[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[S. 2987 Introduced in Senate (IS)]







106th CONGRESS
  2d Session
                                S. 2987

 To amend title XVIII of the Social Security Act to promote access to 
      health care services in rural areas, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             July 27, 2000

 Mr. Roberts (for himself, Mr. Grassley, Mr. Jeffords, Mr. Thomas, and 
  Mr. Conrad) 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 promote access to 
      health care services in rural areas, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Rural Health Care 
in the 21st Century Act of 2000''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
                        TITLE I--HIGH TECHNOLOGY

Sec. 101. High technology acquisition grant and loan program.
Sec. 102. Refinement of medicare reimbursement for telehealth services.
Sec. 103. Extension of telemedicine demonstration projects.
  TITLE II--IMPROVEMENTS IN THE DISPROPORTIONATE SHARE HOSPITAL (DSH) 
                                PROGRAM

Sec. 201. Disproportionate share hospital adjustment for rural 
                            hospitals.
 TITLE III--IMPROVEMENTS IN THE CRITICAL ACCESS HOSPITAL (CAH) PROGRAM

Sec. 301. Treatment of swing-bed services furnished by critical access 
                            hospitals.
Sec. 302. Treatment of ambulance services furnished by certain critical 
                            access hospitals.
Sec. 303. Treatment of home health services furnished by certain 
                            critical access hospitals.
Sec. 304. Designation of a single fiscal intermediary for all critical 
                            access hospitals.
Sec. 305. Establishment of an all-inclusive payment option for 
                            outpatient critical access hospital 
                            services.
       TITLE IV--OUTPATIENT SERVICES FURNISHED BY RURAL PROVIDERS

Sec. 401. Permanent guarantee of pre-BBA payment levels for outpatient 
                            services furnished by rural hospitals.
Sec. 402. Provider-based rural health clinic cap exemption.
Sec. 403. Payment for certain physician assistant services.
Sec. 404. Exclusion of rural health clinic services from the PPS for 
                            skilled nursing facilities.
Sec. 405. Bonus payments for rural home health agencies.
                           TITLE V--BAD DEBT

Sec. 501. Restoration of full payment for bad debts of qualified 
                            medicare beneficiaries.
      TITLE VI--NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM

Sec. 601. Exclusion of certain amounts received under the National 
                            Health Service Corps scholarship program.
 TITLE VII--TECHNICAL CORRECTIONS TO BALANCED BUDGET REFINEMENT ACT OF 
                                  1999

Sec. 701. Extension of option to use rebased target amounts to all sole 
                            community hospitals.
Sec. 702. Payments to critical access hospitals for clinical diagnostic 
                            laboratory tests.

                        TITLE I--HIGH TECHNOLOGY

SEC. 101. HIGH TECHNOLOGY ACQUISITION GRANT AND LOAN PROGRAM.

    (a) Establishment of Program.--Title III of the Public Health 
Service Act (42 U.S.C. 241 et seq.) is amended by inserting after 
section 330D the following:

``SEC. 330E. HIGH TECHNOLOGY ACQUISITION GRANT AND LOAN PROGRAM.

    ``(a) Establishment of Program.--The Secretary, acting through the 
Director of the Office of Rural Health Policy (of the Health Resources 
and Services Administration), shall establish a High Technology 
Acquisition Grant and Loan Program for the purpose of--
            ``(1) improving the quality of health care in rural areas 
        through the acquisition of advanced medical technology;
            ``(2) fostering the development the networks described in 
        section 330D(c);
            ``(3) promoting resource sharing between urban and rural 
        facilities; and
            ``(4) improving patient safety and outcomes through the 
        acquisition of high technology, including software, information 
        services, and staff training.
    ``(b) Grants and Loans.--Under the program established under 
subsection (a), the Secretary, acting through the Director of the 
Office of Rural Health Policy, may award grants and make loans to any 
eligible entity (as defined in subsection (d)(1)) for any costs 
incurred by the eligible entity in acquiring eligible equipment and 
services (as defined in subsection (d)(2)).
    ``(c) Limitations.--
            ``(1) In general.--Subject to paragraph (2), the total 
        amount of grants and loans made under this section to an 
        eligible entity may not exceed $100,000.
            ``(2) Federal sharing.--
                    ``(A) Grants.--The amount of any grant awarded 
                under this section may not exceed 70 percent of the 
                costs to the eligible entity in acquiring eligible 
                equipment and services.
                    ``(B) Loans.--The amount of any loan made under 
                this section may not exceed 90 percent of the costs to 
                the eligible entity in acquiring eligible equipment and 
                services.
    ``(d) Definitions.--In this section:
            ``(1) Eligible entity.--The term `eligible entity' means a 
        hospital, health center, or any other entity that the Secretary 
        determines is appropriate that is located in a rural area or 
        region.
            ``(2) Eligible equipment and services.--The term `eligible 
        equipment and services' includes--
                    ``(A) unit dose distribution systems;
                    ``(B) software and information services and staff 
                training;
                    ``(C) wireless devices to transmit medical orders;
                    ``(D) clinical health care informatics systems, 
                including bar code systems designed to avoid medication 
                errors and patient tracking systems; and
                    ``(E) any other technology that improves the 
                quality of health care provided in rural areas.
    ``(e) Authorization of Appropriations.--For the purpose of carrying 
out this section there are authorized to be appropriated such sums as 
may be necessary for each of the fiscal years 2001 through 2006.''.

SEC. 102. REFINEMENT OF MEDICARE REIMBURSEMENT FOR TELEHEALTH SERVICES.

    (a) Revision of Telehealth Payment Methodology and Elimination of 
Fee-Sharing Requirement.--Section 4206(b) of the Balanced Budget Act 
of 1997 (42 U.S.C. 1395l note) is amended to read as follows:
    ``(b) Methodology for Determining Amount of Payments.--
            ``(1) In general.--The Secretary shall pay to--
                    ``(A) the physician or practitioner at a distant 
                site that provides an item or service under subsection 
                (a) an amount equal to the amount that such physician 
                or provider would have been paid had the item or 
                service been provided without the use of a 
                telecommunications system; and
                    ``(B) the originating site a facility fee for 
                facility services furnished in connection with such 
                item or service.
            ``(2) Application of part b coinsurance and deductible.--
        Any payment made under this section shall be subject to the 
        coinsurance and deductible requirements under subsections 
        (a)(1) and (b) of section 1833 of the Social Security Act (42 
        U.S.C. 1395l).
            ``(3) Definitions.--In this subsection:
                    ``(A) Distant site.--The term `distant site' means 
                the site at which the physician or practitioner is 
                located at the time the item or service is provided via 
                a telecommunications system.
                    ``(B) Facility fee.--The term `facility fee' means 
                an amount equal to--
                            ``(i) for 2000 and 2001, $20; and
                            ``(ii) for a subsequent year, the facility 
                        fee under this subsection for the previous year 
                        increased by the percentage increase in the MEI 
                        (as defined in section 1842(i)(3)) for such 
                        subsequent year.
                    ``(C) Originating site.--
                            ``(i) In general.--The term `originating 
                        site' means the site described in clause (ii) 
                        at which the eligible telehealth beneficiary 
                        under the medicare program is located at the 
                        time the item or service is provided via a 
                        telecommunications system.
                            ``(ii) Sites described.--The sites 
                        described in this paragraph are as follows:
                                    ``(I) On or before January 1, 2002, 
                                the office of a physician or a 
                                practitioner, a critical access 
                                hospital, a rural health clinic, and a 
                                Federally qualified health center.
                                    ``(II) On or before January 1, 
                                2003, the sites described in subclause 
                                (I), a hospital, a skilled nursing 
                                facility, a comprehensive outpatient 
                                rehabilitation facility, a renal 
                                dialysis facility, an ambulatory 
                                surgical center, an Indian Health 
                                Service facility, and a community 
                                mental health center.''.
    (b) Elimination of Requirement for Telepresenter.--Section 4206 of 
the Balanced Budget Act of 1997 (42 U.S.C. 1395l note) is amended--
            (1) in subsection (a), by striking ``, notwithstanding that 
        the individual physician'' and all that follows before the 
        period at the end; and
            (2) by adding at the end the following new subsection:
    ``(e) Telepresenter Not Required.--Nothing in this section shall be 
construed as requiring an eligible telehealth beneficiary to be 
presented by a physician or practitioner for the provision of an item 
or service via a telecommunications system.''.
    (c) Reimbursement for Medicare Beneficiaries Who Do Not Reside in a 
HPSA.--Section 4206(a) of the Balanced Budget Act of 1997 (42 U.S.C. 
1395l note), as amended by subsection (b), is amended--
            (1) by striking ``In General.--Not later than'' and 
        inserting the following: ``Telehealth Services Reimbursed.--
            ``(1) In general.--Not later than'';
            (2) by striking ``furnishing a service for which payment'' 
        and all that follows before the period and inserting ``to an 
        eligible telehealth beneficiary''; and
            (3) by adding at the end the following new paragraph:
            ``(2) Eligible telehealth beneficiary defined.--In this 
        section, the term `eligible telehealth beneficiary' means a 
        beneficiary under the medicare program under title XVIII of the 
        Social Security Act (42 U.S.C. 1395 et seq.) that resides in--
                    ``(A) an area that is designated as a health 
                professional shortage area under section 332(a)(1)(A) 
                of the Public Health Service Act (42 U.S.C. 
                254e(a)(1)(A));
                    ``(B) a county that is not included in a 
                Metropolitan Statistical Area;
                    ``(C) an inner-city area that is medically 
                underserved (as defined in section 330(b)(3) of the 
                Public Health Service Act (42 U.S.C. 254b(b)(3))); or
                    ``(D) an area in which there is a Federal 
                telemedicine demonstration program.''.
    (d) Telehealth Coverage for Direct Patient Care.--
            (1) In general.--Section 4206 of the Balanced Budget Act of 
        1997 (42 U.S.C. 1395l note), as amended by subsection (c), is 
        amended--
                    (A) in subsection (a)(1), by striking 
                ``professional consultation via telecommunications 
                systems with a physician'' and inserting ``items and 
                services for which payment may be made under such part 
                that are furnished via a telecommunications system by a 
                physician''; and
                    (B) by adding at the end the following new 
                subsection:
    ``(f) Coverage of Items and Services.--Payment for items and 
services provided pursuant to subsection (a) shall include payment for 
professional consultations, office visits, office psychiatry services, 
including any service identified as of July 1, 2000, by HCPCS codes 
99241-99275, 99201-99215, 90804-90815, and 90862, and any additional 
item or service specified by the Secretary.''.
            (2) Study and report regarding additional items and 
        services.--
                    (A) Study.--The Secretary of Health and Human 
                Services shall conduct a study to identify items and 
                services in addition to those described in section 
                4206(f) of the Balanced Budget Act of 1997 (as added by 
                paragraph (1)) that would be appropriate to provide 
                payment under title XVIII of the Social Security Act 
                (42 U.S.C. 1395 et seq.).
                    (B) Report.--Not later than 2 years after the date 
                of enactment of this Act, the Secretary shall submit a 
                report to Congress on the study conducted under 
                subparagraph (A) together with such recommendations for 
                legislation that the Secretary determines are 
                appropriate.
    (e) All Physicians and Practitioners Eligible for Telehealth 
Reimbursement.--Section 4206(a) of the Balanced Budget Act of 1997 (42 
U.S.C. 1395l note), as amended by subsection (d), is amended--
            (1) in paragraph (1), by striking ``(described in section 
        1842(b)(18)(C) of such Act (42 U.S.C. 1395u(b)(18)(C))''; and
            (2) by adding at the end the following new paragraph:
            ``(3) Practitioner defined.--For purposes of paragraph (1), 
        the term `practitioner' includes--
                    ``(A) a practitioner described in section 
                1842(b)(18)(C) of the Social Security Act (42 U.S.C. 
                1395u(b)(18)(C)); and
                    ``(B) a physical, occupational, or speech 
                therapist.''.
    (f) Telehealth Services Provided Using Store-and-Forward 
Technologies.--Section 4206(a)(1) of the Balanced Budget Act of 1997 
(42 U.S.C. 1395l note), as amended by subsection (e), is amended by 
adding at the end the following new paragraph:
            ``(4) Use of store-and-forward technologies.--For purposes 
        of paragraph (1), in the case of any Federal telemedicine 
        demonstration program in Alaska or Hawaii, the term 
        `telecommunications system' includes store-and-forward 
        technologies that provide for the asynchronous transmission of 
        health care information in single or multimedia formats.''.
    (g) Construction Relating to Home Health Services.--Section 4206(a) 
of the Balanced Budget Act of 1997 (42 U.S.C. 1395l note), as amended 
by subsection (f), is amended by adding at the end the following new 
paragraph:
            ``(5) Construction relating to home health services.--
                    ``(A) In general.--Nothing in this section or in 
                section 1895 of the Social Security Act (42 U.S.C. 
                1395fff) shall be construed as preventing a home health 
                agency that is receiving payment under the prospective 
                payment system described in such section from 
                furnishing a home health service via a 
                telecommunications system.
                    ``(B) Limitation.--The Secretary shall not consider 
                a home health service provided in the manner described 
                in subparagraph (A) to be a home health visit for 
                purposes of--
                            ``(i) determining the amount of payment to 
                        be made under the prospective payment system 
                        established under section 1895 of the Social 
                        Security Act (42 U.S.C. 1395fff); or
                            ``(ii) any requirement relating to the 
                        certification of a physician required under 
                        section 1814(a)(2)(C) of such Act (42 U.S.C. 
                        1395f(a)(2)(C)).''.
    (h) Effective Date.--The amendments made by this Act shall apply to 
items and services provided on or after the date of enactment of this 
Act.

SEC. 103. EXTENSION OF TELEMEDICINE DEMONSTRATION PROJECTS.

    The Secretary of Health and Human Services shall maintain through 
September 30, 2003, the grant and operational phases of any 
telemedicine demonstration project conducted under the medicare program 
under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.)--
            (1) for which funds were expended before the date of 
        enactment of the Balanced Budget Act of 1997 (Public Law 105-
        133; 111 Stat. 251); and
            (2) that is ongoing as of the date of enactment of this 
        Act.

  TITLE II--IMPROVEMENTS IN THE DISPROPORTIONATE SHARE HOSPITAL (DSH) 
                                PROGRAM

SEC. 201. DISPROPORTIONATE SHARE HOSPITAL ADJUSTMENT FOR RURAL 
              HOSPITALS.

    (a) Application of Uniform 15 Percent Threshold.--Section 
1886(d)(5)(F)(v) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(F)(v)) is amended by striking ``exceeds--'' and all that 
follows and inserting ``exceeds 15 percent.''.
    (b) Change in Payment Percentage Formulas.--Section 1886(d)(5)(F) 
of the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)) is amended--
            (1) in clause (iv), by striking ``and that--'' and all that 
        follows and inserting ``is equal to the percentage determined 
        in accordance with the applicable formula described in clause 
        (vii).'';
            (2) in clause (vii), by striking ``clause (iv)(I)'' and 
        inserting ``clause (iv)''; and
            (3) by striking clause (viii) and inserting the following 
        new clause:
    ``(viii) No hospital described in clause (iv) may receive a payment 
amount under this section that is less than the payment amount that 
would have been made under this section if the amendments made by 
section 201 of the Rural Health Care in the 21st Century Act of 2000 
had not been enacted.''.
    (c) Effective Date.--The amendments made by this section apply to 
discharges occurring on or after October 1, 2000.

 TITLE III--IMPROVEMENTS IN THE CRITICAL ACCESS HOSPITAL (CAH) PROGRAM

SEC. 301. TREATMENT OF SWING-BED SERVICES FURNISHED BY CRITICAL ACCESS 
              HOSPITALS.

    (a) Exemption From SNF PPS.--Section 1888(e)(7) of the Social 
Security Act (42 U.S.C. 1395yy(e)(7)) is amended--
            (1) in the heading, by striking ``Transition for'' and 
        inserting ``Treatment of'';
            (2) in subparagraph (A), by striking ``In general.--The'' 
        and inserting ``Transition.--Except as provided in subparagraph 
        (C), the'';
            (3) in subparagraph (B), by striking ``, for which'' and 
        all that follows before the period at the end and inserting 
        ``(other than critical access hospitals)''; and
            (4) by adding at the end the following new subparagraph:
                    ``(C) Critical access hospitals.--In the case of 
                facilities described in subparagraph (B) that are 
                critical access hospitals--
                            ``(i) the prospective payment system 
                        established under this subsection shall not 
                        apply to services furnished pursuant to an 
                        agreement described in section 1883; and
                            ``(ii) such services shall be paid on the 
                        basis specified in subsection (a)(3) of such 
                        section.''.
    (b) Payment Basis for Swing-Bed Services Furnished by Critical 
Access Hospitals.--Section 1883(a) of the Social Security Act (42 
U.S.C. 1395tt(a)) is amended--
            (1) in paragraph (2)(A), by inserting ``(other than a 
        critical access hospital)'' after ``any hospital''; and
            (2) by adding at the end the following new paragraph:
            ``(3) Notwithstanding any other provision of this title, a 
        critical access hospital shall be paid for services furnished 
        under an agreement entered into under this section on the basis 
        of the reasonable costs of such services (as determined under 
        section 1861(v)).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to cost reporting periods beginning on or after October 1, 1999.

SEC. 302. TREATMENT OF AMBULANCE SERVICES FURNISHED BY CERTAIN CRITICAL 
              ACCESS HOSPITALS.

    (a) Exemption From Ambulance Fee Schedule.--
            (1) In general.--Section 1834(l) of the Social Security Act 
        (42 U.S.C. 1395m(l)) is amended by adding at the end the 
        following new paragraph:
            ``(8) Inapplicability of fee schedule to certain 
        services.--In the case of ambulance services (described in 
        section 1861(s)(7)) that are provided in a locality by a 
        critical access hospital that is the only provider of ambulance 
        services in the locality, or by an entity that is owned and 
        operated by such a critical access hospital--
                    ``(A) the fee schedule established under this 
                subsection shall not apply; and
                    ``(B) payment under this part shall be paid on the 
                basis of the reasonable costs incurred in providing 
                such services.''.
            (2) Conforming amendments.--Section 1833(a)(1) of the 
        Social Security Act (42 U.S.C. 1395l(a)(1)) is amended--
                    (A) in subparagraph (R)--
                            (i) by inserting ``except as provided in 
                        subparagraph (T),'' before ``with respect''; 
                        and
                            (ii) by striking ``and'' at the end; and
                    (B) in subparagraph (S), by striking the semicolon 
                at the end and inserting ``, and (T) with respect to 
                ambulance services described in section 1834(l)(8), the 
                amount paid shall be 80 percent of the lesser of the 
                actual charge for the services or the amount determined 
                under such section;''.
            (3) Effective date.--The amendments made by this subsection 
        shall apply to cost reporting periods beginning on or after 
        October 1, 1999.
    (b) Exemption From Reasonable Cost Reductions.--
            (1) Exemption.--Section 1861(v)(1)(U) of the Social 
        Security Act (42 U.S.C. 1395x(v)(1)(U)) is amended by inserting 
        after the first sentence the following new sentence: ``The 
        reductions required by the preceding sentence shall not apply 
        in the case of ambulance services that are provided in a 
        locality on or after October 1, 1999, by a critical access 
        hospital that is the only provider of ambulance services in the 
        locality, or by an entity that is owned and operated by such a 
        critical access hospital.''.
            (2) Technical amendment.--Section 1861(v)(1) of the Social 
        Security Act (42 U.S.C. 1395x(v)(1)) is amended by realigning 
        subparagraph (U) so as to align the left margin of such 
        subparagraph with the left margin of subparagraph (T).

SEC. 303. TREATMENT OF HOME HEALTH SERVICES FURNISHED BY CERTAIN 
              CRITICAL ACCESS HOSPITALS.

    (a) Exemption From Home Health Interim Payment System.--Section 
1861(v)(1)(L) of the Social Security Act (42 U.S.C. 1395x(v)(1)(L)) is 
amended by adding at the end the following new clause:
                            ``(xi) The preceding provisions of this 
                        subparagraph shall not apply to home health 
                        services that are furnished on or after October 
                        1, 2000, by a home health agency that is--
                                    ``(I) the only home health agency 
                                serving a locality; and
                                    ``(II) owned and operated by a 
                                critical access hospital.''.
    (b) Exemption From PPS.--
            (1) In general.--Section 1895 of the Social Security Act 
        (42 U.S.C. 1395fff) is amended by adding at the end the 
        following new subsection:
    ``(e) Exemption.--The prospective payment system established under 
this section shall not apply in determining payments for home health 
services furnished by a home health agency that is--
            ``(1) the only home health agency serving a locality; and
            ``(2) owned and operated by a critical access hospital.''.
            (2) Conforming amendment.--Section 1833(a)(2)(A) of the 
        Social Security Act (42 U.S.C. 1395(a)(2)(A)) is amended by 
        inserting ``home health services described in section 1895(e) 
        and other than'' after ``other than''.
            (3) Technical amendment.--Section 1833(a)(2)(A) of the 
        Social Security Act (42 U.S.C. 1395(a)(2)(A)) is amended by 
        striking ``drug) (as defined in section 1861(kk))'' and 
        inserting ``drug (as defined in section 1861(kk)))''.
            (4) Effective date.--The amendments made by this subsection 
        shall apply to cost reporting periods beginning on or after 
        October 1, 2000.

SEC. 304. DESIGNATION OF A SINGLE FISCAL INTERMEDIARY FOR ALL CRITICAL 
              ACCESS HOSPITALS.

    Section 1816 of the Social Security Act (42 U.S.C. 1395h) is 
amended by adding at the end the following:
    ``(m) Not later than October 1, 2000, the Secretary shall designate 
a national agency or organization with an agreement under this section 
to perform functions under the agreement with respect to each critical 
access hospital electing to have such functions performed by such 
agency or organization.''.

SEC. 305. ESTABLISHMENT OF AN ALL-INCLUSIVE PAYMENT OPTION FOR 
              OUTPATIENT CRITICAL ACCESS HOSPITAL SERVICES.

    (a) All-Inclusive Payment Option for Outpatient Critical Access 
Hospital Services.--Section 1834(g) of the Social Security Act (42 
U.S.C. 1395m(g)) is amended--
            (1) by striking paragraph (1) and inserting the following 
        new paragraph:
            ``(1) Election of cah.--At the election of a critical 
        access hospital, the amount of payment for outpatient critical 
        access hospital services under this part shall be determined 
        under paragraph (2) or (3), such amount determined under either 
        paragraph without regard to the amount of the customary or 
        other charge.''; and
            (2) by striking paragraph (3) and inserting the following 
        new paragraph:
            ``(3) All-inclusive rate.--If a critical access hospital 
        elects this paragraph to apply, with respect to both facility 
        services and professional services, there shall be paid amounts 
        equal to the reasonable costs of the critical access hospital 
        in providing such services (except that in the case of clinical 
        diagnostic laboratory services furnished by a critical access 
        hospital the amount of payment shall be equal to 100 percent of 
        the reasonable costs of the critical access hospital in 
        providing such services), less the amount that such hospital 
        may charge as described in section 1866(a)(2)(A).''.
    (b) Effective Date.--The amendments made by subparagraph (a) shall 
take effect as if included in the enactment of section 403(d) of the 
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 
(113 Stat. 1501A-371), as enacted into law by section 1000(a)(6) of 
Public Law 106-113.

       TITLE IV--OUTPATIENT SERVICES FURNISHED BY RURAL PROVIDERS

SEC. 401. PERMANENT GUARANTEE OF PRE-BBA PAYMENT LEVELS FOR OUTPATIENT 
              SERVICES FURNISHED BY RURAL HOSPITALS.

    (a) In General.--Section 1833(t)(7)(D) of the Social Security Act 
(42 U.S.C. 1395l(t)(7)(D)), as added by section 202 of the Medicare, 
Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (113 Stat. 
1501A-342), as enacted into law by section 1000(a)(6) of Public Law 
106-113, is amended to read as follows:
                    ``(D) Hold harmless provisions for small rural 
                hospitals and cancer hospitals.--In the case of a 
                hospital located in a rural area and that has not more 
                than 100 beds or a hospital described in section 
                1886(d)(1)(B)(v), for covered OPD services for which 
                the PPS amount is less than the pre-BBA amount, the 
                amount of payment under this subsection shall be 
                increased by the amount of such difference.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect as if included in the enactment of section 202 of the 
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 
(113 Stat. 1501A-342), as enacted into law by section 1000(a)(6) of 
Public Law 106-113.

SEC. 402. PROVIDER-BASED RURAL HEALTH CLINIC CAP EXEMPTION.

    (a) In General.--The matter in section 1833(f) of the Social 
Security Act (42 U.S.C. 1395l(f)) preceding paragraph (1) is amended by 
striking ``with less than 50 beds'' and inserting ``with an average 
daily patient census that does not exceed 50''.
    (b) Effective Date.--The amendment made by subparagraph (A) applies 
to services furnished on or after January 1, 2001.

SEC. 403. PAYMENT FOR CERTAIN PHYSICIAN ASSISTANT SERVICES.

    (a) Payment for Certain Physician Assistant Services.--Section 
1842(b)(6)(C) of the Social Security Act (42 U.S.C. 1395u(b)(6)(C)) is 
amended by striking ``for such services provided before January 1, 
2003,''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on the date of enactment of this Act.

SEC. 404. EXCLUSION OF RURAL HEALTH CLINIC SERVICES FROM THE PPS FOR 
              SKILLED NURSING FACILITIES.

    (a) In General.--Section 1888(e)(2)(A)(ii) of the Social Security 
Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting after the 
first sentence the following: ``Services described in this clause also 
include services that are provided by a physician, a physician 
assistant, a nurse practitioner, a certified nurse midwife, or a 
qualified psychologist who is employed, or otherwise under contract, 
with a rural health clinic.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished on or after January 1, 2001.

SEC. 405. BONUS PAYMENTS FOR RURAL HOME HEALTH AGENCIES.

    (a) Increase in Payment Rates for Rural Agencies.--
            (1) In general.--Section 1895(b) of the Social Security Act 
        (42 U.S.C. 1395fff(b)) is amended by adding at the end the 
        following new paragraph:
            ``(7) Additional payment amount for services furnished in 
        rural areas.--In the case of home health services furnished in 
        a rural area (as defined in section 1886(d)(2)(D)), the 
        Secretary shall provide for an addition or adjustment to the 
        payment amount otherwise made under this section for services 
        furnished in a rural area in an amount equal to 10 percent of 
        the amount otherwise determined under this subsection.''.
            (2) Waiving budget neutrality.--Section 1895(b)(3) of such 
        Act (42 U.S.C. 1395fff(b)(3)) is amended by adding at the end 
        the following new subparagraph:
                    ``(D) No adjustment for additional payments for 
                rural services.--The Secretary shall not reduce the 
                standard prospective payment amount (or amounts) under 
                this paragraph applicable to home health services 
                furnished during a period to offset the increase in 
                payments resulting from the application of paragraph 
                (7) (relating to services furnished in rural areas).''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to episodes of care beginning on or after April 1, 2001.

                           TITLE V--BAD DEBT

SEC. 501. RESTORATION OF FULL PAYMENT FOR BAD DEBTS OF QUALIFIED 
              MEDICARE BENEFICIARIES.

    (a) Medicare Cost-Sharing Uncollectible and Not Covered by Medicaid 
State Plans.--Section 1902(n)(3)(B) of the Social Security Act (42 
U.S.C. 1396a(n)(3)(B)) is amended--
            (1) by inserting ``(i)'' after ``(B)''; and
            (2) by adding at the end the following new clause:
            ``(ii) the amount of medicare cost-sharing that is 
        uncollectible from the beneficiary because of clause (i) and 
        that is not paid by any other individual or entity shall be 
        deemed to be bad debt for purposes of title XVIII; and''.
    (b) Recognition of 100 Percent of Bad Debt.--
            (1) Nonapplication of reduction.--Section 1861(v)(1)(T) of 
        the Social Security Act (42 U.S.C. 1395x(v)(1)(T)) is amended 
        by inserting ``(other than any amount deemed to be bad debt 
        under section 1902(n)(3)(B)(ii))'' after ``amounts under this 
        title''.
            (2) Recognition with respect to certified nurse 
        anesthetists, nurse practitioners, and clinical nurse 
        specialists.--Section 1833 of the Social Security Act (42 
        U.S.C. 1395l) is amended--
                    (A) in subsection (l)(5)(B), by striking ``No 
                hospital'' and inserting ``Except as provided in 
                section 1902(n)(3)(B)(ii), no hospital''; and
                    (B) in subsection (r)(2), by striking ``No 
                hospital'' and inserting ``Except as provided in 
                section 1902(n)(3)(B)(ii), no hospital''.
    (c) Technical Amendment.--Section 1861(v)(1)(T) of the Social 
Security Act (42 U.S.C. 1395x(v)(1)(T)) is amended by striking 
``1833(t)(5)(B)'' and inserting ``1833(t)(8)(B)'' in the matter 
preceding clause (i).
    (d) Effective Date.--The amendments made by this section shall 
apply to bad debt incurred on or after the date of enactment of this 
Act.

      TITLE VI--NATIONAL HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM

SEC. 601. EXCLUSION OF CERTAIN AMOUNTS RECEIVED UNDER THE NATIONAL 
              HEALTH SERVICE CORPS SCHOLARSHIP PROGRAM.

    (a) In General.--Section 117(c) of the Internal Revenue Code of 
1986 (relating to the exclusion from gross income amounts received as a 
qualified scholarship) is amended--
            (1) by striking ``Subsections (a)'' and inserting the 
        following:
            ``(1) In general.--Except as provided in paragraph (2), 
        subsections (a)''; and
            (2) by adding at the end the following new paragraph:
            ``(2) Exception.--Paragraph (1) shall not apply to any 
        amount received by an individual under the National Health 
        Service Corps Scholarship Program under section 338A(g)(1)(A) 
        of the Public Health Service Act.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to amounts received in taxable years beginning after December 31, 
1994.

 TITLE VII--TECHNICAL CORRECTIONS TO BALANCED BUDGET REFINEMENT ACT OF 
                                  1999

SEC. 701. EXTENSION OF OPTION TO USE REBASED TARGET AMOUNTS TO ALL SOLE 
              COMMUNITY HOSPITALS.

    (a) In General.--Section 1886(b)(3)(I)(i) of the Social Security 
Act (42 U.S.C. 1395ww(b)(3)(I)(i)) (as added by section 405 of the 
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 
(113 Stat. 1501A-372), as enacted into law by section 1000(a)(6) of 
Public Law 106-113) is amended--
            (1) in the matter preceding subclause (I)--
                    (A) by striking ``for its cost reporting period 
                beginning during 1999 is paid on the basis of the 
                target amount applicable to the hospital under 
                subparagraph (C) and that''; and
                    (B) by striking ``such target amount'' and 
                inserting ``the amount otherwise determined under 
                subsection (d)(5)(D)(i)'';
            (2) in subclause (I), by striking ``target amount otherwise 
        applicable'' and all that follows through ``target amount')'' 
        and inserting ``the amount otherwise applicable to the hospital 
        under subsection (d)(5)(D)(i) (referred to in this clause as 
        the `subsection (d)(5)(D)(i) amount')''; and
            (3) in each of subclauses (II) and (III), by striking 
        ``subparagraph (C) target amount'' and inserting ``subsection 
        (d)(5)(D)(i) amount''.
    (b) Effective Date.--The amendments made by this section shall take 
effect as if included in the enactment of the Medicare, Medicaid, and 
SCHIP Balanced Budget Refinement Act of 1999, as enacted into law by 
section 1000(a)(6) of Public Law 106-113.

SEC. 702. PAYMENTS TO CRITICAL ACCESS HOSPITALS FOR CLINICAL DIAGNOSTIC 
              LABORATORY TESTS.

    (a) Payment on Cost Basis Without Beneficiary Cost-Sharing.--
            (1) In general.--Section 1833(a)(6) of the Social Security 
        Act (42 U.S.C. 1395l(a)(6)) is amended by inserting 
        ``(including clinical diagnostic laboratory services furnished 
        by a critical access hospital)'' after ``outpatient critical 
        access hospital services''.
            (2) No beneficiary cost-sharing.--
                    (A) In general.--Section 1834(g) of the Social 
                Security Act (42 U.S.C. 1395m(g)) is amended by 
                inserting ``(except that in the case of clinical 
                diagnostic laboratory services furnished by a critical 
                access hospital the amount of payment shall be equal to 
                100 percent of the reasonable costs of the critical 
                access hospital in providing such services)'' before 
                the period at the end.
                    (B) BBRA amendment.--Section 1834(g) of the Social 
                Security Act (42 U.S.C. 1395m(g)) is amended--
                            (i) in paragraph (1), by inserting 
                        ``(except that in the case of clinical 
                        diagnostic laboratory services furnished by a 
                        critical access hospital the amount of payment 
                        shall be equal to 100 percent of the reasonable 
                        costs of the critical access hospital in 
                        providing such services)'' after ``such 
                        services,''; and
                            (ii) in paragraph (2)(A), by inserting 
                        ``(except that in the case of clinical 
                        diagnostic laboratory services furnished by a 
                        critical access hospital the amount of payment 
                        shall be equal to 100 percent of the reasonable 
                        costs of the critical access hospital in 
                        providing such services)'' before the period at 
                        the end.
    (b) Conforming Amendments.--Paragraphs (1)(D)(i) and (2)(D)(i) of 
section 1833(a) of the Social Security Act (42 U.S.C. 
1395l(a)(1)(D)(i); 1395l(a)(2)(D)(i)) are each amended by striking ``or 
which are furnished on an outpatient basis by a critical access 
hospital''.
    (c) Technical Amendment.--Section 403(d)(2) of the Medicare, 
Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (113 Stat. 
1501A-371), as enacted into law by section 1000(a)(6) of Public Law 
106-113, is amended by striking ``subsection (a)'' and inserting 
``paragraph (1)''.
    (d) Effective Dates.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendments made by this section shall apply to services 
        furnished on or after November 29, 1999.
            (2) BBRA and technical amendments.--The amendments made by 
        subsections (a)(2)(B) and (c) shall take effect as if included 
        in the enactment of section 403(d) of the Medicare, Medicaid, 
        and SCHIP Balanced Budget Refinement Act of 1999 (113 Stat. 
        1501A-371), as enacted into law by section 1000(a)(6) of Public 
        Law 106-113.
                                 <all>