1.Short
title; table of contents
(a)This Act may be cited
as the Medicare Rural Health Access
Improvement Act of 2008
.
(b)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.
<enum>I</enum><header>Provisions
relating to Medicare part A</header>
<section commented="no" display-inline="no-display-inline" id="idABCEAF319D2648B48D00A50A3F1B0864"><enum>101.</enum><header>Extension of
Medicare FLEX grants</header><text display-inline="no-display-inline">Section
1820(j) of the Social Security Act (42 U.S.C. 1395i–4(j)) is amended by
striking <quote>2008</quote> and inserting <quote>2009</quote>.</text>
</section><section id="id2E443E14518540369737D6AEB6493526"><enum>102.</enum><header>Improvements
to the medicare-dependent hospital (MDH) program</header>
<subsection id="id3AB4EACAE83149FAB75FD99313C98C56"><enum>(a)</enum><header>Use of non-wage
adjusted PPS rate</header><text>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:</text>
<quoted-block display-inline="no-display-inline" id="id4AE5D6F107BC4FE0B7AD8C68BC32B518" style="OLC">
<clause id="id1778CC8B07FB40588BEB143CD65ABD06" indent="up3"><enum>(v)</enum><text>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).</text>
</clause><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="id8625704EDF574FB9B47F2958551A954F"><enum>(b)</enum><header>Enhanced
payment for amount by which the target exceeds the PPS
rate</header><text>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 <quote>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</quote> after <quote>October 1,
2006</quote>.</text>
</subsection></section><section id="H08531D2582B24ACE9D2D97522B750500"><enum>103.</enum><header>Rebasing for
sole community hospitals</header>
<subsection id="HFEBA6498A63D4D0F97879466406158E3"><enum>(a)</enum><header>Rebasing
permitted</header><text display-inline="yes-display-inline">Section 1886(b)(3)
of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395ww">42 U.S.C. 1395ww(b)(3)</external-xref>) is
amended by adding at the end the following new subparagraph:</text>
<quoted-block display-inline="no-display-inline" id="H6DF81C7122EF42EAB4B644DC98AB2200" other-style="archaic" style="other">
<subparagraph id="H899B696BF3E3422C9F350068013CAD36" indent="up2"><enum>(L)</enum><clause commented="no" display-inline="yes-display-inline" id="H129A9CAC833342A88C2B15E3CE56669E"><enum>(i)</enum><text display-inline="yes-display-inline">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.</text>
</clause><clause id="HAFF305ABFC6840999C2CAC12E288A947" indent="up1"><enum>(ii)</enum><text display-inline="yes-display-inline">For purposes of this subparagraph, the term
<quote>subparagraph (L) rebased target amount</quote> has the meaning given the
term <term>target amount</term> in subparagraph (C), except that—</text>
<subclause id="H7CD35B03DD0F4003974E952B18E6AA73"><enum>(I)</enum><text display-inline="yes-display-inline">there shall be substituted for the base
cost reporting period the 12-month cost reporting period beginning during
fiscal year 2002;</text>
</subclause><subclause id="H306DDD1EAF314EFEAB966D8E4DE2ED74"><enum>(II)</enum><text display-inline="yes-display-inline">any reference in subparagraph (C)(i) to the
<quote>first cost reporting period</quote> described in such subparagraph is
deemed a reference to the first cost reporting period beginning on or after
October 1, 2008; and</text>
</subclause><subclause id="HEC6BD58690984C03B5185FDCB7CBBD28"><enum>(III)</enum><text display-inline="yes-display-inline">the applicable percentage increase shall
only be applied under subparagraph (C)(iv) for discharges occurring in fiscal
years beginning with fiscal year
2009.</text>
</subclause></clause></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="H16ED194182CE47B28DCC0035AD22C641"><enum>(b)</enum><header>Conforming
amendments</header><text>Section 1886(b)(3) of the Social Security Act
(<external-xref legal-doc="usc" parsable-cite="usc/42/1395ww">42 U.S.C.
1395ww(b)(3)</external-xref>) is amended—</text>
<paragraph id="HD6893E471CF349BAA704FFE4524EA7D"><enum>(1)</enum><text>in
subparagraph (C), in the matter preceding clause (i), by striking
<quote>subparagraph (I)</quote> and inserting <quote>subparagraphs (I) and
(L)</quote>; and</text>
</paragraph><paragraph id="HEFE5C991354A4E439FC96C1EEE5C44AE"><enum>(2)</enum><text>in subparagraph
(I)(i), in the matter preceding subclause (I), by striking <quote>For</quote>
and inserting <quote>Subject to subparagraph (L), for</quote>.</text>
</paragraph></subsection></section><section id="id83970EAD84F6467CAE0081E9433E388E"><enum>104.</enum><header>Temporary
improvements to the Medicare inpatient hospital payment adjustment for
low-volume hospitals</header><text display-inline="no-display-inline">Section
1886(d)(12) of the <act-name parsable-cite="SSA">Social Security Act</act-name>
(42 U.S.C. 1395ww(d)(12)) is amended—</text>
<paragraph id="idC4194CE394544D2594E1D0E260AEE3E2"><enum>(1)</enum><text>in subparagraph
(A), by inserting <quote>or (D)</quote> after <quote>subparagraph
(B)</quote>;</text>
</paragraph><paragraph id="idB8BF98E9EF714B67BA42D036060909DC"><enum>(2)</enum><text>in subparagraph
(B), by striking <quote>The Secretary</quote> and inserting <quote>For
discharges occurring in fiscal years 2005 through 2008 and for discharges
occurring in fiscal year 2011 and subsequent fiscal years, the
Secretary</quote>;</text>
</paragraph><paragraph id="id08D3896BE6744CD7AB2A87B831EF96DF"><enum>(3)</enum><text display-inline="yes-display-inline">in subparagraph (C)(i)—</text>
<subparagraph id="id5016970EEDF04CF59BF687ED7647A09C"><enum>(A)</enum><text>by inserting
<quote>(or, with respect to fiscal years 2009 and 2010, 15 road miles)</quote>
after <quote>25 road miles</quote>; and</text>
</subparagraph><subparagraph id="id4393CE41CB824E448F6AAE575E000EA5"><enum>(B)</enum><text display-inline="yes-display-inline">by inserting <quote>(or, with respect to
fiscal years 2009 and 2010, 2,000 discharges of individuals entitled to, or
enrolled for, benefits under part A)</quote> after <quote>800
discharges</quote>; and</text>
</subparagraph></paragraph><paragraph id="id4135756AAA1A45FA80451A861E61DDC4"><enum>(4)</enum><text>by adding at the
end the following new subparagraph:</text>
<quoted-block display-inline="no-display-inline" id="id0121F58BC213495F9C204A62263DCD2F" style="OLC">
<subparagraph id="id087B5F2FC304422EB67E8CF45D1E2B1C"><enum>(D)</enum><header>Temporary
applicable percentage increase</header><text>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.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section id="HF3C2F58790054634B604406152583211"><enum>105.</enum><header>Temporary
elimination of the DSH adjustment cap</header><text display-inline="no-display-inline">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: <quote>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.</quote>.</text>
</section><enum>II</enum><header>Provisions
relating to Medicare part B</header>
<section commented="no" display-inline="no-display-inline" id="HDD1E73D2D39C4E389B65CE6EA0BDB058"><enum>201.</enum><header>Extension and
expansion of the Medicare hold harmless provision under the prospective payment
system for hospital outpatient department (HOPD) services for certain
hospitals</header><text display-inline="no-display-inline">Section
1833(t)(7)(D)(i) of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395l">42 U.S.C. 1395l(t)(7)(D)</external-xref>(i)) is
amended—</text>
<paragraph commented="no" display-inline="no-display-inline" id="idDCA79BA45CD346DF991BFBB34C005A6C"><enum>(1)</enum><text display-inline="yes-display-inline">in subclause (II)—</text>
<subparagraph commented="no" display-inline="no-display-inline" id="idB27F381E95924BF4AD2FD6F7B8C76C3D"><enum>(A)</enum><text>in the first
sentence, by striking <quote>2009</quote> and inserting <quote>2010</quote>;
and</text>
</subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="id235C2EBB85A041AA85B24CC9CEE9ACCC"><enum>(B)</enum><text display-inline="yes-display-inline">by striking the second sentence and
inserting the following new sentence: <quote>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.</quote>; and</text>
</subparagraph></paragraph><paragraph display-inline="no-display-inline" id="id542FD63A7AC64C9C92335A1EF0FEEA79"><enum>(2)</enum><text>by adding at the
end the following new subclause:</text>
<quoted-block display-inline="no-display-inline" id="idBA2299F4EBAE4096B84D5D1419002E08" style="OLC">
<subclause commented="no" display-inline="no-display-inline" id="H88468B0D56F440408CF5C3054BBDDDA" indent="up1"><enum>(III)</enum><text display-inline="yes-display-inline">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.</text>
</subclause><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section commented="no" id="ID48D66CE8B9974B56BE58F5213CE23819"><enum>202.</enum><header>Treatment of
rural sole community hospitals and medicare dependent, small rural hospitals
under the prospective payment system for hospital outpatient department (HOPD)
services</header><text display-inline="no-display-inline">Section 1833(t)(13)
of the Social Security Act (<external-xref legal-doc="usc" parsable-cite="usc/42/1395l">42 U.S.C. 1395l(t)(13)</external-xref>) is
amended—</text>
<paragraph commented="no" id="id28031A8E3E3D4566B5776F66B25E3D1D"><enum>(1)</enum><text display-inline="yes-display-inline">in the heading, by striking
<quote><header-in-text level="paragraph" style="OLC">Authorization of
adjustment</header-in-text></quote> and inserting <quote><header-in-text level="paragraph" style="OLC">Adjustment</header-in-text></quote>;</text>
</paragraph><paragraph commented="no" id="id1BAC7B5ACEC142BA93B6F0BFA6368CA7"><enum>(2)</enum><text>in subparagraph
(B)—</text>
<subparagraph commented="no" id="id770B54CD9C224DA19BF49640BE8C488D"><enum>(A)</enum><text>in the heading,
by inserting <quote><header-in-text level="subparagraph" style="OLC">for 2006,
2007, and 2008</header-in-text></quote> after <quote><header-in-text level="subparagraph" style="OLC">adjustment</header-in-text></quote>;
and</text>
</subparagraph><subparagraph commented="no" id="id5610C926E587446EA417AD4D97F69BE2"><enum>(B)</enum><text>by adding at the
end the following new sentence: <quote>Such authority shall apply with respect
to services furnished in 2006, 2007, or 2008.</quote>; and</text>
</subparagraph></paragraph><paragraph commented="no" id="id288929EB0B474B8E99BB25E9DFCC93A2"><enum>(3)</enum><text>by adding at the
end the following new subparagraph:</text>
<quoted-block display-inline="no-display-inline" id="idAD29A3B0C4E94FA98E535082331EFB61" style="OLC">
<subparagraph commented="no" id="id425700AD61EF4EA3831A3CD39A04288F"><enum>(C)</enum><header>Adjustment for
2009 and subsequent years for certain rural hospitals</header>
<clause commented="no" id="id9EF5509B66184A31894AF62FFDF9467C"><enum>(i)</enum><header>Adjustment</header>
<subclause commented="no" id="id7A8566CCA06C438BB715A8AB3FD2523E"><enum>(I)</enum><header>In
general</header><text>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.</text>
</subclause><subclause commented="no" id="id26FE2F1DFD07460F897E9B0E52C3EAF7"><enum>(II)</enum><header>Revision with
notice and comment</header><text>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.</text>
</subclause></clause><clause commented="no" id="idEA20C1DE59684E81847375C2C937EF98"><enum>(ii)</enum><header>Not applicable
to pass-through devices, drugs, and biologicals</header><text>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).</text>
</clause><clause commented="no" id="id72D3CB76C61544C889E5A32168ABFECC"><enum>(iii)</enum><header>Exemption
from budget neutrality</header><text>The provisions of this subparagraph shall
not be effected in a budget-neutral manner under this
subsection.</text>
</clause></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section id="idB5003EF8197C44FFAA631C9EBF91F396"><enum>203.</enum><header>Permanent
treatment of Medicare reasonable costs payments for certain clinical diagnostic
laboratory tests furnished to hospital patients in certain rural
areas</header><text display-inline="no-display-inline">Section 1833 of the
Social Security Act (42 U.S.C. 1395l) is amended by adding at the end the
following new subsection:</text>
<quoted-block display-inline="no-display-inline" id="id570E539A5793478AB7003B41E639ADCC" style="OLC">
<subsection id="idE4BC34736F004480B8044F816A26F648"><enum>(v)</enum><header>Reasonable
costs payments for certain clinical diagnostic laboratory tests furnished to
hospital patients in certain rural areas</header>
<paragraph id="ID46A327CF697548488806B629AE7A561D"><enum>(1)</enum><header>In
general</header><text>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.</text>
</paragraph><paragraph id="ID5DB2867CBC8D4A21A6E9ECF7B1EBC160"><enum>(2)</enum><header>Provision as
part of outpatient hospital services</header><text>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 <short-title>Medicare Rural
Health Access Improvement Act of 2008</short-title>).</text>
</paragraph><paragraph id="ID8F34552F828E4AF08BC941B48BDF469A"><enum>(3)</enum><header>Reference</header><text>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.</text>
</paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</section><section id="idBD6BFA05622F42FDB1B679CFBA41AD8D"><enum>204.</enum><header>Clarification
of payment for clinical laboratory tests furnished by critical access
hospitals</header>
<subsection id="IDACEA5FC2C6D043499DF60FC08154EB56"><enum>(a)</enum><header>In
general</header><text><external-xref legal-doc="act" parsable-cite="SSA/1834(g)(4)">Section 1834(g)(4)</external-xref> of the
<act-name parsable-cite="SSA">Social Security Act</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/42/1395m(g)(4)">42 U.S.C.
1395m(g)(4)</external-xref>) is amended—</text>
<paragraph id="IDB07589F68E134799801E119434BEDF65"><enum>(1)</enum><text>in the heading,
by striking <quote><header-in-text level="paragraph" style="OLC">no beneficiary
cost-sharing for</header-in-text></quote> and inserting <quote><header-in-text level="paragraph" style="OLC">treatment of</header-in-text></quote>; and</text>
</paragraph><paragraph id="ID2EB4011E34D84FCABF2D6E15BB03E6EC"><enum>(2)</enum><text>by adding at the
end the following new sentence: <quote>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.</quote>.</text>
</paragraph></subsection><subsection commented="no" display-inline="no-display-inline" id="ID06BE084B07864328AC0A877A09FEA541"><enum>(b)</enum><header>Effective
date</header><text>The amendments made by subsection (a) shall apply to
services furnished on or after January 1, 2009.</text>
</subsection></section><section id="HA9B31C9F1B9E41AD8C930600008CD58F" section-type="subsequent-section"><enum>205.</enum><header>Extension of
Medicare incentive payment program for physician scarcity areas</header><text display-inline="no-display-inline">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—</text>
<paragraph id="idBC23D2BFF2B047059A0922618DE041A5"><enum>(1)</enum><text display-inline="yes-display-inline">in paragraph (1), by striking <quote>before
July 1, 2008</quote> and inserting <quote>before January 1, 2010</quote>;
and</text>
</paragraph><paragraph commented="no" id="id1FD1D9B22C7447FD8A475464F59887C4"><enum>(2)</enum><text>in paragraph
(4)(D), by striking <quote>before July 1, 2008</quote> and inserting
<quote>before January 1, 2010</quote>.</text>
</paragraph></section><section id="id26E2A80811F94DDDA4BA101B7AFA23F3"><enum>206.</enum><header>Revisions to
the work geographic adjustment under the Medicare physician fee
schedule</header>
<subsection id="H7C6BF9A6A0954ACFA38C097EE3AD5E5D"><enum>(a)</enum><header>Extension of
floor</header><text display-inline="yes-display-inline">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 <quote>before July 1, 2008</quote> and
inserting <quote>before January 1, 2010</quote>.</text>
</subsection><subsection id="id869A3696D54B48AB8791E69D781B6F2C"><enum>(b)</enum><header>Recognition of
equality of physician work in all geographic areas</header><text>Section
1848(e)(1) of the Social Security Act (42 U.S.C. 1395w–4(e)(1)) is
amended—</text>
<paragraph id="id43ECA5E782FE474B88955BC708CB5971"><enum>(1)</enum><text>in subparagraph
(A), in the matter preceding clause (i), by striking <quote>subparagraphs
(B)</quote> through <quote>the Secretary</quote> and inserting <quote>the
succeeding provisions of this paragraph, the Secretary</quote>; and</text>
</paragraph><paragraph id="idE924882145CF48B3A6C1ADC40B0B1DB7"><enum>(2)</enum><text>by inserting
after subparagraph (E) the following new subparagraph:</text>
<quoted-block display-inline="no-display-inline" id="idFBF62E276DFD4A719C3677F41450F5F5" style="OLC">
<subparagraph id="ID93bea3a940a9437f96abecb9e1a1d4e9"><enum>(F)</enum><header>Recognition of
equality of physician work in all geographic areas</header><text>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.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></subsection></section><section id="idC66C239E53DF47EBAEB59EA6ECB51C86"><enum>207.</enum><header>Revisions to
the practice expense geographic adjustment under the Medicare physician fee
schedule</header>
<subsection id="ID4E01C786250145A6A3A6EC223B2DCA6F"><enum>(a)</enum><header>Establishment
of floor</header><text display-inline="yes-display-inline">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:</text>
<quoted-block id="IDB184BA3A55EA4E71968D3C776A6E979E" style="OLC">
<subparagraph id="ID28E078A5E4D340E9840EE01E4409E1F1"><enum>(H)</enum><header>Floor at 1.0 on
practice expense geographic index</header><text>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.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="id92D835E24E074C038CF54E31AA5CE142"><enum>(b)</enum><header>More
appropriate recognition of practice expense differences in employee wages and
office rents among geographic areas</header><text>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:</text>
<quoted-block display-inline="no-display-inline" id="id0FB85F99B7FE43F6B4ECEF508F349F79" style="OLC">
<subparagraph id="IDf7955422d9564069a742c7ff1378121a"><enum>(I)</enum><header>More
appropriate recognition of differences in employee wages and office rents among
areas</header>
<clause id="ID33efcaeca9604010bbcace7599058eb7"><enum>(i)</enum><header>In
general</header><text>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
<fraction>1/2</fraction> 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.</text>
</clause><clause id="IDcc52eef4919247978f58eda5c833bb3e"><enum>(ii)</enum><header>Limitations on
available data</header><text>The limitations on available data described in
this clause are the following:</text>
<subclause id="ID2a65ce7ca5d6476d8cad8f15ffba9eac"><enum>(I)</enum><text>The need to use
proxy data to reflect differences in employee wages and rents among
areas.</text>
</subclause><subclause id="ID38e11807638c4218befbe9f89634fb0e"><enum>(II)</enum><text>Wages for some
categories of employees being determined in national markets.</text>
</subclause><subclause id="ID9978b7e5c7d54db0a6e9d4af2507761a"><enum>(III)</enum><text>Physicians
having to compete for some employees in market areas that cross fee schedule
areas.</text>
</subclause><subclause id="ID0806b2d2b9924e3fae287037fa3cf6b2"><enum>(IV)</enum><text>Physicians in
rural areas frequently having to locate their offices close to urban areas and
competing with urban rent
markets.</text>
</subclause></clause></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection></section><section id="IDB4F6FB08B8FB4763AF28883C6819D5F2"><enum>208.</enum><header>Extension of
treatment of certain physician pathology services under Medicare</header><text display-inline="no-display-inline">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 <quote>2007, and the first 6 months of 2008</quote> and inserting
<quote>2007, 2008, and 2009</quote>.</text>
</section><section id="id803F1D8150C447B0ABEBF9AC12A9E2AB"><enum>209.</enum><header>Extension of
increased Medicare payments for rural ground ambulance services</header><text display-inline="no-display-inline">Section 1834(l)(13) of the Social Security
Act (42 U.S.C. 1395m(l)(13)) is amended—</text>
<paragraph id="id9CDBE9B40ACE43AE8E8B384C9E095002"><enum>(1)</enum><text>in subparagraph
(A), in the heading, by striking <quote><header-in-text level="subparagraph" style="OLC">In general</header-in-text></quote> and inserting
<quote><header-in-text level="subparagraph" style="OLC">For the second half of
2004 and for 2005 and 2006</header-in-text></quote>;</text>
</paragraph><paragraph id="ID5e64b32637c746c9a6d133e88da28504"><enum>(2)</enum><text>by redesignating
subparagraph (B) as subparagraph (C);</text>
</paragraph><paragraph id="ID47ac20878e484b75b6f4fae4ed27d84b"><enum>(3)</enum><text>by inserting the
following after subparagraph (A):</text>
<quoted-block display-inline="no-display-inline" id="id0FF68EF5E24C48A2A259CB428F9CCE98" style="OLC">
<subparagraph id="ID0c781eac93c141868d7d4c6044c165f4"><enum>(B)</enum><header>For the second
half of 2008 and for 2009 with respect to rural areas</header><text>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.</text>
</subparagraph><after-quoted-block>;
and</after-quoted-block></quoted-block>
</paragraph><paragraph id="ID8b2e74d790a2458a9ca237e1fd36bdc5"><enum>(4)</enum><text>in subparagraph
(C), as redesignated by paragraph (2)—</text>
<subparagraph id="id11B0CA76AAC5462DA8319807D7A26924"><enum>(A)</enum><text>in the heading,
by striking <quote><header-in-text level="subparagraph" style="OLC">Application
of increased payments after 2006</header-in-text></quote> and inserting
<quote><header-in-text level="subparagraph" style="OLC">No effect on subsequent
periods</header-in-text></quote>; and</text>
</subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="id38CE085AAEE049F1AE277E54F2136E1B"><enum>(B)</enum><text>by adding at the
end the following new sentence: <quote>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.</quote>.</text>
</subparagraph></paragraph></section><section id="id8BD58A5F325B418983FF73C74B6DC7AD"><enum>210.</enum><header>Adding
hospital-based renal dialysis centers (including satellites) as originating
sites for payment of telehealth services</header>
<subsection id="idA07B6C81DFAD44EEA4540FDE9B3DB090"><enum>(a)</enum><header>In
general</header><text>Section 1834(m)(4)(C)(ii) of the
<act-name parsable-cite="SSA">Social Security Act</act-name> (42 U.S.C.
1395m(m)(4)(C)(ii)) is amended by adding at the end the following new
subclause:</text>
<quoted-block act-name="Social Security Act" id="ID291B3149F7EC438D973F9CDB46099519">
<subclause id="ID4457B55E2BDF4903853ADF7E975C0285"><enum>(VI)</enum><text>A hospital-based
or critical access hospital-based renal dialysis center (including
satellites).</text>
</subclause><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection commented="no" id="id0871895D3CD54E9890E4ED38062FAC1F"><enum>(b)</enum><header>Effective
Date</header><text display-inline="yes-display-inline">The amendment made by
this section shall apply to services furnished on or after January 1,
2009.</text>
</subsection></section><section id="id0D3DBFF1435D4F00BE8BFEBE231ED003"><enum>211.</enum><header>Adding skilled
nursing facilities as originating sites for payment of telehealth
services</header>
<subsection id="ID9372d3c0466149cebad20bbc6db7eef2"><enum>(a)</enum><header>Addition</header>
<paragraph id="id0EA4F222C0C94F82B47B0E9E10DA211C"><enum>(1)</enum><header>In
general</header><text>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:</text>
<quoted-block display-inline="no-display-inline" id="idE1206C1C4E1B46E4AF6EFA3367439C08" style="OLC">
<subclause id="ID5af9eef6dbab4fd8bcee24f47bc57a92"><enum>(VII)</enum><text>A skilled
nursing facility (as defined in section
1819(a)).</text>
</subclause><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph><paragraph id="id64B7B83D17CC439D98F8B47EA3591DB3"><enum>(2)</enum><header>Conforming
amendment</header><text>Section 1888(e)(2)(A)(ii) of the Social Security Act
(42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting <quote>telehealth
services furnished under section 1834(m)(4)(C)(ii)(VII),</quote> after
<quote>section 1861(s)(2),</quote>.</text>
</paragraph></subsection><subsection id="IDa3b1ffd49a3f4778b21cf36e3739d2c7"><enum>(b)</enum><header>Effective
date</header><text>The amendments made by subsection (a) shall apply to
telehealth services furnished on or after January 1, 2009.</text>
</subsection></section><section id="ID0EB8454AF7F84B5EB465C307156AF031"><enum>212.</enum><header>Rural health
clinic improvements</header><text display-inline="no-display-inline">Section
1833(f) of the <act-name parsable-cite="SSA">Social Security Act</act-name> (42
U.S.C. 1395l(f)) is amended—</text>
<paragraph id="id1FCD466A204C465F8E1F7FA44F50F2C2"><enum>(1)</enum><text>in paragraph (1),
by striking <quote>, and</quote> at the end and inserting a semicolon;</text>
</paragraph><paragraph id="idE9C0FF12EBE14F49907AD5C015218EAD"><enum>(2)</enum><text>in paragraph
(2)—</text>
<subparagraph id="id5188DE7ED6A34BE8B2AD2EC7EA6A67B4"><enum>(A)</enum><text>by inserting
<quote>(before 2009)</quote> after <quote>in a subsequent year</quote>;
and</text>
</subparagraph><subparagraph id="id551A03E7F76C40ED9283B5B5CB808B5F"><enum>(B)</enum><text>by striking the
period at the end and inserting a semicolon; and</text>
</subparagraph></paragraph><paragraph id="id9031C69B0AE84D9FA069C04157425DBC"><enum>(3)</enum><text>by adding at the
end the following new paragraphs:</text>
<quoted-block display-inline="no-display-inline" id="idAEECDD94285B49D8878F121F06D0DD17" style="OLC">
<paragraph id="id8AE843E08D5A4669BBB2E516564D5D65"><enum>(3)</enum><text>in 2009, at $92
per visit; and</text>
</paragraph><paragraph commented="no" display-inline="no-display-inline" id="idEE1790F52FDB43DBB5B326D00560A316"><enum>(4)</enum><text>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.</text>
</paragraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section id="id5A6EA7E761824456849FDC761F74EFA6"><enum>213.</enum><header>Exemption for
suppliers in small MSAs and rural areas</header>
<subsection id="id8F0BFACB6D474EEFB5190D5AC978F557"><enum>(a)</enum><header>Exemption</header><text>Section
1847(a)(3) of the Social Security Act (42 U.S.C. 1395w–3(a)(3)) is
amended—</text>
<paragraph id="idB08D5E2552BD40B59362054F55E9B089"><enum>(1)</enum><text>in the matter
preceding subparagraph (A), by striking <quote>may</quote> and inserting
<quote>shall</quote>; and</text>
</paragraph><paragraph id="id05B27181D661449F81AD0FED5AE14D99"><enum>(2)</enum><text>by striking
subparagraph (A) and inserting the following:</text>
<quoted-block display-inline="no-display-inline" id="idA0C0C5F0FE334BB48011B691F181FB4E" style="OLC">
<subparagraph id="id194D872C537943879889D4B7546FD73A"><enum>(A)</enum><text>rural areas and
small metropolitan statistical areas with a population of 600,000 or less;
and</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></subsection><subsection id="ID9511cd31ba2c4aaf916c2b114c84f8ee"><enum>(b)</enum><header>Inapplicability
of competitively bid prices to rural and small MSAs</header><text>Section
1834(a)(1)(F)(ii) of the Social Security Act (42 U.S.C. 1395m(a)(1)(F)(ii)) is
amended by striking <quote>the Secretary</quote> and inserting <quote>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</quote>.</text>
</subsection><subsection id="ID31be79452a774899b3d955b4fc7e3235"><enum>(c)</enum><header>Effective date;
exception</header>
<paragraph id="id4ED2C2494B2C41BDA3477BAD9657E3F6"><enum>(1)</enum><header>Effective
date</header><text>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).</text>
</paragraph><paragraph id="id658FDB8C809A48559D246D968165EDC1"><enum>(2)</enum><header>Exception</header><text>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.</text>
</paragraph></subsection></section><section id="id75B3CE00BCB8424F9F63281564862E12"><enum>214.</enum><header>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</header>
<subsection id="ID2ed51bbe8fc743e4b4d9674331b9b1ab"><enum>(a)</enum><header>Ordering
post-hospital extended care services</header>
<paragraph id="id5CC9C5B2D44641C2993624CE197C8684"><enum>(1)</enum><header>In
general</header><text>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
<quote>nurse practitioner or clinical nurse specialist</quote> and inserting
<quote>nurse practitioner, a clinical nurse specialist, or a physician
assistant (as those terms are defined in section 1861(aa)(5))</quote>.</text>
</paragraph><paragraph id="idFBCC1B362BCE48DD8A45572729957509"><enum>(2)</enum><header>Conforming
amendment</header><text>Section 1814(a) of the Social Security Act (42 U.S.C.
1395f(a)) is amended, in the second sentence, by striking <quote>or clinical
nurse specialist</quote> and inserting <quote>clinical nurse specialist, or
physician assistant</quote>.</text>
</paragraph></subsection><subsection id="IDBAF4CC3323594F369FB86F6440439E40"><enum>(b)</enum><header>Recognition of
attending physician assistants as attending physicians To serve hospice
patients</header>
<paragraph id="ID557FA49ACA1C4536A32A3A3FEC76FB90"><enum>(1)</enum><header>In
General</header><text>Section 1861(dd)(3)(B) of the Social Security Act (42
U.S.C. 1395x(dd)(3)(B)) is amended—</text>
<subparagraph id="idB1DC9406D9C949A1AB99223169DFCC5E"><enum>(A)</enum><text>by striking
<quote>or nurse</quote> and inserting <quote>, the nurse</quote>; and</text>
</subparagraph><subparagraph id="id2222B093442240798B46560769BB12D1"><enum>(B)</enum><text>by inserting
<quote>, or the physician assistant (as defined in such subsection)</quote>
after <quote>subsection (aa)(5))</quote>.</text>
</subparagraph></paragraph><paragraph id="ID35BA217F1AD24B2AA118E539BCD5E11D"><enum>(2)</enum><header>Clarification
of hospice role of physician assistants</header><text>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 <quote>or a physician assistant</quote> after <quote>a
nurse practitioner</quote>.</text>
</paragraph></subsection><subsection commented="no" display-inline="no-display-inline" id="IDb14dbc1473c6481484366101d1308688"><enum>(c)</enum><header>Effective
date</header><text>The amendments made by this section shall apply to items and
services furnished on or after January 1, 2009.</text>
</subsection></section>