1.Short
title; table of contents
(a)This Act may be cited
as the Medicare Rural Health Access
Improvement Act of 2009
.
(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. 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.
<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>fiscal years 2009 and 2010</quote> each place it appears and
inserting <quote>fiscal years 2009, 2010, and 2011</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, 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).</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, 2009, or 85 percent in the case of discharges occurring on or after
October 1, 2009, and before October 1, 2011</quote> after <quote>October 1,
2006</quote>.</text>
</subsection></section><section id="id83970EAD84F6467CAE0081E9433E388E"><enum>103.</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 2009 and for discharges
occurring in fiscal year 2012 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 2010 and 2011, 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 2010 and 2011, 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 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.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section id="HF3C2F58790054634B604406152583211"><enum>104.</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,
2009, and before October 1, 2011.</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), in the second
sentence—</text>
<subparagraph commented="no" display-inline="no-display-inline" id="idEC65791EC8154A1EBA2D57863CC5954B"><enum>(A)</enum><text display-inline="yes-display-inline">by striking <quote>and 85</quote> and
inserting <quote>85</quote>; and</text>
</subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="idDFB948EE0DF346CAA7F4A28D5967E491"><enum>(B)</enum><text>by inserting the
following before the period at the end: <quote>, and 100 percent with respect
to such services furnished in 2010</quote>; and</text>
</subparagraph></paragraph><paragraph commented="no" display-inline="no-display-inline" id="id7803E9332F664F2B8497CFBA72466F14"><enum>(2)</enum><text>in subclause
(III)—</text>
<subparagraph commented="no" display-inline="no-display-inline" id="id715306B38BD04E03AF7D77A870FEDCCD"><enum>(A)</enum><text>by striking
<quote>2010</quote> and inserting <quote>2011</quote>; and</text>
</subparagraph><subparagraph commented="no" display-inline="no-display-inline" id="id1695ADA562FE4045BD41B773108DBFBF"><enum>(B)</enum><text>by striking
<quote>85 percent</quote> and inserting <quote>the applicable percentage (as
determined under the second sentence of subclause (II) for the
year)</quote>.</text>
</subparagraph></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
through 2009</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, 2008, or 2009.</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
2010 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, 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.</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, 2011, 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="id26E2A80811F94DDDA4BA101B7AFA23F3"><enum>203.</enum><header>Recognition of
equality of physician work in all geographic areas under the Medicare physician
fee schedule</header><text display-inline="no-display-inline">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></section><section id="idC66C239E53DF47EBAEB59EA6ECB51C86"><enum>204.</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 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.</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>205.</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), 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 <quote>and 2009</quote> and inserting
<quote>2009, and 2010</quote>.</text>
</section><section id="id803F1D8150C447B0ABEBF9AC12A9E2AB"><enum>206.</enum><header>Extension of
increased Medicare payments for rural ground ambulance services</header><text display-inline="no-display-inline">Section 1834(l)(13)(A) of the Social
Security Act (42 U.S.C. 1395m(l)(13)(A)) is amended—</text>
<paragraph id="idF7A7576A328943EB8F6B44BAC4DCEFAD"><enum>(1)</enum><text>in the matter
preceding clause (i)—</text>
<subparagraph id="id7EE5674F98E7411184D924C1CE97F050"><enum>(A)</enum><text>by striking
<quote>2007, and for</quote> and inserting <quote>2007, for</quote>; and</text>
</subparagraph><subparagraph id="idCEBD5AC394414A6995FF14B72EE55F09"><enum>(B)</enum><text>by inserting
<quote>, and for such services described in clause (i) furnished on or after
January 1, 2010, and before January 1, 2011</quote> after <quote>2010</quote>;
and</text>
</subparagraph></paragraph><paragraph id="id978335F29D0A4EA1AA3D98CE8610631A"><enum>(2)</enum><text>in clause (i), by
inserting <quote>, or 5 percent if such service is furnished on or after
January 1, 2010, and before January 1, 2011</quote> after
<quote>2010</quote>.</text>
</paragraph></section><section id="ID0EB8454AF7F84B5EB465C307156AF031"><enum>207.</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 2010)</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 2010, 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>208.</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</header><text>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>
</subsection></section><section id="id75B3CE00BCB8424F9F63281564862E12"><enum>209.</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, 2010.</text>
</subsection></section>