S 318 ISCommentsClose CommentsPermalink

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.CommentsClose CommentsPermalink

January 26, 2009CommentsClose CommentsPermalink

Mr. GRASSLEY introduced the following bill; which was read twice and referred to the Committee on FinanceCommentsClose CommentsPermalink

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.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,CommentsClose CommentsPermalink

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title- This Act may be cited as the ‘Medicare Rural Health Access Improvement Act of 2009’.CommentsClose CommentsPermalink





(b) Table of Contents- The table of contents of this Act is as follows:CommentsClose CommentsPermalink





Sec. 1. Short title; table of contents.CommentsClose CommentsPermalink

TITLE I--PROVISIONS RELATING TO MEDICARE PART A

Sec. 101. Extension of Medicare FLEX grants.CommentsClose CommentsPermalink





Sec. 102. Improvements to the medicare-dependent hospital (MDH) program.CommentsClose CommentsPermalink





Sec. 103. Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals.CommentsClose CommentsPermalink





Sec. 104. Temporary elimination of the DSH adjustment cap.CommentsClose CommentsPermalink

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.CommentsClose CommentsPermalink





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.CommentsClose CommentsPermalink





Sec. 203. Recognition of equality of physician work in all geographic areas under the Medicare physician fee schedule.CommentsClose CommentsPermalink





Sec. 204. Revisions to the practice expense geographic adjustment under the Medicare physician fee schedule.CommentsClose CommentsPermalink





Sec. 205. Extension of treatment of certain physician pathology services under Medicare.CommentsClose CommentsPermalink





Sec. 206. Extension of increased Medicare payments for rural ground ambulance services.CommentsClose CommentsPermalink





Sec. 207. Rural health clinic improvements.CommentsClose CommentsPermalink





Sec. 208. Exemption for suppliers in small MSAs and rural areas.CommentsClose CommentsPermalink





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.CommentsClose CommentsPermalink

TITLE I--PROVISIONS RELATING TO MEDICARE PART ACommentsClose CommentsPermalink

SEC. 101. 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’.CommentsClose CommentsPermalink

SEC. 102. IMPROVEMENTS TO THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM.

(a) 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:CommentsClose CommentsPermalink





‘(v) 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).’.CommentsClose CommentsPermalink





(b) 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’.CommentsClose CommentsPermalink

SEC. 103. 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--CommentsClose CommentsPermalink





(1) in subparagraph (A), by inserting ‘or (D)’ after ‘subparagraph (B)’;CommentsClose CommentsPermalink





(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’;CommentsClose CommentsPermalink





(3) in subparagraph (C)(i)--CommentsClose CommentsPermalink





(A) by inserting ‘(or, with respect to fiscal years 2010 and 2011, 15 road miles)’ after ‘25 road miles’; andCommentsClose CommentsPermalink





(B) 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’; andCommentsClose CommentsPermalink





(4) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(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.’.CommentsClose CommentsPermalink

SEC. 104. 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.’.CommentsClose CommentsPermalink

TITLE II--PROVISIONS RELATING TO MEDICARE PART BCommentsClose CommentsPermalink

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.

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





(1) in subclause (II), in the second sentence--CommentsClose CommentsPermalink





(A) by striking ‘and 85’ and inserting ‘85’; andCommentsClose CommentsPermalink





(B) by inserting the following before the period at the end: ‘, and 100 percent with respect to such services furnished in 2010’; andCommentsClose CommentsPermalink





(2) in subclause (III)--CommentsClose CommentsPermalink





(A) by striking ‘2010’ and inserting ‘2011’; andCommentsClose CommentsPermalink





(B) by striking ‘85 percent’ and inserting ‘the applicable percentage (as determined under the second sentence of subclause (II) for the year)’.CommentsClose CommentsPermalink

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.

Section 1833(t)(13) of the Social Security Act (42 U.S.C. 1395l(t)(13)) is amended--CommentsClose CommentsPermalink





(1) in the heading, by striking ‘AUTHORIZATION OF ADJUSTMENT’ and inserting ‘ADJUSTMENT’;CommentsClose CommentsPermalink





(2) in subparagraph (B)--CommentsClose CommentsPermalink





(A) in the heading, by inserting ‘FOR 2006 THROUGH 2009’ after ‘ADJUSTMENT’; andCommentsClose CommentsPermalink





(B) by adding at the end the following new sentence: ‘Such authority shall apply with respect to services furnished in 2006, 2007, 2008, or 2009.’; andCommentsClose CommentsPermalink





(3) by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(C) ADJUSTMENT FOR 2010 AND SUBSEQUENT YEARS FOR CERTAIN RURAL HOSPITALS-CommentsClose CommentsPermalink





‘(i) ADJUSTMENT-CommentsClose CommentsPermalink





‘(I) 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.CommentsClose CommentsPermalink





‘(II) 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.CommentsClose CommentsPermalink





‘(ii) 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).CommentsClose CommentsPermalink





‘(iii) EXEMPTION FROM BUDGET NEUTRALITY- The provisions of this subparagraph shall not be effected in a budget-neutral manner under this subsection.’.CommentsClose CommentsPermalink

SEC. 203. 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--CommentsClose CommentsPermalink





(1) 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’; andCommentsClose CommentsPermalink





(2) by inserting after subparagraph (E) the following new subparagraph:CommentsClose CommentsPermalink





‘(F) 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.’.CommentsClose CommentsPermalink

SEC. 204. REVISIONS TO THE PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.

(a) 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:CommentsClose CommentsPermalink





‘(H) 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.’.CommentsClose CommentsPermalink





(b) 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:CommentsClose CommentsPermalink





‘(I) MORE APPROPRIATE RECOGNITION OF DIFFERENCES IN EMPLOYEE WAGES AND OFFICE RENTS AMONG AREAS-CommentsClose CommentsPermalink





‘(i) 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.CommentsClose CommentsPermalink





‘(ii) LIMITATIONS ON AVAILABLE DATA- The limitations on available data described in this clause are the following:CommentsClose CommentsPermalink





‘(I) The need to use proxy data to reflect differences in employee wages and rents among areas.CommentsClose CommentsPermalink





‘(II) Wages for some categories of employees being determined in national markets.CommentsClose CommentsPermalink





‘(III) Physicians having to compete for some employees in market areas that cross fee schedule areas.CommentsClose CommentsPermalink





‘(IV) Physicians in rural areas frequently having to locate their offices close to urban areas and competing with urban rent markets.’.CommentsClose CommentsPermalink

SEC. 205. 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’.CommentsClose CommentsPermalink

SEC. 206. 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--CommentsClose CommentsPermalink





(1) in the matter preceding clause (i)--CommentsClose CommentsPermalink





(A) by striking ‘2007, and for’ and inserting ‘2007, for’; andCommentsClose CommentsPermalink





(B) by inserting ‘, and for such services described in clause (i) furnished on or after January 1, 2010, and before January 1, 2011’ after ‘2010’; andCommentsClose CommentsPermalink





(2) 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’.CommentsClose CommentsPermalink

SEC. 207. RURAL HEALTH CLINIC IMPROVEMENTS.

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





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





(2) in paragraph (2)--CommentsClose CommentsPermalink





(A) by inserting ‘(before 2010)’ after ‘in a subsequent year’; andCommentsClose CommentsPermalink





(B) by striking the period at the end and inserting a semicolon; andCommentsClose CommentsPermalink





(3) by adding at the end the following new paragraphs:CommentsClose CommentsPermalink





‘(3) in 2010, at $92 per visit; andCommentsClose CommentsPermalink





‘(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) furnished as of the first day of that year.’.CommentsClose CommentsPermalink

SEC. 208. EXEMPTION FOR SUPPLIERS IN SMALL MSAS AND RURAL AREAS.

(a) Exemption- Section 1847(a)(3) of the Social Security Act (42 U.S.C. 1395w-3(a)(3)) is amended--CommentsClose CommentsPermalink





(1) in the matter preceding subparagraph (A), by striking ‘may’ and inserting ‘shall’; andCommentsClose CommentsPermalink





(2) by striking subparagraph (A) and inserting the following:CommentsClose CommentsPermalink





‘(A) rural areas and small metropolitan statistical areas with a population of 600,000 or less; and’.CommentsClose CommentsPermalink





(b) 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’.CommentsClose CommentsPermalink





(c) 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).CommentsClose CommentsPermalink

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.

(a) Ordering Post-Hospital Extended Care Services-CommentsClose CommentsPermalink





(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 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))’.CommentsClose CommentsPermalink





(2) 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’.CommentsClose CommentsPermalink





(b) Recognition of Attending Physician Assistants as Attending Physicians To Serve Hospice Patients-CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1861(dd)(3)(B) of the Social Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amended--CommentsClose CommentsPermalink





(A) by striking ‘or nurse’ and inserting ‘, the nurse’; andCommentsClose CommentsPermalink





(B) by inserting ‘, or the physician assistant (as defined in such subsection)’ after ‘subsection (aa)(5))’.CommentsClose CommentsPermalink





(2) 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’.CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2010.CommentsClose CommentsPermalink