,i #aadth ,,congress #ast ,session ,h4 ,r4 #cbbe ,,in ,,the ,,house ,,of ,,representatives ,july #bg1 #bjae ,mr4 ,graves of ,missouri 7for himself and ,mr4 ,loebsack7 introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means and the ,budget1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend titles ,,xviii and ,,xix of the ,social ,security ,act to provide for enhanced payments to rural health care providers under the ,medicare and ,medicaid programs1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,save ,rural ,hospitals ,act4 7b7 ,findings ,congress finds the following3 7#a7 ,more than #fj1jjj1jjj individuals in rural areas of the ,united ,states rely on rural hospitals and other providers as critical access points to health care4 7#b7 ,access to health care is essential to communities that ,americans living in rural areas call home4 7#c7 ,americans living in rural areas are older1 poorer1 and sicker than ,americans living in urban areas4 7#d7 ,from ,january #bjaj until ,july #h1 #bjae1 #ee rural hospitals have closed in the ,united ,states1 according to the ,university of ,north ,carolina's ,cecil ,g4 ,sheps ,center for ,health ,services ,research1 and the rate of these closures is increasing4 7#e7 ,two hundred and eighty-three hospitals are at risk of closing1 according to i,vantage's ,hospital ,strength ,,index study1 and such closings would mean that #gjj1jjj patients would be left without local access to care1 #ej1jjj community jobs would be lost1 #cf1jjj healthcare jobs would be lost1 and #aj1fjj1jjj1jjj would be lost from the gross domestic product4 7#f7 ,rural ,medicare beneficiaries already face a number of challenges when trying to access health care services close to home1 including the weather1 geography1 and cultural1 social1 and language barriers4 7#g7 ,seventy-seven percent of rural counties in the ,united ,states are designated as primary care health professional shortage areas while #i percent have no physicians at all4 7#h7 ,seniors living in rural areas are forced to travel significant distances for care4 7#i7 ,on average1 trauma victims in rural areas must travel twice as far as victims in urban areas to the closest hospital1 and1 as a result1 #fj percent of trauma deaths occur in rural areas1 even though only #bj percent of ,americans live in rural areas4 7#aj7 ,with the #bhc hospitals on the brink of closure1 #gjj1jjj ,americans living in rural areas are on the brink of losing access to the closest emergency room4 7c7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4 ,title ,i--,rural provider payment stabilization ,subtitle ,a--,rural hospitals ,sec4 #aja4 ,eliminating ,medicare sequestration for rural hospitals4 ,sec4 #ajb4 ,reversing cuts to reimbursement of bad debt for critical access hospitals 7,c,a,hs7 and rural hospitals4 ,sec4 #ajc4 ,extending payment levels for low-volume hospitals and ,medicare-dependent hospitals 7,m,d,hs74 ,sec4 #ajd4 ,reinstating revised diagnosis-related group payments for ,m,d,hs and sole community hospitals 7,s,c,hs74 ,sec4 #aje4 ,reinstating hold harmless treatment for hospital outpatient services for ,s,c,hs4 ,sec4 #ajf4 ,delaying application of penalties for failure to be a meaningful electronic health record user4 ,sec4 #ajg4 ,eliminating rural ,medicare and ,medicaid disproportionate share hospital payment reductions4 ,subtitle ,b--,other rural providers ,sec4 #aaa4 ,making permanent increased ,medicare payments for ground ambulance services in rural areas4 ,sec4 #aab4 ,extending ,medicaid primary care payments4 ,title ,,ii--,rural ,medicare beneficiary equity ,sec4 #bja4 ,equalizing beneficiary copayments for services furnished by ,c,a,hs4 ,title ,,iii--,regulatory relief ,sec4 #cja4 ,eliminating #if-;hour physician certification requirement with respect to inpatient ,,cah services4 ,sec4 #cjb4 ,rebasing supervision requirements4 ,sec4 #cjc4 ,reforming practices of recovery audit contractors under ,medicare4 ,title ,,iv--,future of rural health care ,sec4 #dja4 ,community outpatient hospital program4 ,sec4 #djb4 ,grant funding to assist rural hospitals4 ,sec4 #djc4 ,,cmmi demonstration of shared savings in rural hospitals4 ,i ,rural provider payment stabilization ,a ,rural hospitals #aja4 ,eliminating ,medicare sequestration for rural hospitals 7a7 ,in general ,section #bef7;d77#g7 of the ,balanced ,budget and ,emergency ,deficit ,control ,act of #aihe 7#b ,u4,s4,c4 #ijf7;d77#g77 is amended by adding at the end the following3 7,d7 ,rural hospitals ,payments under part ,a or part ,b of title ,,xviii of the ,social ,security ,act with respect to items and services furnished by a critical access hospital 7as defined in section #ahfa7mm77#a7 of such ,act71 a sole community hospital 7as defined in section #ahhf7;d77#e77;,d77iii7 of such ,act71 a medicare-dependent small rural hospital 7as defined in section #ahhf7;d77#e77;,g77iv7 of such ,act71 or a subsection 7d7 hospital located in a rural area 7as defined in section #ahhf7;d77#b77;,d7 of such ,act74 4 7b7 ,applicability ,the amendment made by this section applies with respect to orders of sequestration effective on or after the date that is #fj days after the date of the enactment of this ,act4 #ajb4 ,reversing cuts to reimbursement of bad debt for critical access hospitals 7,c,a,hs7 and rural hospitals 7a7 ,rural hospitals ,section #ahfa7v77#a77,t77v7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7v77#a77,t77v77 is amended by inserting before the period the following3 or1 in the case of a hospital located in a rural area1 by #cj percent of such amount otherwise allowable4 7b7 ,c,a,hs ,section #ahfa7v77#a77,w77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7v77#a77,w77ii77 is amended by inserting after or 7,v7 the following3 1 a critical access hospital4 7c7 ,applicability ,the amendments made by this section apply with respect to cost reporting periods beginning more than #fj days after the date of the enactment of this ,act4 #ajc4 ,extending payment levels for low-volume hospitals and ,medicare-dependent hospitals 7,m,d,hs7 7a7 ,extension of increased payments for ,m,d,hs 7#a7 ,extension of payment methodology ,section #ahhf7;d77#e77;,g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,g771 as amended by section #bje7;a7 of the ,medicare ,access and ,,chip ,reauthorization ,act of #bjae1 is amended-- 7,a7 in clause 7i71 by striking 1 and before ,october #a1 #bjag2 and 7,b7 in clause 7ii77,,ii71 by striking 1 and before ,october #a1 #bjag4 7#b7 ,conforming amendments 7,a7 ,extension of target amount ,section #ahhf7;b77#c77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,d771 as amended by section #bje7;b7 of the ,medicare ,access and ,,chip ,reauthorization ,act of #bjae1 is amended-- 7i7 in the matter preceding clause 7i71 by striking 1 and before ,october #a1 #bjag2 and 7ii7 in clause 7iv71 by striking during fiscal year #aiih through fiscal year #bjag and inserting during or after fiscal year #aiih4 7,b7 ,extending the period during which hospitals can decline reclassification as urban ,section #aceja7;e77#b7 of the ,omnibus ,budget ,reconciliation ,act of #aiic 7#db ,u4,s4,c4 #acieww note71 as amended by section #bje7;b7 of the ,medicare ,access and ,,chip ,reauthorization ,act of #bjae1 is amended-- 7i7 by inserting after #bjag the following3 or a subsequent fiscal year2 and 7ii7 in subparagraph 7,c71 by inserting after such reclassification the following3 during the #a-year period that begins on the date of the notification of the hospital under subparagraph 7,a74 7b7 ,extension of ,increased ,payments for ,low-,volume ,hospitals ,section #ahhf7;d77#ab7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#ab771 as amended by section #bjd of the ,medicare ,access and ,,chip ,reauthorization ,act of #bjae1 is amended-- 7#a7 in subparagraph 7,b7-- 7,a7 in the heading1 by inserting after increase the following3 through fiscal year #bjaj2 and 7,b7 by striking and for discharges occurring in fiscal year #bjah and subsequent fiscal years2 7#b7 in subparagraph 7,c77i7-- 7,a7 by striking #be road miles 7or1 with respect to fiscal years #bjaa through #bjag1 #ae road miles7 and inserting #ae road miles2 and 7,b7 striking 7or1 with respect to fiscal years #bjaa through #bjag1 #a1fjj discharges of individuals entitled to1 or enrolled for1 benefits under part ,a7 and inserting or #a1fjj discharges of individuals entitled to1 or enrolled for1 benefits under part ,a2 and 7#c7 in subparagraph 7,d7-- 7,a7 by amending the heading to read as follows3 ,applicable percentage increase after fiscal year #bjaj2 and 7,b7 by striking in fiscal years #bjaa through #bjag and inserting in fiscal year #bjaa and each subsequent fiscal year4 #ajd4 ,reinstating revised diagnosis-related group payments for ,m,d,hs and sole community hospitals 7,s,c,hs7 7a7 ,payments for ,m,d,hs and ,s,c,hs for ,value-,based ,incentive ,programs ,section #ahhf7o77#g77;,d77ii77,i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7o77#g77;,d77ii77,i77 is amended by inserting or after fiscal year #bjaf after #bjac4 7b7 ,payments for ,m,d,hs and ,s,c,hs under hospital readmissions reduction program ,section #ahhf7q77#b77;,b77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7q77#b77;,b77i77 is amended by inserting or after fiscal year #bjaf after #bjac4 #aje4 ,reinstating hold harmless treatment for hospital outpatient services for ,s,c,hs ,section #ahcc7t77#g77;,d77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t77#g77;,d77i77 is amended-- 7#a7 in the heading1 by striking ,temporary and inserting ,permanent2 7#b7 in subclause 7,,ii7-- 7,a7 in the first sentence1 by inserting or on or after ,january #a1 #bjaf1 after ,january #a1 #bjac12 and 7,b7 in the second sentence1 by inserting 1 or during or after #bjaf after or #bjab2 and 7#c7 in subclause 7,,iii71 in the first sentence1 by inserting or on or after ,january #a1 #bjaf1 after ,january #a1 #bjac14 #ajf4 ,delaying application of penalties for failure to be a meaningful electronic health record user 7a7 ,in general ,section #ahhf7;b77#c77;,b77ix77,i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,b77ix77,i77 is amended by adding at the end the following3 ,in the case of a hospital located in a rural area1 each fiscal year referred to in the first sentence of this subclause shall be applied as if it were a reference to the year that is #d fiscal years later44 7b7 ,applicability ,the amendment made by this section applies with respect fiscal years beginning after the date of the enactment of this ,act4 #ajg4 ,eliminating rural ,medicare and ,medicaid disproportionate share hospital payment reductions 7a7 ,medicare ,section #ahhf7r77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7r77#a77 is amended by inserting before #be percent the following3 7unless such hospital is located in a rural area1 as defined in subsection 7d77#b77;,d774 7b7 ,medicaid ,section #aibc7;f77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4#acifr-#d7;f77#c77 is amended-- 7#a7 in subparagraph 7,a7 by striking subparagraph 7,e7 and inserting subparagraphs 7,e7 and 7,f72 and 7#b7 by adding at the end the following3 7,f7 ,increase in allotments and payments for rural hospitals 7i7 ,allotments ,the ,,dsh allotment for a ,state with respect to a fiscal year that would be determined under this paragraph for the ,state for the fiscal year without application of this subparagraph1 notwithstanding subparagraphs 7,b71 7,c71 and 7,e71 shall be increased by the product of the reduction to such ,state under paragraph 7#g77;,a77i77,i7 for such fiscal year and the percentage of ,medicaid enrollees residing in the ,state that live in a rural area 7as defined in section #ahhf7;d77#b77;,d771 subject to clause 7iii74 7ii7 ,payments ,the payments to a ,state under section #aijc7;a7 for each calendar quarter shall be increased by the product of the reduction to such ,state under paragraph 7#g77;,a77i77,,ii7 for such fiscal year and the percentage of ,medicaid enrollees residing in the ,state that live in a rural area 7as defined in section #ahhf7;d77#b77;,d771 subject to clause 7iii74 7iii7 ,assurances regarding application of increased funds to hospitals in rural areas ,a ,state may only receive an increased allotment or payment under this paragraph if such ,state provides such assurances as the ,secretary may require that any funds received due to the increase in clauses 7i7 and 7ii7 shall be allotted to hospitals located in rural areas as an additional amount above what would be allotted to such hospitals without application of such clause4 4 7c7 ,applicability ,the amendments made by this section apply with respect to fiscal year #bjag4 ,b ,other rural providers #aaa4 ,making permanent increased ,medicare payments for ground ambulance services in rural areas ,section #ahcd7l77#ac7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ac77 is amended-- 7#a7 by striking ,temporary increase and inserting ,increase2 and 7#b7 in subparagraph 7,a7-- 7,a7 in the matter preceding clause 7i71 by striking 1 and before ,january #a1 #bjah2 and 7,b7 in clause 7i71 by striking 1 and before ,january #a1 #bjah4 #aab4 ,extending ,medicaid primary care payments 7a7 ,in general ,section #aijb7;a77#ac77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acif;a7a77#ac77;,c77 is amended by inserting after #bjad the following3 7or in the case of a primary care services furnished by a physician located in a rural area1 as defined in section #ahhf7;d77#b77;,d71 furnished in any year74 7b7 ,applicability 7#a7 ,in general ,except as provided in paragraph 7#b71 the amendment made by this section applies to services furnished in a year beginning on or after such date4 7#b7 ,exception if state legislation required ,in the case of a ,state plan for medical assistance under title ,,xix of the ,social ,security ,act which the ,secretary of ,health and ,human ,services determines requires ,state legislation 7other than legislation appropriating funds7 in order for the plan to meet the additional requirement imposed by the amendment made by this section1 the ,state plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the ,state legislature that begins after the date of the enactment of this ,act4 ,for purposes of the previous sentence1 in the case of a ,state that has a #b-year legislative session1 each year of such session shall be deemed to be a separate regular session of the ,state legislature4 ,,ii ,rural ,medicare beneficiary equity #bja4 ,equalizing beneficiary copayments for services furnished by ,c,a,hs 7a7 ,in general ,section #ahff7;a77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#b77;,a77 is amended by adding at the end the following3 ,in the case of outpatient critical access hospital services for which payment is made under section #ahcd7;g71 clause 7ii7 of the first sentence shall be applied by substituting #bj percent of the lesser of the actual charge or the payment basis under this part for such services if the critical access hospital were treated as a hospital for #bj per centum of the reasonable charge for such items and services4 7b7 ,applicability ,the amendment made by this section applies with respect to services furnished during a year that begins more than #fj days after the date of the enactment of this ,act4 ,,iii ,regulatory relief #cja4 ,eliminating #if-;hour physician certification requirement with respect to inpatient ,,cah services 7a7 ,in general ,section #ahad7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77 is amended-- 7#a7 in paragraph 7#f71 by adding and at the end2 7#b7 in paragraph 7#g77;,e71 by striking 2 and and inserting a period2 and 7#c7 by striking paragraph 7#h74 7b7 ,applicability ,the amendments made by this section apply with respect to services furnished during a year that begins more than #fj days after the date of the enactment of this ,act4 #cjb4 ,rebasing supervision requirements 7a7 ,therapeutic hospital outpatient services 7#a7 ,supervision requirements ,section #ahcc of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7 is amended by adding at the end the following3 7aa7 ,physician supervision requirements for therapeutic hospital outpatient services 7#a7 ,general supervision for therapeutic services ,except as may be provided under paragraph 7#b71 insofar as the ,secretary requires the supervision by a physician or a non-physician practitioner for payment for therapeutic hospital outpatient services 7as defined in paragraph 7#e77;,a77 furnished under this part1 such requirement shall be met if such services are furnished under the general supervision 7as defined in paragraph 7#e77;,b77 of the physician or non-physician practitioner1 as the case may be4 7#b7 ,exceptions process for high-risk or complex medical services requiring a direct level of supervision 7,a7 ,in general ,subject to the succeeding provisions of this paragraph1 the ,secretary shall establish a process for the designation of therapeutic hospital outpatient services furnished under this part that1 by reason of complexity or high risk1 require-- 7i7 direct supervision 7as defined in paragraph 7#e77;,c77 for the entire service2 or 7ii7 direct supervision during the initiation of the service followed by general supervision for the remainder of the service4 7,b7 ,consultation with clinical experts 7i7 ,in general ,under the process established under subparagraph 7,a71 before the designation of any therapeutic hospital outpatient service for which direct supervision may be required under this part1 the ,secretary shall consult with a panel of outside experts described in clause 7ii7 to advise the ,secretary with respect to each such designation4 7ii7 ,advisory panel on supervision of therapeutic hospital outpatient services ,for purposes of clause 7i71 a panel of outside experts described in this clause is a panel appointed by the ,secretary1 based on nominations submitted by hospital1 rural health1 and medical organizations representing physicians1 non-physician practitioners1 and hospital administrators1 as the case may be1 that meets the following requirements3 7,i7 ,composition ,the panel shall be composed of at least #ae physicians and non-physician practitioners who furnish therapeutic hospital outpatient services for which payment is made under this part and who collectively represent the medical specialties that furnish such services1 and of #d hospital administrators of hospitals located in rural areas 7as defined in section #ahhf7;d77#b77;,d77 or critical access hospitals4 7,,ii7 ,practical experience required for physicians and non-physician practitioners ,during the #ab-month period preceding appointment to the panel by the ,secretary1 each physician or non-physician practitioner described in subclause 7,i7 shall have furnished therapeutic hospital outpatient services for which payment was made under this part4 7,,iii7 ,minimum rural representation requirement for physicians and non-physician practitioners ,not less than #ej percent of the membership of the panel that is comprised of physicians and non-physician practitioners shall be physicians or non-physician practitioners described in subclause 7,i7 who practice in rural areas 7as defined in section #ahhf7;d77#b77;,d77 or who furnish such services in critical access hospitals4 7iii7 ,application of ,,faca ,the ,federal ,advisory ,committee ,act 7#e ,u4,s4,c4 #b ,app471 other than section #ad of such ,act1 shall apply to the panel of outside experts appointed by the ,secretary under clause 7ii74 7,c7 ,special rule for outpatient critical access hospital services ,insofar as a therapeutic outpatient hospital service that is an outpatient critical access hospital service is designated as requiring direct supervision under the process established under subparagraph 7,a71 the ,secretary shall deem the critical access hospital furnishing that service as having met the requirement for direct supervision for that service if1 when furnishing such service1 the critical access hospital meets the standard for personnel required as a condition of participation under section #dhe4fah7;d7 of title #db1 ,code of ,federal ,regulations 7as in effect on the date of the enactment of this subsection74 7,d7 ,consideration of compliance burdens ,under the process established under subparagraph 7,a71 the ,secretary shall take into account the impact on hospitals and critical access hospitals in complying with requirements for direct supervision in the furnishing of therapeutic hospital outpatient services1 including hospital resources1 availability of hospital-privileged physicians1 specialty physicians1 and non-physician practitioners1 and administrative burdens4 7,e7 ,requirement for notice and comment rulemaking ,under the process established under subparagraph 7,a71 the ,secretary shall only designate therapeutic hospital outpatient services requiring direct supervision under this part through proposed and final rulemaking that provides for public notice and opportunity for comment4 7,f7 ,rule of construction ,nothing in this subsection shall be construed as authorizing the ,secretary to apply or require any level of supervision other than general or direct supervision with respect to the furnishing of therapeutic hospital outpatient services4 7#c7 ,initial list of designated services ,the ,secretary shall include in the proposed and final regulation for payment for hospital outpatient services for #bjag under this part a list of initial therapeutic hospital outpatient services1 if any1 designated under the process established under paragraph 7#b77;,a7 as requiring direct supervision under this part4 7#d7 ,direct supervision by non-physician practitioners for certain hospital outpatient services permitted 7,a7 ,in general ,subject to the succeeding provisions of this subsection1 a non-physician practitioner may directly supervise the furnishing of-- 7i7 therapeutic hospital outpatient services under this part1 including cardiac rehabilitation services 7under section #ahfa7;eee77#a771 intensive cardiac rehabilitation services 7under section #ahfa7;eee77#d771 and pulmonary rehabilitation services 7under section #ahfa7;fff77#a772 and 7ii7 those hospital outpatient diagnostic services 7described in section #ahfa7s77#b77;,c77 that require direct supervision under the fee schedule established under section #ahdh4 7,b7 ,requirements ,subparagraph 7,a7 shall apply insofar as the non-physician practitioner involved meets the following requirements3 7i7 ,scope of practice ,the non-physician practitioner is acting within the scope of practice under ,state law applicable to the practitioner4 7ii7 ,additional requirements ,the non-physician practitioner meets such requirements as the ,secretary may specify4 7#e7 ,definitions ,in this subsection3 7,a7 ,therapeutic hospital outpatient services ,the term therapeutic hospital outpatient services means hospital services described in section #ahfa7s77#b77;,b7 furnished by a hospital or critical access hospital and includes-- 7i7 cardiac rehabilitation services and intensive cardiac rehabilitation services 7as defined in paragraphs 7#a7 and 7#d71 respectively1 of section #ahfa7;eee772 and 7ii7 pulmonary rehabilitation services 7as defined in section #ahfa7;fff77#a774 7,b7 ,general supervision 7i7 ,overall direction and control of physician ,subject to clause 7ii71 with respect to the furnishing of therapeutic hospital outpatient services for which payment may be made under this part1 the term general supervision means such services that are furnished under the overall direction and control of a physician or non-physician practitioner1 as the case may be4 7ii7 ,presence not required ,for purposes of clause 7i71 the presence of a physician or non-physician practitioner is not required during the performance of the procedure involved4 7,c7 ,direct supervision 7i7 ,provision of assistance and direction ,subject to clause 7ii71 with respect to the furnishing of therapeutic hospital outpatient services for which payment may be made under this part1 the term direct supervision means that a physician or non-physician practitioner1 as the case may be1 is immediately available 7including by telephone or other means7 to furnish assistance and direction throughout the furnishing of such services4 ,such term includes1 with respect to the furnishing of a therapeutic hospital outpatient service for which payment may be made under this part1 direct supervision during the initiation of the service followed by general supervision for the remainder of the service 7as described in paragraph 7#b77;,a77ii774 7ii7 ,presence in room not required ,for purposes of clause 7i71 a physician or non-physician practitioner1 as the case may be1 is not required to be present in the room during the performance of the procedure involved or within any other physical boundary as long as the physician or non-physician practitioner1 as the case may be1 is immediately available4 7,d7 ,non-physician practitioner defined ,the term non-physician practitioner means an individual who-- 7i7 is a physician assistant1 a nurse practitioner1 a clinical nurse specialist1 a clinical social worker1 a clinical psychologist1 a certified nurse midwife1 or a certified registered nurse anesthetist1 and includes such other practitioners as the ,secretary may specify2 and 7ii7 with respect to the furnishing of therapeutic outpatient hospital services1 meets the requirements of paragraph 7#d77;,b74 4 7#b7 ,conforming amendment ,section #ahfa7;eee77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7eee77#b77;,b77 is amended by inserting 1 and a non-physician practitioner 7as defined in section #ahcc7;aa77#e77;,d77 may supervise the furnishing of such items and services in the hospital after in the case of items and services furnished under such a program in a hospital1 such availability shall be presumed4 7b7 ,prohibition on retroactive enforcement of revised interpretation 7#a7 ,repeal of regulatory clarification ,the restatement and clarification under the final rulemaking changes to the ,medicare hospital outpatient prospective payment system and calendar year #bjji payment rates 7published in the ,federal ,register on ,november #ah1 #bjjh1 #gc ,fed4 ,reg4 #fhgjb through #fhgjd7 with respect to requirements for direct supervision by physicians for therapeutic hospital outpatient services 7as defined in paragraph 7#c77 for purposes of payment for such services under the ,medicare program shall have no force or effect in law4 7#b7 ,hold harmless ,a hospital or critical access hospital that furnishes therapeutic hospital outpatient services during the period beginning on ,january #a1 #bjja1 and ending on the later of ,december #ca1 #bjaf1 or the date on which the final regulation promulgated by the ,secretary of ,health and ,human ,services to carry out this section takes effect1 for which a claim for payment is made under part ,b of title ,,xviii of the ,social ,security ,act shall not be subject to any civil or criminal action or penalty under ,federal law for failure to meet supervision requirements under the regulation described in paragraph 7#a71 under program manuals1 or otherwise4 7#c7 ,therapeutic hospital outpatient services defined ,in this subsection1 the term therapeutic hospital outpatient services means medical and other health services furnished by a hospital or critical access hospital that are-- 7,a7 hospital services described in subsection 7s77#b77;,b7 of section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex72 7,b7 cardiac rehabilitation services or intensive cardiac rehabilitation services 7as defined in paragraphs 7#a7 and 7#d71 respectively1 of subsection 7eee7 of such section72 or 7,c7 pulmonary rehabilitation services 7as defined in subsection 7fff77#a7 of such section74 #cjc4 ,reforming practices of recovery audit contractors under ,medicare 7a7 ,elimination of contingency fee payment system ,section #ahic7;h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;ddd7h771 as amended by section #eje7;b7 of the ,medicare ,access and ,,chip ,reauthorization ,act of #bjae1 is amended-- 7#a7 in paragraph 7#a71 by inserting 1 for recovery activities conducted during a fiscal year before fiscal year #bjaf after ,under the contracts2 and 7#b7 by adding at the end the following new paragraph3 7#aa7 ,payment for recovery activities performed after fiscal year #bjae 7,a7 ,in general ,under the contracts1 subject to paragraphs 7,b7 and 7,c71 payment shall be made to recovery audit contractors for recovery activities conducted during fiscal year #bjaf and each fiscal year thereafter in the same manner1 and from the same amounts1 as payment is made to eligible entities under contracts entered into for recovery activities conducted during fiscal year #bjae under subsection 7a74 7,b7 ,prohibition on incentive payments ,under the contracts1 payment made to a recovery audit contractor for recovery activities conducted during fiscal year #bjaf or any fiscal year thereafter may not include any incentive payments4 7,c7 ,performance accountability 7i7 ,in general ,under the contracts1 payment made to a recovery audit contractor for recovery activities conducted during fiscal year #bjaf or any fiscal year thereafter shall1 in the case that the contractor has a complex audit denial overturn rate at the end of such fiscal year 7as calculated under the methodology described in clause 7iv77 that is 4#a or greater1 be reduced in an amount determined in accordance with clause 7ii74 7ii7 ,payment reductions 7,i7 ,sliding scale of amount of reductions ,the ,secretary shall establish1 for purposes of determining the amount of a reduction in payment to a recovery audit contractor under clause 7i7 for recovery activities conducted during fiscal year1 a linear sliding scale of payment reductions for recovery audit contractors for such fiscal year4 ,under such linear sliding scale1 the amount of such a reduction in payment to a recovery audit contractor for a fiscal year shall be calculated in a manner that provides for such reduction to be greater than the reduction for such fiscal year for recovery audit contractors that have complex audit denial overturn rates at the end of such fiscal year 7as calculated under the methodology described in clause 7iv77 that are lower than the complex audit denial overturn rate of the contractor at the end of such fiscal year 7as so calculated74 7,,ii7 ,manner of collecting reduction ,the ,secretary may assess and collect the reductions in payment to recovery audit contractors under clause 7i7 in such manner as the ,secretary may specify 7such as by reducing the amount paid to the contractor for recovery activities conducted during a fiscal year or by assessing the reduction as a separate penalty payment to be paid to the ,secretary by the contractor with respect to each complex audit denial issued by the contractor that is overturned on appeal74 7iii7 ,timing of determinations of payment reductions ,the ,secretary shall1 with respect to a recovery audit contractor1 determine not later than six months after the end of a fiscal year-- 7,i7 whether to reduce payment to the recovery audit contractor under clause 7i7 for recovery activities conducted during such fiscal year2 and 7,,ii7 in the case that the ,secretary determines to so reduce payment to the contractor1 the amount of such payment reduction4 7iv7 ,methodology for calculation of overturned complex audit denial overturn rate 7,i7 ,calculation of overturn rate ,the ,secretary shall calculate a complex audit denial overturn rate for a recovery audit contractor for a fiscal year by-- 7aa7 determining1 with respect to the contract entered into under paragraph 7#a7 by the contractor1 the number of complex audit denials issued by the contractor under the contract 7including denials issued before such fiscal year and during such fiscal year7 that are overturned on appeal2 and 7bb7 dividing the number determined under item 7aa7 by the number of complex audit denials issued by the contractor under such contract 7including denials issued before such fiscal year and during such fiscal year74 7,,ii7 ,fairness and transparency ,the ,secretary shall calculate the percentage described in subclause 7,i7 in a fair and transparent manner4 7,,iii7 ,accounting for subsequently overturned appeals ,the ,secretary shall calculate the percentage described in subclause 7,i7 in a manner that accounts for the likelihood that complex audit denials issued by the contractor for such fiscal year will be overturned on appeal in a subsequent fiscal year4 7,,iv7 ,complex audit denial defined ,in this subparagraph1 the term complex audit denial means a denial by a recovery audit contractor of a claim for payment under this title submitted by a hospital1 psychiatric hospital1 or critical access hospital that is so denied by the contractor after the contractor has-- 7aa7 requested that the hospital1 psychiatric hospital1 or critical access hospital1 in order to support such claim for payment1 provide supporting medical records to the contractor2 and 7bb7 reviewed such medical records in order to determine whether an improper payment has been made to the hospital1 psychiatric hospital1 or critical access hospital for such claim4 7,v7 ,overturned on appeal defined ,in this subparagraph1 the term overturned on appeal means1 with respect to a complex audit denial1 a denial that is overturned on appeal at the reconsideration level1 the redetermination level1 or the administrative law judge hearing level4 7,d7 ,application to existing contracts ,not later than #fj days after the date of the enactment of this paragraph1 the ,secretary shall modify1 as necessary1 each contract under paragraph 7#a7 that the ,secretary entered into prior to such date of enactment in order to ensure that payment with respect to recovery activities conducted under such contract is made in accordance with the requirements described in this paragraph4 4 7b7 ,elimination of ,one-,year ,timely ,filing ,limit ,to ,rebill ,part ,b ,claims 7#a7 ,in general ,section #ahdb7;b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77 is amended by adding at the end the following new paragraph3 7#bj7 ,exception to the one-year timely filing limit for certain rebilled claims 7,a7 ,in general ,in the case of a claim submitted under this part by a hospital 7as defined in subparagraph 7,b77i77 for hospital services with respect to which there was a previous claim submitted under part ,a as inpatient hospital services or inpatient critical access hospital services that was denied by a medicare contractor 7as defined in subparagraph 7,b77ii77 because of a determination that the inpatient admission was not medically reasonable and necessary under section #ahfb7;a77#a77;,a71 the deadline described in this paragraph is #ahj days after the date of the final denial of such claim under part ,a4 7,b7 ,definitions ,in this paragraph3 7i7 ,hospital ,the term hospital has the meaning given such term in section #ahfa7;e7 and includes a psychiatric hospital 7as defined in section #ahfa7;f77 and a critical access hospital 7as defined in section #ahfa7mm77#a774 7ii7 ,medicare contractor ,the term medicare contractor has the meaning given such term under section #ahhi7;g71 and includes a recovery audit contractor with a contract under section #ahic7;h74 7iii7 ,final denial ,the term final denial means-- 7,i7 in the case that a hospital elects not to appeal a denial described in subparagraph 7,a7 by a medicare contractor1 the date of such denial2 or 7,,ii7 in the case that a hospital elects to appeal a such a denial1 the date on which such appeal is exhausted4 4 7#b7 ,conforming amendments 7,a7 ,section #ahce7;a77#a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acien7a77#a77 is amended by inserting or1 in the case of a claim described in section #ahdb7;b77#bj71 not later than the deadline described in such paragraph after the date of service4 7,b7 ,section #ahdb7;b77#c77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieu7b77#c77;,b77 is amended in the flush language following clause 7ii7 by inserting or1 in the case of a claim described in section #ahdb7;b77#bj71 not later than the deadline described in such paragraph after the date of service4 7#c7 ,applicability ,the amendments made by this subsection apply to claims submitted under part ,b of title ,,xviii of the ,social ,security ,act for hospital services for which there was a previous claim submitted under part ,a as inpatient hospital services or inpatient critical access hospital services that was subject to a final denial 7as defined in paragraph 7#bj77;,b77iii7 of section #ahdb7;b7 of such ,act 7#db ,u4,s4,c4 #acieu7b77 on or after the date of the enactment of this ,act4 7c7 ,medical documentation considered for medical necessity reviews of claims for inpatient hospital services ,section #ahfb7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciey7a77 is amended by adding at the end the following new sentence3 ,a determination under paragraph 7#a7 of whether inpatient hospital services or inpatient critical access hospital services furnished to an individual on or after the date of the enactment of this sentence are reasonable and necessary shall be based solely upon information available to the admitting physician at the time of the inpatient admission of the individual for such inpatient services1 as documented in the medical record4 ,,iv ,future of rural health care #dja4 ,community outpatient hospital program 7a7 ,in general 7#a7 ,community outpatient hospital and qualified outpatient services defined ,section #ahfa of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7 is amended-- 7,a7 in the last sentence of subsection 7e71 by inserting before the period at the end or a community outpatient hospital 7as defined in subsection 7iii77#a772 and 7,b7 by adding at the end the following3 7iii7 ,community outpatient hospital 7#a7 ,the term community outpatient hospital means a facility that-- 7,a7 at any time during the period beginning on the date that is #e years before the date of the enactment of this subsection and ending on ,december #ca1 #bjad1 was a critical access hospital1 or is a hospital with not more than #ej beds that is-- 7i7 located in a rural area 7as defined in section #ahhf7;d77#b77;,d772 or 7ii7 treated as being located in a rural area under section #ahhf7;d77#h77;,e72 7,b7 provides emergency medical care and observation care available on a #bd-;hour basis2 7,c7 with respect to continuous care for an individual1 does not provide care over #b or more consecutive midnights2 7,d7 does not provide any acute care inpatient beds and has protocols in place for the timely transfer of patients who require other inpatient services2 7,e7 has the resources required of a level ,,iv or higher trauma center 7as verified by the ,american ,college of ,surgeons or other means specified by the ,secretary71 or has available for consultation on a #bd-;hour basis a health care professional who successfully completed the ,advanced ,trauma ,life ,support ,course offered by the ,american ,college of ,surgeons 7or an equivalent course as determined by the ,secretary7 within the preceding #d years2 7,f7 has in effect a transfer agreement with a level ,i or level ,,ii trauma center designated under section #abca7a7 of the ,public ,health ,service ,act2 7,g7 meets the requirements of subsection 7aa77#b77;,i72 7,h7 has been approved by the ,state in which the facility is located for treatment as a community outpatient hospital2 7,i7 notifies the ,secretary at such time and in such manner as the ,secretary may require of the intent of such facility to be designated as a community outpatient facility2 and 7,j7 meets such staff training and certification requirements as the ,secretary may require4 7#b7 ,nothing in this subsection or section #ahcd7r7 shall be construed to prohibit a community outpatient hospital from having an agreement under section #ahhc for the provision of extended care services4 7#c7 ,unless the context otherwise requires1 a reference to a community outpatient hospital in this title shall be deemed to also be a reference to a critical access hospital4 7jjj7 ,qualified outpatient services ,the term qualified outpatient services means medical and other health services furnished on an outpatient basis by a community outpatient hospital1 rural health clinic 7as defined in section #ahfa7;aa77#b771 federally qualified health center 7as defined in section #ahfa7;aa77#d771 or an entity certified by the ,health ,resources and ,services ,administration as a federally qualified health center look-alike1 including1 for individuals who require services from a hospital or critical access hospital1 transportation services from such community outpatient hospital to a hospital or critical access hospital4 4 7#b7 ,payment for qualified outpatient services ,section #ahcd of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7 is amended by adding at the end the following3 7r7 ,payment for qualified outpatient services 7#a7 ,in general ,the amount of payment for qualified outpatient services is equal to #aje percent of the reasonable costs of providing such services4 7#b7 ,telehealth services as reasonable costs ,for purposes of this subsection1 with respect to qualified outpatient services1 costs reasonably associated with having a backup physician available via a telecommunications system shall be considered reasonable costs4 4 7b7 ,waiver of distance requirement for replacement ,c,a,hs2 subsequent redesignation of community outpatient hospitals as ,c,a,hs ,section #ahbj7;c77#b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#d7;c77#b77 is amended-- 7#a7 in subparagraph 7,b77i77,i71 by inserting 1 subject to subparagraph 7,f71 before is located2 and 7#b7 by adding at the end the following3 7,f7 ,option to waive distance requirement ,the ,state may waive the distance requirement described in subparagraph 7,b77i77,i7 with respect to a facility located in the ,state that is seeking designation as a critical access hospital under this paragraph if the total number of waivers for such facilities does not exceed the number of facilities that are critical access hospitals without such a waiver4 7,g7 ,redesignation of a critical access hospital as a community outpatient hospital ,a community outpatient hospital may elect to be redesignated as a community outpatient hospital by notifying the ,secretary at the same time and in the same manner as notifications under section #ahfa7;iii77#a77;,i7 if such community outpatient hospital-- 7i7 meets the requirements in paragraphs 7#a7 and 7#c7 of section #ahbj7;e72 and 7ii7 was designated as a critical access hospital under this paragraph on the date that the ,secretary first considered such community outpatient hospital to be a community outpatient hospital4 4 7c7 ,conforming amendments 7#a7 ,reasonable cost for ,c,o,hs ,section #ahfa7v77#g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7v77#g77 is amended by adding at the end the following3 7,e7 ,for additional items included in reasonable cost for community outpatient hospitals and for determination of payment amounts for qualified outpatient services1 see section #ahcd7r74 4 7#b7 ,c,o,hs as covered services ,section #ahcb7;a77#b77;,h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciek7a77#b77;,h77 is amended by inserting and qualified outpatient services 7as defined in section #ahfa7;iii77#b77 before the semicolon4 7#c7 ,,coh payments ,section #ahcc7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7a77 is amended-- 7,a7 in paragraph 7#h71 by striking 2 and2 7,b7 in paragraph 7#i71 by striking the period at the end and inserting 2 and2 and 7,c7 by inserting after paragraph 7#i7 the following3 7#aj7 in the case of qualified outpatient services1 the amounts described in section #ahcd7r74 4 7#d7 ,effective date ,the amendments made by this subsection shall apply to items and services furnished on or after the first day of the first calendar year beginning more than #a year after the date of the enactment of this ,act4 7d7 ,reports ,the ,secretary of ,health and ,human ,services shall submit to ,congress three reports on the impact of community outpatient hospitals on the availability of health care and health outcomes in rural areas 7as defined in section #ahhf7;d77#b77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#b77;,d77 as follows3 7#a7 ,initial report ,an initial report approximately #b years after the date of the enactment of this ,act4 7#b7 ,interim report ,an interim report approximately #e years after the date of the enactment of this ,act4 7#c7 ,final report ,a final report approximately #aj years after the date of the enactment of this ,act4 #djb4 ,grant funding to assist rural hospitals ,section #ccj;,a of the ,public ,health ,service ,act 7#db ,u4,s4,c #bed;c7 is amended-- 7#a7 in subsection 7b7-- 7,a7 in paragraph 7#a71 by striking ,director specified in subsection 7d7 and inserting ,director of the ,office of ,rural ,health ,policy of the ,health ,resources and ,services ,administration2 7,b7 by adding at the end the following3 7#f7 ,eligible rural hospital ,the term eligible rural hospital means-- 7,a7 a hospital 7as defined in section #ahfa7;e7 of the ,social ,security ,act7 that-- 7i7 has fewer than #ej beds2 and 7ii7 is located in a rural area 7as defined in section #ahhf7;d77#b77;,d7 of such ,act7 or treated as being located in a rural area pursuant to section #ahhf7;d77#h77;,e7 of such ,act2 7,b7 a community outpatient hospital 7as defined in section #ahfa7;iii7 of such ,act72 or 7,c7 a critical access hospital 7as defined in #ahfa7mm7 of such ,act74 2 and 7#b7 by adding at the end the following3 7i7 ,quality improvement and compliance grants for eligible rural hospitals 7#a7 ,grants ,the ,director may award grants to eligible rural hospitals to assist such hospitals with reporting on quality and to prepare such hospitals to transition to value-based reimbursement4 7#b7 ,applications ,to be eligible to receive a grant under this subsection1 an eligible rural hospital shall prepare and submit to the ,secretary an application1 at such time1 in such manner1 and containing such information as the ,secretary may require1 including a description of-- 7,a7 how the eligible rural hospital will use the funds provided under the grant2 and 7,b7 how the project will be evaluated4 7#c7 ,authorization of appropriations ,there is authorized to be appropriated for each fiscal year 7beginning with fiscal year #bjag7 #ab1jjj1jjj to carry out this subsection4 7j7 ,outreach grants for rural hospital population health 7#a7 ,grants ,to help eligible rural hospitals meet a specific community need identified in a community needs assessment1 the ,director may award grants to eligible rural hospitals4 7#b7 ,limitation on size of grants to ,c,o,hs ,the ,secretary may not award more than #fej1jjj each fiscal year to a community outpatient hospital that is described in subsection 7b77#f77;,b74 7#c7 ,applications ,to be eligible to receive a grant under this subsection1 an eligible rural hospital shall prepare and submit to the ,secretary an application1 at such time1 in such manner1 and containing such information as the ,secretary may require1 including-- 7,a7 a description of how the eligible rural hospital will use the funds provided under the grant2 7,b7 the results of community needs assessment that identified the specific community need described in paragraph 7#a72 and 7,c7 a description of how the project will be evaluated4 7#d7 ,authorization of appropriations ,there is authorized to be appropriated for each fiscal year 7beginning with fiscal year #bjag7-- 7,a7 #ae1jjj1jjj for grants to eligible rural hospitals described in paragraphs 7,a7 and 7,c7 of subsection 7b77#f72 and 7,b7 #ej1jjj1jjj for grants to eligible rural hospitals described in paragraph 7,b7 of such subsection4 7k7 ,,ems ,grant ,funding 7#a7 ,grants ,the ,director may award grants to eligible rural hospitals to develop and implement strategies to develop successful emergency medical services programs that meet community needs1 provide quality care1 and address workforce and funding problems4 7#b7 ,applications ,to be eligible to receive a grant under this subsection1 an eligible rural hospital shall prepare and submit to the ,secretary an application1 at such time1 in such manner1 and containing such information as the ,secretary may require1 including a description of-- 7,a7 how the eligible rural hospital will use the funds provided under the grant2 7,b7 any multistate collaborations involved in using such funds2 and 7,c7 how the use of funds will be evaluated4 7#c7 ,authorization of appropriations ,there is authorized to be appropriated for each fiscal year 7beginning with fiscal year #bjag7 #b1jjj1jjj to carry out this subsection4 4 #djc4 ,,cmmi demonstration of shared savings in rural hospitals ,section #aaae;,a7b77#b77;,b7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7b77#b77;,b77 is amended by adding at the end the following3 7xxv7 ,promoting greater shared savings with hospitals located in rural areas1 with critical access hospitals 7as defined in section #ahfa7mm77#a771 and with community outpatient hospitals 7as defined in section #ahfa7;iii77#a774 4