[Senate Report 114-109]
[From the U.S. Government Publishing Office]
Calendar No. 188
114th Congress } { Report
SENATE
1st Session } { 114-109
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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 2015
_______
July 30, 2015.--Ordered to be printed
_______
Mr. Hatch, from the Committee on Finance,
submitted the following
R E P O R T
[To accompany S. 1461]
The Committee on Finance, to which was referred the bill
(S. 1461) to provide for the extension of the enforcement
instruction on supervision requirements for outpatient
therapeutic services in critical access and small rural
hospitals through 2015, having considered the same, reports
favorably thereon with an amendment and recommends that the
bill, as amended, do pass.
I. LEGISLATIVE BACKGROUND
The Committee on Finance, to which was referred (S. 1461),
to provide for the extension of the enforcement instruction on
supervision requirements for outpatient therapeutic services in
critical access and small rural hospitals through 2015, reports
favorably thereon with an amendment and recommends the bill, as
amended, do pass.
Background and need for legislative action
In the calendar year (CY) 2009 Medicare hospital outpatient
prospective payment system (OPPS) final rule, the Centers for
Medicare and Medicaid Services (CMS) restated and clarified a
2001 policy that required direct physician supervision for
outpatient therapeutic services furnished in a hospital
outpatient department unless another supervision level is
specified for the service. The final rule discussed that direct
supervision means a physician or a non-physician practitioner
must be immediately available to furnish assistance and
direction throughout a procedure in the hospital outpatient
department. CAHs and small rural hospitals raised concerns that
the policy increased confusion about the types of therapeutic
services that would fall under the supervision requirements.
While CMS currently does not enforce federal requirements
related to direct supervision for certain outpatient
therapeutic services in CAHs and small rural hospitals,
providers advocate that lingering confusion could lead to
health care access issues for Medicare patients.
II. EXPLANATION OF THE BILL
A. Extension of Medicare enforcement instruction on
supervision requirements for outpatient therapeutic services in
CAHs and small rural hospitals through 2015.
PRESENT LAW
In the calendar year (CY) 2009 Medicare hospital outpatient
prospective payment system (OPPS) final rule, the Centers for
Medicare and Medicaid Services (CMS) restated and clarified a
2001 policy that required direct physician supervision for
outpatient therapeutic services furnished in a hospital
outpatient department unless another supervision level is
specified for the service. The final rule discussed that direct
supervision means a physician or a non-physician practitioner
must be immediately available to furnish assistance and
direction throughout a procedure in the hospital outpatient
department. Critical access hospitals (CAHs) and small rural
hospitals raised concerns that the policy increased confusion
about the types of therapeutic services that would fall under
the supervision requirements.
In 2010, CMS instructed its Medicare contractors not to
evaluate or enforce the supervision requirements for
therapeutic services furnished to individuals in CAHs for all
of CY 2010. As CMS continued to refine its direct supervision
policy, the agency extended its non-enforcement instruction
through CY 2011 and expanded it to include both CAHs and small
rural hospitals (defined as having 100 or fewer beds, being
geographically located in a rural area, or are paid under the
hospital outpatient PPS using a rural wage index).
Meanwhile, in 2012, CMS established an independent review
process that allows the Advisory Panel on Hospital Outpatient
Payment (HOP Panel) to advise CMS regarding stakeholder
requests for changes in the required supervision level for a
specific hospital outpatient therapeutic service. As the HOP
Panel conducted its review, in CY 2012 CMS again delayed
enforcement of the direct supervision policy for CAHs and small
rural hospitals through CY 2013. CMS noted, however, that CY
2013 would be the final year the agency would extend the non-
enforcement instruction. In December 2014, Congress passed, and
the President signed, P.L. 113-198 which required CMS to
continue through CY 2014 the instruction to not enforce
Medicare's direct supervision requirement for outpatient
therapeutic services furnished at critical access hospitals and
small rural hospitals.
EXPLANATION OF PROVISION
S. 1461, as modified, would extend, through December 31,
2015, the instruction to not enforce Medicare's direct
supervision requirements for outpatient therapeutic services
furnished at critical access hospitals and small rural
hospitals.
EFFECTIVE DATE
The provision applies to months beginning after December
31, 2014 and expires after December 31, 2015.
III. BUDGET EFFECTS OF THE BILL
A. Committee Estimates
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.
B. Budget Authority
In compliance with section 308(a)(1) of the Congressional
Budget and Impoundment Control Act of 1974 (P.L. 93-344), the
Committee states that no provisions of the bill as reported
involve new or increased budget authority.
C. Consultation With Congressional Budget Office
In accordance with section 403 of the Congressional Budget
and Impoundment Control Act of 1974 (P.L. 93-344), the
Committee advises that the Congressional Budget Office has
submitted a statement on the bill. 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, July 9, 2015.
Hon. Orrin G. Hatch,
Chairman, Committee on Finance,
U.S. Senate, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for S. 1461, 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 2015.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Lori Housman,
who can be reached at 226-9010.
Sincerely,
Keith Hall.
Enclosure.
S. 1461--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 2015
S. 1461 would require the Secretary of Health and Human
Services to continue to apply, through calendar year 2015, 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. (Those services are subject to
supervision requirements established under state laws.)
Because CBO expects that S. 1461 would not change how CMS
enforces the direct supervision requirement, we estimate that
enacting the bill would have no significant effect on the
federal budget. Enacting S. 1461 would not affect direct
spending or revenues; therefore, 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.
IV. VOTES OF THE COMMITTEE
In compliance with paragraph 7(b) of rule XXVI of the
Standing Rules of the Senate, the Committee states that, with a
majority present, the one year extension of the enforcement
instructions on supervision requirements of outpatient
therapeutic services in Critical Access Hospitals (CAHs) and
small rural hospitals, as modified, was ordered favorably
reported by voice vote on June 24, 2015.
V. REGULATORY IMPACT AND OTHER MATTERS
A. Regulatory Impact
Pursuant to paragraph 11(b) of rule XXVI of the Standing
Rules of the Senate, the Committee makes the following
statement concerning the regulatory impact that might be
incurred in carrying out the provisions of the bill.
Impact on individuals and businesses, personal privacy and paperwork
In carrying out the provisions of the bill, there is no
expected imposition of additional administrative requirements
or regulatory burdens on individuals or businesses. The
provisions of the bill do not impact personal privacy.
B. Unfunded 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 of 1995 (P.L. 104-4). The Congressional Budget Office
estimates 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.
VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED
In the opinion of the Committee, it is necessary in order
to expedite the business of the Senate, to dispense with the
requirements of paragraph 12 of Rule XXVI of the Standing Rules
of the Senate (relating to the showing of changes in existing
law made by the bill as reported by the Committee).
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