II
111th CONGRESS
1st Session
S. 318
IN THE SENATE OF THE UNITED STATES
January 26, 2009
Mr. Grassley 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 improve access to health care under the Medicare program for beneficiaries residing in rural areas.
Short title; table of contents
Short title
This Act may be cited
as the Medicare Rural Health Access
Improvement Act of 2009
.
Table of contents
The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I—Provisions relating to Medicare part A
Sec. 101. Extension of Medicare FLEX grants.
Sec. 102. Improvements to the medicare-dependent hospital (MDH) program.
Sec. 103. Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals.
Sec. 104. Temporary elimination of the DSH adjustment cap.
TITLE II—Provisions relating to Medicare part B
Sec. 201. Extension and expansion of the Medicare hold harmless provision under the prospective payment system for hospital outpatient department (HOPD) services for certain hospitals.
Sec. 202. Treatment of rural sole community hospitals and medicare dependent, small rural hospitals under the prospective payment system for hospital outpatient department (HOPD) services.
Sec. 203. Recognition of equality of physician work in all geographic areas under the Medicare physician fee schedule.
Sec. 204. Revisions to the practice expense geographic adjustment under the Medicare physician fee schedule.
Sec. 205. Extension of treatment of certain physician pathology services under Medicare.
Sec. 206. Extension of increased Medicare payments for rural ground ambulance services.
Sec. 207. Rural health clinic improvements.
Sec. 208. Exemption for suppliers in small MSAs and rural areas.
Sec. 209. 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.
Provisions relating to Medicare part A
Extension of Medicare FLEX grants
Section
1820(j) of the Social Security Act (42 U.S.C. 1395i–4(j)) is amended by
striking fiscal years 2009 and 2010
each place it appears and
inserting fiscal years 2009, 2010, and 2011
.
Improvements to the medicare-dependent hospital (MDH) program
Use of non-wage adjusted PPS rate
Section 1886(d)(5)(G) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended by adding at the end the following new clause:
In the case of discharges occurring on or after October 1, 2009, and before October 1, 2011, in determining the amount under paragraph (1)(A)(iii) for purposes of clauses (i) and (ii)(II), such amount shall, if it results in greater payments to the hospital, be determined without regard to any adjustment for different area wage levels under paragraph (3)(E).
.
Enhanced payment for amount by which the target exceeds the PPS rate
Section 1886(d)(5)(G)(ii)(II) of the Social Security Act (42
U.S.C. 1395ww(d)(5)(G)(ii)(II)) is amended by inserting , and before
October 1, 2009, or 85 percent in the case of discharges occurring on or after
October 1, 2009, and before October 1, 2011
after October 1,
2006
.
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)) is amended—
in subparagraph
(A), by inserting or (D)
after subparagraph
(B)
;
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
;
in subparagraph (C)(i)—
by inserting
(or, with respect to fiscal years 2010 and 2011, 15 road miles)
after 25 road miles
; and
by inserting (or, with respect to
fiscal years 2010 and 2011, 2,000 discharges of individuals entitled to, or
enrolled for, benefits under part A)
after 800
discharges
; and
by adding at the end the following new subparagraph:
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.
.
Temporary elimination of the DSH adjustment cap
Section 1886(d)(5)(F)(xiv)(II) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(F)(xiv)(II)) is amended by adding at the
end the following new sentence: The preceding sentence shall not apply
to any hospital in the case of discharges occurring on or after October 1,
2009, and before October 1, 2011.
.
Provisions relating to Medicare part B
Extension and expansion of the Medicare hold harmless provision under the prospective payment system for hospital outpatient department (HOPD) services for certain hospitals
Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended—
in subclause (II), in the second sentence—
by striking and 85
and
inserting 85
; and
by inserting the
following before the period at the end: , and 100 percent with respect
to such services furnished in 2010
; and
in subclause (III)—
by striking
2010
and inserting 2011
; and
by striking
85 percent
and inserting the applicable percentage (as
determined under the second sentence of subclause (II) for the
year)
.
Treatment of rural sole community hospitals and medicare dependent, small rural hospitals under the prospective payment system for hospital outpatient department (HOPD) services
Section 1833(t)(13) of the Social Security Act (42 U.S.C. 1395l(t)(13)) is amended—
in the heading, by striking
Authorization of
adjustment
and inserting Adjustment
;
in subparagraph (B)—
in the heading,
by inserting for 2006
through 2009
after adjustment
;
and
by adding at the
end the following new sentence: Such authority shall apply with respect
to services furnished in 2006, 2007, 2008, or 2009.
; and
by adding at the end the following new subparagraph:
Adjustment for 2010 and subsequent years for certain rural hospitals
Adjustment
In general
Subject to clause (ii), in the case of covered OPD services furnished on or after January 1, 2010, by a sole community hospital (as defined in subparagraph (D)(iii) of section 1886(d)(5)) located in a rural area or a medicare-dependent, small rural hospital (as defined in subparagraph (G)(iv) of such section, the amount of payment that would otherwise be made for such service under this subsection shall be increased by an amount equal to 7.1 percent of such amount. Such increase shall be applied before calculating outliers and coinsurance.
Revision with notice and comment
In the case of covered OPD services furnished on or after January 1, 2011, the Secretary may revise the percent described in subclause (I) through the promulgation of a regulation.
Not applicable to pass-through devices, drugs, and biologicals
The increase under clause (i) shall not apply to the payment for a device, drug, or biological described in clause (i), (ii), (iii), or (iv) of paragraph (6)(A).
Exemption from budget neutrality
The provisions of this subparagraph shall not be effected in a budget-neutral manner under this subsection.
.
Recognition of equality of physician work in all geographic 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—
in subparagraph
(A), in the matter preceding clause (i), by striking subparagraphs
(B)
through the Secretary
and inserting the
succeeding provisions of this paragraph, the Secretary
; and
by inserting after subparagraph (E) the following new subparagraph:
Recognition of equality of physician work in all geographic areas
In recognition of the fact that the physician work for a service is the same in all geographic areas, and should be similarly valued under this title, for services furnished on or after January 1, 2010, the geographic index for physician work under subparagraph (A)(iii) shall be 1.0 in all fee schedule areas.
.
Revisions to the practice expense geographic adjustment under the Medicare physician fee schedule
Establishment of floor
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:
Floor at 1.0 on practice expense geographic index
After calculating the practice expense geographic index in subparagraph (A)(i), for purposes of payment for services furnished on or after January 1, 2010, 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.
.
More appropriate recognition of practice expense differences in employee wages and office rents among geographic areas
Section 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w–4(e)(1)), as amended by subsection (a), is amended by adding at the end the following new subparagraph:
More appropriate recognition of differences in employee wages and office rents among areas
In general
In recognition of the limitations on available data (as described in clause (ii)) for use as the employee wage and office rent proxies in the practice expense geographic index described in subparagraph (A)(i), and in order to more appropriately reflect differences among different fee schedule areas, for services furnished on or after January 1, 2010, such practice expense geographic index shall be an index which reflects 1/2 of the difference between the relative costs of employee wages and rents in each of the different fee schedule areas and the national average of such employee wages and rents.
Limitations on available data
The limitations on available data described in this clause are the following:
The need to use proxy data to reflect differences in employee wages and rents among areas.
Wages for some categories of employees being determined in national markets.
Physicians having to compete for some employees in market areas that cross fee schedule areas.
Physicians in rural areas frequently having to locate their offices close to urban areas and competing with urban rent markets.
.
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
.
Extension of increased Medicare payments for rural ground ambulance services
Section 1834(l)(13)(A) of the Social Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended—
in the matter preceding clause (i)—
by striking
2007, and for
and inserting 2007, for
; and
by inserting
, and for such services described in clause (i) furnished on or after
January 1, 2010, and before January 1, 2011
after 2010
;
and
in clause (i), by
inserting , or 5 percent if such service is furnished on or after
January 1, 2010, and before January 1, 2011
after
2010
.
Rural health clinic improvements
Section 1833(f) of the Social Security Act (42 U.S.C. 1395l(f)) is amended—
in paragraph (1),
by striking , and
at the end and inserting a semicolon;
in paragraph (2)—
by inserting
(before 2010)
after in a subsequent year
;
and
by striking the period at the end and inserting a semicolon; and
by adding at the end the following new paragraphs:
in 2010, at $92 per visit; and
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) furnished as of the first day of that year.
.
Exemption for suppliers in small MSAs and rural areas
Exemption
Section 1847(a)(3) of the Social Security Act (42 U.S.C. 1395w–3(a)(3)) is amended—
in the matter
preceding subparagraph (A), by striking may
and inserting
shall
; and
by striking subparagraph (A) and inserting the following:
rural areas and small metropolitan statistical areas with a population of 600,000 or less; and
.
Inapplicability of competitively bid prices to rural and small MSAs
Section
1834(a)(1)(F)(ii) of the Social Security Act (42 U.S.C. 1395m(a)(1)(F)(ii)) is
amended by striking the Secretary
and inserting except in
the case of any area that is exempt from the programs under section 1847
pursuant to subsection (a)(3)(A) of such section, the Secretary
.
Effective date
The amendments made by this section shall take effect as if included in the enactment of section 302 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2223).
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
Ordering post-hospital extended care services
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))
.
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
.
Recognition of attending physician assistants as attending physicians To serve hospice patients
In General
Section 1861(dd)(3)(B) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amended—
by striking
or nurse
and inserting , the nurse
; and
by inserting
, or the physician assistant (as defined in such subsection)
after subsection (aa)(5))
.
Clarification of hospice role of physician assistants
Section
1814(a)(7)(A)(i)(I) of the Social Security Act (42 U.S.C. 1395f(a)(7)(A)(i)(I))
is amended by inserting or a physician assistant
after a
nurse practitioner
.
Effective date
The amendments made by this section shall apply to items and services furnished on or after January 1, 2010.