TASK DEFINITION: In this task, you are given text for US Congressional and California state bills, your task is to generate a summary for this bill.
PROBLEM: SECTION 1. SHORT TITLE.

This Act may be cited as the ''Opioid Use Disorder Treatment
Expansion and Modernization Act''.

SEC. 2. FINDING.

The Congress finds that opioid use disorder has become a public
health epidemic that must be addressed by increasing awareness and
access to all treatment options for opioid use disorder, overdose
reversal, and relapse prevention.

SEC. 3. OPIOID USE DISORDER TREATMENT MODERNIZATION.

(a) In General.--Section 303(g)(2) of the Controlled Substances Act
(21 U.S.C. 823(g)(2)) is amended--
(1) in subparagraph (B), by striking clauses (i), (ii), and
(iii) and inserting the following:
''(i) The practitioner is a qualifying practitioner (as
defined in subparagraph (G)).
''(ii) With respect to patients to whom the practitioner
will provide such drugs or combinations of drugs, the
practitioner has the capacity to provide directly, by referral,
or in such other manner as determined by the Secretary--
''(I) all schedule III, IV, and V drugs, as well as
unscheduled medications approved by the Food and Drug
Administration, for the treatment of opioid use
disorder, including such drugs and medications for
maintenance, detoxification, overdose reversal, and
relapse prevention, as available; and
''(II) appropriate counseling and other appropriate
ancillary services.
''(iii)(I) The total number of such patients of the
practitioner at any one time will not exceed the applicable
number. Except as provided in subclause (II), the applicable
number is 30.
''(II) The applicable number is 100 if, not sooner than 1
year after the date on which the practitioner submitted the
initial notification, the practitioner submits a second
notification to the Secretary of the need and intent of the
practitioner to treat up to 100 patients.
''(III) The Secretary may by regulation change such total
number.
''(IV) The Secretary may exclude from the applicable number
patients to whom such drugs or combinations of drugs are
directly administered by the qualifying practitioner in the
office setting.
''(iv) If the Secretary by regulation increases the total
number of patients which a qualifying practitioner is permitted
to treat pursuant to clause (iii)(II), the Secretary shall
require such a practitioner to obtain a written agreement from
each patient, including the patient's signature, that the
patient--
''(I) will receive an initial assessment and
treatment plan and periodic assessments and treatment
plans thereafter;
''(II) will be subject to medication adherence and
substance use monitoring;
''(III) understands available treatment options,
including all drugs approved by the Food and Drug
Administration for the treatment of opioid use
disorder, including their potential risks and benefits;
and
''(IV) understands that receiving regular
counseling services is critical to recovery.
''(v) The practitioner will comply with the reporting
requirements of subparagraph (D)(i)(IV).'';
(2) in subparagraph (D)--
(A) in clause (i), by adding at the end the
following:
''(IV) The practitioner reports to the Secretary, at such
times and in such manner as specified by the Secretary, such
information and assurances as the Secretary determines
necessary to assess whether the practitioner continues to meet
the requirements for a waiver under this paragraph.'';
(B) in clause (ii), by striking ''Upon receiving a
notification under subparagraph (B)'' and inserting
''Upon receiving a determination from the Secretary
under clause (iii) finding that a practitioner meets
all requirements for a waiver under subparagraph (B)'';
and
(C) in clause (iii)--
(i) by inserting ''and shall forward such
determination to the Attorney General'' before
the period at the end of the first sentence;
and
(ii) by striking ''physician'' and
inserting ''practitioner'';
(3) in subparagraph (G)--
(A) by amending clause (ii)(IV) to read as follows:
''(IV) The physician has, with respect to the
treatment and management of opiate-dependent patients,
completed not less than 8 hours of training (through
classroom situations, seminars at professional society
meetings, electronic communications, or otherwise) that
is provided by the American Society of Addiction
Medicine, the American Academy of Addiction Psychiatry,
the American Medical Association, the American
Osteopathic Association, the American Psychiatric
Association, or any other organization that the
Secretary determines is appropriate for purposes of
this subclause. Such training shall address--
''(aa) opioid maintenance and
detoxification;
''(bb) appropriate clinical use of all
drugs approved by the Food and Drug
Administration for the treatment of opioid use
disorder;
''(cc) initial and periodic patient
assessments (including substance use
monitoring);
''(dd) individualized treatment planning;
overdose reversal; relapse prevention;
''(ee) counseling and recovery support
services;
''(ff) staffing roles and considerations;
''(gg) diversion control; and
''(hh) other best practices, as identified
by the Secretary.''; and
(B) by adding at the end the following:
''(iii) The term 'qualifying practitioner' means--
''(I) a qualifying physician, as defined in clause
(ii); or
''(II) during the period beginning on the date of
the enactment of the Opioid Use Disorder Treatment
Expansion and Modernization Act and ending on the date
that is 3 years after such date of enactment, a
qualifying other practitioner, as defined in clause
(iv).
''(iv) The term 'qualifying other practitioner' means a
nurse practitioner or physician assistant who satisfies each of
the following:
''(I) The nurse practitioner or physician assistant
is licensed under State law to prescribe schedule III,
IV, or V medications for the treatment of pain.
''(II) The nurse practitioner or physician
assistant satisfies one or more of the following:
''(aa) Has completed not fewer than 24
hours of initial training addressing each of
the topics listed in clause (ii)(IV) (through
classroom situations, seminars at professional
society meetings, electronic communications, or
otherwise) provided by the American Society of
Addiction Medicine, the American Academy of
Addiction Psychiatry, the American Medical
Association, the American Osteopathic
Association, the American Nurses Credentialing
Center, the American Psychiatric Association,
the American Association of Nurse
Practitioners, the American Academy of
Physician Assistants, or any other organization
that the Secretary determines is appropriate
for purposes of this subclause.
''(bb) Has such other training or
experience as the Secretary determines will
demonstrate the ability of the nurse
practitioner or physician assistant to treat
and manage opiate-dependent patients.
''(III) The nurse practitioner or physician
assistant is supervised by or works in collaboration
with a qualifying physician, if the nurse practitioner
or physician assistant is required by State law to
prescribe medications for the treatment of opioid use
disorder in collaboration with or under the supervision
of a physician.
The Secretary may review and update the requirements for being
a qualifying other practitioner under this clause.''; and
(4) in subparagraph (H)--
(A) in clause (i), by inserting after subclause
(II) the following:
''(III) Such other elements of the requirements under this
paragraph as the Secretary determines necessary for purposes of
implementing such requirements.''; and
(B) by amending clause (ii) to read as follows:
''(ii) Not later than 1 year after the date of enactment of the
Opioid Use Disorder Treatment Expansion and Modernization Act, the
Secretary shall update the treatment improvement protocol containing
best practice guidelines for the treatment of opioid-dependent patients
in office-based settings. The Secretary shall update such protocol in
consultation with experts in opioid use disorder research and
treatment.''.
(b) Recommendation of Revocation or Suspension of Registration in
Case of Substantial Noncompliance.--The Secretary of Health and Human
Services may recommend to the Attorney General that the registration of
a practitioner be revoked or suspended if the Secretary determines,
according to such criteria as the Secretary establishes by regulation,
that a practitioner who is registered under section 303(g)(2) of the
Controlled Substances Act (21 U.S.C. 823(g)(2)) is not in substantial
compliance with the requirements of such section, as amended by this
Act.
(c) Opioid Defined.--Section 102(18) of the Controlled Substances
Act (21 U.S.C. 802(18)) is amended by inserting ''or 'opioid''' after
''The term 'opiate'''.
(d) Reports to Congress.--
(1) In general.--Not later than 2 years after the date of
enactment of this Act and not less than over every 5 years
thereafter, the Secretary of Health and Human Services, in
consultation with the Drug Enforcement Administration and
experts in opioid use disorder research and treatment, shall--
(A) perform a thorough review of the provision of
opioid use disorder treatment services in the United
States, including services provided in opioid treatment
programs and other specialty and nonspecialty settings;
and
(B) submit a report to the Congress on the findings
and conclusions of such review.
(2) Contents.--Each report under paragraph (1) shall
include an assessment of--
(A) compliance with the requirements of section
303(g)(2) of the Controlled Substances Act (21 U.S.C.
823(g)(2)), as amended by this Act;
(B) the measures taken by the Secretary of Health
and Human Services to ensure such compliance;
(C) whether there is further need to increase or
decrease the number of patients a waivered practitioner
is permitted to treat, as provided for by the amendment
made by subsection (a)(1);
(D) the extent to which, and proportions with
which, the full range of Food and Drug Administration-
approved treatments for opioid use disorder are used in
routine health care settings and specialty substance
use disorder treatment settings;
(E) access to, and use of, counseling and recovery
support services, including the percentage of patients
receiving such services;
(F) changes in State or local policies and
legislation relating to opioid use disorder treatment;
(G) the use of prescription drug monitoring
programs by practitioners who are permitted to dispense
narcotic drugs to individuals pursuant to a waiver
under section 303(g)(2) of the Controlled Substances
Act (21 U.S.C. 823(g)(2));
(H) the findings resulting from inspections by the
Drug Enforcement Administration of practitioners
described in subparagraph (G); and
(I) the effectiveness of cross-agency collaboration
between Department of Health and Human Services and the
Drug Enforcement Administration for expanding effective
opioid use disorder treatment.

SEC. 4. SENSE OF CONGRESS.

It is the Sense of Congress that, with respect to the total number
of patients that a qualifying physician (as defined in subparagraph
(G)(iii) of section 303(g)(2) of the Controlled Substances Act (21
U.S.C. 823(g)(2)) can treat at any one time pursuant to such section,
the Secretary of Health and Human Services should consider raising such
total number to 250 patients following a third notification to the
Secretary of the need and intent of the physician to treat up to 250
patients that is submitted to the Secretary not sooner than 1 year
after the date on which the physician submitted to the Secretary a
second notification to treat up to 100 patients.

SEC. 5. PARTIAL FILLS OF SCHEDULE II CONTROLLED SUBSTANCES.

(a) In General.--Section 309 of the Controlled Substances Act (21
U.S.C. 829) is amended by adding at the end the following:
''(f) Partial Fills of Schedule II Controlled Substances.--
''(1) Partial fills.--
''(A) In general.--A prescription for a controlled
substance in schedule II may be partially filled if--
''(i) it is not prohibited by State law;
''(ii) the prescription is written and
filled in accordance with the Controlled
Substances Act (21 U.S.C. 801 et seq.),
regulations prescribed by the Attorney General,
and State law;
''(iii) the partial fill is requested by
the patient or the practitioner that wrote the
prescription; and
''(iv) the total quantity dispensed in all
partial fillings does not exceed the total
quantity prescribed.
''(B) Other circumstances.--A prescription for a
controlled substance in schedule II may be partially
filled in accordance with section 1306.13 of title 21,
Code of Federal Regulations (as in effect on the date
of enactment of the Reducing Unused Medications Act of
2016).
''(2) Remaining portions.--
''(A) In general.--Except as provided in
subparagraph (B), remaining portions of a partially
filled prescription for a controlled substance in
schedule II--
''(i) may be filled; and
''(ii) shall be filled not later than 30
days after the date on which the prescription
is written.
''(B) Emergency situations.--In emergency
situations, as described in subsection (a), the
remaining portions of a partially filled prescription
for a controlled substance in schedule II--
''(i) may be filled; and
''(ii) shall be filled not later than 72
hours after the prescription is issued.''.
(b) Rule of Construction.--Nothing in this section shall be
construed to affect the authority of the Attorney General to allow a
prescription for a controlled substance in schedule III, IV, or V of
section 202(c) of the Controlled Substances Act (21 U.S.C. 812(c)) to
be partially filled.

Passed the House of Representatives May 11, 2016.

Attest:

KAREN L. HAAS,

Clerk.

SOLUTION: Opioid Use Disorder Treatment Expansion and Modernization Act (Sec. 3) This bill amends the Controlled Substances Act to revise the requirements for a practitioner to administer, dispense, or prescribe narcotic drugs for maintenance or detoxification treatment in an office-based opioid treatment program. Currently, a practitioner must notify the Department of Health and Human Services (HHS) and certify that he or she is a qualifying physician (i.e., a state-licensed physician with certain expertise), has the capacity to refer patients for appropriate counseling and ancillary services, and will comply with a patient limit. The patient limit is how many patients the practitioner can treat under the office-based treatment program at one time. This legislation expands qualifying practitioners to include nurse practitioners and physician assistants who are licensed in a state, have expertise (such as relevant training or expertise), and prescribe medications for opioid use disorder in collaboration with or under the supervision of a qualifying physician if state law requires physician oversight of prescribing authority. Additionally, it requires a qualifying practitioner to also certify that he or she will comply with reporting requirements and has the capacity to provide directly or by referral, or in another manner prescribed by HHS, all drugs approved by the Food and Drug Administration to treat opioid use disorder. HHS may issue regulations to change the maximum patient limit for a qualifying practitioner. If HHS increases the limit, then a qualifying practitioner must additionally certify that he or she will obtain written consent from each patient regarding available treatment options. HHS must update the treatment improvement protocol containing best practice guidelines for the treatment of opioid-dependent patients in office-based settings. HHS may recommend revoking or suspending the registration of a practitioner who fails to comply with the requirements of this Act. (Sec. 4) The bill expresses the sense of Congress that HHS should consider raising from 100 to 250 the maximum patient limit for a qualifying physician. (Sec. 5) It amends the Controlled Substances Act to allow a pharmacist to partially fill a prescription for a schedule II controlled substance (such as a prescription opioid painkiller) if: (1) it is not prohibited by state law, (2) it is prescribed in accordance with existing laws and regulations, (3) it is requested by the patient or prescribing practitioner, and (4) the total quantity dispensed in partial fillings does not exceed the total quantity prescribed. Additionally, a pharmacist may partially fill a prescription for a schedule II controlled substance in other circumstances in accordance with existing Drug Enforcement Administration (DEA) regulations. (Current DEA regulations permit partial fills when a pharmacist cannot supply a full quantity, a patient resides in a long-term care facility, or a patient is terminally ill.) The remaining of a partially filled prescription may be filled within 30 days or, in the case of an emergency situation, within 72 hours.

PROBLEM: SECTION 1. SHORT TITLE.

This Act may be cited as the ''Rural Emergency Acute Care Hospital
Act''.

SEC. 2. FINDINGS.

Congress finds the following:
(1) According to the University of North Carolina's Center
for Health Services Research, 55 rural hospitals have closed in
the Unites States since January 2010.
(2) In 2014, iVantage conducted a study for the National
Rural Health Association and found 283 hospitals at risk of
closure based upon performance indicators that matched those
facilities already forced to close in this decade.
(3) Researchers at the University of North Carolina
identified inpatient volume as a substantial contributing
factor to the financial performance of rural hospitals, with
many of the at-risk hospitals having an average daily bed
census of less than 2.
(4) Adverse impacts to the local economy and the loss of
timely access to emergency medical care are 2 major effects of
rural hospital closures.
(5) According to the National Center for Rural Health
Works, the typical rural hospital creates over 140 jobs and
generates $6,800,000 in compensation while serving an average
population of 14,600.
(6) The 2014 iVantage study estimates that the 283 at-risk
hospitals could result in the loss of 36,000 health care jobs,
50,000 community jobs, and $10,600,000,000 in gross domestic
product.
(7) Time is the most critical factor for achieving
successful outcomes in emergency medicine, and emergency
medical clinicians refer to the time-sensitive period during
which successful outcomes may be best achieved as the ''golden
hour''.
(8) The National Conference of State Legislatures states
that 60 percent of trauma deaths in the United States occur in
rural areas, where only 15 percent of the population is
represented.
(9) The disproportionate percentage of trauma deaths in
rural areas is likely attributable in large part to a
combination of response time to the scene and distance to the
nearest emergency room to stabilize trauma victims.
(10) The percentage of trauma deaths occurring in rural
areas could continue to increase as more rural hospitals close,
further limiting access to emergency services and requiring
patients to travel longer distances to receive emergency
medical care.
(11) The creation of a rural emergency hospital designation
under the Medicare program will allow facilities in rural areas
to provide emergency medical services without having to
maintain inpatient beds.
(12) In addition to providing emergency care, rural
emergency hospitals could convert the space previously used for
inpatient services to provide other medical services including,
but not limited to, observation care, skilled nursing facility
care, infusion services, hemodialysis, home health, hospice,
nursing home care, population health, and telemedicine
services.

SEC. 3. RURAL EMERGENCY HOSPITAL PROGRAM.

(a) In General.--
(1) Rural emergency hospital and services defined.--Section
1861 of the Social Security Act (42 U.S.C. 1395x) is amended--
(A) in subsection (e), in the last sentence of the
matter following paragraph (9), by inserting ''or a
rural emergency hospital (as defined in section
1861(iii)(1))'' before the period at the end; and
(B) by adding at the end the following subsection:

''Rural Emergency Hospital; Rural Emergency Hospital Outpatient
Services

''(iii)(1) The term 'rural emergency hospital' means a facility
that--
''(A)(i) as of December 31, 2014--
''(I) was a critical access hospital; or
''(II) was a hospital with not more than 50
beds located in a county (or equivalent unit of
local government) in a rural area (as defined
in section 1886(d)(2)(D)), or was a hospital
with not more than 50 beds that was treated as
being located in a rural area pursuant to
section 1886(d)(8)(E); or
''(ii) was a critical access hospital described in
clause (i)(I) or a hospital described in clause (i)(II)
that ceased operations during the period beginning on
the date that is 5 years prior to the date of the
enactment of this subsection and ending on December 30,
2014;
''(B) provides 24-hour emergency medical care and
observation care that does not exceed an annual per patient
average of 24 hours or more than 1 midnight;
''(C) does not provide any acute care inpatient beds and
has protocols in place for the timely transfer of patients who
require acute care inpatient services or other inpatient
services;
''(D) has elected to be designated as a rural emergency
hospital;
''(E) has received approval to operate as a rural emergency
hospital from the State under section 1834(r)(3)(A); and
''(F) is certified by the Secretary under section
1834(r)(3)(B).
''(2) The term 'rural emergency hospital outpatient services' means
medical and other health services furnished by a rural emergency
hospital on an outpatient basis.
''(3) Nothing in this subsection or section 1834(r)(3) shall be
construed to prohibit a rural emergency hospital from providing
extended care services.''.
(2) Payment for rural emergency hospital services.--
(A) In general.--Section 1833(a) of the Social
Security Act (42 U.S.C. 1395l(a)) is amended--
(i) in paragraph (8), by striking ''and''
at the end;
(ii) in paragraph (9), by striking the
period at the end and inserting ''; and''; and
(iii) by inserting after paragraph (9) the
following new paragraph:
''(10) in the case of rural emergency hospital emergency
services and services provided by a rural emergency hospital or
other provider of ambulance services to transport patients who
require acute care inpatient services or other inpatient
services from such rural emergency hospital to a hospital or
critical access hospital, the amounts described in section
1834(r).''.
(B) Payment amount.--Section 1834 of the Social
Security Act (42 U.S.C. 1395m) is amended by adding at
the end the following subsection:
''(r) Payment Rules Relating to Rural Emergency Hospitals.--
''(1) Payment for rural emergency hospital outpatient
services.--
''(A) In general.--The amount of payment for rural
emergency hospital outpatient services of a rural
emergency hospital is equal to 110 percent of the
reasonable costs of providing such services.
''(B) Telehealth services.--For purposes of this
paragraph, in determining the reasonable costs of
providing rural emergency hospital outpatient services,
costs associated with having a backup physician
available via a telecommunications system shall be
considered reasonable costs.
''(2) Payment for transportation services.--The amount of
payment for services provided by a rural emergency hospital or
other provider of ambulance services to transport patients who
require acute care inpatient services or other inpatient
services from such rural emergency hospital to a hospital or
critical access hospital is equal to 110 percent of the
reasonable costs of providing such services.
''(3) Requirements for rural emergency hospitals.--
''(A) State approval to operate as a rural
emergency hospital.--No payment shall be made under
this subsection to a facility, or to a provider of
ambulance services providing transportation services
from such facility, unless the State in which the
facility is located has approved the facility's
designation as a rural emergency hospital.
''(B) Certification of rural emergency hospital.--
''(i) In general.--No payment shall be made
under this subsection to a facility, or to a
provider of ambulance services providing
transportation services from such facility,
unless the facility has been certified by the
Secretary as a rural emergency hospital.
''(ii) Certification requirements.--The
Secretary shall certify a facility as a rural
emergency hospital if the facility--
''(I) meets the criteria for rural
emergency hospitals described in
subparagraphs (A) through (E) of
section 1861(iii)(1);
''(II) either--
''(aa) is verified by the
American College of Surgeons as
having the resources required
of a level IV trauma center or
higher; or
''(bb) employs healthcare
professionals that successfully
completed the Advanced Trauma
Life Support Course offered by
the American College of
Surgeons within the preceding 4
years;
''(III) has in effect a transfer
agreement with a level I or level II
trauma center; and
''(IV) meets such staff training
and certification requirements as the
Secretary may require.
''(4) Coinsurance.--
''(A) In general.--The amount of payment for rural
emergency hospital services or transportation services
made to a rural emergency hospital or other provider of
ambulance services under this subsection shall be
reduced by the coinsurance amount described in
subparagraph (B).
''(B) Coinsurance amount.--The coinsurance amount
described in this subparagraph, with respect to an item
or service provided by a rural emergency hospital or
provider of ambulance services, shall be calculated in
the same manner as the coinsurance amount for an
outpatient critical access hospital service is
calculated under section 1866(a)(2).''.
(b) Waiver of Distance Requirement for Replacement CAHs; Subsequent
Redesignation of Rural Emergency Hospitals as CAHs.--Section 1820(c)(2)
of the Social Security Act (42 U.S.C. 1395i-4(c)(2)) is amended--
(1) in subparagraph (B)(i)(I), by inserting ''subject to
subparagraph (F),'' before ''is located''; and
(2) by adding at the end the following new subparagraphs:
''(F) Option to waive distance requirement.--
Beginning on the date of the enactment of this
subparagraph, for every critical access hospital
located in a State that is certified as a rural
emergency hospital under section 1834(r)(3)(B), the
State shall have the option of waiving the distance
requirement described in subparagraph (B)(i)(I) with
respect to another facility located in the State that
is seeking designation as a critical access hospital
under this paragraph.
''(G) Redesignation of a rural emergency hospital
as a critical access hospital.--A rural emergency
hospital that was previously designated as a critical
access hospital under this paragraph may elect to be
redesignated as a critical access hospital (in the same
manner that the hospital was originally designated as a
critical access hospital) at any time, subject to such
conditions as the Secretary may establish.''.
(c) Studies and Reports.--
(1) Studies.--The Secretary of Health & Human Services
shall conduct 3 studies to evaluate the impact of rural
emergency hospitals on the availability of health care and
health outcomes in rural areas (as defined in section
1886(d)(2)(D) of the Social Security Act (42 U.S.C. 1395ww)).
The Secretary shall conduct a study--
(A) 2 years after the date of the enactment of this
Act;
(B) 5 years after the date of the enactment of this
Act; and
(C) 10 years after the date of the enactment of
this Act.
(2) Reports.--Not later than 6 months after each date that
the Secretary of Health & Human Services is required to conduct
a study under paragraph (1), the Secretary shall submit a
report to Congress containing the results of each such study.
(d) Effective Date.--The amendments made by this section shall
apply to items and services furnished on or after the date that is 1
year after the date of the enactment of this Act.

SEC. 4. INCLUSION OF EMERGENCY MEDICINE AS HEALTH SERVICES UNDER THE
NATIONAL HEALTH SERVICE CORPS.

Section 331(a)(3)(D) of the Public Health Service Act (42 U.S.C.
254d(a)(3)(D)) is amended by inserting '', and includes emergency
medicine provided by physicians in a rural emergency hospital (as
defined in section 1861(iii) of the Social Security Act)'' before the
period.

SEC. 5. PERMITTING HOSPITALS WITH APPROVED RESIDENCY PROGRAMS IN
EMERGENCY MEDICINE TO INCLUDE TIME SPENT BY INTERNS AND
RESIDENTS IN THE EMERGENCY DEPARTMENT OF A RURAL HOSPITAL
IN FULL-TIME EQUIVALENT COUNT.

(a) Indirect Medical Education.--Section 1886(d)(5)(B)(iv) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended by
adding at the end the following new subclause:
''(III) Effective for discharges occurring on or after
October 1, 2015, all of the time spent in patient care
activities in the emergency department of a rural hospital by
interns and residents in emergency medicine from a hospital
with an approved medical residency training program (as defined
in subsection (h)(5)(A)) in such specialty shall be included in
determining the number of full-time equivalent interns and
residents in such program if the hospital with such program
incurs the costs of the stipends and fringe benefits of the
interns or residents during the time the interns or residents
spend in that rural hospital in accordance with subclause (II).
In this subclause, the term 'rural hospital' means a hospital
that is located in a rural area (as defined for purposes of
paragraph (2)(D)).''.
(b) Direct Medical Education.--Section 1886(h)(4)(E) of the Social
Security Act (42 U.S.C. 1395(h)(4)) is amended--
(1) in clause (ii), by striking the period at the end and
inserting ''; and'';
(2) by inserting after clause (ii) the following new
clause:
''(iii) effective for cost reporting
periods beginning on or after July 1, 2015, all
of the time so spent in the emergency
department of a rural hospital by residents in
emergency medicine from a hospital with an
approved medical residency training program in
such specialty shall be counted towards the
determination of full-time equivalency in such
program if the hospital with such program bears
all, or substantially all, of the costs of
training such residents in the rural hospital.
In this subparagraph, the term 'rural hospital'
means a hospital that is located in a rural
area (as defined for purposes of subsection
(d)(2)(D)).''; and
(3) by adding at the end the following new sentence: ''For
purposes of this subparagraph, the emergency department of a
rural hospital described in clause (iii) is a nonprovider
setting.''.

SOLUTION: Rural Emergency Acute Care Hospital Act This bill amends title XVIII (Medicare) of the Social Security Act to designate as a rural emergency hospital any facility that as of December 31, 2014, was: a critical access hospital (CAH) or a hospital with at most 50 beds located in a county in a rural area or treated as located in a rural area, or one of such hospitals that ceased operations during the period beginning five years before enactment of this Act and ending on December 30, 2014. A rural emergency hospital: must provide 24-hour emergency medical care and observation care not exceeding an annual per patient average of 24 hours or more than 1 midnight, does not provide any acute care inpatient beds and has protocols in place for the timely transfer of patients who require acute care inpatient services or other inpatient services, has elected to be designated as a rural emergency hospital, has received approval to operate as one from the state, and is certified by the Department of Health and Human Services (HHS). Medicare part B (Supplementary Medical Insurance Benefits) shall cover rural emergency hospital emergency services as well as ambulance services provided by a rural emergency hospital or other provider to transport patients who require acute care inpatient services or other inpatient services from the rural emergency hospital to a hospital or a CAH. Payment for rural emergency hospital outpatient services of a rural emergency hospital, including telehealth and ambulance services, shall be 110% percent of their reasonable costs. Rural emergency hospitals must be approved by the state and certified by HHS. States shall have the option of waiving a specified distance requirement between a CAH certified as a rural emergency hospital and another facility located in the state that is seeking designation as a CAH. Primary health services which the National Health Service Corps may provide under the Public Health Service Act shall include emergency medicine provided by physicians in a rural emergency hospital. Hospitals with approved residency programs in emergency medicine shall include time spent by interns and residents in the emergency department of a rural hospital in the full-time equivalent count with respect to reimbursement for the indirect (stipend, fringe benefit) and direct (all or substantially all training) costs of medical education in subsection (d) hospitals. (Generally, a subsection [d] hospital is an acute care hospital, particularly one that receives payments under Medicare's inpatient prospective payment system [IPPS] when providing covered inpatient services to eligible beneficiaries.)

PROBLEM: That the following sums
are appropriated, out of any money in the Treasury not otherwise
appropriated, for the Departments of Agriculture, Education, Health and
Human Services, and Transportation for the fiscal year ending September
30, 2005, and for other purposes, namely:

TITLE I--DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE

salaries and expenses

(including transfers of funds)

For expenses, not otherwise provided for, necessary to prevent,
control, and eradicate pests and plant and animal diseases; to carry
out inspection, quarantine, and regulatory activities; and to protect
the environment, as authorized by law, $866,361,000, of which
$4,119,000 shall be available for the control of outbreaks of insects,
plant diseases, animal diseases and for control of pest animals and
birds to the extent necessary to meet emergency conditions: Provided,
That this appropriation shall be available for the operation and
maintenance of aircraft and the purchase of not to exceed four, of
which two shall be for replacement only: Provided further, That, in
addition, in emergencies which threaten any segment of the agricultural
production industry of this country, the Secretary may transfer from
other appropriations or funds available to the agencies or corporations
of the Department such sums as may be deemed necessary, to be available
only in such emergencies for the arrest and eradication of contagious
or infectious disease or pests of animals, poultry, or plants, and for
expenses in accordance with sections 10411 and 10417 of the Animal
Health Protection Act (7 U.S.C. 8310 and 8316) and sections 431 and 442
of the Plant Protection Act (7 U.S.C. 7751 and 7772), and any
unexpended balances of funds transferred for such emergency purposes in
the preceding fiscal year shall be merged with such transferred
amounts: Provided further, That appropriations hereunder shall be
available pursuant to law (7 U.S.C. 2250) for the repair and alteration
of leased buildings and improvements, but unless otherwise provided the
cost of altering any one building during the fiscal year shall not
exceed 10 percent of the current replacement value of the building.
In fiscal year 2005, the agency is authorized to collect fees to
cover the total costs of providing technical assistance, goods, or
services requested by States, other political subdivisions, domestic
and international organizations, foreign governments, or individuals,
provided that such fees are structured such that any entity's liability
for such fees is reasonably based on the technical assistance, goods,
or services provided to the entity by the agency, and such fees shall
be credited to this account, to remain available until expended,
without further appropriation, for providing such assistance, goods, or
services.

RURAL DEVELOPMENT PROGRAMS

Rural Community Advancement Program

For the cost of direct loans, loan guarantees, and grants, as
authorized by 7 U.S.C. 1926, 1926a, 1926c, 1926d, and 1932, except for
sections 381E-H and 381N of the Consolidated Farm and Rural Development
Act, $963,013,500, to remain available until expended, of which
$86,439,000 shall be for rural community programs described in section
381E(d)(1) of such Act; of which $801,594,500 shall be for the rural
utilities programs described in sections 381E(d)(2), 306C(a)(2), and
306D of such Act; and of which $74,980,000 shall be for the rural
business and cooperative development programs described in sections
381E(d)(3) and 310B(f) of such Act.

Rural Housing Service

rural housing insurance fund program account

(including transfer of funds)

For gross obligations for the principal amount of direct and
guaranteed loans as authorized by title V of the Housing Act of 1949,
to be available from funds in the rural housing insurance fund, as
follows: $5,198,275,000 for loans to section 502 borrowers, as
determined by the Secretary, of which $2,200,000,000 shall be for
direct loans, and of which $2,725,185,000 shall be for unsubsidized
guaranteed loans; $35,000,000 for section 504 housing repair loans;
$116,545,000 for section 515 rental housing; $100,000,000 for section
538 guaranteed multi-family housing loans; $5,045,000 for section 524
site loans; $11,501,000 for credit sales of acquired property, of which
up to $1,501,000 may be for multi-family credit sales; and $5,000,000
for section 523 self-help housing land development loans.
For the cost of direct and guaranteed loans, including the cost of
modifying loans, as defined in section 502 of the Congressional Budget
Act of 1974, as follows: section 502 loans, $288,368,000, of which
$254,760,000 shall be for direct loans, and of which $33,608,000 to
remain available until expended, shall be for unsubsidized guaranteed
loans; section 504 housing repair loans, $10,171,000; section 515
rental housing, $54,881,000; section 538 multi-family housing
guaranteed loans, $3,490,000; multi-family credit sales of acquired
property, $727,000: Provided, That of the total amount appropriated in
this paragraph, $7,100,000 shall be available through June 30, 2005,
for authorized empowerment zones and enterprise communities and
communities designated by the Secretary of Agriculture as Rural
Economic Area Partnership Zones.
In addition, for administrative expenses necessary to carry out the
direct and guaranteed loan programs, $465,886,000, which shall be
transferred to and merged with the appropriation for ''Rural
Development, Salaries and Expenses''.

Rural Utilities Service

rural telephone bank program account

(including transfer of funds)

The Rural Telephone Bank is hereby authorized to make such
expenditures, within the limits of funds available to such corporation
in accord with law, and to make such contracts and commitments without
regard to fiscal year limitations as provided by section 104 of the
Government Corporation Control Act, as may be necessary in carrying out
its authorized programs. During fiscal year 2005 and within the
resources and authority available, gross obligations for the principal
amount of direct loans shall be $173,503,000.
In addition, for administrative expenses, including audits,
necessary to carry out the loan programs, $3,328,000, which shall be
transferred to and merged with the appropriation for ''Rural
Development, Salaries and Expenses''.

distance learning, telemedicine, and broadband program

For the principal amount of direct distance learning and
telemedicine loans, $300,000,000; and for the principal amount of
direct broadband telecommunication loans, $675,917,000.
For grants for telemedicine and distance learning services in rural
areas, as authorized by 7 U.S.C. 950aaa et seq., $50,000,000, to remain
available until expended.
For the cost of telemedicine and distance learning services loans
in rural areas, as authorized by 7 U.S.C. 950aaa et seq., $4,260,000,
to remain available until expended.
For the cost of broadband loans, as authorized by 7 U.S.C. 901 et
seq., $17,229,000: Provided further, That the cost of direct loans
shall be as defined in section 502 of the Congressional Budget Act of
1974.
In addition, $18,000,000, to remain available until expended, for a
grant program to finance broadband transmission in rural areas eligible
for Distance Learning and Telemedicine Program benefits authorized by 7
U.S.C. 950aaa.

TITLE II--DEPARTMENT OF EDUCATION

SCHOOL IMPROVEMENT PROGRAMS

rural education achievement program

For carrying out rural education activities authorized by part B of
title VI of the Elementary and Secondary Education Act of 1965,
$300,000,000, which shall become available on July 1, 2005, and remain
available through September 30, 2006, for academic year 2005-2006.

TITLE III--DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

health resources and services

programs of special importance to rural america

For carrying out sections 330, 330A, 330I, 330J, 331 through 338I,
338J, 340, 340G, 747, 750, 751, 752, 754, 757, and 846 of the Public
Health Service Act, sections 711 and 1820 of the Social Security Act,
and the Rural Access to Emergency Devices Act, $2,547,066,000, all of
which shall be derived from general revenues notwithstanding section
1820(j) of the Social Security Act.

TITLE IV--DEPARTMENT OF TRANSPORTATION

OFFICE OF THE SECRETARY

Payments to Air Carriers

(airport and airway trust fund)

To carry out the essential air service program under 49 U.S.C.
41731 through 41742, $115,000,000 to be derived from the Airport and
Airway Trust Fund and from amounts received by the Federal Aviation
Administration credited to the amount established under section 45303
of Title 49, U.S.C., to remain available until expended.

TITLE V--OFFSET

In the case of taxpayers with adjusted gross income in excess of
$1,000,000 for calendar year 2004, the amount of the tax reduction
resulting from enactment of the Jobs and Growth Tax Relief
Reconciliation Act of 2003 (Public Law 108-27) and enactment of the
Economic Growth and Tax Relief Reconciliation Act of 2001 (Public Law
107-16) shall be reduced by 5.1 percent.

SOLUTION:
Appropriates FY 2005 appropriations to the Department of Agriculture for the: (1) Animal and Plant Health Inspection Service; (2) Rural Community Advancement Program; (3) Rural Housing Service; and (4) Rural Utilities Service (rural telephone bank program account, and distance learning, telemedicine, and broadband program).

Appropriates FY 2005 appropriations to the Department of Education for the rural education achievement program.

Appropriates FY 2005 appropriations to the Department of Health and Human Services for rural programs of the Health Resources and Services Administration.

Appropriates FY 2005 appropriations to the Department of Transportation for air carrier payments.

States that for taxpayers with adjusted gross income in excess of $1 million for calendar year 2004 the amount of the tax reduction resulting from enactment of the Jobs and Growth Tax Relief Reconciliation Act of 2003 and enactment of the Economic Growth and Tax Relief Reconciliation Act of 2001 shall be reduced by 5.1 percent.