[Congressional Record Volume 152, Number 75 (Tuesday, June 13, 2006)]
[Senate]
[Pages S5789-S5794]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. THOMAS (for himself, Mr. Conrad, Mr. Harkin, Mr. Roberts, 
        Ms. Collins, Mr. Dayton, Mr. Salazar, Mr. Domenici, Mr. Burns, 
        Mr. Dorgan, Mr. Thune, Mr. Johnson, Mr. Nelson of Nebraska, Ms. 
        Murkowski and Ms. Snowe):
  S. 3500. A bill to amend title VIII of the Social Security Act to 
protect and preserve access of Medicare beneficiaries in rural areas to 
health care providers under the Medicare program, and for other 
purposes; to the Committee on Finance.
  Mr. THOMAS. Mr. President, I am pleased to rise today to introduce 
the Rural Hospital and Provider Equity, R-HoPE, Act of 2006 with 
Senator Conrad, Senator Harkin, Senator Roberts, and fellow Senate 
Rural Health Caucus members Senators Collins, Dayton, Salazar, Burns, 
Domenici, Dorgan, Thune, Johnson, Ben Nelson, and Murkowski. As always, 
it is important to note that rural health care legislation has a long 
history of bipartisan collaboration and cooperation.
  The 108th Congress reaped unparalleled successes in terms of rural 
health care legislation. When Congress enacted the Medicare 
Modernization Act, MMA, it included a comprehensive health care package 
specifically tailored with rural communities, hospitals, and providers 
in mind. This was the largest rural provider payment package ever 
considered by Congress.
  As Republican cochairman of the Senate Rural Health Caucus, I was 
proud to help lead the effort to put rural providers on a level playing 
field with their urban neighbors. We enacted commonsense Medicare 
payment equity provisions critical to maintaining access to quality 
health care in isolated and underserved areas. Rural America achieved a 
significant victory, and we have much to celebrate. However, our 
mission is not complete. Several of the MMA's rural health provisions 
have expired, or are set to expire this year. That is why I have 
introduced the Rural Hospital and Provider Equity Act--to finish the 
work we started 3 years ago.
  This legislation not only reauthorizes expiring rural MMA provisions 
but also takes additional steps to address inequities in the Medicare 
payment system that continually place rural providers at a 
disadvantage. My bill recognizes the unique needs of rural hospitals 
and levels the playing field between rural and urban providers.
  Rural hospitals are more dependent on Medicare payments as part of 
their total revenue. In fact, Medicare accounts for almost 70 percent 
of total revenue for small, rural hospitals. Rural hospitals have lower 
patient volumes, but must compete nationally to recruit providers due 
to the nursing--and other health professional--workforce shortages. 
Additional burdens are placed on rural hospitals and providers because 
of higher uninsured and underinsured rates in rural America. Also, 
seniors living in rural areas tend to be poorer and have more chronic 
conditions than their urban and suburban counterparts.
  First, the Rural Hospital and Provider Equity Act recognizes the 
special circumstances rural hospitals face and addresses these issues 
by equalizing Medicare disproportionate share hospital, DSH, payments. 
These add-on payments help hospitals cover the costs of serving a high 
proportion of low-income and uninsured patients. Current law allows 
urban facilities to receive unlimited add-ons corresponding with the 
amount of patients served. However, small or rural hospital add-on 
payments are capped at 12 percent. This measure eliminates the rural 
hospital cap, bringing their payments in line with the benefits urban 
facilities receive.
  Second, the bill recognizes that low-volume hospitals have a higher 
cost per case which results in negative operating margins. To alleviate 
this problem, we established a low-volume inpatient payment adjustment 
for hospitals that have less than 2000 annual discharges per year and 
are located more than 15 miles from another hospital. This provision 
will improve payments for approximately one-third of all rural 
hospitals.
  In addition to these Medicare payment reforms, this legislation 
strengthens the over 3,000 rural health clinics that serve many rural 
Americans. Under current law, rural health clinics receive an all-
inclusive payment rate that is capped at approximately $63. This 
payment has not been adjusted--except for inflation--since 1988. To 
recognize the rising costs of health care, this bill raises the rural 
health clinic cap to $82, making it comparable to the rate Community 
Health Centers receive. By caring for folks in underserved areas, rural 
health clinics and community health centers are a key component of the 
rural health care delivery system. As not every small town can sustain 
a hospital, we need to ensure these types of facilities are paid 
adequately and are provided enough flexibility to meet the health care 
needs of the communities they serve.
  Home health care agencies are another critical element of the 
continuum of care in rural areas. These providers face unique 
circumstances in the distances they are required to travel to provide 
services. The current Medicare payment system does not make adequate 
adjustments to reflect the reality of rural and frontier health care. 
This bill recognizes the situation these providers face by ensuring 
their Medicare payments cover their costs to provide Medicare services.
  As you all may know, there are approximately 1,165 hospitals 
nationwide that have converted to critical access hospital, CAH, 
status. This program was created in the Balanced Budget Act of 1997 to 
ensure folks in small, rural communities would have access to 24-hour 
emergency services as well as some hospital care in their hometowns. 
Fifty-two percent of my State's hospitals have downsized to Critical 
Access Hospital status. The measure I have introduced contains several 
provisions to strengthen this important rural hospital program.
  The Rural Hospital and Provider Equity Act will also ensure rural 
areas can maintain access to important emergency medical services, EMS. 
Rural EMS providers are primarily volunteers who have difficulty 
recruiting, retaining, and educating EMS personnel. Rural EMS providers 
also have less capital to buy and upgrade essential, lifesaving 
equipment. The legislation will assist ambulance providers in 
collecting payments for transporting patients to the hospital after 
answering a 911 call regardless of the final diagnosis. This is a 
commonsense approach and ensures that all aspects of emergency care are 
operating under the same definition of emergency.
  It is important for the Federal Government to remember that one 
payment system does not fit all. Rural providers care for patients 
under much different circumstances than their urban counterparts. This 
legislation is designed to ensure rural hospitals, rural health 
clinics, rural ambulance providers, rural home health agencies, rural 
mental health providers, rural physicians, and other critical allied 
health clinicians are paid accurately and fairly. I strongly encourage 
all my colleagues with an interest in rural health to cosponsor this 
legislation.
  Finally, I want to thank the American Hospital Association, the 
National Rural Health Association, the Federation of American 
Hospitals, the National Association of Rural Health Clinics, the 
National Association for Home Care, the American Academy of

[[Page S5790]]

Nurse Practitioners, the American Ambulance Association, and the 
Association of Marriage and Family Therapists, for their work and 
support in this effort.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 3500

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Rural 
     Hospital and Provider Equity (HoPE) Act of 2006''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.
Sec. 2. Fairness in the Medicare disproportionate share hospital (DSH) 
              adjustment for rural hospitals.
Sec. 3. Extension and Expansion of Medicare hold harmless provision 
              under the prospective payment system for hospital 
              outpatient department (HOPD) services.
Sec. 4. Improvement of definition of low-volume hospital for purposes 
              of the Medicare inpatient hospital payment adjustment.
Sec. 5. Extension of Medicare wage index reclassifications for certain 
              hospitals.
Sec. 6. Extension of Medicare reasonable costs payments for certain 
              clinical diagnostic laboratory tests furnished to 
              hospital patients in certain rural areas.
Sec. 7. Critical access hospital improvements.
Sec. 8. Capital infrastructure revolving loan program.
Sec. 9. Extension of Medicare incentive payment program for physician 
              scarcity areas.
Sec. 10. Extension of floor on medicare work geographic adjustment.
Sec. 11. Medicare home health care planning improvements.
Sec. 12. Rural health clinic improvements.
Sec. 13. Community health center collaborative access expansion.
Sec. 14. Applying add-on policy for home health services furnished in a 
              rural area for 2007.
Sec. 15. Use of medical conditions for coding ambulance services.
Sec. 16. Extension of increased Medicare payments for ground ambulance 
              services in rural areas.
Sec. 17. Improvement in payments to retain emergency and other capacity 
              for ambulances in rural areas.
Sec. 18. Coverage of marriage and family therapist services and mental 
              health counselor services under part B of the Medicare 
              program.
Sec. 19. Medicare remote monitoring pilot projects.
Sec. 20. Facilitating the provision of telehealth services across State 
              lines.

     SEC. 2. FAIRNESS IN THE MEDICARE DISPROPORTIONATE SHARE 
                   HOSPITAL (DSH) ADJUSTMENT FOR RURAL HOSPITALS.

       Section 1886(d)(5)(F)(xiv)(II) of the Social Security Act 
     (42 U.S.C. 1395ww(d)(5)(F)(xiv)(II)) is amended--
       (1) by striking ``or, in the case'' and all that follows 
     through ``subparagraph (G)(iv)''; and
       (2) by inserting at the end the following new sentence: 
     ``The preceding sentence shall not apply to any hospital with 
     respect to discharges occurring on or after October 1, 
     2006.''.

     SEC. 3. EXTENSION AND EXPANSION OF MEDICARE HOLD HARMLESS 
                   PROVISION UNDER THE PROSPECTIVE PAYMENT SYSTEM 
                   FOR HOSPITAL OUTPATIENT DEPARTMENT (HOPD) 
                   SERVICES.

       (a) Extension.--
       (1) In general.--Section 1833(t)(7)(D)(i) of the Social 
     Security Act (42 U.S.C. 1395l(t)(7)(D)(i)), as amended by 
     section 5105 of the Deficit Reduction Act of 2005 (Public Law 
     109-171), is amended--
       (A) in subclause (I)--
       (i) by striking ``(I)'';
       (ii) by striking ``(iii)) located in a rural area'' and 
     inserting ``(iii))''; and
       (iii) by striking ``before January 1, 2006'' and inserting 
     ``before January 1, 2009''; and
       (B) by striking subclause (II).
       (2) Effective date.--The amendments made by paragraph (1) 
     shall apply to covered OPD services furnished on or after 
     January 1, 2006.
       (b) Study and Report.--
       (1) Study.--The Secretary of Health and Human Services 
     shall conduct a study to determine if, under the prospective 
     payment system for hospital outpatient department services 
     under section 1833(t) of the Social Security Act (42 U.S.C. 
     1395l(t)), costs incurred by sole community hospitals (as 
     defined in section 1886(d)(5)(D)(iii) of such Act (42 U.S.C. 
     1395ww(d)(5)(D)(iii))) located in urban areas by ambulatory 
     payment classification groups (APCs) exceed those costs 
     incurred by other hospitals located in urban areas.
       (2) Report.--Not later than January 1, 2008, the Secretary 
     of Health and Human Services shall submit to Congress a 
     report on the study conducted under paragraph (1) together 
     with recommendations for such legislation and administrative 
     action as the Secretary determines to be appropriate.

     SEC. 4. IMPROVEMENT OF DEFINITION OF LOW-VOLUME HOSPITAL FOR 
                   PURPOSES OF THE MEDICARE INPATIENT HOSPITAL 
                   PAYMENT ADJUSTMENT.

       Section 1886(d)(12)(C)(i) of the Social Security Act (42 
     U.S.C. 1395ww(d)(12)(C)(i)) is amended by inserting ``(or, 
     beginning with fiscal year 2007, 2,000 discharges)'' after 
     ``800 discharges''.

     SEC. 5. EXTENSION OF MEDICARE WAGE INDEX RECLASSIFICATIONS 
                   FOR CERTAIN HOSPITALS.

       (a) MMA Provision.--Section 508 of the Medicare 
     Prescription Drug, Improvement, and Modernization Act of 2003 
     (42 U.S.C. 1395ww note) is amended by adding at the end the 
     following new subsection:
       ``(g) Three-Year Extension for Certain Hospitals.--
       ``(1) In general.--In the case of a hospital described in 
     paragraph (2)--
       ``(A) subsections (a)(3) and (b) shall be applied by 
     substituting `6-year period' for `3-year period'; and
       ``(B) the limitation under subsection (e) shall not apply 
     after March 31, 2007.
       ``(2) Hospital described.--A hospital described in this 
     paragraph is a hospital--
       ``(A) that is reclassified to an area under this section as 
     of the day before the date of enactment of this subsection; 
     and
       ``(B)(i) that is located in a State with less than 10 
     people per square mile; or
       ``(ii)(I) that is located in a rural area; and
       ``(II) for which the Secretary has determined the extension 
     under this subsection to be appropriate.''.
       (b) Additional Provision.--The Secretary of Health and 
     Human Services shall extend the special exception 
     reclassification of a sole community hospital located in a 
     State with less than 10 people per square mile (made under 
     the authority of section 1886(d)(5)(I)(i) of the Social 
     Security Act (42 U.S.C. 1395ww(d)(5)(I)(i)) and contained in 
     the final rule promulgated by the Secretary in the Federal 
     Register on August 11, 2004 (69 Fed. Reg. 49107)) for 3 years 
     through fiscal year 2010.

     SEC. 6. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS FOR 
                   CERTAIN CLINICAL DIAGNOSTIC LABORATORY TESTS 
                   FURNISHED TO HOSPITAL PATIENTS IN CERTAIN RURAL 
                   AREAS.

       Section 416(b) of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (Public Law 108-
     173; 117 Stat. 2282; 42 U.S.C. 1395l-4(b)) is amended by 
     striking ``2-year'' and inserting ``4-year''.

     SEC. 7. CRITICAL ACCESS HOSPITAL IMPROVEMENTS.

       (a) Clarification of Payment for Clinical Laboratory Tests 
     Furnished by Critical Access Hospitals.--
       (1) In general.--Section 1834(g)(4) of the Social Security 
     Act (42 U.S.C. 1395m(g)(4)) is amended--
       (A) in the heading, by striking ``no beneficiary cost-
     sharing'' and inserting ``treatment of''; and
       (B) by adding at the end the following new sentence: ``For 
     purposes of the preceding sentence and section 1861(mm)(3), 
     clinical diagnostic laboratory services furnished by a 
     critical access hospital shall be treated as being furnished 
     as part of outpatient critical access services without regard 
     to whether--
       ``(A) the individual with respect to whom such services are 
     furnished is physically present in the critical access 
     hospital at the time the specimen is collected;
       ``(B) such individual is registered as an outpatient on the 
     records of, and receives such services directly from, the 
     critical access hospital; or
       ``(C) payment is (or, but for this subsection, would be) 
     available for such services under the fee schedule 
     established under section 1833(h).''.
       (2) Effective date.--The amendments made by paragraph (1) 
     shall apply to cost reporting periods beginning on or after 
     October 1, 2003.
       (b) Elimination of Isolation Test for Cost-Based Ambulance 
     Reimbursement.--
       (1) In general.--Section 1834(l)(8) of the Social Security 
     Act (42 U.S.C. 1395m(l)(8)) is amended--
       (A) in subparagraph (B)--
       (i) by striking ``owned and''; and
       (ii) by inserting ``(including when such services are 
     provided by the entity under an arrangement with the 
     hospital)'' after ``hospital''; and
       (B) by striking the comma at the end of subparagraph (B) 
     and all that follows and inserting a period.
       (2) Effective date.--The amendments made by this subsection 
     shall apply to services furnished on or after January 1, 
     2007.

     SEC. 8. CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM.

       (a) In General.--Part A of title XVI of the Public Health 
     Service Act (42 U.S.C. 300q et seq.) is amended by adding at 
     the end the following new section:


            ``CAPITAL INFRASTRUCTURE REVOLVING LOAN PROGRAM

       ``Sec. 1603.  (a) Authority To Make and Guarantee Loans.--
       ``(1) Authority to make loans.--The Secretary may make 
     loans from the fund established under section 1602(d) to any 
     rural entity for projects for capital improvements, 
     including--

[[Page S5791]]

       ``(A) the acquisition of land necessary for the capital 
     improvements;
       ``(B) the renovation or modernization of any building;
       ``(C) the acquisition or repair of fixed or major movable 
     equipment; and
       ``(D) such other project expenses as the Secretary 
     determines appropriate.
       ``(2) Authority to guarantee loans.--
       ``(A) In general.--The Secretary may guarantee the payment 
     of principal and interest for loans made to rural entities 
     for projects for any capital improvement described in 
     paragraph (1) to any non-Federal lender.
       ``(B) Interest subsidies.--In the case of a guarantee of 
     any loan made to a rural entity under subparagraph (A), the 
     Secretary may pay to the holder of such loan, for and on 
     behalf of the project for which the loan was made, amounts 
     sufficient to reduce (by not more than 3 percent) the net 
     effective interest rate otherwise payable on such loan.
       ``(b) Amount of Loan.--The principal amount of a loan 
     directly made or guaranteed under subsection (a) for a 
     project for capital improvement may not exceed $5,000,000.
       ``(c) Funding Limitations.--
       ``(1) Government credit subsidy exposure.--The total of the 
     Government credit subsidy exposure under the Credit Reform 
     Act of 1990 scoring protocol with respect to the loans 
     outstanding at any time with respect to which guarantees have 
     been issued, or which have been directly made, under 
     subsection (a) may not exceed $50,000,000 per year.
       ``(2) Total amounts.--Subject to paragraph (1), the total 
     of the principal amount of all loans directly made or 
     guaranteed under subsection (a) may not exceed $250,000,000 
     per year.
       ``(d) Capital Assessment and Planning Grants.--
       ``(1) Nonrepayable grants.--Subject to paragraph (2), the 
     Secretary may make a grant to a rural entity, in an amount 
     not to exceed $50,000, for purposes of capital assessment and 
     business planning.
       ``(2) Limitation.--The cumulative total of grants awarded 
     under this subsection may not exceed $2,500,000 per year.
       ``(e) Termination of Authority.--The Secretary may not 
     directly make or guarantee any loan under subsection (a) or 
     make a grant under subsection (d) after September 30, 
     2010.''.
       (b) Rural Entity Defined.--Section 1624 of the Public 
     Health Service Act (42 U.S.C. 300s-3) is amended by adding at 
     the end the following new paragraph:
       ``(15)(A) The term `rural entity' includes--
       ``(i) a rural health clinic, as defined in section 
     1861(aa)(2) of the Social Security Act;
       ``(ii) any medical facility with at least 1 bed, but with 
     less than 50 beds, that is located in--
       ``(I) a county that is not part of a metropolitan 
     statistical area; or
       ``(II) a rural census tract of a metropolitan statistical 
     area (as determined under the most recent modification of the 
     Goldsmith Modification, originally published in the Federal 
     Register on February 27, 1992 (57 Fed. Reg. 6725));
       ``(iii) a hospital that is classified as a rural, regional, 
     or national referral center under section 1886(d)(5)(C) of 
     the Social Security Act; and
       ``(iv) a hospital that is a sole community hospital (as 
     defined in section 1886(d)(5)(D)(iii) of the Social Security 
     Act).
       ``(B) For purposes of subparagraph (A), the fact that a 
     clinic, facility, or hospital has been geographically 
     reclassified under the Medicare program under title XVIII of 
     the Social Security Act shall not preclude a hospital from 
     being considered a rural entity under clause (i) or (ii) of 
     subparagraph (A).''.
       (c) Conforming Amendments.--Section 1602 of the Public 
     Health Service Act (42 U.S.C. 300q-2) is amended--
       (1) in subsection (b)(2)(D), by inserting ``or 
     1603(a)(2)(B)'' after ``1601(a)(2)(B)''; and
       (2) in subsection (d)--
       (A) in paragraph (1)(C), by striking ``section 
     1601(a)(2)(B)'' and inserting ``sections 1601(a)(2)(B) and 
     1603(a)(2)(B)''; and
       (B) in paragraph (2)(A), by inserting ``or 1603(a)(2)(B)'' 
     after ``1601(a)(2)(B)''.

     SEC. 9. EXTENSION OF MEDICARE INCENTIVE PAYMENT PROGRAM FOR 
                   PHYSICIAN SCARCITY AREAS.

       Section 1833(u)(1) of the Social Security Act (42 U.S.C. 
     1395l(u)(1)) is amended by striking ``before January 1, 
     2008'' and inserting ``before January 1, 2009''.

     SEC. 10. EXTENSION OF FLOOR ON MEDICARE WORK GEOGRAPHIC 
                   ADJUSTMENT.

       Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 
     1395w-4(e)(1)(E)) is amended by striking ``before January 1, 
     2007'' and inserting ``before January 1, 2009''.

     SEC. 11. MEDICARE HOME HEALTH CARE PLANNING IMPROVEMENTS.

       (a) 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--
       (1) by striking ``subparagraph (B)'' and inserting 
     ``subparagraphs (B) and (C)'';
       (2) by inserting ``(as those terms are defined in section 
     1861(aa)(5))'' after ``clinical nurse specialist'';
       (3) by inserting ``or home health agency (as the case may 
     be)'' after ``facility''; and
       (4) by inserting ``(or in the case of services described in 
     subparagraph (C), a physician assistant (as defined in 
     1861(aa)(5)) under the supervision of a physician)'' after 
     ``collaboration with a physician''.
       (b) Conforming Amendments.--(1) Section 1814(a) of the 
     Social Security Act (42 U.S.C. 1395f(a)) is amended--
       (A) in paragraph (2)(C), by inserting ``a nurse 
     practitioner, a clinical nurse specialist, or a physician 
     assistant (as the case may be)'' after ``physician'' each 
     place it appears;
       (B) in the second sentence, by striking ``or clinical nurse 
     specialist'' and inserting ``clinical nurse specialist, or 
     physician assistant'';
       (C) in the third sentence--
       (i) by striking ``physician certification'' and inserting 
     ``certification'';
       (ii) by inserting ``(or on January 1, 2007, in the case of 
     regulations to implement the amendments made by section 11 of 
     the Rural Hospital and Provider Equity (HoPE) Act of 2006)'' 
     after ``1981''; and
       (iii) by striking ``a physician who'' and inserting ``a 
     physician, nurse practitioner, clinical nurse specialist, or 
     physician assistant who''; and
       (D) in the fourth sentence, by inserting ``, nurse 
     practitioner, clinical nurse specialist, or physician 
     assistant'' after ``physician''.
       (2) Section 1835(a) of the Social Security Act (42 U.S.C. 
     1395n(a)) is amended--
       (A) in paragraph (2)--
       (i) in the matter preceding subparagraph (A), by inserting 
     ``or, in the case of services described in subparagraph (A), 
     a physician, or a nurse practitioner or clinical nurse 
     specialist (as those terms are defined in 1861(aa)(5)), who 
     does not have a direct or indirect employment relationship 
     with the home health agency but is working in collaboration 
     with a physician (or a physician assistant (as defined in 
     1861(aa)(5)) under the supervision of a physician)'' after 
     ``a physician''; and
       (ii) in subparagraph (A) by inserting ``a nurse 
     practitioner, a clinical nurse specialist, or a physician 
     assistant (as the case may be)'' after ``physician'' each 
     place it appears;
       (B) in the third sentence, by inserting ``, nurse 
     practitioner, clinical nurse specialist, or physician 
     assistant (as the case may be)'' after physician;
       (C) in the fourth sentence--
       (i) by striking ``physician certification'' and inserting 
     ``certification'';
       (ii) by inserting ``(or on January 1, 2007, in the case of 
     regulations to implement the amendments made by section 11 of 
     the Rural Hospital and Provider Equity (HoPE) Act of 2006)'' 
     after ``1981''; and
       (iii) by striking ``a physician who'' and inserting ``a 
     physician, nurse practitioner, clinical nurse specialist, or 
     physician assistant who''; and
       (D) in the fifth sentence, by inserting ``, nurse 
     practitioner, clinical nurse specialist, or physician 
     assistant'' after ``physician''.
       (3) Section 1861 of the Social Security Act (42 U.S.C. 
     1395x) is amended--
       (A) in subsection (m)--
       (i) in the matter preceding paragraph (1)--
       (I) by inserting ``, or a nurse practitioner, clinical 
     nurse specialist, or physician assistant (as those terms are 
     defined in subsection (aa)(5))'' after ``physician'' the 
     first place it appears; and
       (II) by inserting ``or a nurse practitioner, clinical nurse 
     specialist, or physician assistant'' after ``physician'' the 
     second place it appears; and
       (ii) in paragraph (3), by inserting ``or a nurse 
     practitioner, clinical nurse specialist, or physician 
     assistant'' after ``physician''; and
       (B) in subsection (o)(2)--
       (i) by inserting ``, nurse practitioners, clinical nurse 
     specialists, or physician assistants (as those terms are 
     defined in subsection (aa)(5))'' after ``physicians''; and
       (ii) by inserting ``, nurse practitioner, clinical nurse 
     specialist, physician assistant,'' after ``physician''
       (4) Section 1895 of the Social Security Act (42 U.S.C. 
     1395fff) is amended--
       (A) in subsection (c)(1), by inserting ``, or the nurse 
     practitioner, clinical nurse specialist, or physician 
     assistant (as those terms are defined in section 
     1861(aa)(5)),'' after ``physician''; and
       (B) in subsection (e)--
       (i) in paragraph (1)(A), by inserting ``, or a nurse 
     practitioner, clinical nurse specialist, or physician 
     assistant (as those terms are defined in section 
     1861(aa)(5)),'' after ``physician''; and
       (ii) in paragraph (2)--
       (I) in the heading, by striking ``Physician certification'' 
     and inserting ``Rule of construction regarding requirement 
     for certification''; and
       (II) by striking ``physician''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2007.

     SEC. 12. 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 2007)'' 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 2007, at $82 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) applicable

[[Page S5792]]

     to primary care services (as so defined) furnished as of the 
     first day of that year.''

     SEC. 13. COMMUNITY HEALTH CENTER COLLABORATIVE ACCESS 
                   EXPANSION.

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

     SEC. 14. APPLYING ADD-ON POLICY FOR HOME HEALTH SERVICES 
                   FURNISHED IN A RURAL AREA FOR 2007.

       Section 421 of Medicare Prescription Drug, Improvement, and 
     Modernization Act of 2003 (Public Law 108-173; 117 Stat. 
     2283), as amended by section 5201(b) of the Deficit Reduction 
     Act of 2005 (Public Law 109-171), is amended--
       (1) in the heading, by striking ``ONE-YEAR'' and inserting 
     ``TEMPORARY''; and
       (2) in subsection (a), by striking ``before January 1, 
     2007'' and inserting ``before January 1, 2008''.

     SEC. 15. USE OF MEDICAL CONDITIONS FOR CODING AMBULANCE 
                   SERVICES.

       Section 1834(l)(7) of the Social Security Act (42 U.S.C. 
     1395m(l)(7)) is amended to read as follows:
       ``(7) Coding system.--
       ``(A) In general.--The Secretary shall, in accordance with 
     section 1173(c)(1)(B) and not later than January 1, 2007, 
     establish a mandatory system or systems for the coding of 
     claims for ambulance services for which payment is made under 
     this subsection, including a code set specifying the medical 
     condition of the individual who is transported and the level 
     of service that is appropriate for the transportation of an 
     individual with that medical condition.
       ``(B) Medical conditions.--The code set established under 
     subparagraph (A) shall take into account the list of medical 
     conditions developed in the course of the negotiated 
     rulemaking process conducted under paragraph (1).''.

     SEC. 16. EXTENSION OF INCREASED MEDICARE PAYMENTS FOR GROUND 
                   AMBULANCE SERVICES IN RURAL AREAS.

       Section 1834(l)(13) of the Social Security Act (42 U.S.C. 
     1395m(l)(13)) is amended--
       (1) in subparagraph (A), in the matter preceding clause 
     (i), by striking ``before January 1, 2007'' and inserting 
     ``before January 1, 2008'';
       (2) in subparagraph (B), in the heading, by striking 
     ``after 2006'' and inserting ``after 2007''.

     SEC. 17. IMPROVEMENT IN PAYMENTS TO RETAIN EMERGENCY AND 
                   OTHER CAPACITY FOR AMBULANCES IN RURAL AREAS.

       (a) In General.--Section 1834(l) of the Social Security Act 
     (42 U.S.C. 1395m(l)) is amended by adding at the end the 
     following new paragraph:
       ``(15) Additional payments for providers furnishing 
     ambulance services in rural areas.--
       ``(A) In general.--In the case of ground ambulance services 
     furnished on or after January 1, 2007, for which the 
     transportation originates in a rural area (as determined 
     under subparagraph (B)), the Secretary shall provide for a 
     percent increase in the base rate of the fee schedule for a 
     trip identified under this subsection.
       ``(B) Identification of rural areas.--The Secretary, in 
     consultation with the Office of Rural Health Policy, shall 
     use the Rural-Urban Commuting Areas (RUCA) coding system, 
     adopted by that Office, to designate rural areas for the 
     purposes of this paragraph. A rural area is any area in RUCA 
     levels 2 through 10 and any unclassified area.
       ``(C) Tiering of rural areas.--The Secretary shall 
     designate 4 tiers of rural areas, using a ZIP Code 
     population-based methodology generated by the RUCA coding 
     system, as follows:
       ``(i) Tier 1.--A rural area that is a high metropolitan 
     commuting area, in which 30 percent or more of the commuting 
     flow is to an urban area, as designated by the Bureau of the 
     Census (RUCA level 2).
       ``(ii) Tier 2.--A rural area that is a low metropolitan 
     commuting area, in which less than 30 percent of the 
     commuting flow is to an urban area or to a large town, as 
     designated by the Bureau of the Census (RUCA levels 3-6).
       ``(iii) Tier 3.--A rural area that is a small town core, as 
     designated by the Bureau of the Census, in which no 
     significant portion of the commuting flow is to an area of 
     population greater than 10,000 people (RUCA levels 7-9).
       ``(iv) Tier 4.--A rural area in which there is no dominant 
     commuting flow (RUCA level 10) and any unclassified area.

     The Secretary shall consult with the Office of Rural Health 
     Policy not less often than every 2 years to update the 
     designation of rural areas in accordance with any changes 
     that are made to the RUCA system.
       ``(D) Payment adjustments for trips in rural areas.--The 
     Secretary shall adjust the payment rate under this section 
     for ambulance trips that originate in each of the tiers 
     established in subparagraph (C) according to the national 
     average cost of full-cost providers for providing ambulance 
     services in each such tier.''.
       (b) Review of Payments for Rural Ambulance Services and 
     Report to Congress.--
       (1) Review.--Not later than July 1, 2009, the Secretary of 
     Health and Human Services shall review the system for 
     adjusting payments for rural ambulance services under section 
     1834(l)(15) of the Social Security Act, as added by 
     subsection (a), to determine the adequacy and appropriateness 
     of such adjustments. In conducting such review, the Secretary 
     shall consult with providers and suppliers affected by such 
     adjustments and with representatives of the ambulance 
     industry generally to determine--
       (A) whether such adjustments adequately cover the 
     additional costs incurred in serving areas of low population 
     density; and
       (B) whether the tiered structure for making such 
     adjustments appropriately reflects the difference in costs of 
     providing services in different types of rural areas.
       (2) Report.--Not later than January 1, 2010, the Secretary 
     shall submit to Congress a report on the review conducted 
     under paragraph (1) together with any recommendations for 
     revision to the systems for adjusting payments for ambulance 
     services in rural areas that the Secretary of Health and 
     Human Services determines appropriate.
       (c) Conforming Amendments.--(1) Section 1834(l) of the 
     Social Security Act (42 U.S.C. 1395m(l)), as amended by 
     subsection (a), is amended by adding at the end the following 
     new paragraph:
       ``(16) Designation of rural areas for mileage payment 
     purposes.--In establishing any differential in the amount of 
     payment for mileage between rural and urban areas in the fee 
     schedule established under paragraph (1), the Secretary 
     shall, in the case of ambulance services furnished on or 
     after January 1, 2007, identify rural areas in the same 
     manner as provided in paragraph (15)(B).''.
       (2) Section 1834(l)(12)(A) of the Social Security Act (42 
     U.S.C. 1395m(l)(12)(A)) is amended by striking ``January 1, 
     2010'' and inserting ``January 1, 2007''.
       (3) Section 1834(l)(13)(A)(i) of the Social Security Act 
     (42 U.S.C. 1395m(l)(13)(A)(i)) is amended--
       (A) by inserting ``(or in the case of such services 
     furnished in 2007, in a rural area identified by the 
     Secretary under paragraph (15)(B))'' after ``such 
     paragraph''; and
       (B) by striking ``paragraphs (11) and (12)'' and inserting 
     ``paragraphs (11), (12), and (15)''.

     SEC. 18. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES 
                   AND MENTAL HEALTH COUNSELOR SERVICES UNDER PART 
                   B OF THE MEDICARE PROGRAM.

       (a) Coverage of Services.--
       (1) In general.--Section 1861(s)(2) of the Social Security 
     Act (42 U.S.C. 1395x(s)(2)), as amended by section 5112 of 
     the Deficit Reduction Act of 2005 (Public Law 109-171), is 
     amended--
       (A) in subparagraph (Z), by striking ``and'' at the end;
       (B) in subparagraph (AA), by inserting ``and'' at the end; 
     and
       (C) by adding at the end the following new subparagraph:
       ``(BB) marriage and family therapist services (as defined 
     in subsection (ccc)(1)) and mental health counselor services 
     (as defined in subsection (ccc)(3));''.
       (2) Definitions.--Section 1861 of the Social Security Act 
     (42 U.S.C. 1395x), as amended by section 5112 of the Deficit 
     Reduction Act of 2005 (Public Law 109-171), is amended by 
     adding at the end the following new subsection:

     ``Marriage and Family Therapist Services; Marriage and Family 
  Therapist; Mental Health Counselor Services; Mental Health Counselor

       ``(ccc)(1) The term `marriage and family therapist 
     services' means services performed by a marriage and family 
     therapist (as defined in paragraph (2)) for the diagnosis and 
     treatment of mental illnesses, which the marriage and family 
     therapist is legally authorized to perform under State law 
     (or the State regulatory mechanism provided by State law) of 
     the State in which such services are performed, as would 
     otherwise be covered if furnished by a physician or as an 
     incident to a physician's professional service, but only if 
     no facility or other provider charges or is paid any amounts 
     with respect to the furnishing of such services.
       ``(2) The term `marriage and family therapist' means an 
     individual who--
       ``(A) possesses a master's or doctoral degree which 
     qualifies for licensure or certification as a marriage and 
     family therapist pursuant to State law;
       ``(B) after obtaining such degree has performed at least 2 
     years of clinical supervised experience in marriage and 
     family therapy; and
       ``(C) in the case of an individual performing services in a 
     State that provides for licensure or certification of 
     marriage and family therapists, is licensed or certified as

[[Page S5793]]

     a marriage and family therapist in such State.
       ``(3) The term `mental health counselor services' means 
     services performed by a mental health counselor (as defined 
     in paragraph (4)) for the diagnosis and treatment of mental 
     illnesses which the mental health counselor is legally 
     authorized to perform under State law (or the State 
     regulatory mechanism provided by the State law) of the State 
     in which such services are performed, as would otherwise be 
     covered if furnished by a physician or as incident to a 
     physician's professional service, but only if no facility or 
     other provider charges or is paid any amounts with respect to 
     the furnishing of such services.
       ``(4) The term `mental health counselor' means an 
     individual who--
       ``(A) possesses a master's or doctor's degree in mental 
     health counseling or a related field;
       ``(B) after obtaining such a degree has performed at least 
     2 years of supervised mental health counselor practice; and
       ``(C) in the case of an individual performing services in a 
     State that provides for licensure or certification of mental 
     health counselors or professional counselors, is licensed or 
     certified as a mental health counselor or professional 
     counselor in such State.''.
       (3) Provision for payment under part b.--Section 
     1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
     1395k(a)(2)(B)) is amended by adding at the end the following 
     new clause:
       ``(v) marriage and family therapist services and mental 
     health counselor services;''.
       (4) Amount of payment.--Section 1833(a)(1) of the Social 
     Security Act (42 U.S.C. 1395l(a)(1)) is amended--
       (A) by striking ``and (V)'' and inserting ``(V)''; and
       (B) by inserting before the semicolon at the end the 
     following: ``, and (W) with respect to marriage and family 
     therapist services and mental health counselor services under 
     section 1861(s)(2)(BB), the amounts paid shall be 80 percent 
     of the lesser of the actual charge for the services or 75 
     percent of the amount determined for payment of a 
     psychologist under subparagraph (L)''.
       (5) Exclusion of marriage and family therapist services and 
     mental health counselor services from skilled nursing 
     facility prospective payment system.--Section 
     1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 
     1395yy(e)(2)(A)(ii)) is amended by inserting ``marriage and 
     family therapist services (as defined in section 
     1861(ccc)(1)), mental health counselor services (as defined 
     in section 1861(ccc)(3)),'' after ``qualified psychologist 
     services,''.
       (6) Inclusion of marriage and family therapists and mental 
     health counselors as practitioners for assignment of 
     claims.--Section 1842(b)(18)(C) of the Social Security Act 
     (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end 
     the following new clauses:
       ``(vii) A marriage and family therapist (as defined in 
     section 1861(ccc)(2)).
       ``(viii) A mental health counselor (as defined in section 
     1861(ccc)(4)).''.
       (b) Coverage of Certain Mental Health Services Provided in 
     Certain Settings.--
       (1) Rural health clinics and federally qualified health 
     centers.--Section 1861(aa)(1)(B) of the Social Security Act 
     (42 U.S.C. 1395x(aa)(1)(B)) is amended by striking ``or by a 
     clinical social worker (as defined in subsection (hh)(1)),'' 
     and inserting ``, by a clinical social worker (as defined in 
     subsection (hh)(1)), by a marriage and family therapist (as 
     defined in subsection (ccc)(2)), or by a mental health 
     counselor (as defined in subsection (ccc)(4)),''.
       (2) Hospice programs.--Section 1861(dd)(2)(B)(i)(III) of 
     the Social Security Act (42 U.S.C. 1395x(dd)(2)(B)(i)(III)) 
     is amended by inserting ``or one marriage and family 
     therapist (as defined in subsection (ccc)(2))'' after 
     ``social worker''.
       (c) Authorization of Marriage and Family Therapists to 
     Develop Discharge Plans for Post-Hospital Services.--Section 
     1861(ee)(2)(G) of the Social Security Act (42 U.S.C. 
     1395x(ee)(2)(G)) is amended by inserting ``marriage and 
     family therapist (as defined in subsection (ccc)(2)),'' after 
     ``social worker,''.
       (d) Effective Date.--The amendments made by this section 
     shall apply with respect to services furnished on or after 
     January 1, 2007.

     SEC. 19. MEDICARE REMOTE MONITORING PILOT PROJECTS.

       (a) Pilot Projects.--
       (1) In general.--Not later than 9 months after the date of 
     enactment of this Act, the Secretary of Health and Human 
     Services (in this section referred to as the ``Secretary'') 
     shall conduct pilot projects under title XVIII of the Social 
     Security Act for the purpose of providing incentives to home 
     health agencies to utilize home monitoring and communications 
     technologies that--
       (A) enhance health outcomes for Medicare beneficiaries; and
       (B) reduce expenditures under such title.
       (2) Site requirements.--
       (A) Urban and rural.--The Secretary shall conduct the pilot 
     projects under this section in both urban and rural areas.
       (B) Site in a small state.--The Secretary shall conduct at 
     least 3 of the pilot projects in a State with a population of 
     less than 1,000,000.
       (3) Definition of home health agency.--In this section, the 
     term ``home health agency'' has the meaning given that term 
     in section 1861(o) of the Social Security Act (42 U.S.C. 
     1395x(o)).
       (b) Medicare Beneficiaries Within the Scope of Projects.--
     The Secretary shall specify the criteria for identifying 
     those Medicare beneficiaries who shall be considered within 
     the scope of the pilot projects under this section for 
     purposes of the application of subsection (c) and for the 
     assessment of the effectiveness of the home health agency in 
     achieving the objectives of this section. Such criteria may 
     provide for the inclusion in the projects of Medicare 
     beneficiaries who begin receiving home health services under 
     title XVIII of the Social Security Act after the date of the 
     implementation of the projects.
       (c) Incentives.--
       (1) Performance targets.--The Secretary shall establish for 
     each home health agency participating in a pilot project 
     under this section a performance target using one of the 
     following methodologies, as determined appropriate by the 
     Secretary:
       (A) Adjusted historical performance target.--The Secretary 
     shall establish for the agency--
       (i) a base expenditure amount equal to the average total 
     payments made to the agency under parts A and B of title 
     XVIII of the Social Security Act for Medicare beneficiaries 
     determined to be within the scope of the pilot project in a 
     base period determined by the Secretary; and
       (ii) an annual per capita expenditure target for such 
     beneficiaries, reflecting the base expenditure amount 
     adjusted for risk and adjusted growth rates.
       (B) Comparative performance target.--The Secretary shall 
     establish for the agency a comparative performance target 
     equal to the average total payments under such parts A and B 
     during the pilot project for comparable individuals in the 
     same geographic area that are not determined to be within the 
     scope of the pilot project.
       (2) Incentive.--Subject to paragraph (3), the Secretary 
     shall pay to each participating home care agency an incentive 
     payment for each year under the pilot project equal to a 
     portion of the Medicare savings realized for such year 
     relative to the performance target under paragraph (1).
       (3) Limitation on expenditures.--The Secretary shall limit 
     incentive payments under this section in order to ensure that 
     the aggregate expenditures under title XVIII of the Social 
     Security Act (including incentive payments under this 
     subsection) do not exceed the amount that the Secretary 
     estimates would have been expended if the pilot projects 
     under this section had not been implemented.
       (d) Waiver Authority.--The Secretary may waive such 
     provisions of titles XI and XVIII of the Social Security Act 
     as the Secretary determines to be appropriate for the conduct 
     of the pilot projects under this section.
       (e) Report to Congress.--Not later than 5 years after the 
     date that the first pilot project under this section is 
     implemented, the Secretary shall submit to Congress a report 
     on the pilot projects. Such report shall contain a detailed 
     description of issues related to the expansion of the 
     projects under subsection (f) and recommendations for such 
     legislation and administrative actions as the Secretary 
     considers appropriate.
       (f) Expansion.--If the Secretary determines that any of the 
     pilot projects under this section enhance health outcomes for 
     Medicare beneficiaries and reduce expenditures under title 
     XVIII of the Social Security Act, the Secretary may initiate 
     comparable projects in additional areas.
       (g) Incentive Payments Have No Effect on Other Medicare 
     Payments to Agencies.--An incentive payment under this 
     section--
       (1) shall be in addition to the payments that a home health 
     agency would otherwise receive under title XVIII of the 
     Social Security Act for the provision of home health 
     services; and
       (2) shall have no effect on the amount of such payments.

     SEC. 20. FACILITATING THE PROVISION OF TELEHEALTH SERVICES 
                   ACROSS STATE LINES.

       (a) In General.--For purposes of expediting the provision 
     of telehealth services, for which payment is made under the 
     Medicare program, across State lines, the Secretary of Health 
     and Human Services shall, in consultation with 
     representatives of States, physicians, health care 
     practitioners, and patient advocates, encourage and 
     facilitate the adoption of provisions allowing for multistate 
     practitioner practice across State lines.
       (b) Definitions.--In subsection (a):
       (1) Telehealth service.--The term ``telehealth service'' 
     has the meaning given that term in subparagraph (F) of 
     section 1834(m)(4) of the Social Security Act (42 U.S.C. 
     1395m(m)(4)).
       (2) Physician, practitioner.--The terms ``physician'' and 
     ``practitioner'' have the meaning given those terms in 
     subparagraphs (D) and (E), respectively, of such section.
       (3) Medicare program.--The term ``Medicare program'' means 
     the program of health insurance administered by the Secretary 
     of Health and Human Services under title XVIII of the Social 
     Security Act (42 U.S.C. 1395 et seq.).
  Mr. CONRAD. Mr. President, today I am pleased to join Senator Thomas 
in introducing the Rural Hospital and Provider Equity Act, or R-HoPE. 
This

[[Page S5794]]

proposal will help shore up health care in rural areas and give rural 
Americans hope that health care will be available when they need it.
  R-HoPE is the next step in addressing the inequities that exist in 
Medicare reimbursement and ensuring access to health services, like 
ambulance, mental health and home health care, in rural communities. 
The proposal has strong bipartisan support. In fact we're pleased to 
have over 12 cosponsors today from both sides of the aisle.
  Our proposal also has broad support among provider groups including 
the National Rural Health Association, the American Hospital 
Association, the American Ambulance Association, Federation of American 
Hospitals, the National Association of Rural Health Clinics, National 
Association for Home Care and Hospice, and the American Academy of 
Nurse Practitioners.
  As my colleagues know, prior to the Medicare Modernization Act, 
Medicare was shortchanging rural providers. Our reimbursement was 
significantly less than our urban counterparts. For example, Mercy 
Hospital in Devil's Lake North Dakota received half as much 
reimbursement for treating pneumonia as Mercy Hospital in New York City 
did. While I will be the first to admit that health care can be more 
expensive in urban areas, it certainly isn't twice the cost. And for 
that matter, rural hospitals don't get a ``rural discount'' when they 
go to buy supplies or new technology. It costs rural hospitals even 
more to purchase technology and supplies because they can't achieve the 
economies of scale that larger, more urban hospitals can.
  The MMA recognized this disparity in reimbursement and took steps to 
close the gap. We secured over $25 billion for rural health care, but 
most of the changes were only temporary. Even with the MMA funding, 
many rural hospitals and providers continue to experience negative 
margins. In 2003, before the MMA passed, rural hospitals had overall 
Medicare margins of negative 5.4 percent--compared to negative 0.9 
percent for urban providers. In its March 2006 report, the Medicare 
Payment Advisory Commission projected that rural hospitals would 
experience negative 4.5-percent margins this year. Facilities cannot 
continue to provide high quality services if they lose over 4 percent 
on every Medicare patient.
  R-HoPE will help continue the progress made by the MMA and add new 
provisions that will protect access to rural health care.
  First, it will help ensure that everyone who chooses to live in a 
rural community has a hospital nearby. For example, the proposal 
recognizes that rural facilities can't achieve the same economies of 
scale as large hospitals by giving extra payments to hospitals with 
fewer than 2,000 patients a year. R-HoPE also reinstates provisions 
that protect rural hospitals against losses under the current 
outpatient payment system. Next, the bill extends an MMA provision that 
has helped rural hospitals to better meet their labor costs by 
improving their ``wage index'' calculation. In addition, the proposal 
would close the gap in payments hospitals receive for serving low-
income patients by giving the same level of special ``disproportionate 
share payments'' that urban areas enjoy. Lastly, the bill establishes a 
new loan program to help rural hospitals repair crumbling buildings.
  Second, R-HoPE would guarantee that rural Americans can see a doctor 
when they are sick. As is the case with most rural States, much of 
North Dakota is designated as a health professional shortage area, 
HPSA. Recruiting doctors to these areas is very difficult, and the 
Medicare program recognized that extra payments are needed when it 
established the 10-percent physician scarcity payment for doctors who 
serve Medicare patients in HPSAs. R-HoPE would extend these vital bonus 
payments. Our proposal also extends a provision from the MMA that 
erases geographic inequities in physician payments.
  Third, our bill would guarantee that when there is an emergency in a 
rural area, an ambulance is there to respond. Many rural ambulance 
services are closing because of low Medicare reimbursement. These 
services are often staffed by volunteers; few first responders are 
paid. R-HoPE would protect rural ambulance services by improving how 
Medicare pays EMS providers in rural areas. The bill also extends a 2-
percent bonus payment for rural ambulance services and takes steps to 
reduce the number of wrongful denials of payment by Medicare 
contractors.
  Fourth, R-HoPE helps to bolster a vital rural health care safety net 
provider, rural health clinics. Our bill would help preserve this 
important source of health care by increasing the all-inclusive payment 
from $63 to $82. In addition, our bill encourages rural health clinics 
to collaborate with community health centers to provide care in rural 
areas.
  Fifth, R-HoPE takes a number of steps to protect the availability of 
home and mental health in rural areas by increasing the number of 
providers who are allowed to order and provide these vital services. It 
also extends the rural add-on payment for home health services provided 
in rural areas and creates a pilot project to use home monitoring 
technology to provide home health services.
  This bill also removes barriers to telehealth. Specifically, the bill 
would address problems that arise when telehealth services are provided 
across State lines and payment is denied because the practitioner isn't 
licensed in the State where the patient resides.
  Finally, the bill we are introducing includes two small changes to 
the critical access hospital, CAH, program that will put these 
facilities on a much sounder financial footing. These provisions would 
ensure CAHs could afford to provide quality ambulance care and receive 
fair reimbursement for lab services provided outside the hospital.
  Rural America is the backbone of this country. We must not turn our 
backs on rural Americans and their health care needs. They have a right 
to the same quality health care enjoyed by other Americans. And that 
right is being threatened by low Medicare reimbursement and limited 
access to providers. R-HoPE truly gives hope to those living in rural 
communities by erasing the inequities in current law that impede access 
to care.
  I want to thank my Senate colleagues who have joined in this effort, 
as well as the organizations who worked with us, for their cooperation 
in developing this important health care proposal. It is my hope that 
this legislation will help strengthen our rural health care system and 
preserve it for generations to come.
                                 ______