[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 1869 Introduced in Senate (IS)]

<DOC>






118th CONGRESS
  1st Session
                                S. 1869

To amend title XVIII of the Social Security Act and title XXVII of the 
Public Health Service Act to ensure fair billing practice for items and 
  services furnished by off-campus hospital locations, to amend such 
  title XVIII to provide for payments for graduate nursing education 
                     costs, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                              June 7, 2023

  Mr. Braun (for himself, Ms. Hassan, and Mr. Kennedy) 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 and title XXVII of the 
Public Health Service Act to ensure fair billing practice for items and 
  services furnished by off-campus hospital locations, to amend such 
  title XVIII to provide for payments for graduate nursing education 
                     costs, 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.

    This Act may be cited as the ``Site-based Invoicing and 
Transparency Enhancement Act'' or the ``SITE Act''.

SEC. 2. ENSURING FAIR BILLING PRACTICE FOR ITEMS AND SERVICES FURNISHED 
              BY OFF-CAMPUS HOSPITAL LOCATIONS.

    (a) Promoting Medicare Site-Neutral Payments.--Section 1833(t)(21) 
of the Social Security Act (42 U.S.C. 1395l(t)(21)) is amended--
            (1) by redesignating subparagraph (E) as subparagraph (G); 
        and
            (2) by inserting after subparagraph (D) the following new 
        subparagraphs:
                    ``(E) Sunset of certain exceptions.--The provisions 
                of clauses (ii) and (iv) of subparagraph (B) shall not 
                apply with respect to applicable items and services 
                furnished on or after January 1, 2025.
                    ``(F) Special payment rule for non-applicable items 
                and services furnished at certain off-campus dedicated 
                emergency departments.--
                            ``(i) In general.--In the case of covered 
                        OPD services furnished by an applicable 
                        dedicated emergency department during 2025 or a 
                        subsequent year, the payment amount for such 
                        service that would otherwise be determined 
                        under this subsection (without regard to the 
                        application of this subparagraph) for such year 
                        shall be reduced by 30 percent.
                            ``(ii) Applicable dedicated emergency 
                        department.--In clause (i), the term 
                        `applicable dedicated emergency department' 
                        means a dedicated emergency department (as 
                        defined in section 489.24(b) of title 42 of the 
                        Code of Federal Regulations) that--
                                    ``(I) is an off-campus outpatient 
                                department of a provider (as defined in 
                                subparagraph (B)); and
                                    ``(II) is located 6 or fewer miles 
                                from another hospital, critical access 
                                hospital, or rural emergency hospital, 
                                including the parent hospital of such 
                                emergency department.''.
    (b) Ensuring Separate NPIs for Off-Campus Outpatient Departments of 
a Provider.--
            (1) In general.--Section 1173(b) of the Social Security Act 
        (42 U.S.C. 1320d-2(b)) is amended by adding at the end the 
        following new paragraph:
            ``(3) Ensuring separate npis for off-campus outpatient 
        departments of a provider.--The standards specified under 
        paragraph (1) shall ensure that, not later than January 1, 
        2025, each off-campus outpatient department of a provider (as 
        defined in section 1833(t)(21)(B)) is assigned a separate 
        unique health identifier from such provider.''.
            (2) Treatment of certain departments as subparts of a 
        hospital.--Not later than January 1, 2025, the Secretary of 
        Health and Human Services shall revise sections 162.408 and 
        162.410 of title 45, Code of Federal Regulations, to ensure 
        that each off-campus outpatient department of a provider (as 
        defined in section 1833(t)(21)(B) of the Social Security Act 
        (42 U.S.C. 1395l(t)(21)(B))) is treated as a subpart (as 
        described in such sections) of such provider and assigned a 
        unique health identifier pursuant to section 1173(b)(3) of such 
        Act (as added by paragraph (1)).
    (c) Billing Requirements for Off-Campus Outpatient Departments of a 
Provider.--
            (1) Medicare.--Section 1866(a)(1) of the Social Security 
        Act (42 U.S.C. 1395cc(a)(1)) is amended--
                    (A) in subparagraph (X), by striking ``and'' at the 
                end;
                    (B) in subparagraph (Y)(ii)(V), by striking the 
                period and inserting ``, and''; and
                    (C) by inserting after subparagraph (Y) the 
                following new subparagraph:
            ``(Z) in the case of a hospital with an off-campus 
        outpatient department of a provider (as defined in section 
        1833(t)(21)(B)), with respect to items and services furnished 
        at such department of a provider on or after January 1, 2025, 
        to include in any claim form submitted under this title 
        (including under part C of this title) for such items and 
        services the unique health identifier established for such 
        department of a provider pursuant to section 1173(b)(3).''.
            (2) Other providers.--Part E of title XXVII of the Public 
        Health Service Act (42 U.S.C. 300gg-131 et seq.) is amended by 
        adding at the end the following new section:

``SEC. 2799B-10. BILLING REQUIREMENTS FOR OFF-CAMPUS DEPARTMENTS OF A 
              PROVIDER OR FACILITY.

    ``A health care provider or facility may not, with respect to items 
and services furnished to an individual at an off-campus outpatient 
department of a provider (as defined in section 1833(t)(21)(B) of the 
Social Security Act) on or after January 1, 2025, submit a claim for 
such items and services to a group health plan or health insurance 
issuer, and may not bill such an individual or hold such individual 
liable for such items and services, unless such items and services are 
billed--
            ``(1) using the separate unique health identifier 
        established for such department pursuant to section 1173(b)(3) 
        of such Act; and
            ``(2) on a HIPAA X12 837P transaction form or CMS 1500 form 
        (or a successor transaction or form).''.
            (3) Effective date.--The amendment made by paragraph (1) 
        shall apply with respect to claims submitted for items and 
        services furnished on or after January 1, 2025.

SEC. 3. PAYMENTS FOR GRADUATE NURSING EDUCATION COSTS.

    (a) In General.--Title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) is amended by adding at the end the following new 
section:

``SEC. 1899C. PAYMENTS FOR GRADUATE NURSING EDUCATION COSTS.

    ``(a) In General.--The Secretary shall provide for payments for 
qualified training costs in accordance with this section. Such payments 
shall be made from the Federal Supplementary Medical Insurance Trust 
Fund under section 1841.
    ``(b) Establishment of Hub Structure.--
            ``(1) Application.--An eligible hospital seeking to operate 
        as a Graduate Nursing Education Hub (in this section referred 
        to as a `Hub') shall submit an application to the Secretary at 
        such time, in such manner, and containing such information as 
        the Secretary may specify.
            ``(2) Selection of eligible hospitals to operate as hub.--
                    ``(A) Establishment of regions.--The Secretary 
                shall establish regions for Hubs based on hospital 
                referral regions.
                    ``(B) Selection of eligible hospitals.--For each 
                hospital referral region, the Secretary shall select 
                not more than one eligible hospital to operate as a 
                Hub.
                    ``(C) Limitation.--An eligible hospital may not be 
                selected to operate, or participate as an eligible 
                partner of, more than one Hub under this section.
                    ``(D) Adjacent regions.--An eligible hospital may 
                be selected to operate as a Hub for one or more 
                adjacent hospital referral regions if no other 
                qualifying eligible hospital submits an application for 
                such regions, in which case the eligible hospital shall 
                operate as a single Hub for such regions.
                    ``(E) Multiple applications.--If more than one 
                eligible hospital submits an application to operate as 
                a Hub for a hospital referral region, the Secretary 
                shall consider each application submitted, giving 
                special consideration to the following:
                            ``(i) The application of the eligible 
                        hospital that includes the greatest number of 
                        applicable schools of nursing that have an 
                        advanced practice registered nurse education 
                        program in the region (or in an adjacent region 
                        if an eligible hospital has not been selected 
                        to operate as a Hub for such region and the 
                        eligible hospital is submitting an application 
                        to operate as a single Hub for both regions).
                            ``(ii) The application of the eligible 
                        hospital that includes the greatest number of 
                        advanced practice registered nurses that have 
                        graduated from participating applicable schools 
                        of nursing over the preceding 3 years.
    ``(c) Hub Requirements.--
            ``(1) Contracts.--Each Hub selected pursuant to subsection 
        (b)(2) must enter into a written agreement with each eligible 
        partner of the Hub that meets contents and terms, as determined 
        by the Secretary, and sets out, at a minimum, the following:
                    ``(A) Partner obligations.--The obligations of the 
                eligible partner with respect to the provision of 
                qualified training.
                    ``(B) Reimbursement.--The obligation of the Hub to 
                reimburse the eligible partner (in a timely manner as 
                the Secretary may specify) for the costs of qualified 
                training for which payment is made under this section 
                that are attributable to such partner.
                    ``(C) Governance structure.--A governance structure 
                that includes the Hub and one or more applicable 
                schools of nursing in the leadership and an oversight 
                process that is developed and approved by the Hub, 
                participating applicable schools of nursing, and other 
                Hub partners, in accordance with requirements 
                established by the Secretary.
                    ``(D) Coordination.--The maintenance of an adequate 
                system for coordination of clinical education sites and 
                preceptors. The Secretary may specify standards for 
                such system.
                    ``(E) Preceptor training.--A system for the Hub to 
                provide at least 4 hours of preceptor training to each 
                preceptor each year.
                    ``(F) Public health needs.--A process for taking 
                into consideration local, State, and regional workforce 
                needs to ensure public health.
    ``(d) Payments.--
            ``(1) Amount of payment.--The amount of payment to a Hub 
        under this section for qualified training costs during a year 
        shall be equal to the product of--
                    ``(A) the annual per student payment amount 
                determined under paragraph (2) for the Hub for the 
                year; and
                    ``(B) the total number of positions distributed to 
                the Hub under subsection (f), as determined by the 
                Secretary.
            ``(2) Determination of hub-specific annual per student 
        payment amount.--The Secretary shall determine, for each Hub, 
        an annual per student payment amount for each year (beginning 
        with 2026). Such amount shall be equal to the unadjusted per 
        student amount determined under paragraph (3), as adjusted for 
        geographic variation in wages in a budget neutral manner, as 
        determined appropriate by the Secretary.
            ``(3) Unadjusted per student amount.--The unadjusted per 
        student amount determined under this paragraph for a year is 
        equal to the product of--
                    ``(A) 750 hours; and
                    ``(B) the median hourly wage for a nurse 
                practitioner in the United States, according to the 
                Occupational Employment and Wage Statistics of the 
                Bureau of Labor Statistics for the most recent year for 
                which such data is available (or an appropriate 
                successor measure), increased or decreased by the 
                percentage change in the consumer price index for all 
                urban consumers (all items; United States city average) 
                from June of the most recent year for which such data 
                is available to the June preceding the year involved.
            ``(4) Permissible uses of payment.--A Hub may use payments 
        provided under this section only for payment of the costs of 
        qualified training.
    ``(e) Number of Training Positions Available.--The maximum number 
of positions for which payment made be made under this section for a 
year shall be equal to--
            ``(1) for each of 2026 and 2027, 10,000 advanced practice 
        registered nurse students;
            ``(2) for each of 2028 and 2029, 15,000 advanced practice 
        registered nurse students;
            ``(3) for each of 2030 and 2031: 20,000 advanced practice 
        registered nurse students; and
            ``(4) for 2032 and subsequent years, the greater of--
                    ``(A) 20,000 advanced practice registered nurse 
                students; or
                    ``(B) the number of advanced practice registered 
                nurse students needed to ensure the ratio of such 
                students to the number of beneficiaries under the 
                program under this title, the Medicaid program under 
                title XIX, and the CHIP program under title XXI during 
                the year is the same as such ratio for 2031.
    ``(f) Distribution of Training Positions.--
            ``(1) In general.--
                    ``(A) Distribution.--The Secretary shall distribute 
                the applicable percent (as defined in subparagraph (B)) 
                of the total number of positions available for 
                distribution under subsection (e) for a year as 
                follows:
                            ``(i) Each Hub shall receive a minimum 
                        number of positions, as determined by the 
                        Secretary.
                            ``(ii) Any remaining positions available 
                        for distribution under this subparagraph shall 
                        be distributed to Hubs based on the following 
                        factors:
                                    ``(I) The number of advanced 
                                practice registered nurses that have 
                                graduated from participating applicable 
                                schools of nursing over the preceding 3 
                                years.
                                    ``(II) The share of the relevant 
                                hospital referral region that is 
                                located in an area designated as a 
                                health professional shortage area under 
                                section 332(a)(1)(A) of the Public 
                                Health Service Act, as determined by 
                                the Secretary.
                                    ``(III) The share of the relevant 
                                hospital referral region that is 
                                located in a frontier State (as defined 
                                in section 1886(d)(3)(E)(iii)(II)).
                                    ``(IV) The share of the relevant 
                                hospital referral region that is 
                                located in a rural area (as defined in 
                                section 1886(d)(2)(D)).
                                    ``(V) Other factors determined 
                                appropriate by the Secretary.
                    ``(B) Applicable percent defined.--For purposes of 
                subparagraph (A), the term `applicable percent' means--
                            ``(i) for 2026 and 2027, 100 percent;
                            ``(ii) for 2028 and 2029, 95 percent; and
                            ``(iii) for 2030 and each subsequent year, 
                        90 percent.
            ``(2) Testing new training models.--
                    ``(A) In general.--The Secretary shall distribute 
                the applicable percent (as defined in subparagraph (B)) 
                of the total number of positions available for 
                distribution under this subsection for a year to test 
                new models of training advanced practice registered 
                nurses and other health care workers or account for 
                different workforce needs (for example, a shortage of 
                certified nurse-midwives or community health workers).
                    ``(B) Applicable percent defined.--For purposes of 
                subparagraph (A), the term `applicable percent' means--
                            ``(i) for 2026 and 2027, 0 percent;
                            ``(ii) for 2028 and 2029, 5 percent; and
                            ``(iii) for 2030 and each subsequent year, 
                        10 percent.
            ``(3)  Redistribution.--The Secretary shall develop a 
        process for redistributing--
                    ``(A) unused positions; and
                    ``(B) positions from terminated or closed Hubs.
    ``(g) Miscellaneous.--
            ``(1) Waiver authority.--The Secretary may waive such 
        requirements of title XI and this title as may be necessary to 
        carry out this section.
            ``(2) Administration.--Chapter 35 of title 44, United 
        States Code, shall not apply to the implementation of this 
        section.
            ``(3) Judicial review.--There shall be no administrative or 
        judicial review under section 1869, 1878, or otherwise, with 
        respect to determinations made under subsection (d) or 
        subsection (f).
            ``(4) No effect on other payments for medical education 
        costs.--Nothing in this section shall affect payments under 
        subsection (d)(5)(B), (h), or (l)(2)(B) of section 1886.
            ``(5) Implementation funding.--For purposes of carrying out 
        this section, there are appropriated, out of amounts in the 
        Treasury not otherwise appropriated, to the Centers for 
        Medicare & Medicaid Services Program Management Account for 
        fiscal year 2024, $100,000,000, to remain available until 
        expended.
            ``(6) Supplement not supplant.--Payments under this section 
        in any given year shall supplement, not supplant, other Federal 
        funds that have been made available in the year for advanced 
        practice registered nurse clinical education or training.
    ``(h) Definitions.--In this section:
            ``(1) Advanced practice registered nurse.--The term 
        `advanced practice registered nurse' includes the following:
                    ``(A) A clinical nurse specialist (as defined in 
                subsection (aa)(5) of section 1861).
                    ``(B) A nurse practitioner (as defined in such 
                subsection).
                    ``(C) A certified registered nurse anesthetist (as 
                defined in subsection (bb)(2) of such section).
                    ``(D) A certified nurse-midwife (as defined in 
                subsection (gg)(2) of such section).
            ``(2) Ambulatory care setting.--The term `ambulatory care 
        setting' includes a Federally qualified health center (as 
        defined in section 1861(aa)(4)), a rural health clinic (as 
        defined in section 1861(aa)(4)), a nurse-managed clinic, an 
        ambulatory practice, a behavioral health clinic (including a 
        clinic certified as a certified community behavioral health 
        clinic pursuant to section 223 of the Protecting Access to 
        Medicare Act of 2014) or other behavioral health setting (as 
        determined appropriate by the Secretary), a physician or 
        practitioner office, a school, a skilled nursing facility or 
        nursing facility (as defined in section 1919(a)), a hospice 
        program, a long-term care facility, and any other setting 
        specified by the Secretary.
            ``(3) Applicable school of nursing.--The term `applicable 
        school of nursing' means an accredited school of nursing (as 
        defined in section 801 of the Public Health Service Act).
            ``(4) Eligible hospital.--The term `eligible hospital' 
        means a hospital or a critical access hospital that has a 
        written agreement described in subsection (c)(1) in place 
        with--
                    ``(A) at least two applicable schools of nursing 
                (or at least one applicable school of nursing if there 
                is only one applicable school of nursing within the 
                hospital referral region); and
                    ``(B) at least one ambulatory care setting that is 
                not owned or operated by a Hub operated by the hospital 
                or critical access hospital.
            ``(5) Eligible partner.--
                    ``(A) In general.--The term `eligible partner' 
                means--
                            ``(i) an applicable school of nursing that 
                        has an advanced practice registered nurse 
                        education program;
                            ``(ii) an entity or practitioner that is a 
                        participating provider under this title or a 
                        State plan under title XIX (or a waiver of such 
                        plan); and
                            ``(iii) any other entity determined 
                        appropriate by the Secretary.
                    ``(B) Limitation.--An applicable school of nursing, 
                entity, or practitioner described in subparagraph (A) 
                may not participate as an eligible partner of more than 
                one Hub under this section.
            ``(6) Qualified training.--
                    ``(A) In general.--The term `qualified training' 
                means training--
                            ``(i) that provides an advanced practice 
                        registered nurse with the clinical skills 
                        necessary to provide primary care, behavioral 
                        health care, obstetric care, preventive care, 
                        transitional care, chronic care management, and 
                        other services appropriate for individuals 
                        entitled to, or enrolled for, benefits under 
                        part A, or enrolled under part B; and
                            ``(ii) subject to subparagraph (B), at 
                        least a third of which is provided in an 
                        ambulatory care setting that is not owned or 
                        operated by a Hub.
                    ``(B) Waiver of requirement for eligible hospitals 
                located in rural or medically undeserved areas.--The 
                Secretary may waive the requirement under subparagraph 
                (A)(ii), or reduce the threshold otherwise applicable 
                under such subparagraph, with respect to an eligible 
                hospital that is located in a rural or medically 
                underserved area.''.
    (b) Exclusion of Payments From Calculation of Fee-for-Service Costs 
Under Medicare Advantage.--Section 1853(c)(1)(D)(i) of the Social 
Security Act (42 U.S.C. 1395w-23(c)(1)(D)(i)) is amended by striking 
``and 1886(n) and 1886(h)'' and inserting ``1886(n), 1886(h), and 
1899C''.
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