[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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