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113th Congress                                            Rept. 113-582
                        HOUSE OF REPRESENTATIVES
 2d Session                                                      Part 1

======================================================================

 
     EXTENSION OF MEDICARE ENFORCEMENT INSTRUCTION ON SUPERVISION 
REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN CRITICAL ACCESS AND 
                   SMALL RURAL HOSPITALS THROUGH 2014

                                _______
                                

 September 9, 2014.--Committed to the Committee of the Whole House on 
            the State of the Union and ordered to be printed

                                _______
                                

  Mr. Upton, from the Committee on Energy and Commerce, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 4067]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 4067) to provide for the extension of the 
enforcement instruction on supervision requirements for 
outpatient therapeutic services in critical access and small 
rural hospitals through 2014, having considered the same, 
report favorably thereon without amendment and recommend that 
the bill do pass.

                                CONTENTS

                                                                   Page
Purpose and Summary..............................................     1
Background and Need for Legislation..............................     2
Committee Consideration..........................................     2
Committee Votes..................................................     2
Committee Oversight Findings.....................................     4
Statement of General Performance Goals and Objectives............     4
New Budget Authority, Entitlement Authority, and Tax Expenditures     4
Earmark, Limited Tax Benefits, and Limited Tariff Benefits.......     4
Committee Cost Estimate..........................................     4
Congressional Budget Office Estimate.............................     4
Federal Mandates Statement.......................................     5
Duplication of Federal Programs..................................     5
Disclosure of Directed Rule Makings..............................     5
Advisory Committee Statement.....................................     5
Applicability to Legislative Branch..............................     5
Section-by-Section Analysis of the Legislation...................     6

                          PURPOSE AND SUMMARY

    H.R. 4067 provides for the reinstatement of the calendar 
year 2013 Medicare enforcement instruction on physician 
supervision requirements for outpatient therapeutic services in 
critical access and small rural hospitals through the end of 
calendar year 2014.

                  BACKGROUND AND NEED FOR LEGISLATION

    The Medicare program is a health care program for seniors 
and those with disabilities, and serves an important function 
in providing access to health care services for those in need 
of care. Authorized by Congress in 1965, it continues to serve 
patients in both rural and urban areas of the country.
    Beginning in calendar year 2009, the Centers for Medicare 
and Medicaid Services (CMS) created new requirements on medical 
providers to provide direct supervision of certain outpatient 
therapy services, but created a moratorium for critical access 
hospitals and small rural hospitals for a period of four years. 
The moratorium ended on January 1, 2014.
    During calendar year 2014, the Committee had become aware 
of confusion among rural providers related to which services 
and instances would fall under the new requirements. In 
addition, the continued work of the Advisory Panel on Hospital 
Outpatient Payment related to identifying the appropriate level 
of supervision for such services appeared to add to provider 
confusion. While the Medicare program currently does not 
enforce Federal requirements related to direct supervision for 
certain outpatient therapeutic services, providers advocate 
that extant confusion could lead to access issues for patients 
in need of care.

                        COMMITTEE CONSIDERATION

    On July 30, 2014, the full Committee on Energy and Commerce 
met in open markup session and ordered H.R. 4067 reported to 
the House, without amendment, by a record vote of 31 yeas and 
11 nays.

                            COMMITTEE VOTES

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report legislation and amendments thereto. A 
motion by Mr. Upton to order H.R. 4067 reported to the House, 
without amendment, was agreed to by a record vote of 31 ayes 
and 11 nays. The following reflects the record votes taken 
during the Committee consideration:


                      COMMITTEE OVERSIGHT FINDINGS

    Pursuant to clause 3(c)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee has not held hearings 
on this legislation.

         STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

    The goal of H.R. 4067 is to provide the provider community 
an opportunity to verify the specific instances and services 
for which the supervision requirements for hospital outpatient 
therapeutic services will be enforced by Medicare contractors.

   NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX EXPENDITURES

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee finds that H.R. 
4067 would result in no new or increased budget authority, 
entitlement authority, or tax expenditures or revenues.

       EARMARK, LIMITED TAX BENEFITS, AND LIMITED TARIFF BENEFITS

    In compliance with clause 9(e), 9(f), and 9(g) of rule XXI, 
the Committee finds that H.R. 4067 contains no earmarks, 
limited tax benefits, or limited tariff benefits.

                        COMMITTEE COST ESTIMATE

    The Committee adopts as its own the cost estimate prepared 
by the Director of the Congressional Budget Office pursuant to 
section 402 of the Congressional Budget Act of 1974.

                  CONGRESSIONAL BUDGET OFFICE ESTIMATE

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
provided by the Congressional Budget Office pursuant to section 
402 of the Congressional Budget Act of 1974.

                                     U.S. Congress,
                               Congressional Budget Office,
                                   Washington, DC, August 12, 2014.
Hon.  Fred Upton,
Chairman, Committee on Energy and Commerce,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 4067, a bill to 
provide for the extension of the enforcement instruction on 
supervision requirements for outpatient therapeutic services in 
critical access and small rural hospitals through 2014.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Lori Housman.
            Sincerely,
                                         Robert A. Sunshine
                                        (For Douglas W. Elmendorf).
    Enclosure.

H.R. 4067--A bill to provide for the extension of the enforcement 
        instruction on supervision requirements for outpatient 
        therapeutic services in critical access and small rural 
        hospitals through 2014

    H.R. 4067 would require the Secretary of Health and Human 
Services to continue to apply through calendar year 2014 an 
exception to requirements that certain outpatient therapeutic 
services furnished in critical access and small rural hospitals 
need to be provided under the direct supervision of physicians 
in the hospital. The Centers for Medicare and Medicaid Services 
(CMS) currently do not enforce federal requirements related to 
direct supervision for those services, and CBO anticipates that 
CMS would not initiate enforcement of such requirements in the 
near future under current law. Rather, those services are 
subject to supervision requirements established under state 
laws.
    Therefore, CBO estimates that enacting H.R. 4067 would have 
no significant effect on the federal budget. Because enacting 
H.R. 4067 would not affect direct spending or revenues, pay-as-
you-go procedures do not apply.
    The bill would not impose intergovernmental or private-
sector mandates as defined in the Unfunded Mandates Reform Act 
and would impose no costs on state, local, or tribal 
governments.
    The CBO staff contact for this estimate is Lori Housman. 
The estimate was approved by Holly Harvey, Deputy Assistant 
Director for Budget Analysis.

                       FEDERAL MANDATES STATEMENT

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

                    DUPLICATION OF FEDERAL PROGRAMS

    No provision of H.R. 4067 establishes or reauthorizes a 
program of the Federal Government known to be duplicative of 
another Federal program, a program that was included in any 
report from the Government Accountability Office to Congress 
pursuant to section 21 of Public Law 111-139, or a program 
related to a program identified in the most recent Catalog of 
Federal Domestic Assistance.

                  DISCLOSURE OF DIRECTED RULE MAKINGS

    The Committee estimates that enacting H.R. 4067 
specifically directs to be completed zero rule makings within 
the meaning of 5 U.S.C. 551.

                      ADVISORY COMMITTEE STATEMENT

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this 
legislation.

                  APPLICABILITY TO LEGISLATIVE BRANCH

    The Committee finds that the legislation does not relate to 
the terms and conditions of employment or access to public 
services or accommodations within the meaning of section 
102(b)(3) of the Congressional Accountability Act.

             SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Extension of enforcement instruction on supervision 
        requirements for Outpatient Therapeutic Services in Critical 
        Access and Small Rural Hospitals through 2014

    Section 1 establishes that the Secretary of Health and 
Human Services shall apply through December 31, 2014 the 
enforcement instructions related to Hospital Outpatient 
Services provided by Critical Access and Small Rural Hospitals 
previously in effect until December 31, 2013.