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114th Congress    }                                 {    Rept. 114-696
                        HOUSE OF REPRESENTATIVES
 2d Session       }                                 {           Part 1

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



 
               CONTINUING ACCESS TO HOSPITALS ACT OF 2016

                                _______
                                

                 July 21, 2016.--Ordered to be printed

                                _______
                                

Mr. Brady of Texas, from the Committee on Ways and Means, submitted the 
                               following

                              R E P O R T

                        [To accompany H.R. 5613]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Ways and Means, to whom was referred the 
bill (H.R. 5613) to provide for the extension of the 
enforcement instruction on supervision requirements for 
outpatient therapeutic services in critical access and small 
rural hospitals through 2016, having considered the same, 
report favorably thereon with an amendment and recommend that 
the bill as amended do pass.

                                CONTENTS

                                                                   Page
 I. SUMMARY AND BACKGROUND............................................2
        A. PURPOSE AND SUMMARY...................................     2
        B. BACKGROUND AND NEED FOR LEGISLATION...................     2
        C. LEGISLATIVE HISTORY...................................     3
II. EXPLANATION OF THE BILL...........................................3
III.VOTES OF THE COMMITTEE............................................4

IV. BUDGET EFFECTS OF THE BILL........................................4
        A. Committee Estimate of Budgetary Effects...............     4
        B. Statement Regarding New Budget Authority and Tax 
            Expenditures Budget Authority........................     4
        C. Cost Estimate Prepared by the Congressional Budget 
            Office...............................................     4
 V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE........5
        A. Committee Oversight Findings and Recommendations......     5
        B. Statement of General Performance Goals and Objectives.     6
        C. Information Relating to Unfunded Mandates.............     6
        D. Congressional Earmarks, Limited Tax Benefits, and 
            Limited Tariff Benefits..............................     6
        E. Duplication of Federal Programs.......................     6
        F. Disclosure of Directed Rule Makings...................     6
VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED.............7
        A. Text of Existing Law Amended or Repealed by the Bill, 
            as Reported..........................................     7
        B. Changes in Existing Law Proposed by the Bill, as 
            Reported.............................................     7

    The amendment is as follows:
  Strike all after the enactment clause and insert the 
following:

SECTION 1. SHORT TITLE.

  This Act may be cited as the ``Continuing Access to Hospitals Act of 
2016'' or the ``CAH Act of 2016''.

SEC. 2. EXTENSION OF ENFORCEMENT INSTRUCTION ON SUPERVISION 
                    REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN 
                    CRITICAL ACCESS AND SMALL RURAL HOSPITALS THROUGH 
                    2016.

  Section 1 of Public Law 113-198, as amended by section 1 of Public 
Law 114-112, is amended--
          (1) in the heading, by striking ``2014 and 2015'' and 
        inserting ``2016''; and
          (2) by striking ``and 2015'' and inserting ``, 2015, and 
        2016''.

SEC. 3. REPORT.

  Not later than one year after the date of the enactment of this Act, 
the Medicare Payment Advisory Commission (established under section 
1805 of the Social Security Act (42 U.S.C. 1395b-6)) shall submit to 
Congress a report analyzing the effect of the extension of the 
enforcement instruction under section 1 of Public Law 113-198, as 
amended by section 1 of Public Law 114-112 and section 2 of this Act, 
on the access to health care by Medicare beneficiaries and on the 
quality of health care furnished to such beneficiaries.

                       I. SUMMARY AND BACKGROUND


                         A. Purpose and Summary

    The bill, H.R. 5613, the ``Continuing Access to Hospitals 
Act of 2016'' (``CAH''), as reported by the Committee on Ways 
and Means on July 7, 2016, requires the department of Health 
and Human Services to continue to instruct Medicare contractors 
not to enforce requirements for direct physician supervision of 
outpatient therapeutic services in critical access and small 
rural hospitals through 2016.

                 B. Background and Need for Legislation

    On July 1, 2016, Representative Jenkins (R-KS) and 
Representative Loebsack (D-IA) introduced H.R. 5613, to provide 
regulatory relief to Critical Access Hospitals (CAHs) by 
temporarily prohibiting the Secretary from enforcing the 
physician supervision requirement.
    The Centers for Medicare & Medicaid Services (CMS) 
finalized its regulation requiring direct physician supervision 
in November 2009. Direct supervision, as defined by 42 Code of 
Federal Regulations (CFR) 410.32, means that a physician or 
non-physician practitioner must be immediately available to 
furnish assistance and direction throughout the performance of 
a procedure. In its manuals, CMS defines services and supplies 
in which the direct supervision requirement applies as those 
non-diagnostic therapeutic services including: clinical 
services, emergency room services and observation services.
    CMS initially proposed to enforce the direct physician 
supervision requirement, where it would ensure CAHs were in 
compliance, beginning January 1, 2014. However, Congress acted 
separately in 2014 and 2015 to override enforcement of the 
requirement. Congress has previously acted, and continues to 
act with this bill, because we are concerned that such 
stringent regulatory requirements may threaten access to care 
for beneficiaries in rural areas. The CAH Act would continue 
temporary relief from enforcement of the requirement for 2016.

                         C. Legislative History


Background

    H.R. 5613 was introduced on July 1, 2016, and was referred 
to the Committee on Energy and Commerce and additionally to the 
Committee on Ways and Means.

Committee hearings

    On July 28, 2015, the Committee on Ways and Means 
Subcommittee on Health held a hearing on the status of rural 
health for Medicare beneficiaries and highlighted Member 
priorities.
    On June 8, 2016, the Committee on Ways and Means 
Subcommittee on Health held a Member day hearing on issues in 
the Medicare program, including CAH issues.

Committee action

    The Committee on Ways and Means marked up H.R. 5613, the 
CAH Act on July 7, 2016, and ordered the bill favorably 
reported to the House of Representatives as amended by a voice 
vote (with a quorum being present).
    In addition to the amendment in the nature of the 
substitute to H.R. 5613 that was favorably reported, the 
Committee on Ways and Means also favorably reported out an 
amendment by Mr. Becerra to the amendment in the nature of a 
substitute, which added a study by the Medicare Payment 
Advisory Commission to analyze the effect of delaying the 
enforcement of the physician supervision requirement on access 
to, and quality of, health care for Medicare beneficiaries.

                      II. EXPLANATION OF THE BILL


               Continuing Access to Hospitals Act of 2016


                              PRESENT LAW

    Under current law, the CMS is enforcing its regulations, 
where CAHs are required to provide for the direct supervision, 
by a physician or non-physician practitioner, over delivery of 
outpatient services.

                           REASONS FOR CHANGE

    Congress acted separately in 2014 (P.L. 113-198) and 2015 
(P.L. 114-112) to override the enforcement of the requirement. 
Congress has previously acted, and continues to act with this 
bill, out of concern that these regulatory requirements may 
threaten access to care for beneficiaries in rural areas.
    CAHs have reported uncertainty in the interpretation of 
``immediately available'' and wide variation in CMS enforcement 
of the definition. Additionally, CAHs have reported uncertainty 
in the definition of ``clinical services'' that would be 
covered by the direct supervision rule.

                        EXPLANATION OF PROVISION

    The legislation prohibits the Secretary from enforcing the 
direct supervision regulations under 42 CFR 410.27 for calendar 
year 2016. 42 CFR 410.27 requires that services and supplies, 
furnished in Critical Access Hospitals (CAHs), that assist 
clinicians in the treatment of patients must be provided with 
direct physician supervision.

                             EFFECTIVE DATE

    The CAH Act would continue temporary relief from 
enforcement of the requirement for 2016.

                      III. VOTES OF THE COMMITTEE

    In compliance with clause 3(b) of rule XIII of the Rules of 
the House of Representatives, the following statement is made 
concerning the vote of the Committee on Ways and Means in its 
consideration of H.R. 5613, the ``Continuing Access to 
Hospitals Act of 2016,'' (``CAH'') on July 7, 2016.
    The Chairman's amendment in the nature of a substitute was 
adopted by a voice vote (with a quorum being present).
    The amendment by Mr. Becerra to the amendment in the nature 
of the substitute to H.R. 5613, which added a study by the 
Medicare Payment Advisory Commission to analyze the effect of 
delaying the enforcement of the physician supervision 
requirement, was agreed to by a voice vote (with a quorum being 
present).
    The bill, H.R. 5613, was ordered favorably reported as 
amended by voice vote (with a quorum being present).

                     IV. BUDGET EFFECTS OF THE BILL


               A. Committee Estimate of Budgetary Effects

    In compliance with clause 3(d) of rule XIII of the Rules of 
the House of Representatives, the following statement is made 
concerning the effects on the budget of the bill, H.R. 5613, as 
reported. The Committee agrees with the estimate prepared by 
the Congressional Budget Office (CBO), which is included below.

B. Statement Regarding New Budget Authority and Tax Expenditures Budget 
                               Authority

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee states that the 
bill involves no new or increased budget authority. The 
Committee states further that the bill involves no new or 
increased tax expenditures.

      C. Cost Estimate Prepared by the Congressional Budget Office

    In compliance with clause 3(c)(3) of rule XIII of the Rules 
of the House of Representatives, requiring a cost estimate 
prepared by the CBO, the following statement by CBO is 
provided.

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 20, 2016.
Hon. Kevin Brady,
Chairman, Committee on Ways and Means,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 5613, the 
Continuing Access to Hospitals Act of 2016.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Lori Housman.
            Sincerely,
                                              Theresa Gullo
                                        (For Keith Hall, Director).
    Enclosure.

H.R. 5613--Continuing Access to Hospitals Act of 2016

    H.R. 5613 would require the Secretary of Health and Human 
Services to continue to apply an exception to the requirement 
that certain outpatient therapeutic services be provided under 
the direct supervision of a physician when they are furnished 
in critical access and small rural hospitals. This exception 
would apply through calendar year 2016. The Centers for 
Medicare and Medicaid Services (CMS) currently does not enforce 
the federal requirement related to direct supervision for those 
services and CBO does not anticipate that CMS will begin 
enforcing the requirement in the near future under current law. 
(Those services are subject to supervision requirements 
established under state laws.)
    Because CBO expects that H.R. 5613 would not change how CMS 
enforces the direct supervision requirement, we estimate that 
enacting H.R. 5613 would not affect direct spending or 
revenues; therefore, pay-as-you-go procedures do not apply. 
Additionally, CBO estimates that enacting H.R. 5613 would not 
increase net direct spending or on-budget deficits in any of 
the four consecutive 10-year periods beginning in 2027.
    H.R. 5613 would require the Medicare Payment Advisory 
Commission to analyze and report to Congress on how enforcing 
the requirement for direct supervision would affect health care 
provided to beneficiaries. CBO estimates that the cost of this 
study would be less than $500,000; that spending would be 
subject to the availability of appropriated funds.
    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.

     V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE


          A. Committee Oversight Findings and Recommendations

    With respect to clause 3(c)(1) of rule XIII of the Rules of 
the House of Representatives, the Committee advises that the 
findings and recommendations of the Committee, based on 
oversight activities under clause 2(b)(1) of rule X of the 
Rules of the House of Representatives, are incorporated in the 
descriptive portions of this report. Statement of General 
Performance Goals and Objectives.

        B. Statement of General Performance Goals and Objectives

    With respect to clause 3(c)(4) of rule XIII of the Rules of 
the House of Representatives, the Committee advises that the 
bill contains no measure that authorizes funding, so no 
statement of general performance goals and objectives for which 
any measure authorizes funding is required.

              C. Information Relating to Unfunded Mandates

    This information is provided in accordance with section 423 
of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104-
4).
    The Committee has determined that the bill does not contain 
Federal mandates on the private sector. The Committee has 
determined that the bill does not impose a Federal 
intergovernmental mandate on State, local, or tribal 
governments.

  D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff 
                                Benefits

    With respect to clause 9 of rule XXI of the Rules of the 
House of Representatives, the Committee has carefully reviewed 
the provisions of the bill, and states that the provisions of 
the bill do not contain any congressional earmarks, limited tax 
benefits, or limited tariff benefits within the meaning of the 
rule.

                   E. Duplication of Federal Programs

    In compliance with Sec. 3(g)(2) of H. Res. 5 (114th 
Congress), the Committee states that no provision of the bill 
establishes or reauthorizes: (1) a program of the Federal 
Government known to be duplicative of another Federal program; 
(2) a program included in any report from the Government 
Accountability Office to Congress pursuant to section 21 of 
Public Law 111-139; or (3) a program related to a program 
identified in the most recent Catalog of Federal Domestic 
Assistance, published pursuant to the Federal Program 
Information Act (Pub. L. No. 95-220, as amended by Pub. L. No. 
98-169).

                 F. Disclosure of Directed Rule Makings

    In compliance with Sec. 3(i) of H. Res. 5 (114th Congress), 
the following statement is made concerning directed rule 
makings: The Committee estimates that the bill requires no 
directed rule makings within the meaning of such section.

       VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED


  A. Text of Existing Law Amended or Repealed by the Bill, as Reported

    In compliance with clause 3(e)(1)(A) of rule XIII of the 
Rules of the House of Representatives, the text of each section 
proposed to be amended or repealed by the bill, as reported, is 
shown below:

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e)(1)(A) of rule XIII of the 
Rules of the House of Representatives, the text of each section 
proposed to be amended or repealed by the bill, as reported, is 
shown below:

PUBLIC LAW 113-198

           *       *       *       *       *       *       *


SECTION 1. EXTENSION OF ENFORCEMENT INSTRUCTION ON SUPERVISION 
                    REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN 
                    CRITICAL ACCESS AND SMALL RURAL HOSPITALS THROUGH 
                    2014 AND 2015.

  The Secretary of Health and Human Services shall continue to 
apply through calendar years 2014 and 2015 the enforcement 
instruction described in the notice of the Centers for Medicare 
& Medicaid Services entitled ``Enforcement Instruction on 
Supervision Requirements for Outpatient Therapeutic Services in 
Critical Access and Small Rural Hospitals for CY 2013'', dated 
November 1, 2012 (providing for an exception to the restatement 
and clarification under the final rulemaking changes to the 
Medicare hospital outpatient prospective payment system and 
calendar year 2009 payment rates (published in the Federal 
Register on November 18, 2008, 73 Fed. Reg. 68702 through 
68704) with respect to requirements for direct supervision by 
physicians for therapeutic hospital outpatient services).

           *       *       *       *       *       *       *


      B. Changes in Existing Law Proposed by the Bill, as Reported

    In compliance with clause 3(e)(1)(B) of rule XIII of the 
Rules of the House of Representatives, changes in existing law 
proposed by the bill, as reported, are shown as follows 
(existing law proposed to be omitted is enclosed in black 
brackets, new matter is printed in italics, existing law in 
which no change is proposed is shown in roman):

         Changes in Existing Law Made by the Bill, as Reported

  In compliance with clause 3(e)(1)(B) of rule XIII of the 
Rules of the House of Representatives, changes in existing law 
proposed by the bill, as reported, are shown as follows (new 
matter is printed in italics and existing law in which no 
change is proposed is shown in roman):

PUBLIC LAW 113-198

           *       *       *       *       *       *       *


SECTION 1. EXTENSION OF ENFORCEMENT INSTRUCTION ON SUPERVISION 
                    REQUIREMENTS FOR OUTPATIENT THERAPEUTIC SERVICES IN 
                    CRITICAL ACCESS AND SMALL RURAL HOSPITALS THROUGH 
                    [2014 AND 2015]  2016.

  The Secretary of Health and Human Services shall continue to 
apply through calendar years 2014 [and 2015], 2015, and 2016 
the enforcement instruction described in the notice of the 
Centers for Medicare & Medicaid Services entitled ``Enforcement 
Instruction on Supervision Requirements for Outpatient 
Therapeutic Services in Critical Access and Small Rural 
Hospitals for CY 2013'', dated November 1, 2012 (providing for 
an exception to the restatement and clarification under the 
final rulemaking changes to the Medicare hospital outpatient 
prospective payment system and calendar year 2009 payment rates 
(published in the Federal Register on November 18, 2008, 73 
Fed. Reg. 68702 through 68704) with respect to requirements for 
direct supervision by physicians for therapeutic hospital 
outpatient services).

           *       *       *       *       *       *       *


                                  [all]