 
"(A) is primarily engaged in furnishing to outpatients services 
described in subparagraphs (A) and (B) of paragraph (1); 
"(B) in the case of a facility which is not a physician-directed 
clinic, has an arrangement (consistent with the provisions of State 
and local law relative to the practice, performance, and delivery of 
health services) with one or more physicians (as defined in sub-
section (r)(l)) under which provision is made for the periodic 
review by such physicians of covered services furnished by phy-
sician assistants and nurse practitioners, the supervision and 
guidance by such physicians of physician assistants and nurse 
practitioners, the preparation by such physicians of such medical 
orders for care and treatment of clinic patients as may be neces-
sary, and the availability of such physicians for such referral of 
and consultation for patients as is necessary and for advice and 
assistance in the management of medical emergencies; and, in the 
case of a physician-directed clinic, has one or more of its staff 
physicians perform the activities accomplished through such an 
arrangement; 
"(C) maintains clinical records on all patients; 
"(D) has arrangements with one or more hospitals, having 
liJ95cc. 
agreements in effect under section 1866, for the referral and admis-
sion of patients requiring inpatient services or such diagnostic or 
other specialized services as are not available at the clinic; 
"(E) has written policies, which are developed with the advice 
of (and with provision for review of such policies from time to 
time by) a group of professional personnel, including one or more 
physicians and one or more physician assistants or nurse practi-
tioners, to govern those services described in paragraph (1) which 
it furnishes; 
"(F) has a physician, physician assistant, or nurse practitioner 
responsible for the execution of policies described in subpara-
graph (E) and relating to the provision of the clinic's services; 
"(G) directly provides routine diagnostic services, including 
clinical laboratory services, as prescribed in regulations by the 
Secretary, and has prompt access to additional diagnostic services 
from facilities meeting requirements under this title; 
"(H) in compliance with State and Federal law, has available 
for administering to patients of the clinic at least such drugs and 
biologicals as are determined by the Secretary to be necessary for 
the treatment of emergency cases (as defined in regulations) and 
PUBLIC LAW 95-210—DEC. 13, 1977 
91 STAT. 1^187 
' , has appropriate procedures or arrangements for storing, admin-
istering, and dispensing any drugs and biologicals; 
"(I) has appropriate procedures for review of utilization of 
clinic services to the extent that the Secretary determines to be 
necessary and feasible; and 
"(J) meets such other requirements as the Secretary may find 
necessary in the interest of the health and safety of the individuals 
who are furnished services by the clinic. 
For the purposes of this title, such term includes only a facility which 
(i) is located in an area that is not an urbanized area (as defined by 
the Bureau of the Census) and that is designated by the Secretary 
either (I) as an area with a shortage of personal health services under 
section 1302(7) of the Public Health Service Act or (II) as a health 
manpower shortage area described in section 332(a)(1)(A) of that 
Act because of its shortage of primary medical care manpower, (ii) 
has filed an agreement with the Secretary by which it agrees not to 
charge any individual or other person for items or services for which 
such individual is entitled to have payment made under this title, 
except for the amount of any deductible or coinsurance amount 
imposed with respect to such items or services (not in excess of the 
amount customarily charged for such items and services by such 
clinic), pursuant to subsections (a) and (b) of section 1833, (iii) 
employs a physician assistant or nurse practitioner, and (iv) is not a 
rehabilitation agency or a facility which is primarily for the care and 
treatment of mental diseases. A facility that is in operation and quali-
fies as a rural health clinic under this title or title XIX and that 
subsequently fails to satisfy the requirement of clause (i) shall be 
considered, for purposes of this title and title XIX, as still satisfying 
the requirement of such clause. 
"(3) The term 'physician assistant' and the term 'nurse practitioner' 
mean, for the purposes of paragraphs (1) and (2), a physician assist-
ant or nurse practitioner who performs such services as such indi-
vidual is legally authorized to perform (in the State in which the 
individual performs such services) in accordance with State law (or 
the State regulatory mechanism provided by State law), and who 
meets such training, education, and experience requirements (or any 
combination thereof) as the Secretary may prescribe in regulations.". 
(e) Any private, nonprofit health care clinic that— 
(1) on July 1,1977, was operating and located in an area which 
on that date (A) was not an urbanized area (as defined by the 
Bureau of the Census) and (B) had a supply of physicians 
insufficient to meet the needs of the area (as determined by the 
Secretary), and 
(2) meets the definition of a rural health clinic under section 
1861 (aa) (2) or section 1905(1) of the Social Security Act, except 
for clause (i) of section 1861 (aa) (2), 
shall be considered, for the purposes of title XVIII or XIX, respec-
tively, of the Social Security Act, as satisfying the definition of a rural 
health clinic under such section. 
(f) Section 1862(a) (3) of such Act is amended by striking out "in 
such cases" and inserting in lieu thereof "in the case of rural health 
clinic services, as defined in section 1861(aa)(l), and in such other 
cases". 
(g) Section 1861 (s) (2) of such Act is amended— 
(1) by striking out "and" at the end of subparagraph (C) (ii); 
(2) by inserting "and" at the end of subparagraph (D); and 
42 use 300e-l. 
42 use 254e. 
Ante, p. 1485. 
42 use 1396. 
42 use 1395x 
note. 
Ante, p. 1485. 
Post, p. 1488. 
42 use 1395. 
42 use 1395y. 
Ante, p. 1485. 
42 use 1395x. 
29-194 0 - 
sn 
91 STAT. 1488 
PUBLIC LAW 95-210—DEC. 13, 1977 
42 u s e 1395x. 
42 u s e 1395aa. 
Ante, p. 1485. 
Effective date. 
42 u s e 1395k 
note. 
(3) by adding the following new subparagraph at the end 
thereof: 
" (E) rural health clinic services;". 
(h) The second sentence of section 1861 (s) of such Act is amended 
by inserting ", a rural health clinic," after "physician's office". 
(i) Section 1864 (a) of such Act is amended— 
(1) by inserting "or whether a facility therein is a rural health 
clinic as defined in section 1861 (aa) (2)," in the first sentence after 
"home health agency,"; 
(2) by inserting "rural health clinic," in the second sentence 
after "nursing facility,"; 
(3) by inserting "rural health clinic," in the last sentence after 
"facility," the first and second times it appears; and 
(4) by striking out "such facility" in the last sentence and 
inserting in lieu thereof "such health care facility, rural health 
clinic". 
(j) The amendments made by this section shall apply to services 
rendered on or after the first day of the third calendar month which 
begins after the date of enactment of this Act. 
"Rural health 
clinic services" 
and "rural health 
clinic." 
MEDICAID AMENDMENTS 
SEC. 2. (a) Paragraph (2) of section 1905(a) of the Social Security 
42 use 1396d. 
Act is amended to read as follows: 
"(2) (A) outpatient hospital services, and (B) consistent with 
' 
State law permitting such services, rural health clinic services (as 
defined in subsection (1)) and any other ambulatory services 
which are offered by a rural health clinic (as defined in subsection 
(1)) and which are otherwise included in the plan;". 
(b) Section 1905 of such Act is amended by adding after subsection 
(k) the following new subsection: 
"(1) The terms 'rural health clinic services' and 'rural health clinic' 
have the meanings given such terms in section 1861 (aa), except that 
(1) clause (ii) of section 1861 (aa) (2) shall not apply to such terms, 
and (2) the physician arrangement required under section 1861 (aa) 
(2) (B) shall only apply with respect to rural health clinic services 
and, with respect to other ambulatory care services, the physician 
arrangement required shall be only such as may be required under the 
State plan for those services.". 
42 use 1396a. 
(c) Section 1902(a) of such Act is amended— 
(1) by striking out the semicolon at the end of paragraph (13) 
and inserting in lieu thereof "; and", and by adding at the end of 
such paragraph the following new subparagraph: 
"(F) for payment for services described in section 1905(a) 
(2) (B) provided by a rural health clinic under the plan of 
100 percent of costs which are reasonable and related to the 
cost of furnishing such services or based on such other tests of 
reasonableness, as the Secretary may prescribe in regulations 
Ante, p. 1485. 
under section 1833(a) (3), or, in the case of services to which 
those regulations do not apply, on such tests of reasonable-
ness as the Secretary may prescribe in regulations under this 
subparagraph;"; and 
(2) by inserting ", or by reason of the fact that the plan provides 
for payment for rural health clinic services only if those services 
are provided by a rural health clinic" before the semicolon at the 
end of paragraph (23). 
PUBLIC LAW 95-210—DEC. 13, 1977 
91 STAT. 144B9 
(d) Section 1910 of such Act is amended— 
.y...:^.y.^.'>-
(1) by amending the heading to read as follows: "CERTIFICATION^ 
AND APPROVAL OR SKILLED NURSING FACILITIES AND OF RURAL HEALTH 
CLINICS" ; 
(2) by striking out "(a)" and inserting in lieu thereof "(a) 
(1)"; 
(3) by striking out "(b)" and inserting in lieu thereof "(2)"; 
and 
(4) by adding at the end thereof the following new subsection: 
"(b) (1) Whenever the Secretary certifies a facility in a State to be 
qualified as a rural health clinic under title XVIII, such facility shall 
be deemed to meet the standards for certification as a rural health 
clinic for purposes of providing rural health clinic services under this 
title. 
"(2) The Secretary shall notify the State agency administering the 
medical assistance plan of his approval or disapproval of any facility 
in that State which has applied for certification by him as a qualified 
rural health clinic". 
(e) Section 1866(c) (2) of such Act is amended by striking out "sec-
tion 1910" and inserting in lieu thereof "section 1910(a)". 
(f) (1) The amendments made by this section shall (except as other-
wise provided in paragraph (2)) apply to medical assistance provided, 
under a State plan approved under title XIX of the Social Security 
Act, on and after the first day of the first calendar quarter that begins 
more than six months after the date of enactment of this Act. 
(2) In the case of a State plan for medical assistance under title 
XIX of the Social Security Act which the Secretary determines 
requires State legislation in order for the plan to meet the additional 
requirements imposed by the amendments made by this section, the 
State plan shall not be regarded as failing to comply with the require-
ments of such title solely on the basis of its failure to meet these addi-
tional requirements before the first day of the first calendar quarter 
beginning after the close of the first regular session of the State legis-
lature that begins after the date of enactment of this Act. 
42 use 1396i. 
Certification. 
42 use 1395. 
Approval. 
42 use 1395cc. 
Effective date. 
42 use 1395cc 
note. 
42 use 1396. 
DEMONSTRATION PROJECTS FOR PHYSICIAN-DIRECTED CLINICS I N URBAN 
MEDICALLY UNDERSERVED AREAS 
SEC. 3. (a) The Secretary shall provide, through demonstration 
projects, reimbursement on a cost basis for services provided by physi-
cian-directed clinics in urban medically underserved areas for which 
payment may be made under title XVIII of the Social Security Act 
and, notwithstanding any other provision of such title, for services 
provided by a physician assistant or nurse practitioner employed by 
such clinics which would otherwise be covered under such title if pro-
vided by a physician. 
(b) The demonstration projects developed under subsection (a) shall 
be of sufficient scope and carried out on a broad enough scale to allow 
the Secretary to evaluate fully— 
(1) the relative advantages and disadvantages of reimburse-
ment on the basis of costs and fee-for-service for physician-
directed clinics employing a physician assistant or nurse 
practitioner; 
(2) the appropriate method of determining the compensation 
for physician services on a cost basis for the purposes of reimburse-
ment of services provided in such clinics; 
(3) the appropriate definition for such clinics; 
42 use 1395b-l 
note. 
Evaluation. 
91 STAT. 1490 
PUBLIC LAW 95-210—DEC. 13, 1977 
42 use 1395. 
Expenditures. 
42 use 1395i. 
42 use 1395t. 
Report to 
eongress. 
Definitions. 
Ante, p. 1485. 
(4) the appropriate criteria to use for the purposes of designat-
ing urban medically underserved areas; and 
(5) such other possible changes in the provisions of title XVIII 
of the Social Security Act as might be appropriate for the efficient 
and cost-effective reimbursement of services provided in such 
clinics. 
(c) Grants, payments under contracts, and other expenditures made 
for demonstration projects under this section shall be made in appro-
priate part from the Federal Hospital Insurance Trust Fund (estab-
lished by section 1817 of the Social Security Act) and the Federal 
Supplementary Medical Insurance Trust Fund (established by sec-
tion 1841 of the Social Security Act). Grants and payments under 
contracts may be made either in advance or by way of reimbursement, 
as may be determined by the Secretary, and shall be made in such 
installments and on such conditions as the Secretary finds necessary to 
carry out the purpose of this section. With respect to any such grant, 
payment, or other expenditure, the amount to be paid from each trust 
fund shall be determined by the Secretary giving due regard to the 
purposes of the demonstration projects. 
(d) The Secretary shall submit to the Congress, no later than Janu-
ary 1, 1981, a complete, detailed report on the demonstration projects 
conducted under subsection (b). Such report shall include any recom-
mendations for legislative changes which the Secretary finds necessary 
or desirable as a result of carrying out such demonstration projects. 
(e) As used in this section, the terms "physician assistant" and 
"nurse practitioner" have the meanings given such terms in section 
1861 (aa) (3) of the Social Security Act. 
42 use 1
3
9
5
Z
Z 
note. 
REPORT BY THE SECRETARY OF HEALTH, EDUCATION, AND WELFARE ON 
MENTAL HEALTH AND OTHER CENTERS 
SEC. 4. (a) The Secretary shall submit to the Congress, no later than 
six months after the date of enactment of this Act, a report on the 
advantages and disadvantages of extending coverage under title 
XVIII of the Social Security Act to urban or rural comprehensive 
mental health centers and to centers for treatment of alcoholism and 
drug abuse. 
(b) The report submitted under subsection (a) shall include evalua-
tions of— 
(1) the need for coverage under such title of services provided 
by such centers; 
(2) the extent of present utilization of such centers by individ-
uals eligible for benefits under such title; 
(3) alternatives to services provided by such centers presently 
available to individuals eligible for benefits under such title; 
(4) the appropriate definition for such centers; 
(5) the types of treatment provided by such centers; 
(6) present Federal and State funding for such centers; 
(7) the extent of coverage by private insurance plans for 
services provided by such centers; 
(8) present and projected costs of services provided by such 
centers; 
(9) availa;ble methods for assuring proper utilization of such 
centers; 
(10) the effect of allowing coverage for services provided by 
such centers on other providers and practitioners; and 
PUBLIC LAW 95-210—DEC. 13, 1977 
91 STAT. 1491 
(11) the need for any demonstration projects for further 
evaluation of the need for coverage for services provided by such 
centers. 
ACCESS TO CERTAIN TAX RETURN INFORMATION BY THE NATIONAL 
INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH 
SEC. 5. Subsection (m) of section 6103 of the Internal Revenue Code 
of 1954 (relating to disclosure of taxpayer identity information) is 26 USC 6103. 
amended to read as follows: 
, , 
"(m) DISCLOSURE OF TAXPAYER IDENTITY INFORMATION.— 
"(1) TAX REFUNDS.—The Secretary may disclose taxpayer 
identity information to the press and other media for purposes 
of notifying persons entitled to tax refunds when the Secretary, 
after reasonable effort and lapse of time, has been unable to locate 
such persons. 
"(2) FEDERAL CLAIMS.—Upon written request, the Secretary 
may disclose the mailing address of a taxpayer to officers and 
employees of an agency personally and directly engaged in, and 
solely for their use in, preparation for any administrative or judi-
cial proceeding (or investigation which may result in such a pro-
ceeding) pertaining to the collection or compromise of a Federal 
claim against such taxpayer in accordance with the provisions of 
section 3 of the Federal Claims Collection Act of 1966. 
31 USC 952. 
"(3) 
NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND 
HEALTH.—Upon written request, the Secretary may disclose the 
mailing address of taxpayers to officers and employees of the 
National Institute for Occupational Safety and Health solely for 
the purpose of locating individuals who are, or may have been, 
exposed to occupational hazards in order to determine the status 
of their health or to inform them of the possible need for medical 
care and treatment.". 
TRANSFER OF PUBLIC HEALTH SERVICE HOSPITAL IN TEXAS 
SEC. 6. If the Secretary acquires the Space Center Memorial Hos-
pital in Nassau Bay, Texas, for the purpose of transferring to it the 
activities and functions of the Public Health Service hospital in 
Galveston, Texas, the Secretary may close the Public Health Service 
hospital in Galveston, Texas. 
Approved December 13, 1977. 
LEGISLATIVE HISTORY: 
HOUSE REPORTS: No. 95-548, pt. I (Comm. on Ways and Means), No. 95-548, pt. II 
(Comm. on Interstate and Foreign Commerce), and No. 95-790 
(Comm. of Conference). 
CONGRESSIONAL RECORD, Vol. 123 (1977): 
Oct. 17, considered and passed House. 
Oct. 19, considered and passed Senate, amended. 
Nov. 29, House and Senate agreed to conference report. 
WEEKLY COMPILATION OF PRESIDENTIAL DOCUMENTS, Vol. 13, No. 51: 
Dec. 13, Presidential statement.