[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1355 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                S. 1355

 To amend title XVIII of the Social Security Act to improve access to 
health care for individuals residing in underserved rural areas and for 
                            other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             June 25, 2009

Mr. Barrasso (for himself and Mr. Wyden) 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 for individuals residing in underserved 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 
Clinic Patient Access and Improvement Act of 2009''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Rural health clinic reimbursement.
Sec. 3. Rural health clinic quality reporting initiative.
Sec. 4. Rural health clinic and community health center collaborative 
                            access expansion.
Sec. 5. GAO report on diabetes education and medical nutrition therapy 
                            services.
Sec. 6. Rural health clinic provider retention demonstration project.
Sec. 7. Definition of rural health clinic.
Sec. 8. Medicare Advantage plan payments.
Sec. 9. Sense of the Senate regarding adequacy of network-based health 
                            plans.

SEC. 2. RURAL HEALTH CLINIC REIMBURSEMENT.

    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 striking ``in a subsequent year'' and 
                inserting ``after 1988 and before 2010''; 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 2010, 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 defined in section 
        1842(i)(3)) applicable to primary care services (as defined in 
        section 1842(i)(4)) furnished as of the first day of that 
        year.''.

SEC. 3. RURAL HEALTH CLINIC QUALITY REPORTING INITIATIVE.

    Section 1833 of the Social Security Act (42 U.S.C. 1395l) is 
amended by adding at the end the following new subsection:
    ``(x) Incentive Payments for Rural Health Clinic Quality 
Reporting.--
            ``(1) In general.--The Secretary shall implement a system 
        to provide incentive payments for the satisfactory reporting of 
        data on quality measures by eligible professionals, as defined 
        in subsection (k)(3)(B) of section 1848, who are employed by a 
        rural health clinic or provide services in a rural health 
        clinic through a contractual arrangement, similar to the 
        reporting system for covered professional services as 
        established under subsections (k) and (m) of such section.
            ``(2) Amount; duration.--Incentive payments in the amount 
        of $2 per visit shall be made to rural health clinics with 
        respect to eligible professionals who furnish rural health 
        clinic services during the period beginning on January 1, 2010, 
        and ending on December 31, 2013.
            ``(3) Payment from trust fund.--The incentive payments 
        provided under this subsection shall be made available from the 
        Federal Supplementary Medical Insurance Trust Fund under 
        section 1841.
            ``(4) Payment limits.--Incentive payments made under this 
        subsection shall not be subject to the payment limits 
        established under subsection (f).
            ``(5) Single form.--The Secretary shall provide rural 
        health clinics that participate in the quality reporting system 
        under this subsection with a single form for submission of data 
        on quality measures and reimbursement claim information.
            ``(6) Reporting.--Not later than December 31, 2012, the 
        Secretary shall prepare and submit a report to Congress on the 
        quality reporting system established under this subsection, 
        including--
                    ``(A) the number and types of services involved in 
                the system;
                    ``(B) the number of rural health clinics 
                participating in the system;
                    ``(C) the overall quality of care that was 
                delivered by the rural health clinics during this 
                period;
                    ``(D) the patient outcomes under the system;
                    ``(E) recommendations for improving the system; and
                    ``(F) any additional related matters that the 
                Secretary determines appropriate.''.

SEC. 4. RURAL HEALTH CLINIC AND COMMUNITY HEALTH CENTER COLLABORATIVE 
              ACCESS EXPANSION.

    Section 330 of the Public Health Service Act (42 U.S.C. 254b) is 
amended by adding at the end the following:
    ``(s) Rule of Construction With Respect to Rural Health Clinics.--
            ``(1) In general.--Nothing in this section shall be 
        construed to prevent a community health center from contracting 
        with a federally certified rural health clinic (as defined by 
        section 1861(aa)(2) of the Social Security Act) for the 
        delivery of primary health care services that are available at 
        the rural health clinic to individuals who would otherwise be 
        eligible for free or reduced cost care if that individual were 
        able to obtain that care at the community health center. Such 
        services may be limited in scope to those primary health care 
        services available in that rural health clinic.
            ``(2) Assurances.--In order for a rural health clinic to 
        receive funds under this section through a contract with a 
        community health center under paragraph (1), such rural health 
        clinic shall establish policies to ensure--
                    ``(A) nondiscrimination based upon the ability of a 
                patient to pay; and
                    ``(B) the establishment of a sliding fee scale for 
                low-income patients.''.

SEC. 5. GAO REPORT ON DIABETES EDUCATION AND MEDICAL NUTRITION THERAPY 
              SERVICES.

    Not later than July 1, 2012, the Comptroller General of the United 
States shall submit to the Committee on Health, Education, Labor, and 
Pensions of the Senate and the Committee on Energy and Commerce of the 
House of Representatives a report concerning the medical nutrition 
therapy counseling services provided by federally qualified health 
clinics. Such report shall specifically examine--
            (1) the availability, health provider cost, reimbursement 
        amount, and barriers to diabetes education and medical 
        nutrition therapy services in federally qualified health 
        clinics;
            (2) the availability, health provider cost, reimbursement 
        amount, and quality outcomes of diabetes education and medical 
        nutrition therapy services in rural and frontier areas;
            (3) the feasibility of implementing diabetes education and 
        medical nutrition therapy services in rural health clinics; and
            (4) to the extent practical, analyze existing health 
        outcomes and cost savings attributed to diabetes education and 
        medical nutrition therapy services provided by federally 
        qualified health centers and the potential health outcomes and 
        cost savings if those services are offered in rural health 
        clinics.

SEC. 6. RURAL HEALTH CLINIC PROVIDER RETENTION DEMONSTRATION PROJECT.

    (a) In General.--The Secretary shall establish a demonstration 
project under which States are awarded grants to examine whether health 
care professionals can be recruited or retained to work in underserved 
rural areas by providing such professionals with medical malpractice 
subsidies.
    (b) Duration; Scope.--The demonstration project shall be 
conducted--
            (1) for a 3-year period, beginning not later than January 
        1, 2011; and
            (2) in not more than 5 States.
    (c) State Application.--A State that desires to receive a grant 
under the demonstration project shall submit to the Secretary an 
application at such time, in such manner, and containing such 
information as the Secretary may require, including adequate assurances 
that the State--
            (1) promotes the establishment and continued maintenance of 
        rural health clinics within the State; and
            (2) is working to improve access to primary care and other 
        health care services for rural residents of the State.
    (d) State Selection.--In awarding grants to States under this 
section, the Secretary shall--
            (1) ensure the participation of States with a diverse 
        selection of rural health clinics, including clinics with 3 or 
        less full-time equivalent physicians, physician assistants, and 
        nurse practitioners;
            (2) ensure the participation of States that maintain both 
        provider-based and independent rural health clinics;
            (3) give preference to States with existing State-funded 
        medical malpractice subsidy programs; and
            (4) give preference to States with 15 or more rural health 
        clinics.
    (e) Distribution of Grant Funds by States to Rural Health 
Clinics.--
            (1) In general.--A State awarded a grant under the 
        demonstration project shall, acting through the State Office of 
        Rural Health, select not less than 5 rural health clinics to 
        receive grant funds for the purpose of subsidizing medical 
        malpractice insurance costs for health care professionals 
        employed by such clinics.
            (2) Rural health clinic application.--A rural health clinic 
        that desires to receive a grant from the State under the 
        demonstration project shall submit to the State Office of Rural 
        Health an application at such time, in such manner, and 
        containing such information as the Secretary may require, 
        including assurances that the clinic shall--
                    (A) provide access to health care services for all 
                individuals, regardless of ability to pay;
                    (B) establish a sliding fee scale for low-income 
                patients;
                    (C) make health care services available to 
                individuals for not less than 20 hours per week; and
                    (D) meet any other requirements established by the 
                Secretary to ensure proper and efficient use of grant 
                funds.
            (3) Required clinic participation.--A State awarded a grant 
        under the demonstration project shall provide grant funds to at 
        least 1 provider-based rural health clinic and at least 1 
        independent rural health clinic.
            (4) Distribution of grant funds.--
                    (A) In general.--Subject to paragraph (B), a State 
                shall provide each rural health clinic participating in 
                the demonstration project with the lesser of--
                            (i) $5,000; or
                            (ii) 50 percent of the aggregate cost of 
                        malpractice insurance purchased by each 
                        physician, physician assistant, nurse 
                        practitioner, and certified nurse midwife (or 
                        purchased by the rural health clinic on behalf 
                        of each physician, physician assistant, nurse 
                        practitioner, and certified nurse midwife) who, 
                        on a weekly basis, provides patient care 
                        services at the rural health clinic for an 
                        average of not less than--
                                    (I) 20 hours per week; or
                                    (II) 80 percent of the operational 
                                hours of the clinic.
                    (B) Special rule for obstetrics and gynecology.--
                Subject to subparagraph (C), in the case of a rural 
                health clinic participating in the demonstration 
                project that provides obstetrical services, a State 
                shall provide such clinic with the lesser of--
                            (i) $10,000; or
                            (ii) 50 percent of the aggregate cost of 
                        malpractice insurance purchased by each 
                        physician, physician assistant, nurse 
                        practitioner, and certified nurse midwife (or 
                        purchased by the rural health clinic on behalf 
                        of each physician, physician assistant, nurse 
                        practitioner, and certified nurse midwife) who 
                        provides obstetrical services at the rural 
                        health clinic.
                    (C) Amount of obstetrical care.--The Administrator 
                of the Office of Rural Health Policy of the Health 
                Resources and Services Administration shall develop 
                standards for the amount of obstetrical care that a 
                rural health clinic would have to provide in order to 
                qualify for a grant under subparagraph (B).
    (f) Reporting.--
            (1) Annual evaluations and reports.--The Secretary, acting 
        through the Administrator of the Office of Rural Health Policy 
        of the Health Resources and Services Administration, shall 
        provide for an annual evaluation of the demonstration project 
        and submit to Congress a report on the status of the project.
            (2) Final evaluation and report.--Not later than 12 months 
        after completion of the demonstration project, the Secretary, 
        acting through the Administrator of the Office of Rural Health 
        Policy of the Health Resources and Services Administration, 
        shall prepare and submit to Congress a final report and 
        evaluation of the project. The report shall include--
                    (A) an assessment of the effectiveness of the 
                project at recruiting and retaining health care 
                professionals in underserved rural areas;
                    (B) an assessment of the feasibility and efficacy 
                of an expansion of the project to all States; and
                    (C) an evaluation of the project in comparison with 
                an expansion of coverage under chapter 171 of title 28, 
                United States Code (commonly referred to as the 
                ``Federal Tort Claims Act'') to include rural health 
                clinics as a means of recruiting and retaining health 
                care professionals in underserved rural areas.
    (g) Definitions.--In this section:
            (1) Certified nurse midwife.--The term ``certified nurse 
        midwife'' has the same meaning given such term in section 
        1861(gg)(2) of the Social Security Act (42 U.S.C. 
        1395x(gg)(2)).
            (2) Demonstration project.--The term ``demonstration 
        project'' means the demonstration project conducted under this 
        section.
            (3) Nurse practitioner; physician assistant; rural health 
        clinic.--The terms ``nurse practitioner'', ``physician 
        assistant'', and ``rural health clinic'' have the same meaning 
        given such terms in section 1861(aa) of the Social Security Act 
        (42 U.S.C. 1395x(aa)).
            (4) Physician.--The term ``physician'' has the same meaning 
        given such term in section 1861(r) of the Social Security Act 
        (42 U.S.C. 1395x(r)).
            (5) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services.

SEC. 7. DEFINITION OF RURAL HEALTH CLINIC.

    Section 1861(aa)(2) of the Social Security Act (42 U.S.C. 
1395x(aa)(2)) is amended in the flush text by inserting before the last 
sentence the following: ``A facility that is in operation, that 
qualifies as a rural health clinic under this title or title XIX and 
that subsequently fails to satisfy the requirement in clause (i) that 
the clinic is not located in an urbanized area, shall, with respect to 
services furnished on or after the date of enactment of the Rural 
Health Clinic Patient Access and Improvement Act of 2009, be 
considered, for purposes of this title and title XIX, as still 
satisfying such requirement if it is determined that the clinic is 
located in an area defined by the State and certified by the Secretary 
as rural.''.

SEC. 8. MEDICARE ADVANTAGE PLAN PAYMENTS.

    (a) In General.--Section 1857(e) of the Social Security Act (42 
U.S.C. 1395w-27(e)) is amended by adding at the end the following:
            ``(4) Minimum payment rate for services furnished by a 
        rural health clinic.--A contract under this section between a 
        Medicare Advantage organization and the Secretary for the 
        offering of a Medicare Advantage plan shall require the 
        organization to provide for a payment rate under the plan for 
        rural health clinic services furnished to enrollees of the plan 
        (whether or nor the services are furnished pursuant to an 
        agreement between the organization and a rural health clinic) 
        that is not less than--
                    ``(A) the applicable payment rate established under 
                part A or part B (which includes the payment of an 
                interim rate and a subsequent cost reconciliation) with 
                respect to the rural health clinic for such rural 
                health clinic services; or
                    ``(B) if the rural health clinic determines 
                appropriate, 103 percent of the applicable interim 
                payment rate established under part A or part B with 
                respect to the rural health clinic for such rural 
                health clinic services.''.
    (b) Effective Date.--The amendments made by this section shall 
apply to Medicare Advantage contract years beginning on or after 
January 1, 2010.

SEC. 9. SENSE OF THE SENATE REGARDING ADEQUACY OF NETWORK-BASED HEALTH 
              PLANS.

    It is the sense of the Senate that network-based health plans 
shall--
            (1) be expected to provide a pool of health care 
        professionals that is adequate to meet the needs of enrollees 
        residing in rural and frontier areas;
            (2) ensure that enrollees residing in rural and frontier 
        areas that have been designated by the Federal Government or a 
        State government as lacking an adequate number of health care 
        professionals are provided with reasonable access to an in-
        network provider;
            (3) make every effort to include as part of their provider 
        network any State-licensed or certified health care 
        professionals (particularly primary care and mental health 
        professionals) that are available in many underserved rural and 
        frontier areas; and
            (4) recognize that reliance on a physician-only network, or 
        forcing enrollees to travel for more than 30 minutes to receive 
        primary care or mental health services from a network provider, 
        does not constitute an ``adequate'' network. The following 
        distances should be used as guidelines in determining distances 
        that correspond to a 30-minute travel time:
                    (A) Under normal conditions with primary roads 
                available: 20 miles.
                    (B) In mountainous terrain or in areas with only 
                secondary roads available: 15 miles.
                    (C) In flat terrain or in areas connected by 
                interstate highways: 25 miles.
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