,,ii  #aad? ,,congress  #a/ ,session    
,s4 #afdh  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,june #bc1 #bjae ,mr4  
,grassley 7= himself & ,mr4 ,g>dn]7     
introduc$ ! foll[+ bill2 :i* 0 read     
twice & ref]r$ to ! ,committee on       
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
create a su/a9able future = rural       
heal?c>e4  #a4 ,%ort title  ,?is ,act   
may be cit$ z ! ,rural ,em]g5cy ,acute  
,c>e ,hospital ,act4  #b4 ,f9d+s        
,congress f9ds ! foll[+3 7#a7 ,accord+  
to ! ,univ]sity ( ,nor? ,c>ol9a's ,c5t] 
= ,heal? ,s]vices ,rese>*1 #ee rural    
hospitals h clos$ 9 ! ,unites ,/ates    
s9ce ,janu>y #bjaj4  7#b7 ,9 #bjad1     
i,vantage conduct$ a /udy = ! ,national 
,rural ,heal? ,association & f\nd #bhc  
hospitals at risk ( closure bas$ ^u     
p]=mance indicators t mat*$ ^?          
facilities already =c$ to close 9 ?is   
decade4  7#c7 ,rese>*]s at ! ,univ]sity 
( ,nor? ,c>ol9a id5tifi$ inpati5t volume
 z a sub/antial contribut+ factor to !  

f9ancial p]=mance ( rural hospitals1 )  
_m ( ! at-risk hospitals hav+ an av]age 
daily b$ c5sus ( less ?an #b4  7#d7     
,adv]se impacts to ! local economy & !  
loss ( timely access to em]g5cy m$ical  
c>e are #b major effects ( rural        
hospital closures4  7#e7 ,accord+ to !  
,national ,c5t] = ,rural ,heal? ,works1 
! typical rural hospital creates ov]    
#adj jobs & g5]ates #f1hjj1jjj 9        
comp5sation :ile s]v+ an av]age         
population ( #ad1fjj4  7#f7 ,! #bjad    
i,vantage /udy e/imates t ! #bhc at-risk
 hospitals c\ld result 9 ! loss (       
#cf1jjj heal? c>e jobs1 #ej1jjj         
community jobs1 & #aj1fjj1jjj1jjj 9     
gross dome/ic product4  7#g7 ,"t is !   
mo/ critical factor = a*iev+ successful 
outcomes 9 em]g5cy m$ic9e1 & em]g5cy    
m$ical cl9icians ref] to ! "t-s5sitive  
p]iod dur+ :i* successful outcomes may  
be be/ a*iev$ z ! gold5 h\r4  7#h7 ,!   
,national ,conf]5ce ( ,/ate             
,legislatures /ates t #fj p]c5t ( trauma
 dea?s 9 ! ,unit$ ,/ates occur 9 rural  

areas1 :]e only #ae p]c5t ( ! population
 is repres5t$4  7#i7 ,! disproportionate
 p]c5tage ( trauma dea?s 9 rural areas  
is likely attributable 9 l>ge "p to a   
comb9ation ( response "t to ! sc5e &    
di/ance to ! ne>e/ em]g5cy room to      
/abilize trauma victims4  7#aj7 ,!      
p]c5tage ( trauma dea?s occurr+ 9 rural 
areas c\ld cont9ue to increase z m rural
 hospitals close1 fur!r limit+ access to
 em]g5cy s]vices & requir+ pati5ts to   
travel long] di/ances to receive em]g5cy
 m$ical c>e4  7#aa7 ,! creation ( a     
rural em]g5cy hospital designation "u ! 
,m$ic>e program w all[ facilities 9     
rural areas to provide em]g5cy m$ical   
s]vices )\t hav+ to ma9ta9 inpati5t b$s4
  7#ab7 ,9 addition to provid+ em]g5cy  
c>e1 rural em]g5cy hospitals c\ld conv]t
 ! space previ\sly us$ = inpati5t       
s]vices to provide o!r m$ical s]vices   
includ+1 b n limit$ to1 obs]vation c>e1 
skill$ nurs+ facility c>e1 infusion     
s]vices1 hemodialysis1 home heal?1      
hospice1 nurs+ home c>e1 population     

heal?1 & telem$ic9e s]vices4  #c4 ,rural
 em]g5cy hospital program  7a7 ,9 g5]al 
7#a7 ,rural em]g5cy hospital & s]vices  
def9$ ,section #ahfa ( ! ,social        
,security ,act 7#db ,u4,s4,c4 #aciex7 is
 am5d$-- 7,a7 9 subsection 7e71 9 ! la/ 
s5t5ce ( ! matt] foll[+ p>agraph 7#i71  
by ins]t+ or a rural em]g5cy hospital 7z
 def9$ 9 section #ahfa7;iii77#a77 be=e !
 p]iod at ! end2 &  7,b7 by add+ at !   
end ! foll[+ subsection3  7iii7 ,rural  
,em]g5cy ,hospital2 ,rural ,em]g5cy     
,hospital ,outpati5t ,s]vices  7#a7 ,!  
t]m rural em]g5cy hospital means a      
facility t-- 7,a7 7i7 z ( ,decemb] #ca1 
#bjad--  7,i7 0 a critical access       
hospital2 or  7,,ii7 0 a hospital ) n m 
?an #ej b$s locat$ 9 a c\nty 7or        
equival5t unit ( local gov]nm5t7 9 a    
rural area 7z def9$ 9 section           
#ahhf7;d77#b77;,d771 or 0 a hospital ) n
 m ?an #ej b$s t 0 treat$ z be+ locat$ 9
 a rural area pursuant to section       
#ahhf7;d77#h77;,e72 or  7ii7 0 a        
critical access hospital describ$ 9     

clause 7i77,i7 or a hospital describ$ 9 
clause 7i77,,ii7 t ceas$ op]ations dur+ 
! p]iod beg9n+ on ! date t is #e ye>s   
prior to ! date ( ! enactm5t ( ?is      
subsection & end+ on ,decemb] #cj1      
#bjad2  7,b7 provides #bd-;h\r em]g5cy  
m$ical c>e & obs]vation c>e t does n    
exce$ an annual p] pati5t av]age ( #bd  
h\rs or m ?an #a midnight2  7,c7 does n 
provide any acute c>e inpati5t b$s & has
 protocols 9 place = ! timely transf] ( 
pati5ts :o require acute c>e inpati5t   
s]vices or o!r inpati5t s]vices2  7,d7  
has elect$ to be designat$ z a rural    
em]g5cy hospital2  7,e7 has receiv$     
approval to op]ate z a rural em]g5cy    
hospital f ! ,/ate "u section           
#ahcd7r77#c77;,a72 &  7,f7 is c]tifi$ by
 ! ,secret>y "u section                 
#ahcd7r77#c77;,b74  7#b7 ,! t]m rural   
em]g5cy hospital outpati5t s]vices means
 m$ical & o!r heal? s]vices furni%$ by a
 rural em]g5cy hospital on an outpati5t 
basis4  7#c7 ,no?+ 9 ?is subsection or  
section #ahcd7r77#c7 %all be con/ru$ to 

prohibit a rural em]g5cy hospital f     
provid+ ext5d$ c>e s]vices4  4  7#b7    
,paym5t = rural em]g5cy hospital s]vices
  7,a7 ,9 g5]al ,section #ahcc7;a7 ( !  
,social ,security ,act 7#db ,u4,s4,c4   
#aciel7a77 is am5d$-- 7i7 9 p>agraph    
7#h71 by /rik+ & at ! end2  7ii7 9      
p>agraph 7#i71 by /rik+ ! p]iod at ! end
 & ins]t+ 2 &2 &  7iii7 by ins]t+ aft]  
p>agraph 7#i7 ! foll[+ new p>agraph3    
7#aj7 9 ! case ( rural em]g5cy hospital 
em]g5cy s]vices & s]vices provid$ by a  
rural em]g5cy hospital or o!r provid] ( 
ambulance s]vices to transport pati5ts  
:o require acute c>e inpati5t s]vices or
 o!r inpati5t s]vices f su* rural       
em]g5cy hospital to a hospital or       
critical access hospital1 ! am\nts      
describ$ 9 section #ahcd7r74  4  7,b7   
,paym5t am\nt ,section #ahcd ( ! ,social
 ,security ,act 7#db ,u4,s4,c4 #aciem7  
is am5d$ by add+ at ! end ! foll[+      
subsection3  7r7 ,paym5t rules relat+ to
 rural em]g5cy hospitals  7#a7 ,paym5t =
 rural em]g5cy hospital outpati5t       

s]vices  7,a7 ,9 g5]al ,! am\nt ( paym5t
 = rural em]g5cy hospital outpati5t     
s]vices ( a rural em]g5cy hospital is   
equal to #aaj p]c5t ( ! reasonable co/s 
( provid+ su* s]vices4  7,b7 ,teleheal? 
s]vices ,= purposes ( ?is p>agraph1 9   
det]m9+ ! reasonable co/s ( provid+     
rural em]g5cy hospital outpati5t        
s]vices1 co/s associat$ ) hav+ a backup 
physician available via a               
telecommunications sy/em %all be        
consid]$ reasonable co/s4  7#b7 ,paym5t 
= transportation s]vices ,! am\nt (     
paym5t = s]vices provid$ by a rural     
em]g5cy hospital or o!r provid] (       
ambulance s]vices to transport pati5ts  
:o require acute c>e inpati5t s]vices or
 o!r inpati5t s]vices f su* rural       
em]g5cy hospital to a hospital or       
critical access hospital is equal to    
#aaj p]c5t ( ! reasonable co/s ( provid+
 su* s]vices4  7#c7 ,requirem5ts = rural
 em]g5cy hospitals  7,a7 ,/ate approval 
to op]ate z a rural em]g5cy hospital ,no
 paym5t %all be made "u ?is subsection  

to a facility1 or to a provid] (        
ambulance s]vices provid+ transportation
 s]vices f su* facility1 unless ! ,/ate 
9 :i* ! facility is locat$ has approv$ !
 facility's designation z a rural       
em]g5cy hospital4  7,b7 ,c]tification ( 
rural em]g5cy hospital  7i7 ,9 g5]al ,no
 paym5t %all be made "u ?is subsection  
to a facility1 or to a provid] (        
ambulance s]vices provid+ transportation
 s]vices f su* facility1 unless !       
facility has be5 c]tifi$ by ! ,secret>y 
z a rural em]g5cy hospital4  7ii7       
,c]tification requirem5ts ,! ,secret>y  
%all c]tify a facility z a rural em]g5cy
 hospital if ! facility-- 7,i7 meets !  
crit]ia = rural em]g5cy hospitals       
describ$ 9 subp>agraphs 7,a7 ?r\gh 7,e7 
( section #ahfa7;iii77#a72  7,,ii7      
ei!r-- 7aa7 is v]ifi$ by ! ,am]ican     
,college ( ,surgeons z hav+ ! res\rces  
requir$ ( a level ,,iv trauma c5t] or   
high]2 or  7bb7 employs heal?c>e        
pr(essionals t successfully complet$ !  
,advanc$ ,trauma ,life ,support ,c\rse  

(f]$ by ! ,am]ican ,college ( ,surgeons 
)9 ! prec$+ #d ye>s2  7,,iii7 has 9     
effect a transf] agreem5t ) a level ,i  
or level ,,ii trauma c5t]2 &  7,,iv7    
meets su* /aff tra9+ & c]tification     
requirem5ts z ! ,secret>y may require4  
7#d7 ,co9surance  7,a7 ,9 g5]al ,! am\nt
 ( paym5t = rural em]g5cy hospital      
s]vices or transportation s]vices made  
to a rural em]g5cy hospital or o!r      
provid] ( ambulance s]vices "u ?is      
subsection %all be r$uc$ by ! co9surance
 am\nt describ$ 9 subp>agraph 7,b74     
7,b7 ,co9surance am\nt ,! co9surance    
am\nt describ$ 9 ?is subp>agraph1 )     
respect to an item or s]vice provid$ by 
a rural em]g5cy hospital or provid] (   
ambulance s]vices1 %all be calculat$ 9 !
 same mann] z ! co9surance am\nt = an   
outpati5t critical access hospital      
s]vice is calculat$ "u section          
#ahff7;a77#b74  4  7b7 ,waiv] ( di/ance 
requirem5t = replacem5t ,c,a,hs2        
subsequ5t r$esignation ( rural em]g5cy  
hospitals z ,c,a,hs ,section            

#ahbj7;c77#b7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;i-#d7;c77#b77 is  
am5d$-- 7#a7 9 subp>agraph 7,b77i77,i71 
by ins]t+ subject to subp>agraph 7,f71  
be=e is locat$2 &  7#b7 by add+ at ! end
 ! foll[+ new subp>agraphs3  7,f7       
,option to waive di/ance requirem5t     
,beg9n+ on ! date ( ! enactm5t ( ?is    
subp>agraph1 = e critical access        
hospital locat$ 9 a ,/ate t is c]tifi$ z
 a rural em]g5cy hospital "u section    
#ahcd7r77#c77;,b71 ! ,/ate %all h !     
option ( waiv+ ! di/ance requirem5t     
describ$ 9 subp>agraph 7,b77i77,i7 )    
respect to ano!r facility locat$ 9 !    
,/ate t is seek+ designation z a        
critical access hospital "u ?is         
p>agraph4  7,g7 ,r$esignation ( a rural 
em]g5cy hospital z a critical access    
hospital ,a rural em]g5cy hospital t 0  
previ\sly designat$ z a critical access 
hospital "u ?is p>agraph may elect to be
 r$esignat$ z a critical access hospital
 79 ! same mann] t ! hospital 0         
orig9ally designat$ z a critical access 

hospital7 at any "t1 subject to su*     
conditions z ! ,secret>y may e/abli%4  4
  7c7 ,/udies & reports  7#a7 ,/udies ,!
 ,secret>y ( ,heal?  ,human ,s]vices    
%all conduct #c /udies to evaluate !    
impact ( rural em]g5cy hospitals on !   
availability ( heal? c>e & heal?        
outcomes 9 rural areas 7z def9$ 9       
section #ahhf7;d77#b77;,d7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4 #acieww774
 ,! ,secret>y %all conduct a /udy--     
7,a7 #b ye>s aft] ! date ( ! enactm5t ( 
?is ,act2  7,b7 #e ye>s aft] ! date ( ! 
enactm5t ( ?is ,act2 &  7,c7 #aj ye>s   
aft] ! date ( ! enactm5t ( ?is ,act4    
7#b7 ,reports ,n lat] ?an #f mon?s aft] 
ea* date t ! ,secret>y ( ,heal?  ,human 
,s]vices is requir$ to conduct a /udy "u
 p>agraph 7#a71 ! ,secret>y %all submit 
a report to ,congress conta9+ ! results 
( ea* su* /udy4  7d7 ,effective date ,! 
am5dm5ts made by ?is section %all apply 
to items & s]vices furni%$ on or aft] ! 
date t is #a ye> aft] ! date ( !        
enactm5t ( ?is ,act4  #d4 ,inclusion (  

em]g5cy m$ic9e z heal? s]vices "u !     
,national ,heal? ,s]vice ,corps ,section
 #cca7;a77#c77;,d7 ( ! ,public ,heal?   
,s]vice ,act 7#db ,u4,s4,c4             
#bed;d7a77#c77;,d77 is am5d$ by ins]t+ 1
 & includes em]g5cy m$ic9e provid$ by   
physicians 9 a rural em]g5cy hospital 7z
 def9$ 9 section #ahfa7;iii7 ( ! ,social
 ,security ,act7 be=e ! p]iod4  #e4     
,p]mitt+ hospitals ) approv$ resid5cy   
programs 9 em]g5cy m$ic9e to include "t 
sp5t by int]ns & resid5ts 9 ! em]g5cy   
dep>tm5t ( a rural hospital 9 full-"t   
equival5t c\nt  7a7 ,indirect m$ical    
education ,section                      
#ahhf7;d77#e77;,b77iv7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#e77;,b77iv77 is am5d$ by    
add+ at ! end ! foll[+ new subclause3   
7,,iii7 ,effective = dis*>ges occurr+ on
 or aft] ,octob] #a1 #bjae1 all ( ! "t  
sp5t 9 pati5t c>e activities 9 ! em]g5cy
 dep>tm5t ( a rural hospital by int]ns &
 resid5ts 9 em]g5cy m$ic9e f a hospital 
) an approv$ m$ical resid5cy tra9+      

program 7z def9$ 9 subsection           
7h77#e77;,a77 9 su* specialty %all be   
includ$ 9 det]m9+ ! numb] ( full-"t     
equival5t int]ns & resid5ts 9 su*       
program if ! hospital ) su* program     
incurs ! co/s ( ! /ip5ds & fr+e b5efits 
( ! int]ns or resid5ts dur+ ! "t !      
int]ns or resid5ts sp5d 9 t rural       
hospital 9 accordance ) subclause       
7,,ii74 ,9 ?is subclause1 ! t]m rural   
hospital means a hospital t is locat$ 9 
a rural area 7z def9$ = purposes (      
p>agraph 7#b77;,d774  4  7b7 ,direct    
m$ical education ,section               
#ahhf7;h77#d77;,e7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acie7;h77#d77 is  
am5d$-- 7#a7 9 clause 7ii71 by /rik+ !  
p]iod at ! end & ins]t+ 2 &2  7#b7 by   
ins]t+ aft] clause 7ii7 ! foll[+ new    
clause3  7iii7 effective = co/ report+  
p]iods beg9n+ on or aft] ,july #a1      
#bjae1 all ( ! "t s sp5t 9 ! em]g5cy    
dep>tm5t ( a rural hospital by resid5ts 
9 em]g5cy m$ic9e f a hospital ) an      
approv$ m$ical resid5cy tra9+ program 9 

su* specialty %all be c\nt$ t[>ds !     
det]m9ation ( full-"t equival5cy 9 su*  
program if ! hospital ) su* program be>s
 all1 or sub/antially all1 ( ! co/s (   
tra9+ su* resid5ts 9 ! rural hospital4  
,9 ?is subp>agraph1 ! t]m rural hospital
 means a hospital t is locat$ 9 a rural 
area 7z def9$ = purposes ( subsection   
7d77#b77;,d774  2 &  7#c7 by add+ at !  
end ! foll[+ new s5t5ce3 ,= purposes (  
?is subp>agraph1 ! em]g5cy dep>tm5t ( a 
rural hospital describ$ 9 clause 7iii7  
is a nonprovid] sett+44