Access to outpatient physical therapy services for medicare beneficiaries as authorized by State law

(a)

In general

(1)

Elimination of required physician referral

(A)

Definition of outpatient physical therapy services

Section 1861(p) of the Social Security Act (42 U.S.C. 1395x(p)) is amended— (i)in the matter preceding paragraph (1), by striking as an outpatient; (ii)by amending paragraph (1) to read as follows:

(1)who is an outpatient, and

;

(iii)in paragraph (2)— (I)by striking physician (as so defined) or by a qualified physical therapist and inserting physician (as defined in paragraph (1), (3), or (4) of subsection (r)) or by a qualified physical therapist (as defined in section 1861(bbb)); and (II)by inserting or a qualified physical therapist (as so defined) after physician the second place it appears; (iv)in paragraph (4)(A)(ii), by striking one or more and all that follows through agency) and; and (v)by amending the fifth sentence to read as follows: “Nothing in this subsection shall be construed as authorizing the provision of services in a State that a qualified physical therapist is not authorized to provide in the State in accordance with State law (or the State regulatory mechanism provided by State law). (B)

Conforming amendments

Section 1835(a)(2) of the Social Security Act (42 U.S.C. 1395n(a)(2)) is amended— (i)in the matter preceding subparagraph (A), by inserting , or in the case of outpatient physical therapy services (as described in subparagraph (C)) and physical therapy services furnished as comprehensive outpatient rehabilitation facility services (described in subparagraph (E)), a qualified physical therapist, after a physician; (ii)in subparagraph (C)— (I)in the matter preceding clause (i), by striking or outpatient occupational therapy services; (II)in clause (i), by striking or occupational therapy services, respectively, and inserting , and; (III)in clause (ii), by striking or qualified occupational therapist, respectively,; and (IV)beginning in clause (ii), by striking by a physician, and (iii) and all that follows and inserting by a physician or a qualified physical therapist;; (iii)in subparagraph (D)— (I)in the matter preceding clause (i), by striking outpatient speech pathology services and inserting outpatient occupational therapy services or outpatient speech-language pathology services; (II)in clause (i), by striking needed speech pathology services and inserting needed occupational therapy services or speech-language pathology services, respectively; and (III)in clause (ii), by striking speech pathologist and inserting occupational therapist or speech-language pathologist, respectively,; and (iv)in subparagraph (E)— (I)in clause (ii), by inserting (or, in the case of comprehensive outpatient rehabilitation facility services consisting of physical therapy services, by a qualified physical therapist) after physician; and (II)in clause (iii), by inserting in the case of comprehensive outpatient rehabilitation facility services not consisting of physical therapy services, before such services. (2)

Definition of qualified physical therapist

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

(bbb)

Qualified physical therapist

The term qualified physical therapist means an individual who is licensed as a physical therapist by the State in which such individual is practicing and who meets the applicable requirements under paragraph (1) or (2): (1)With respect to individuals graduating from a professional physical therapy education program on or after January 1, 2003, the individual— (A)has received a master’s or doctoral degree from a professional physical therapy education program that has been accredited by a national physical therapy education accreditation agency recognized by the Secretary of Education; or (B)has graduated from a professional physical therapy education program outside the United States with a curriculum that is substantially equivalent (as determined by an accreditation agency described in subparagraph (A)) to the curricula of programs for professional physical therapy education programs in the United States that are accredited by such an accreditation agency. (2)With respect to individuals licensed as physical therapists by a State before 2003, the individual was, or upon application to the Secretary could have been, qualified under regulations of the Secretary in effect before such date to furnish physical therapy services under this title, as determined by the Secretary.

(b)

Preserving existing law for outpatient occupational therapy services

(1)

Definition

Section 1861(g) of the Social Security Act (42 U.S.C. 1395x(g)) is amended to read as follows:

(g)

Outpatient occupational therapy services

The term outpatient occupational therapy services means occupational therapy services furnished by a provider of services, a clinic, a rehabilitation agency, or a public health agency, or by others under an arrangement with, and under the supervision of, such a provider, clinic, rehabilitation agency, or public health agency to an individual as an outpatient— (1)who is under the care of a physician (as defined in paragraph (1), (3), or (4) of subsection (r)); (2)with respect to whom a plan prescribing the type, amount, and duration of occupational therapy services that are furnished to such individual has been established by a physician (as so defined) or by an occupational therapist and is periodically reviewed by a physician (as so defined);

excluding, however—

(3)any item or service if it would not be included under subsection (b) if furnished to an inpatient of a hospital; and (4)any such service— (A)if furnished by a clinic, rehabilitation agency, or by others under arrangements with such clinic or agency, unless such clinic or rehabilitation agency— (i)provides an adequate program of occupational therapy services for outpatients and has the facilities and personnel required for such program or required for the supervision of such a program, in accordance with such requirements as the Secretary may specify; (ii)has policies, established by a group of professional personnel, including one or more occupational therapists, to govern the services (referred to in clause (i)) it provides; (iii)maintains clinical records on all patients; (iv)if such clinic or agency is situated in a State in which State or applicable local law provides for the licensing of institutions of this nature— (I)is licensed pursuant to such law, or (II)is approved by the agency of such State or locality responsible for licensing institutions of this nature, as meeting the standards established for such licensing; and (v)meets such other conditions relating to the health and safety of individuals who are furnished services by such clinic or agency on an outpatient basis, as the Secretary may find necessary, and provides the Secretary on a continuing basis with a surety bond that is not less than $50,000; or (B)if furnished by a public health agency, unless such agency meets such other conditions relating to the safety of individuals who are furnished services by such agency on an outpatient basis, as the Secretary may find necessary.

The term outpatient occupational therapy services also includes occupational therapy services furnished an individual by an occupational therapist (in the office of the occupational therapist or in such individual’s home) who meets licensing and other standards prescribed by the Secretary in regulations, otherwise than under an arrangement with and under the supervision of a provider of services, clinic, rehabilitation agency, or public health agency, if the furnishing of such services meets such conditions relating to health and safety as the Secretary may find necessary. In addition, such term includes occupational therapy services that meet the requirements of the first sentence of this subsection except that they are furnished to an inpatient of a hospital or extended care facility. Nothing in this subsection shall be construed as requiring, with respect to outpatients who are not entitled to benefits under this title, an occupational therapist to provide outpatient occupational therapy services only to outpatients who are under the care of a physician or pursuant to a plan of care established by a physician. The Secretary may waive the requirement of a surety bond under paragraph (4)(A)(v) in the case of a clinic or agency that provides a comparable surety bond under State law.

(2)

Conforming amendments

(A)

Scope of benefits

Section 1832(a)(2)(C) of the Social Security Act (42 U.S.C. 1395k(a)(2)(C)) is amended by striking such sentence applies through the operation of section 1861(g)) and inserting the second sentence of section 1861(g) applies). (B)

Payment of benefits

Section 1833(g)(3) of the Social Security Act (42 U.S.C. 1395l(g)(3)) is amended by striking section 1861(p) and all that follows through section 1861(g) and inserting section 1861(g) (but not described in subsection (a)(8)(B)). (C)

Provider claims procedures

The second sentence of section 1835(a) of the Social Security Act (42 U.S.C. 1395n(a)) is amended— (i)by striking section 1861(p)(4)(A) (or meets the requirements of such section through the operation of section 1861(g)) and inserting section 1861(p)(4)(A) or section 1861(g)(4)(A); (ii)by striking section 1861(p)(4)(B) (or meets the requirements of such section through the operation of section 1861(g)) and inserting section 1861(p)(4)(B) or section 1861(g)(4)(B); and (iii)by striking (as therein defined) or (through the operation of section 1861(g)) with respect to the furnishing of outpatient occupational therapy services and inserting (as defined in section 1861(p)) or outpatient occupational therapy services (as defined in section 1861(g)), respectively. (D)

Agreements with providers

Section 1866(e)(1) of the Social Security Act (42 U.S.C. 1395cc(e)(1)) is amended— (i)by striking section 1861(p)(4)(A) (or meets the requirements of such section through the operation of section 1861(g)) and inserting section 1861(p)(4)(A) or section 1861(g)(4)(A); (ii)by striking section 1861(p)(4)(B) (or meets the requirements of such section through the operation of section 1861(g)) and inserting section 1861(p)(4)(B) or section 1861(g)(4)(B); and (iii)by striking (as therein defined) or (through the operation of section 1861(g)) with respect to the furnishing of outpatient occupational therapy services and inserting (as defined in section 1861(p)) or outpatient occupational therapy services (as defined in section 1861(g)), respectively. (c)

Separate statutory treatment for outpatient physical therapy services and outpatient speech-language pathology services

(1)

Scope of benefits

Section 1832(a)(2)(C) of the Social Security Act (42 U.S.C. 1395k(a)(2)(C)), as amended by subsection (b)(2)(A), is amended— (A)by striking and outpatient and inserting , outpatient; and (B)by inserting before the semicolon the following: , and outpatient speech-language pathology services. (2)

Payment of benefits

Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended— (A)in subparagraphs (A) and (B) of subsection (a)(8), by striking services, (which includes outpatient speech-language pathology services) and outpatient occupational therapy services each place it appears and inserting services, outpatient occupational therapy services, and outpatient speech-language pathology services; and (B)in subsection (g)— (i)in paragraphs (1) and (3), by striking paragraph (4) each place it appears and inserting paragraph (5); and (ii)by redesignating paragraph (4) as paragraph (5) and inserting after paragraph (3) the following new paragraph:

(4)Subject to paragraph (5), in the case of speech-language pathology services (of the type described in section 1861(ll)(4) (but not described in subsection (a)(8)(B)) and speech-language pathology services of such type that are furnished by a physician or as incident to physicians’ services), with respect to expenses incurred in any calendar year, no more than the amount specified in paragraph (2) for the year shall be considered as incurred expenses for purposes of subsections (a) and (b).

(3)

Provider claims procedures

The second sentence of section 1835(a) of the Social Security Act (42 U.S.C. 1395n(a)), as amended by subsection (b)(2)(C), is amended— (A)by striking or section 1861(g)(4)(A) and inserting , section 1861(g)(4)(A), or section 1861(ll)(5)(A); (B)by striking or section 1861(g)(4)(B) and inserting , section 1861(g)(4)(B), or section 1861(ll)(4)(B)(ii)(II); and (C)by striking or outpatient occupational services (as defined in section 1861(g)) and inserting , outpatient occupational services (as defined in section 1861(g)), or outpatient speech-language pathology services (as defined in section 1861(ll)(4)(A)). (4)

Agreements with providers

Section 1866(e)(1) of the Social Security Act (42 U.S.C. 1395cc(e)(1)), as amended by subsection (b)(2)(D), is amended— (A)by striking “or section 1861(g)(4)(A)” and inserting 1861(g)(4)(A), or section 1861(ll)(5)(A)”; (B)by striking or section 1861(g)(4)(B) and inserting , section 1861(g)(4)(B), or section 1861(ll)(4)(B)(ii)(II); and (C)by striking or outpatient occupational services (as defined in section 1861(g)) and inserting , outpatient occupational services (as defined in section 1861(g)), or outpatient speech-language pathology services (as defined in section 1861(ll)(4)(A)). (5)

Definitions

Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended— (A)in subsection (p), by striking the fourth sentence; (B)in subsection (s)(2)(D), by striking services and outpatient occupational therapy services and inserting services, outpatient occupational therapy services, and outpatient speech-language pathology services; and (C)in subsection (ll), by adding at the end the following new paragraphs:

(4) (A)Subject to subparagraph (B), the term outpatient speech-language pathology services means speech-language pathology services that are furnished by a provider of services, a clinic, a rehabilitation agency, or a public health agency, or by others under an arrangement with, and under the supervision of, such provider, clinic, rehabilitation agency, or public health agency to an individual as an outpatient— (i)who is under the care of a physician (as defined in paragraph (1), (3), or (4) of subsection (r)); and (ii)with respect to whom a plan prescribing the type, amount, and duration of speech-language pathology services that are furnished to such individual has been established by a physician (as so defined) or by a qualified speech-language pathologist and is periodically reviewed by a physician (as so defined). (B)Such term does not include— (i)any item or service if it would not be included under subsection (b) if furnished to an inpatient of a hospital; or (ii)any item or service— (I)if furnished by a clinic, rehabilitation agency, or by others under arrangements with such clinic or agency, unless such clinic or rehabilitation agency meets the requirements of paragraph (5); and (II)if furnished by a public health agency, unless such agency meets such other conditions relating to the safety of individuals who are furnished services by such agency on an outpatient basis, as the Secretary may find necessary. (C)Such term also includes speech-language pathology services that meet the requirements of the preceding sentence except that they are furnished to an inpatient of a hospital or extended care facility. Nothing in this subsection shall be construed as requiring, with respect to outpatients who are not entitled to benefits under this title, a speech-language pathologist to provide outpatient speech-language pathology services only to outpatients who are under the care of a physician or pursuant to a plan of care established by a physician. The Secretary may waive the requirement of a surety bond under paragraph (5)(E) in the case of a clinic or agency that provides a comparable surety bond under State law. (5)A clinic or rehabilitation agency meets the requirements of this paragraph if it— (A)provides an adequate program of speech-language pathology services for outpatients and has the facilities and personnel required for such program or required for the supervision of such a program, in accordance with such requirements as the Secretary may specify; (B)has policies, established by a group of professional personnel, including one or more speech-language pathologists, to govern the services (referred to in subparagraph (A)) it provides; (C)maintains clinical records on all patients; (D)in the case of a clinic or agency that is situated in a State in which State or applicable local law provides for the licensing of institutions of this nature— (i)is licensed pursuant to such law, or (ii)is approved by the agency of such State or locality responsible for licensing institutions of this nature, as meeting the standards established for such licensing; and (E)meets such other conditions relating to the health and safety of individuals who are furnished services by such clinic or agency on an outpatient basis, as the Secretary may find necessary, and provides the Secretary on a continuing basis with a surety bond that is not less than $50,000.

(d)

Effective date

The amendments made by this section shall apply to items and services furnished on or after January 1, 2006.