[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[S. 2786 Introduced in Senate (IS)]







110th CONGRESS
  2d Session
                                S. 2786

 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.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             March 13, 2008

 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.

    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 ``Medicare Rural 
Health Access Improvement Act of 2008''.
    (b) 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. Rebasing for sole community hospitals.
Sec. 104. Temporary improvements to the Medicare inpatient hospital 
                            payment adjustment for low-volume 
                            hospitals.
Sec. 105. 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. Permanent treatment of Medicare reasonable costs payments for 
                            certain clinical diagnostic laboratory 
                            tests furnished to hospital patients in 
                            certain rural areas.
Sec. 204. Clarification of payment for clinical laboratory tests 
                            furnished by critical access hospitals.
Sec. 205. Extension of Medicare incentive payment program for physician 
                            scarcity areas.
Sec. 206. Revisions to the work geographic adjustment under the 
                            Medicare physician fee schedule.
Sec. 207. Revisions to the practice expense geographic adjustment under 
                            the Medicare physician fee schedule.
Sec. 208. Extension of treatment of certain physician pathology 
                            services under Medicare.
Sec. 209. Extension of increased Medicare payments for rural ground 
                            ambulance services.
Sec. 210. Adding hospital-based renal dialysis centers (including 
                            satellites) as originating sites for 
                            payment of telehealth services.
Sec. 211. Adding skilled nursing facilities as originating sites for 
                            payment of telehealth services.
Sec. 212. Rural health clinic improvements.
Sec. 213. Exemption for suppliers in small MSAs and rural areas.
Sec. 214. 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.

            TITLE I--PROVISIONS RELATING TO MEDICARE PART A

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 ``2008'' and inserting ``2009''.

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:
    ``(v) In the case of discharges occurring on or after October 1, 
2008, 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).''.
    (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, 2008, or 85 percent in the case of discharges occurring on 
or after October 1, 2008, and before October 1, 2011'' after ``October 
1, 2006''.

SEC. 103. REBASING FOR SOLE COMMUNITY HOSPITALS.

    (a) Rebasing Permitted.--Section 1886(b)(3) of the Social Security 
Act (42 U.S.C. 1395ww(b)(3)) is amended by adding at the end the 
following new subparagraph:
    ``(L)(i) For cost reporting periods beginning on or after October 
1, 2008, in the case of a sole community hospital there shall be 
substituted for the amount otherwise determined under subsection 
(d)(5)(D)(i) of this section, if such substitution results in a greater 
amount of payment under this section for the hospital, the subparagraph 
(L) rebased target amount.
    ``(ii) For purposes of this subparagraph, the term `subparagraph 
(L) rebased target amount' has the meaning given the term `target 
amount' in subparagraph (C), except that--
            ``(I) there shall be substituted for the base cost 
        reporting period the 12-month cost reporting period beginning 
        during fiscal year 2002;
            ``(II) any reference in subparagraph (C)(i) to the `first 
        cost reporting period' described in such subparagraph is deemed 
        a reference to the first cost reporting period beginning on or 
        after October 1, 2008; and
            ``(III) the applicable percentage increase shall only be 
        applied under subparagraph (C)(iv) for discharges occurring in 
        fiscal years beginning with fiscal year 2009.''.
    (b) Conforming Amendments.--Section 1886(b)(3) of the Social 
Security Act (42 U.S.C. 1395ww(b)(3)) is amended--
            (1) in subparagraph (C), in the matter preceding clause 
        (i), by striking ``subparagraph (I)'' and inserting 
        ``subparagraphs (I) and (L)''; and
            (2) in subparagraph (I)(i), in the matter preceding 
        subclause (I), by striking ``For'' and inserting ``Subject to 
        subparagraph (L), for''.

SEC. 104. 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--
            (1) in subparagraph (A), by inserting ``or (D)'' after 
        ``subparagraph (B)'';
            (2) in subparagraph (B), by striking ``The Secretary'' and 
        inserting ``For discharges occurring in fiscal years 2005 
        through 2008 and for discharges occurring in fiscal year 2011 
        and subsequent fiscal years, the Secretary'';
            (3) in subparagraph (C)(i)--
                    (A) by inserting ``(or, with respect to fiscal 
                years 2009 and 2010, 15 road miles)'' after ``25 road 
                miles''; and
                    (B) by inserting ``(or, with respect to fiscal 
                years 2009 and 2010, 2,000 discharges of individuals 
                entitled to, or enrolled for, benefits under part A)'' 
                after ``800 discharges''; and
            (4) by adding at the end the following new subparagraph:
                    ``(D) Temporary applicable percentage increase.--
                For discharges occurring in fiscal years 2009 or 2010, 
                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.''.

SEC. 105. 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, 
2008, and before October 1, 2010.''.

            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.

    Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 
1395l(t)(7)(D)(i)) is amended--
            (1) in subclause (II)--
                    (A) in the first sentence, by striking ``2009'' and 
                inserting ``2010''; and
                    (B) by striking the second sentence and inserting 
                the following new sentence: ``For purposes of the 
                preceding sentence, the applicable percentage shall be 
                95 percent with respect to covered OPD services 
                furnished in 2006, 90 percent with respect to such 
                services furnished in 2007, 85 percent with respect to 
                such services furnished in 2008, 100 percent with 
                respect to such services furnished in 2009, and 100 
                percent with respect to such services furnished in 
                2010.''; and
            (2) by adding at the end the following new subclause:
                            ``(III) In the case of a sole community 
                        hospital (as defined in section 
                        1886(d)(5)(D)(iii)), for covered OPD services 
                        furnished on or after January 1, 2009, and 
                        before January 1, 2011, for which the PPS 
                        amount is less than the pre-BBA amount, the 
                        amount of payment under this subsection shall 
                        be increased by 100 percent of the amount of 
                        such difference.''.

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--
            (1) in the heading, by striking ``Authorization of 
        adjustment'' and inserting ``Adjustment'';
            (2) in subparagraph (B)--
                    (A) in the heading, by inserting ``for 2006, 2007, 
                and 2008'' after ``adjustment''; and
                    (B) by adding at the end the following new 
                sentence: ``Such authority shall apply with respect to 
                services furnished in 2006, 2007, or 2008.''; and
            (3) by adding at the end the following new subparagraph:
                    ``(C) Adjustment for 2009 and subsequent years for 
                certain rural hospitals.--
                            ``(i) Adjustment.--
                                    ``(I) In general.--Subject to 
                                clause (ii), in the case of covered OPD 
                                services furnished on or after January 
                                1, 2009, 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.
                                    ``(II) Revision with notice and 
                                comment.--In the case of covered OPD 
                                services furnished on or after January 
                                1, 2010, the Secretary may revise the 
                                percent described in subclause (I) 
                                through the promulgation of a 
                                regulation.
                            ``(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).
                            ``(iii) Exemption from budget neutrality.--
                        The provisions of this subparagraph shall not 
                        be effected in a budget-neutral manner under 
                        this subsection.''.

SEC. 203. PERMANENT TREATMENT OF MEDICARE REASONABLE COSTS PAYMENTS FOR 
              CERTAIN CLINICAL DIAGNOSTIC LABORATORY TESTS FURNISHED TO 
              HOSPITAL PATIENTS IN CERTAIN RURAL AREAS.

    Section 1833 of the Social Security Act (42 U.S.C. 1395l) is 
amended by adding at the end the following new subsection:
    ``(v) Reasonable Costs Payments for Certain Clinical Diagnostic 
Laboratory Tests Furnished to Hospital Patients in Certain Rural 
Areas.--
            ``(1) In general.--Notwithstanding subsections (a), (b), 
        and (h) and section 1834(d)(1), in the case of a clinical 
        diagnostic laboratory test covered under this part that is 
        furnished during a cost reporting period beginning on or after 
        July 1, 2008, by a hospital with fewer than 50 beds that is 
        located in a qualified rural area (identified under paragraph 
        (12)(B)(iii) of section 1834(l)) as part of outpatient services 
        of the hospital, the amount of payment for such test shall be 
        100 percent of the reasonable costs of the hospital in 
        furnishing such test.
            ``(2) Provision as part of outpatient hospital services.--
        For purposes of paragraph (1), in determining whether clinical 
        diagnostic laboratory services are furnished as part of 
        outpatient services of a hospital, the Secretary shall apply 
        the same rules that are used to determine whether clinical 
        diagnostic laboratory services are furnished as an outpatient 
        critical access hospital service under section 1834(g)(4) 
        (determined without regard to the amendments made by section 
        204 of the Medicare Rural Health Access Improvement Act of 
        2008).
            ``(3) Reference.--For the treatment of certain clinical 
        diagnostic laboratory tests furnished prior to July 1, 2007, 
        see section 416 of the Medicare Prescription Drug, Improvement, 
        and Modernization Act of 2003, as extended by section 105 of 
        division B of the Tax Relief and Health Care Act of 2006 and 
        section 107 of the Medicare, Medicaid, and SCHIP Extension Act 
        of 2007.''.

SEC. 204. CLARIFICATION OF PAYMENT FOR CLINICAL LABORATORY TESTS 
              FURNISHED BY CRITICAL ACCESS HOSPITALS.

    (a) In General.--Section 1834(g)(4) of the Social Security Act (42 
U.S.C. 1395m(g)(4)) is amended--
            (1) in the heading, by striking ``no beneficiary cost-
        sharing for'' and inserting ``treatment of''; and
            (2) by adding at the end the following new sentence: ``For 
        purposes of the preceding sentence and section 1861(mm)(3), 
        clinical diagnostic laboratory services furnished by a critical 
        access hospital shall be treated as being furnished as part of 
        outpatient critical access services without regard to whether 
        the individual with respect to whom such services are furnished 
        is physically present in the critical access hospital at the 
        time the specimen is collected or was in a skilled nursing 
        facility or a clinic that is owned by, or co-located with, the 
        critical access hospital.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to services furnished on or after January 1, 2009.

SEC. 205. EXTENSION OF MEDICARE INCENTIVE PAYMENT PROGRAM FOR PHYSICIAN 
              SCARCITY AREAS.

    Section 1833(u) of the Social Security Act (42 U.S.C. 1395l(u)), as 
amended by section 102 of the Medicare, Medicaid, and SCHIP Extension 
Act of 2007 (Public Law 110-173), is amended--
            (1) in paragraph (1), by striking ``before July 1, 2008'' 
        and inserting ``before January 1, 2010''; and
            (2) in paragraph (4)(D), by striking ``before July 1, 
        2008'' and inserting ``before January 1, 2010''.

SEC. 206. REVISIONS TO THE WORK GEOGRAPHIC ADJUSTMENT UNDER THE 
              MEDICARE PHYSICIAN FEE SCHEDULE.

    (a) Extension of Floor.--Section 1848(e)(1)(E) of the Social 
Security Act (42 U.S.C. 1395w-4(e)(1)(E)), as amended by section 103 of 
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 
110-173), is amended by striking ``before July 1, 2008'' and inserting 
``before January 1, 2010''.
    (b) Recognition of Equality of Physician Work in All Geographic 
Areas.--Section 1848(e)(1) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)) is amended--
            (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''; and
            (2) by inserting after subparagraph (E) the following new 
        subparagraph:
                    ``(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.''.

SEC. 207. 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:
                    ``(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 in 2009, 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.''.
    (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:
                    ``(I) More appropriate recognition of differences 
                in employee wages and office rents among areas.--
                            ``(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.
                            ``(ii) Limitations on available data.--The 
                        limitations on available data described in this 
                        clause are the following:
                                    ``(I) The need to use proxy data to 
                                reflect differences in employee wages 
                                and rents among areas.
                                    ``(II) Wages for some categories of 
                                employees being determined in national 
                                markets.
                                    ``(III) Physicians having to 
                                compete for some employees in market 
                                areas that cross fee schedule areas.
                                    ``(IV) Physicians in rural areas 
                                frequently having to locate their 
                                offices close to urban areas and 
                                competing with urban rent markets.''.

SEC. 208. 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), and section 104 
of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 
110-173), is amended by striking ``2007, and the first 6 months of 
2008'' and inserting ``2007, 2008, and 2009''.

SEC. 209. EXTENSION OF INCREASED MEDICARE PAYMENTS FOR RURAL GROUND 
              AMBULANCE SERVICES.

    Section 1834(l)(13) of the Social Security Act (42 U.S.C. 
1395m(l)(13)) is amended--
            (1) in subparagraph (A), in the heading, by striking ``In 
        general'' and inserting ``For the second half of 2004 and for 
        2005 and 2006'';
            (2) by redesignating subparagraph (B) as subparagraph (C);
            (3) by inserting the following after subparagraph (A):
                    ``(B) For the second half of 2008 and for 2009 with 
                respect to rural areas.--After computing the rates with 
                respect to ground ambulance services under the other 
                applicable provisions of this subsection, in the case 
                of such services furnished on or after July 1, 2008, 
                and before January 1, 2010, for which the 
                transportation originates in a rural area described in 
                paragraph (9) or in a rural census tract described in 
                such paragraph, the fee schedule established under this 
                section shall provide that the rate for the service 
                otherwise established, after application of any 
                increase under paragraphs (11) and (12), shall be 
                increased by 5 percent.''; and
            (4) in subparagraph (C), as redesignated by paragraph (2)--
                    (A) in the heading, by striking ``Application of 
                increased payments after 2006'' and inserting ``No 
                effect on subsequent periods''; and
                    (B) by adding at the end the following new 
                sentence: ``The increased payments under subparagraph 
                (B) shall not be taken into account in calculating 
                payments for services furnished after the period 
                specified in such subparagraph.''.

SEC. 210. ADDING HOSPITAL-BASED RENAL DIALYSIS CENTERS (INCLUDING 
              SATELLITES) AS ORIGINATING SITES FOR PAYMENT OF 
              TELEHEALTH SERVICES.

    (a) In General.--Section 1834(m)(4)(C)(ii) of the Social Security 
Act (42 U.S.C. 1395m(m)(4)(C)(ii)) is amended by adding at the end the 
following new subclause:
                                    ``(VI) A hospital-based or critical 
                                access hospital-based renal dialysis 
                                center (including satellites).''.
    (b) Effective Date.--The amendment made by this section shall apply 
to services furnished on or after January 1, 2009.

SEC. 211. ADDING SKILLED NURSING FACILITIES AS ORIGINATING SITES FOR 
              PAYMENT OF TELEHEALTH SERVICES.

    (a) Addition.--
            (1) In general.--Section 1834(m)(4)(C)(ii) of the Social 
        Security Act (42 U.S.C. 1395m(m)(4)(C)(ii)), as amended by 
        section 210, is amended by adding at the end the following new 
        subclause:
                                    ``(VII) A skilled nursing facility 
                                (as defined in section 1819(a)).''.
            (2) Conforming amendment.--Section 1888(e)(2)(A)(ii) of the 
        Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended 
        by inserting ``telehealth services furnished under section 
        1834(m)(4)(C)(ii)(VII),'' after ``section 1861(s)(2),''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to telehealth services furnished on or after January 1, 2009.

SEC. 212. RURAL HEALTH CLINIC IMPROVEMENTS.

    Section 1833(f) of the Social Security Act (42 U.S.C. 1395l(f)) is 
amended--
            (1) in paragraph (1), by striking ``, and'' at the end and 
        inserting a semicolon;
            (2) in paragraph (2)--
                    (A) by inserting ``(before 2009)'' after ``in a 
                subsequent year''; and
                    (B) by striking the period at the end and inserting 
                a semicolon; and
            (3) by adding at the end the following new paragraphs:
            ``(3) in 2009, at $92 per visit; and
            ``(4) in a subsequent year, at the limit established under 
        this subsection for the previous year increased by the 
        percentage increase in the MEI (as so defined) furnished as of 
        the first day of that year.''.

SEC. 213. 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--
            (1) in the matter preceding subparagraph (A), by striking 
        ``may'' and inserting ``shall''; and
            (2) by striking subparagraph (A) and inserting the 
        following:
                    ``(A) rural areas and small metropolitan 
                statistical areas with a population of 600,000 or less; 
                and''.
    (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''.
    (c) Effective Date; Exception.--
            (1) Effective date.--Subject to paragraph (2), 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).
            (2) Exception.--The amendments made by this section shall 
        not apply to contracts entered into under section 1847 of the 
        Social Security Act (42 U.S.C. 1395w-3) prior to September 1, 
        2008, pursuant to the implementation of subsection 
        (a)(1)(B)(i)(I) of such section 1847.

SEC. 214. 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.--
            (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))''.
            (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''.
    (b) Recognition of Attending Physician Assistants as Attending 
Physicians To Serve Hospice Patients.--
            (1) In general.--Section 1861(dd)(3)(B) of the Social 
        Security Act (42 U.S.C. 1395x(dd)(3)(B)) is amended--
                    (A) by striking ``or nurse'' and inserting ``, the 
                nurse''; and
                    (B) by inserting ``, or the physician assistant (as 
                defined in such subsection)'' after ``subsection 
                (aa)(5))''.
            (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''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2009.
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