[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 318 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                 S. 318

 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

                            January 26, 2009

 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 2009''.
    (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. Temporary improvements to the Medicare inpatient hospital 
                            payment adjustment for low-volume 
                            hospitals.
Sec. 104. 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. Recognition of equality of physician work in all geographic 
                            areas under the Medicare physician fee 
                            schedule.
Sec. 204. Revisions to the practice expense geographic adjustment under 
                            the Medicare physician fee schedule.
Sec. 205. Extension of treatment of certain physician pathology 
                            services under Medicare.
Sec. 206. Extension of increased Medicare payments for rural ground 
                            ambulance services.
Sec. 207. Rural health clinic improvements.
Sec. 208. Exemption for suppliers in small MSAs and rural areas.
Sec. 209. 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 ``fiscal years 2009 and 2010'' each place it 
appears and inserting ``fiscal years 2009, 2010, and 2011''.

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, 
2009, 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, 2009, or 85 percent in the case of discharges occurring on 
or after October 1, 2009, and before October 1, 2011'' after ``October 
1, 2006''.

SEC. 103. 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 2009 and for discharges occurring in fiscal year 2012 
        and subsequent fiscal years, the Secretary'';
            (3) in subparagraph (C)(i)--
                    (A) by inserting ``(or, with respect to fiscal 
                years 2010 and 2011, 15 road miles)'' after ``25 road 
                miles''; and
                    (B) by inserting ``(or, with respect to fiscal 
                years 2010 and 2011, 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 2010 or 2011, 
                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. 104. 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, 
2009, and before October 1, 2011.''.

            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), in the second sentence--
                    (A) by striking ``and 85'' and inserting ``85''; 
                and
                    (B) by inserting the following before the period at 
                the end: ``, and 100 percent with respect to such 
                services furnished in 2010''; and
            (2) in subclause (III)--
                    (A) by striking ``2010'' and inserting ``2011''; 
                and
                    (B) by striking ``85 percent'' and inserting ``the 
                applicable percentage (as determined under the second 
                sentence of subclause (II) for the year)''.

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 through 
                2009'' 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, 2008, or 2009.''; and
            (3) by adding at the end the following new subparagraph:
                    ``(C) Adjustment for 2010 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, 2010, 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, 2011, 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. RECOGNITION OF EQUALITY OF PHYSICIAN WORK IN ALL GEOGRAPHIC 
              AREAS UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE.

    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. 204. 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 on or after January 
                1, 2010, 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. 205. 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), section 104 of 
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 
110-173) and section 136 of the Medicare Improvements for Patients and 
Providers Act of 2008 (Public Law 110-275), is amended by striking 
``and 2009'' and inserting ``2009, and 2010''.

SEC. 206. EXTENSION OF INCREASED MEDICARE PAYMENTS FOR RURAL GROUND 
              AMBULANCE SERVICES.

    Section 1834(l)(13)(A) of the Social Security Act (42 U.S.C. 
1395m(l)(13)(A)) is amended--
            (1) in the matter preceding clause (i)--
                    (A) by striking ``2007, and for'' and inserting 
                ``2007, for''; and
                    (B) by inserting ``, and for such services 
                described in clause (i) furnished on or after January 
                1, 2010, and before January 1, 2011'' after ``2010''; 
                and
            (2) in clause (i), by inserting ``, or 5 percent if such 
        service is furnished on or after January 1, 2010, and before 
        January 1, 2011'' after ``2010''.

SEC. 207. 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 2010)'' 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 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 so defined) furnished as of 
        the first day of that year.''.

SEC. 208. 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.--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).

SEC. 209. 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, 2010.
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