; and (2) by adding at the end the following new paragraph: (8) Requirements for certain facilities described For purposes of paragraph (2)(B), with respect to a facility which is not a physician-directed clinic, the following requirements are described in this paragraph: (A) Arrangement The facility has an arrangement consistent with the provisions of State and local law relative to the practice, performance, and delivery of health services, with one or more physician assistants (as defined in paragraph (5)(A)) or one or more nurse practitioners (as defined in such paragraph). (B) Practice and oversight requirements (i) In general Subject to clause (ii), the delivery of health services under such arrangement shall be in accordance with State law or the State regulatory mechanism governing the practice of physician assistants or nurse practitioners. (ii) Exception if no State laws or regulations applicable In the case where a State does not have laws or regulations governing the practice, performance, and delivery of health services by a physician assistant or nurse practitioner, the Secretary shall adopt regulations for facilities located in such State that provide for the periodic review by physicians of covered services furnished by physician assistants and nurse practitioners, the supervision and guidance by such physicians of physician assistants and nurse practitioners, and the preparation by such physicians of such medical orders for care and treatment of clinic patients as is necessary. Such regulations shall also require facilities located in such a State to have arrangements with physicians for referral of and consultation for patients as the facility deems necessary and for advice and assistance in the management of medical emergencies. . (b) Effective date The amendments made by this section shall take effect on the date of the enactment of this Act. 3. Removing outdated laboratory requirements (a) In general Section 1861(aa)(2)(G) of the Social Security Act ( 42 U.S.C. 1395x(aa)(2)(G) ) is amended by