S. 1157Senate111th Congress (2009-2011)In Committee

Craig Thomas Rural Hospital and Provider Equity Act of 2009

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1 earlier action

SenateIntro Referral Latest Action

Read twice and referred to the Committee on Finance.

Finance Committee

May 21, 2009

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SenateIntro Referral

Introduced in Senate

May 21, 2009

SenateIntro Referral

Read twice and referred to the Committee on Finance.

Finance Committee

May 21, 2009

Floor Debate

2 members

What members said about S. 1157 on the floor

1 Republican1 Democrat

Sen. Sheldon WhitehouseD-RI · Jul 7, 2009

Madam President, I have spoken many times on the floor of the Senate about the desperate need for reform of our broken health care system. Today the Congress stands at a moment of historic…

Madam President, I have spoken many times on the floor of the Senate about the desperate need for reform of our broken health care system. Today the Congress stands at a moment of historic opportunity. The attention, hopes, and anxieties of the American people are focused on us like never before.

We have seen over the course of the last 60 years constant lament over the

system's flaws and failure--failure when true opportunities for reform arise. President Obama has now challenged this Congress to reform our Nation's health care system, to expand access to insurance, to improve below-average results, and to bring down its costs. It is about this last challenge--the challenge of our unimaginable and grotesque health care costs--that I speak today.

In his recent speech to the AMA, the President called escalating health care costs ``a threat to our economy . . . an escalating burden on our families and businesses . . . a ticking time-bomb for the federal budget, and . . . unsustainable for the United States of America.''

I hope all of us share his sense of urgency. Our country's economic future may well depend on it.

Over the past few weeks, I have been privileged to work with my HELP Committee colleagues to make long-awaited reforms and investments to control costs and wring savings from the system. In that process, much attention has been paid to the Congressional Budget Office's cost and savings estimates--estimates that, in many cases, have significant limitations.

CBO, as we know, plays a vital role in our legislative branch by ensuring that we have objective, nonpartisan estimates of the likely costs and savings to the Federal budget of legislation. These estimates can help us make responsible and efficient use of the taxpayers' money, but we must recognize that in the particular context of health care reform, they are fundamentally limited by CBO's professional restrictions.

CBO can only estimate health care costs and savings that have historic precedent. For example, since we have the experience of Medicaid and the Children's Health Insurance Program, CBO can estimate how much expanding coverage to all needy families will cost. These subsidies account for the vast majority of CBO's $600 billion estimate of the 10-year cost of the HELP Committee bill.

On the cost savings side, however, CBO's capability is limited. We know our health care system is on an unsustainable course, and there is broad agreement on which of the broken pieces need fixing, but it is impossible to estimate cost savings with the degree of certainty CBO requires to provide what we call a score.

CBO's Director has been refreshingly candid about this. In a recent letter to our budget chairman, Senator Conrad, he writes the following:

Changes in government policy have the potential to yield

large reductions in both national health expenditures and

Federal health care spending without harming health.

He continues:

Moreover, many experts agree on some general directions in

which the government's health policies should move, typically

involving changes in the information and incentives that

doctors and patients have when making decisions about health

care. Yet many of the specific changes that might ultimately

prove most important cannot be foreseen today and could be

developed only over time through experimentation and

learning.

CBO's professional discipline requires it to score legislation through a rearview mirror, looking back, and basing its calculations on what it can chronicle has happened in the past. But when we propose to take the country in a new direction, when there is a turn in the road, when we seek to fulfill President Obama's promise of true change in America, the rearview mirror doesn't help much. We have not been where we need to go.

In addition, getting there will require leadership, creativity, and perseverance. It will require executive administration with constant adjustments and improvements as we work toward our goal. Those factors are beyond the capability of CBO to predict.

I speak not to criticize the hard-working public servants of the Congressional Budget Office. They do an exemplary job with the tools at their disposal. Americans owe them a particular debt of gratitude now for how incredibly hard they have worked over these past weeks, but their tools come with their own limitations. The point of this reform is to turn around a system that is spiraling out of control. We spent 18 percent of our gross domestic product on health care, the next highest spending Nation in the world--the next worst is Switzerland, at 11 percent. Even if our success in this reform is limited to shaving a few percentage points off our national expenditure on health care, that change will be worth hundreds of billions of dollars a year. Yes, there will need to be an initial investment in health care reform, but the potential savings are multiples larger. CBO's inability to score those savings does not mean that those savings are not both real and substantial.

One measure of the potential savings is the recent report of the President's Council of Economic Advisers, June 2009. I ask unanimous consent that the executive summary of this document be printed in the Record.

This report compares the share of America's gross domestic product spent on health care to the share spent by our international industrialized competitors. It also looks to the wide variation in health care expense and quality, region to region, within the United States of America. From each of these measures, the report comes to the same conclusion: They estimate excess health care expenditures of about 5 percent of GDP, which translates to $700 billion per year. Former Treasury Secretary O'Neill has written recently that the target is $1 trillion per year. Whether $700 billion or $1 trillion, that is a savings target that is worth an enormous expenditure of executive and legislative effort to achieve, particularly when all the evidence suggests that achieving it will actually improve health care outcomes for the American people.

Perfect examples of the savings that await us are in quality of care. I have spoken before about the Keystone Project up in Michigan which reformed care in a significant number of Michigan's intensive care units. It reduced infections, respiratory complications, and other medical errors. Between March 2004 and June 2005, just a little over a year, the project is documented to have saved 1,578 lives, 81,020 days patients otherwise would have spent in the hospital, and over 165 million health care dollars--just in a little over a year, just in intensive care units, just in one State, and not even all of the intensive care units in that State.

In my home State, the Rhode Island Quality Institute has taken this model statewide with every hospital participating, and we are already seeing hospital-acquired infections and costs declining.

Why aren't these quality reforms happening spontaneously all over the country? Because government and private insurers haven't set up the right rules for the game. When we began our intensive care unit reform in Rhode Island, the Hospital Association of Rhode Island estimated a $400,000 cost for a potential $8 million savings from the ICU reform program. That is a 20-to-1 return on investment. Super deal, right? Who wouldn't take that? Well, the hospitals pointed out that all the savings--the $8 million--went to the payers--to Medicare, to the insurance companies--and all the costs and all the trouble and all the risk came out of their own pockets. The savings actually cut hospital revenues. So with a lot of business experience around this Chamber, do we know a lot of businesses that would spend $400,000 in cash in order to lose $8 million in revenues? That is not a good economic proposition. We have made the rules such that it is not a good economic proposition for hospitals to invest that way.

That is why the HELP Committee bill changes payment incentives and invests in grant programs so it begins to make economic sense for doctors and hospitals to invest in lifesaving and cost-saving quality improvements. If we can make it an economic win for providers to improve quality this way, think of the torrent of American ingenuity that will unleash. Now we are stuck. We are stuck in a bog of market failure, with the connection between risk and reward--the fundamental connection between risk and reward that is the basic engine of American capitalism--interrupted and disabled. But CBO can't score that innovation because we haven't been down this road before. There is nothing in the rearview mirror for CBO professionals to work with to determine what those savings will be.

There is a similar problem in disease prevention. A study by the Trust for America's Health found that investing $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent tobacco use could save the country more than $16 billion annually within 5 years. Out of the $16 billion in savings, Medicare could save more than $5 billion, Medicaid could save more than $1.9 billion, and private payers could save more than $9 billion, but those program providers don't get funded. That is why the HELP Committee bill establishes a prevention and public health investment fund to provide expanded and sustained nationwide investment in preventing illness. Well run, the savings could be enormous. But CBO can't score it because we haven't been down this road before, and there is nothing in the rearview mirror for CBO professionals to work with.

A third area for significant efficiencies and savings is the contentious, inefficient billing and approval process.

Right now, doctors and insurance companies are locked in an arms race. Private insurers delay claims and deny claims for reimbursement and throw up barriers to payment, and the providers, in turn, staff up and hire consultants and add people to fight back. This battle creates a colossal burden on the system, consuming perhaps 10 to 15 percent of all private insurance expenditure and then creating a reciprocal and probably actually greater cost shadow out in the provider community from having to fight back against that 10- to 15-percent expenditure. It all adds no overall health care value--none. It is pure administrative cost shifting. Even the insurance industry estimates that $30 billion per year could be saved through simplification of that process. That is why the HELP Committee bill has strong administrative simplification requirements. But again, CBO can't score it because this is another new road. Again, there is nothing in the rearview mirror for CBO to work with.

Finally, multiple studies show that the private insurance market is plagued by inefficiency and waste. While administrative costs for Medicare run about 3 to 5 percent, overhead for private insurers is an astounding 20 to 27 percent--charges that consumers pay for higher premiums. A Commonwealth Fund report indicates that private insurer administrative costs increased 109 percent--they more than doubled-- private insurer administrative costs more than doubled from 2000 to 2006, just in 6 years. The McKinsey Global Institute and a leading health economist indicate that Americans spend roughly $128 billion annually on ``excess administrative overhead''--that is, $128 billion on excess administrative overhead--in the private health insurance market.

That is why the HELP Committee bill establishes a strong nonprofit public health insurance option that would compete on even terms with private insurance companies, bringing down premiums, negotiating more efficient provider payments, and increasing consumer access--all through the power of free market competition. All this is done through the power of free market competition. But, again, CBO cannot score it because we have not been down that road before. There is, again, nothing in the rearview mirror for CBO professionals to work with.

In the 1930s, Franklin Delano Roosevelt's proposal for an innovative program called the Tennessee Valley Authority faced this dour prediction from a Member of the House of Representatives:

Mr. Speaker, I think I can accurately predict no one in

this generation will see materialize the industrial empire

dream of the Tennessee Valley.

Another Member remarked:

The development of power in that particular locality of the

Nation . . . can be of no general good.''

Had FDR been cowed and discouraged by such pessimism, by the difficulty and uncertainty and novelty of his task, the TVA would never have brought electricity, jobs, and prosperity to millions of Americans.

Likewise, today, it is precisely because our reforms are innovative and because they will take energy, commitment, and leadership to achieve that they are unscorable. That should be an inspiration to us, not a discouragement. Through this reform bill, we must challenge ourselves and the Obama administration to do that which economists and commentators cannot specifically score and analyze. With strong leadership and dedication, we can not only bend the cost curve, we can break it.

Let's set a hard target, say, $500 billion in annual savings, and see how fast we can get there. Let's make this the Apollo project of our generation. The stakes are high enough to justify that effort.

I thank the Chair and yield the floor.

Sen. John BarrassoR-WY · Jul 7, 2009

Madam President, I ask unanimous consent to speak for up to 10 minutes in morning business and that Senator Sessions be recognized when I have finished. Madam President, most everybody knows I am an…

Madam President, I ask unanimous consent to speak for up to 10 minutes in morning business and that Senator Sessions be recognized when I have finished.

Madam President, most everybody knows I am an orthopedic surgeon. In Wyoming, many refer to me as ``Wyoming's doctor.'' That is because for over two decades folks have invited me into their home with statewide television and radio health reports, where I gave people information on how they can stay healthy and how to keep down the cost of their medical care. I ended each report by saying: ``Here in Wyoming, I'm Dr. John Barrasso, helping you care for yourself.''

That is also my philosophy for government--helping people help themselves. As medical director of the Wyoming Health Fairs, I worked to give people around the Cowboy State access to lifesaving preventive tests and low-cost medical screenings.

My goal was always to encourage families to eat right, exercise, manage chronic diseases, and stop smoking because prevention is one of the keys to a long and happy and healthy life.

As I travel home every weekend, I hear the concerns people have about health care and the cost of their medical care. They are concerned about the specific cost of their medical care and how it affects them and their family budgets. Many families across Wyoming and in this country worry that they will lose the health care coverage they currently have. Others cannot afford insurance today. That is what is wrong with our current health care system. That is what we need to fix.

I know from firsthand experience that doing nothing is simply not an option. We must be careful, thoughtful, and deliberate about the changes we make. Health care is a very complex and an intensely personal issue. It deserves a national debate--a serious, open, and transparent national debate.

I welcome the opportunity to talk about the concerns of people living longer and needing more care and more advanced care. The concerns are affordable care, access to care, and high-quality care.

In the midst of this debate, we cannot stand for rural Americans to be left behind. They need access to high-quality, affordable health care like everybody else.

When I first came to the Senate, I promised the people of Wyoming I would fight each and every day to protect and modernize our rural health care delivery system. I committed to do my part to strengthen our rural hospitals, rural health clinics, and community health centers. I committed to do my part to increase rural America's access to primary health care services and to aid in the successful recruitment and retention of nurses, nurse practitioners, doctors, and physician assistants all across rural and frontier America.

There are obstacles faced by our hospitals, clinics, and our providers--obstacles they have to overcome to deliver quality care to all the families in rural America. They end up having to do it in an environment of markedly limited resources. The Federal Government needs to recognize these important differences and then respond with appropriate policy.

The people of Wyoming know I am here not just as their Senator but also as a rural doctor who has practiced medicine, fighting on their behalf.

Recently, I joined three of my colleagues to introduce S. 1157, the Craig Thomas Rural Hospital and Provider Equity Act.

Today, I rise to talk about a different bill that I have introduced alongside my colleague from Oregon, Senator Ron Wyden. It is called the Rural Health Clinic Patient Access and Improvement Act.

This legislation is a great example of what true bipartisanship can produce. I thank Senator Wyden and his staff for working so hard to collaborate with me on this very important bill. I commend him for his dedication to helping rural Americans have equal access to the high- quality medical care they deserve.

This legislation strengthens America's 3,500 rural health clinics that serve rural and frontier communities.

Rural health clinics are a highly valued medical provider in communities all across this country. In Wyoming, we have rural health clinics located in communities that many people have never heard of, such as Baggs, Glenrock, Hulett, Lovell, Medicine Bow, Saratoga, and my wife Bobbie's hometown of Thermopolis. These clinics make sure people have access to primary care as close to home as possible. That is not easy to.

To give you a snapshot of Wyoming's health care landscape, we have only 26

hospitals and 18 rural health clinics spread over nearly 100,000 square miles, which is a remarkably large distance. With vast distances, complex medical cases, and increased demand for technologically advanced medical care, the rural health care system is certainly not one size fits all.

Let me explain what this Rural Health Clinic Patient Access and Improvement Act actually does.

First, the rural health clinics currently receive an all-inclusive payment rate that is capped at $76. That payment has not been adjusted--except for inflation--since 1988. We all know that medical inflation has gone up at a much greater rate than regular inflation.

This bill addresses this problem by raising the rural health clinic cap from $76 to $92. Rural health clinics are a key component of the rural health care delivery system, and we need to make sure there is fair pay for patients who are taken care of in those facilities.

We also need to give them enough flexibility to meet their community's health care needs.

Additionally, this measure would establish a new quality reporting program for rural health clinics.

Three years ago, Congress required the Centers for Medicare and Medicaid to create a physician quality reporting system. This program offers bonus payments to doctors who report quality measures on Medicare services.

The quality incentive program is linked to the Medicare physician fee schedule. Rural health clinics, though, are not paid using the physician fee schedule. If Congress wants to pay doctors based not on volume but on the quality of care, then it is important to remember that the one-size-fits-all approach will not work here.

That is why this bill ensures that a comparable quality incentive is available to rural health care providers.

Third, the Rural Health Clinic Patient Access and Improvement Act would create a provider retention demonstration project. It is a five- State project that will study the extent to which a medical professional can be encouraged and enticed to practice in an underserved rural and frontier area.

The States would be given grants to help physicians, physician assistants, nurse practitioners, and certified nurse midwives to help them pay a small portion of their medical liability costs.

I believe these incentives will help draw more providers--especially those who deliver babies--to work in an underserved area because their malpractice insurance is the same whether they deliver 1 baby or 100. In these small areas, there aren't that many babies being born each year, so the cost, while it is the same for malpractice insurance, has to be distributed over a fewer number of patients. This will encourage them to practice in underserved areas.

Wyoming has too few primary care providers for the population we must serve. My State is not alone. This bill that Senator Wyden and I have introduced reflects our commitment to ensure rural Americans have access to high-quality health care services.

I strongly encourage all my colleagues with an interest in rural health to cosponsor this bipartisan piece of legislation.

I yield the floor.

Bill Text

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Introduced in SenateIssued May 21, 2009

111th CONGRESS

1st Session

S. 1157

IN THE SENATE OF THE UNITED STATES

May 21, 2009

Mr. Conrad (for himself, Mr. Roberts, Mr. Harkin, and Mr. Barrasso) introduced the following bill; which was read twice and referred to the Committee on Finance

A BILL

To amend title XVIII of the Social Security Act to protect and preserve access of Medicare beneficiaries in rural areas to health care providers under the Medicare program, and for other purposes.

Short title; table of contents

(a)

Short title

This Act may be cited as the Craig Thomas Rural Hospital and Provider Equity Act of 2009.

(b)

Table of Contents

The table of contents of this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Fairness in the Medicare disproportionate share hospital (DSH) adjustment for rural hospitals.

Sec. 3. Revision of the Medicare hold harmless provision under the prospective payment system for hospital outpatient department (HOPD) services.

Sec. 4. Improvement of definition of low-volume hospital for purposes of the Medicare inpatient hospital payment adjustment and temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals.

Sec. 5. Extension of Medicare wage index reclassifications for certain hospitals.

Sec. 6. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas.

Sec. 7. Elimination of isolation test for cost-based ambulance reimbursement for critical access hospitals.

Sec. 8. Capital infrastructure revolving loan program.

Sec. 9. Extension of Medicare incentive payment program for physician scarcity areas.

Sec. 10. Extension of floor on Medicare work geographic adjustment.

Sec. 11. Permitting physician assistants to order post-hospital extended care services; permitting physician assistants when delegated by a physician to order hospice care; improving care planning for Medicare home health services.

Sec. 12. Rural health clinic improvements.

Sec. 13. Community health center collaborative access expansion.

Sec. 14. Application of the temporary Medicare payment increase for home health services furnished in a rural area to 2010.

Sec. 15. Extension of increased Medicare payments for rural ground ambulance services.

Sec. 16. Coverage of marriage and family therapist services and mental health counselor services under Part

B of the Medicare program.

Sec. 17. Extension of treatment of certain physician pathology services under Medicare.

Sec. 18. Medicare remote monitoring pilot projects.

Sec. 19. Facilitating the provision of telehealth services across State lines.

Sec. 20. Medicare Part A payment for anesthesiologist services in certain rural hospitals based on CRNA pass-through rules.

Sec. 21. Temporary floor on the practice expense geographic index for services furnished in rural areas under the Medicare physician fee schedule.

Sec. 22. Temporary floor on Medicare hospital area wage index for certain hospitals.

Sec. 23. Revisions to standard for designation of sole community hospitals.

Fairness in the Medicare disproportionate share hospital (DSH) adjustment for rural hospitals

Section 1886(d)(5)(F)(xiv)(II) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)(xiv)(II)) is amended—

(1)

by striking or, in the case and all that follows through subparagraph (G)(iv); and

(2)

by inserting at the end the following new sentence: The preceding sentence shall not apply to any hospital with respect to discharges occurring on or after October 1, 2010..

Revision of the Medicare hold harmless provision under the prospective payment system for hospital outpatient department (HOPD) services

Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended—

(1)

in subclause (II)—

(A)

by striking 2010 and inserting 2011;

(B)

by striking and 85 and inserting 85; and

(C)

in the second sentence, by inserting , and 100 percent with respect to such services furnished in 2010 before the period at the end; and

(2)

in subclause (III)—

(A)

by striking 2010 and inserting 2011;

(B)

by striking 85 percent and inserting the applicable percentage; and

(C)

by adding at the end the following new sentence: For purposes of the preceding sentence, the applicable percentage shall be 85 percent with respect to covered OPD services furnished in 2009 and 100 percent for such services furnished in 2010.

Improvement of definition of low-volume hospital for purposes of the Medicare inpatient hospital payment adjustment and temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals

(a)

Improvement of definition of low-volume hospital for purposes of the Medicare inpatient hospital payment adjustment

Section 1886(d)(12)(C)(i) of the Social Security Act (42 U.S.C. 1395ww(d)(12)(C)(i)) is amended by inserting (or, beginning with fiscal year 2010, 2,000 discharges) after 800 discharges.

(b)

Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals

Section 1886(d)(12) of the Social Security Act (42 U.S.C. 1395ww(d)(12)), as amended by subsection (a), is amended—

(1)

in subparagraph (A), by inserting or (D) after subparagraph (B);

(2)

in subparagraph (B), by striking The Secretary and inserting For discharges occurring in fiscal years 2005 through 2009 and for discharges occurring in fiscal year 2012 and subsequent fiscal years, the Secretary;

(3)

in subparagraph (C)(i), by inserting (or, with respect to fiscal years 2010 and 2011, 15 road miles) after 25 road miles; and

(4)

by adding at the end the following new subparagraph:

(D)

Temporary applicable percentage increase

For discharges occurring in fiscal years 2010 or 2011, the Secretary shall determine an applicable percentage increase for purposes of subparagraph (A) using a linear sliding scale ranging from 25 percent for low-volume hospitals with fewer than an appropriate number (as determined by the Secretary) of discharges of individuals entitled to, or enrolled for, benefits under part A in the fiscal year to 0 percent for low-volume hospitals with greater than 2,000 discharges of such individuals in the fiscal year.

Extension of Medicare wage index reclassifications for certain hospitals

(a)

Extension of correction of mid-year reclassification expiration for certain hospitals

(1)

In general

In the case of a hospital described in paragraph (2), effective September 30, 2009, the Secretary of Health and Human Services shall apply subsection (a) of section 106 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395ww note), as amended by section 124(a) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110–275) by substituting September 30, 2010 for September 30, 2009.

(2)

Hospital described

A hospital described in this paragraph is a hospital—

(A)

that is described in subsection (a) of such section 106; and

(B)

(i)

that is located in a rural area; and

(ii)

for which the Secretary of Health and Human Services has determined the extension under this subsection to be appropriate.

(b)

Additional Extension

The Secretary of Health and Human Services shall extend the special exception reclassification of a sole community hospital located in a State with less than 10 people per square mile (made under the authority of section 1886(d)(5)(I)(i) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(I)(i)) and contained in the final rule promulgated by the Secretary in the Federal Register on August 11, 2004 (69 Fed. Reg. 49107)) under section 117(a)(2) of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110–173), as amended by section 124(b) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110–275), through September 30, 2010.

(c)

Not budget neutral

The provisions of this section shall not be effected in a budget-neutral manner.

Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas

Section 416(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395l–4(b)), as amended by section 107 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110–173), is amended by inserting , or, beginning during the period beginning on July 1, 2010, and ending on June 30, 2011 after 2008.

Elimination of isolation test for cost-based ambulance reimbursement for critical access hospitals

(a)

In general

Section 1834(l)(8) of the Social Security Act (42 U.S.C. 1395m(l)(8)) is amended—

(1)

in subparagraph (B)—

(A)

by striking owned and; and

(B)

by inserting (including when such services are provided by the entity under an arrangement with the hospital) after hospital; and

(2)

by striking the comma at the end of subparagraph (B) and all that follows and inserting a period.

(b)

Effective date

The amendments made by this section shall apply to services furnished on or after January 1, 2010.

Capital infrastructure revolving loan program

(a)

In General

Part A of title XVI of the Public Health Service Act (42 U.S.C. 300q et seq.) is amended by adding at the end the following new section:

1603.

Capital infrastructure revolving loan program

(a)

Authority To Make and Guarantee Loans

(1)

Authority to make loans

The Secretary may make loans from the fund established under section 1602(d) to any rural entity for projects for capital improvements, including—

(A)

the acquisition of land necessary for the capital improvements;

(B)

the renovation or modernization of any building;

(C)

the acquisition or repair of fixed or major movable equipment; and

(D)

such other project expenses as the Secretary determines appropriate.

(2)

Authority to guarantee loans

(A)

In general

The Secretary may guarantee the payment of principal and interest for loans made to rural entities for projects for any capital improvement described in paragraph (1) to any non-Federal lender.

(B)

Interest subsidies

In the case of a guarantee of any loan made to a rural entity under subparagraph (A), the Secretary may pay to the holder of such loan, for and on behalf of the project for which the loan was made, amounts sufficient to reduce (by not more than 3 percent) the net effective interest rate otherwise payable on such loan.

(b)

Amount of Loan

The principal amount of a loan directly made or guaranteed under subsection (a) for a project for capital improvement may not exceed $5,000,000.

(c)

Funding Limitations

(1)

Government credit subsidy exposure

The total of the Government credit subsidy exposure under the Credit Reform Act of 1990 scoring protocol with respect to the loans outstanding at any time with respect to which guarantees have been issued, or which have been directly made, under subsection (a) may not exceed $50,000,000 per year.

(2)

Total amounts

Subject to paragraph (1), the total of the principal amount of all loans directly made or guaranteed under subsection (a) may not exceed $250,000,000 per year.

(d)

Capital Assessment and Planning Grants

(1)

Nonrepayable grants

Subject to paragraph (2), the Secretary may make a grant to a rural entity, in an amount not to exceed $50,000, for purposes of capital assessment and business planning.

(2)

Limitation

The cumulative total of grants awarded under this subsection may not exceed $2,500,000 per year.

(e)

Termination of Authority

The Secretary may not directly make or guarantee any loan under subsection (a) or make a grant under subsection (d) after September 30, 2013.

(b)

Rural Entity Defined

Section 1624 of the Public Health Service Act (42 U.S.C. 300s–3) is amended by adding at the end the following new paragraph:

(15)

(A)

The term rural entity includes—

(i)

a rural health clinic, as defined in section 1861(aa)(2) of the Social Security Act;

(ii)

any medical facility with at least 1 bed, but with less than 50 beds, that is located in—

(I)

a county that is not part of a metropolitan statistical area; or

(II)

a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725));

(iii)

a hospital that is classified as a rural, regional, or national referral center under section 1886(d)(5)(C) of the Social Security Act; and

(iv)

a hospital that is a sole community hospital (as defined in section 1886(d)(5)(D)(iii) of the Social Security Act).

(B)

For purposes of subparagraph (A), the fact that a clinic, facility, or hospital has been geographically reclassified under the Medicare program under title XVIII of the Social Security Act shall not preclude a hospital from being considered a rural entity under clause (i) or (ii) of subparagraph (A).

(c)

Conforming Amendments

Section 1602 of the Public Health Service Act (42 U.S.C. 300q–2) is amended—

(1)

in subsection (b)(2)(D), by inserting or 1603(a)(2)(B) after 1601(a)(2)(B); and

(2)

in subsection (d)—

(A)

in paragraph (1)(C), by striking section 1601(a)(2)(B) and inserting sections 1601(a)(2)(B) and 1603(a)(2)(B); and

(B)

in paragraph (2)(A), by inserting or 1603(a)(2)(B) after 1601(a)(2)(B).

Extension of Medicare incentive payment program for physician scarcity areas

Section 1833(u)(1) of the Social Security Act (42 U.S.C. 1395l(u)(1)) is amended by inserting , and such services furnished on or after January 1, 2010, and before July 1, 2011 after 2008.

10.

Extension of floor on Medicare work geographic adjustment

Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w–4(e)(1)(E)) is amended by striking before January 1, 2010 and inserting before January 1, 2011.

11.

Permitting physician assistants to order post-hospital extended care services; permitting physician assistants when delegated by a physician to order hospice care; improving care planning for Medicare home health services

(a)

Permitting physician assistants To order post-hospital extended care services and To provide for recognition of attending physician assistants as attending physicians To serve hospice patients

(1)

Ordering post-hospital extended care services

(A)

In general

Section 1814(a)(2) of the Social Security Act (42 U.S.C. 1395f(a)(2)), in the matter preceding subparagraph (A), is amended by striking nurse practitioner or clinical nurse specialist and inserting nurse practitioner, a clinical nurse specialist, or a physician assistant (as those terms are defined in section 1861(aa)(5)).

(B)

Conforming amendment

Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is amended, in the second sentence, by striking or clinical nurse specialist and inserting clinical nurse specialist, or physician assistant.

(2)

Recognition of attending physician assistants as attending physicians To serve hospice patients

(A)

In General

Section 1861(dd)(3)(B) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amended—

(i)

by striking or nurse and inserting , the nurse; and

(ii)

by inserting , or the physician assistant (as defined in such subsection) after subsection (aa)(5)).

(B)

Permitting physician assistants when delegated by a physician to order hospice care

Section 1814(a)(7)(A) of such Act (42 U.S.C. 1395f(a)(7)(A)) is amended—

(i)

in clause (i)(I), by inserting or a physician assistant as delegated by such attending physician after nurse practitioner); and

(ii)

in clause (ii), by inserting or physician assistant after physician.

(b)

Improving care planning for Medicare home health services

(1)

In general

Section 1814(a)(2) of the Social Security Act (42 U.S.C. 1395f(a)(2)), in the matter preceding subparagraph (A), is amended by inserting , or in the case of services described in subparagraph (C), a physician, or a nurse practitioner or clinical nurse specialist who is working in collaboration with a physician in accordance with State law, or a certified nurse-midwife (as defined in section 1861(gg)) as authorized by State law, or a physician assistant (as defined in section 1861(aa)(5)) under the supervision of a physician after collaboration with a physician.

(2)

Conforming amendments

(A)

Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)), as amended by subsection (a), is amended—

(i)

in paragraph (2)(C), by inserting , a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife, or a physician assistant (as the case may be) after physician each place it appears;

(ii)

in the second sentence, by striking clinical nurse specialist, or physician assistant and inserting clinical nurse specialist, certified nurse-midwife, or physician assistant;

(iii)

in the third sentence—

(I)

by striking physician certification and inserting certification;

(II)

by inserting (or on January 1, 2010, in the case of regulations to implement the amendments made by section 11 of the Craig Thomas Rural Hospital and Provider Equity Act of 2009) after 1981; and

(III)

by striking a physician who and inserting a physician, nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant who; and

(iv)

in the fourth sentence, by inserting , nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant after physician.

(B)

Section 1835(a) of the Social Security Act (42 U.S.C. 1395n(a)) is amended—

(i)

in paragraph (2)—

(I)

in the matter preceding subparagraph (A), by inserting or, in the case of services described in subparagraph (A), a physician, or a nurse practitioner or clinical nurse specialist (as those terms are defined in 1861(aa)(5)) who is working in collaboration with a physician in accordance with State law, or a certified nurse-midwife (as defined in section 1861(gg)) as authorized by State law, or a physician assistant (as defined in section 1861(aa)(5)) under the supervision of a physician after a physician; and

(II)

in each of clauses (ii) and (iii) of subparagraph (A) by inserting , a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife, or a physician assistant (as the case may be) after physician;

(ii)

in the third sentence, by inserting , nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant (as the case may be) after physician;

(iii)

in the fourth sentence—

(I)

by striking physician certification and inserting certification;

(II)

by inserting (or on January 1, 2010, in the case of regulations to implement the amendments made by section 11 of the Craig Thomas Rural Hospital and Provider Equity Act of 2009) after 1981; and

(III)

by striking a physician who and inserting a physician, nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant who; and

(iv)

in the fifth sentence, by inserting , nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant after physician.

(C)

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended—

(i)

in subsection (m)—

(I)

in the matter preceding paragraph (1)—

(aa)

by inserting a nurse practitioner or a clinical nurse specialist (as those terms are defined in subsection (aa)(5)), a certified nurse-midwife (as defined in section 1861(gg)), or a physician assistant (as defined in subsection (aa)(5)) after physician the first place it appears; and

(bb)

by inserting a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife, or a physician assistant after physician the second place it appears; and

(II)

in paragraph (3), by inserting a nurse practitioner, a clinical nurse specialist, a certified nurse-midwife, or a physician assistant after physician; and

(ii)

in subsection (o)(2)—

(I)

by inserting , nurse practitioners or clinical nurse specialists (as those terms are defined in subsection (aa)(5)), certified nurse-midwives (as defined in section 1861(gg)), or physician assistants (as defined in subsection (aa)(5)) after physicians; and

(II)

by inserting , nurse practitioner, clinical nurse specialist, certified nurse-midwife, physician assistant, after physician.

(D)

Section 1895 of the Social Security Act (42 U.S.C. 1395fff) is amended—

(i)

in subsection (c)(1), by inserting , the nurse practitioner or clinical nurse specialist (as those terms are defined in section 1861(aa)(5)), the certified nurse-midwife (as defined in section 1861(gg)), or the physician assistant (as defined in section 1861(aa)(5)), after physician; and

(ii)

in subsection (e)—

(I)

in paragraph (1)(A), by inserting , a nurse practitioner or clinical nurse specialist (as those terms are defined in section 1861(aa)(5)), a certified nurse-midwife (as defined in section 1861(gg)), or a physician assistant (as defined in section 1861(aa)(5)) after physician; and

(II)

in paragraph (2)—

(aa)

in the heading, by striking Physician certification and inserting Rule of construction regarding requirement for certification; and

(bb)

by striking physician.

(c)

Effective Date

The amendments made by this section shall apply to items and services furnished on or after January 1, 2010.

12.

Rural health clinic improvements

Section 1833(f) of the Social Security Act (42 U.S.C. 1395l(f)) is amended—

(1)

in paragraph (1), by striking , and at the end and inserting a semicolon;

(2)

in paragraph (2)—

(A)

by inserting (before 2010) after in a subsequent year; and

(B)

by striking the period at the end and inserting a semicolon; and

(3)

by adding at the end the following new paragraphs:

(3)

in 2010, at $92 per visit; and

(4)

in a subsequent year, at the limit established under this subsection for the previous year increased by the percentage increase in the MEI (as so defined) applicable to primary care services (as so defined) furnished as of the first day of that year.

13.

Community health center collaborative access expansion

Section 330 of the Public Health Service Act (42 U.S.C. 254b) is amended by adding at the end the following:

(s)

Miscellaneous Provisions

(1)

Rule of construction with respect to rural health clinics

(A)

In general

Nothing in this section shall be construed to prevent a community health center from contracting with a federally certified rural health clinic (as defined by section 1861(aa)(2) of the Social Security Act) for the delivery of primary health care services that are available at the rural health clinic to individuals who would otherwise be eligible for free or reduced cost care if that individual were able to obtain that care at the community health center. Such services may be limited in scope to those primary health care services available in that rural health clinic.

(B)

Assurances

In order for a rural health clinic to receive funds under this section through a contract with a community health center under paragraph (1), such rural health clinic shall establish policies to ensure—

(i)

nondiscrimination based upon the ability of a patient to pay; and

(ii)

the establishment of a sliding fee scale for low-income patients.

14.

Application of the temporary Medicare payment increase for home health services furnished in a rural area to 2010

Section 421 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395fff note), as amended by section 5201(b) of the Deficit Reduction Act of 2005 (42 U.S.C. 1395fff note), is amended—

(1)

in the section heading, by striking One-year and inserting Temporary; and

(2)

in subsection (a), by inserting and episodes and visits ending on or after January 1, 2010, and before January 1, 2011, after January 1, 2007,.

15.

Extension of increased Medicare payments for rural ground ambulance services

Section 1834(l)(13) of the Social Security Act (42 U.S.C. 1395m(l)(13)) is amended—

(1)

in subparagraph (A), in the heading, by striking In general and inserting For the second half of 2004 and for 2005, 2006, the second half of 2008, and 2009;

(2)

by redesignating subparagraph (B) as subparagraph (C);

(3)

by inserting the following after subparagraph (A):

(B)

For 2010 and 2011 for rural areas

After computing the rates with respect to ground ambulance services under the other applicable provisions of this subsection, in the case of such services furnished on or after January 1, 2010, and before January 1, 2012, for which the transportation originates in a rural area described in paragraph (9) or in a rural census tract described in such paragraph, the fee schedule established under this section shall provide that the rate for the service otherwise established, after application of any increase under paragraphs (11) and (12), shall be increased by 5 percent.

; and

(4)

in subparagraph (C), as redesignated by paragraph (2)—

(A)

in the heading, by striking Application of increased payments after applicable period and inserting No effect on subsequent periods; and

(B)

by adding at the end the following new sentence: The increased payments under subparagraph (B) shall not be taken into account in calculating payments for services furnished after the period specified in such subparagraph..

16.

Coverage of marriage and family therapist services and mental health counselor services under Part B of the Medicare program

(a)

Coverage of Services

(1)

In general

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—

(A)

in subparagraph (DD), by striking and after the semicolon at the end;

(B)

in subparagraph (EE), by inserting and after the semicolon at the end; and

(C)

by adding at the end the following new subparagraph:

(FF)

marriage and family therapist services (as defined in subsection (hhh)(1)) and mental health counselor services (as defined in subsection (hhh)(3));

(2)

Definitions

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

(hhh)

Marriage and Family Therapist Services; Marriage and Family Therapist; Mental Health Counselor Services; Mental Health Counselor

(1)

The term marriage and family therapist services means services performed by a marriage and family therapist (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses, which the marriage and family therapist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as an incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.

(2)

The term marriage and family therapist means an individual who—

(A)

possesses a master’s or doctoral degree which qualifies for licensure or certification as a marriage and family therapist pursuant to State law;

(B)

after obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; and

(C)

in the case of an individual performing services in a State that provides for licensure or certification of marriage and family therapists, is licensed or certified as a marriage and family therapist in such State.

(3)

The term mental health counselor services means services performed by a mental health counselor (as defined in paragraph (4)) for the diagnosis and treatment of mental illnesses which the mental health counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services.

(4)

The term mental health counselor means an individual who—

(A)

possesses a master’s or doctor’s degree in mental health counseling or a related field;

(B)

after obtaining such a degree has performed at least 2 years of supervised mental health counselor practice; and

(C)

in the case of an individual performing services in a State that provides for licensure or certification of mental health counselors or professional counselors, is licensed or certified as a mental health counselor or professional counselor in such State.

(3)

Provision for payment under part b

Section 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 1395k(a)(2)(B)) is amended by adding at the end the following new clause:

(v)

marriage and family therapist services (as defined in section 1861(hhh)(1)) and mental health counselor services (as defined in section 1861(hhh)(3));

(4)

Amount of payment

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—

(A)

by striking and (W) and inserting (W); and

(B)

by inserting before the semicolon at the end the following: , and (X) with respect to marriage and family therapist services and mental health counselor services under section 1861(s)(2)(BB), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist under subparagraph (L).

(5)

Exclusion of marriage and family therapist services and mental health counselor services from skilled nursing facility prospective payment system

Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting marriage and family therapist services (as defined in section 1861(hhh)(1)), mental health counselor services (as defined in section 1861(hhh)(3)), after qualified psychologist services,.

(6)

Inclusion of marriage and family therapists and mental health counselors as practitioners for assignment of claims

Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clauses:

(vii)

A marriage and family therapist (as defined in section 1861(hhh)(2)).

(viii)

A mental health counselor (as defined in section 1861(hhh)(4)).

(b)

Coverage of Certain Mental Health Services Provided in Certain Settings

(1)

Rural health clinics and federally qualified health centers

Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by striking or by a clinical social worker (as defined in subsection (hh)(1)) and inserting , by a clinical social worker (as defined in subsection (hh)(1)), by a marriage and family therapist (as defined in subsection (hhh)(2)), or by a mental health counselor (as defined in subsection (hhh)(4)).

(2)

Hospice programs

Section 1861(dd)(2)(B)(i)(III) of the Social Security Act (42 U.S.C. 1395x(dd)(2)(B)(i)(III)) is amended by inserting , marriage and family therapist, or mental health counselor after social worker.

(c)

Authorization of marriage and family therapists and mental health counselors To develop discharge plans for post-hospital services

Section 1861(ee)(2)(G) of the Social Security Act (42 U.S.C. 1395x(ee)(2)(G)) is amended by inserting , including a marriage and family therapist and a mental health counselor who meets qualification standards established by the Secretary before the period at the end.

(d)

Effective Date

The amendments made by this section shall apply with respect to services furnished on or after January 1, 2010.

17.

Extension of treatment of certain physician pathology services under Medicare

Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as enacted into law by section 1(a)(6) of Public Law 106–554), as amended by section 732 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w–4 note), section 104 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395w–4 note), section 104 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110–173), and section 136 of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110–275), is amended by striking and 2009 and inserting 2009, and 2010.

18.

Medicare remote monitoring pilot projects

(a)

Pilot projects

(1)

In general

Not later than 9 months after the date of enactment of this Act, the Secretary of Health and Human Services (in this section referred to as the Secretary) shall conduct pilot projects under title XVIII of the Social Security Act for the purpose of providing incentives to home health agencies to utilize home monitoring and communications technologies that—

(A)

enhance health outcomes for Medicare beneficiaries; and

(B)

reduce expenditures under such title.

(2)

Site requirements

(A)

Urban and Rural

The Secretary shall conduct the pilot projects under this section in both urban and rural areas.

(B)

Site in a small state

The Secretary shall conduct at least 3 of the pilot projects in a State with a population of less than 1,000,000.

(3)

Definition of home health agency

In this section, the term home health agency has the meaning given that term in section 1861(o) of the Social Security Act (42 U.S.C. 1395x(o)).

(b)

Medicare beneficiaries within the scope of projects

The Secretary shall specify the criteria for identifying those Medicare beneficiaries who shall be considered within the scope of the pilot projects under this section for purposes of the application of subsection (c) and for the assessment of the effectiveness of the home health agency in achieving the objectives of this section. Such criteria may provide for the inclusion in the projects of Medicare beneficiaries who begin receiving home health services under title XVIII of the Social Security Act after the date of the implementation of the projects.

(c)

Incentives

(1)

Performance targets

The Secretary shall establish for each home health agency participating in a pilot project under this section a performance target using one of the following methodologies, as determined appropriate by the Secretary:

(A)

Adjusted historical performance target

The Secretary shall establish for the agency—

(i)

a base expenditure amount equal to the average total payments made to the agency under parts A and B of title XVIII of the Social Security Act for Medicare beneficiaries determined to be within the scope of the pilot project in a base period determined by the Secretary; and

(ii)

an annual per capita expenditure target for such beneficiaries, reflecting the base expenditure amount adjusted for risk and adjusted growth rates.

(B)

Comparative performance target

The Secretary shall establish for the agency a comparative performance target equal to the average total payments under such parts A and B during the pilot project for comparable individuals in the same geographic area that are not determined to be within the scope of the pilot project.

(2)

Incentive

Subject to paragraph (3), the Secretary shall pay to each participating home care agency an incentive payment for each year under the pilot project equal to a portion of the Medicare savings realized for such year relative to the performance target under paragraph (1).

(3)

Limitation on expenditures

The Secretary shall limit incentive payments under this section in order to ensure that the aggregate expenditures under title XVIII of the Social Security Act (including incentive payments under this subsection) do not exceed the amount that the Secretary estimates would have been expended if the pilot projects under this section had not been implemented.

(d)

Waiver authority

The Secretary may waive such provisions of titles XI and XVIII of the Social Security Act as the Secretary determines to be appropriate for the conduct of the pilot projects under this section.

(e)

Report to Congress

Not later than 5 years after the date that the first pilot project under this section is implemented, the Secretary shall submit to Congress a report on the pilot projects. Such report shall contain a detailed description of issues related to the expansion of the projects under subsection (f) and recommendations for such legislation and administrative actions as the Secretary considers appropriate.

(f)

Expansion

If the Secretary determines that any of the pilot projects under this section enhance health outcomes for Medicare beneficiaries and reduce expenditures under title XVIII of the Social Security Act, the Secretary may initiate comparable projects in additional areas.

(g)

Incentive payments have no effect on other Medicare payments to agencies

An incentive payment under this section—

(1)

shall be in addition to the payments that a home health agency would otherwise receive under title XVIII of the Social Security Act for the provision of home health services; and

(2)

shall have no effect on the amount of such payments.

19.

Facilitating the provision of telehealth services across State lines

(a)

In general

For purposes of expediting the provision of telehealth services, for which payment is made under the Medicare program, across State lines, the Secretary of Health and Human Services shall, in consultation with representatives of States, physicians, health care practitioners, and patient advocates, encourage and facilitate the adoption of provisions allowing for multistate practitioner practice across State lines.

(b)

Definitions

In subsection (a):

(1)

Telehealth service

The term telehealth service has the meaning given that term in subparagraph (F) of section 1834(m)(4) of the Social Security Act (42 U.S.C. 1395m(m)(4)).

(2)

Physician, practitioner

The terms physician and practitioner have the meaning given those terms in subparagraphs (D) and (E), respectively, of such section.

(3)

Medicare program

The term Medicare program means the program of health insurance administered by the Secretary of Health and Human Services under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).

20.

Medicare Part A payment for anesthesiologist services in certain rural hospitals based on CRNA pass-through rules

(a)

In general

Section 1814 of the Social Security Act (42 U.S.C. 1395f) is amended by adding at the end the following new subsection:

(m)

Anesthesiologist services provided in certain rural hospitals

(1)

Notwithstanding any other provision of this title, coverage and payment shall be provided under this part for physicians' services that are anesthesia services furnished by a physician who is an anesthesiologist in a rural hospital described in paragraph (3) in the same manner as payment is made under the exception provided in section 9320(k) of the Omnibus Budget Reconciliation Act of 1986, as added by section 608(c)(2) of the Family Support Act of 1988 and amended by section 6132 of the Omnibus Budget Reconciliation Act of 1989, (relating to payment on a reasonable cost, pass-through basis) for certified registered nurse anesthetist services furnished by a certified registered nurse anesthetist in a hospital described in such section 9320(k).

(2)

No payment shall be made under any other provision of this title for physicians' services for which payment is made under this subsection.

(3)

A rural hospital described in this paragraph is a hospital described in section 9320(k) of the Omnibus Budget Reconciliation Act of 1986, as so added and amended, except that—

(A)

any reference in such section to a certified registered nurse anesthetist or an anesthetist is deemed a reference to a physician who is an anesthesiologist or an anesthesiologist, respectively; and

(B)

any reference to January 1, 1988 or 1987 is deemed a reference to such date and year as the Secretary shall specify.

(b)

Effective date

The amendment made by subsection (a) shall apply to services furnished during cost reporting periods beginning on or after the date of the enactment of this Act.

21.

Temporary floor on the practice expense geographic index for services furnished in rural areas under the Medicare physician fee schedule

Section 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w–4(e)(1)) is amended by adding at the end the following new subparagraph:

(H)

Floor at 1.0 on practice expense geographic index for services furnished in rural areas

After calculating the practice expense geographic index in subparagraph (A)(i), for purposes of payment for services furnished in a rural area on or after January 1, 2010, and before January 1, 2012, the Secretary shall increase the practice expense geographic index to 1.0 for any locality for which such practice expense geographic index is less than 1.0.

22.

Temporary floor on Medicare hospital area wage index for certain hospitals

Section 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395ww(d)(3)(E) is amended—

(1)

in clause (i), by striking clause (ii) and inserting clauses (ii) and (iii); and

(2)

by adding at the end the following new clause:

(iii)

Temporary floor for certain hospitals

After establishing the factors under the first sentence of clause (i), for purposes of payment for discharges occurring on or after January 1, 2010, and before January 1, 2012, the Secretary shall increase the factor to 1.0 for hospitals located in a State with less than 10 people per square mile for which such factor is less than 1.0. The Secretary shall apply the fourth sentence of clause (i) as if this clause had not been enacted.

23.

Revisions to standard for designation of sole community hospitals

Section 1886(d)(5)(D)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(D)(iv)) is amended by adding at the end the following new sentence: Under such standard, the time required for an individual to travel to the nearest alternative source of care shall be measured over improved roads maintained by a local, State, or Federal Government entity for use by the general public which is the most expeditious and accessible route as designated by law enforcement for emergency vehicle travel..