,i  #aae? ,,congress  #a/ ,session  ,h4 
,r4 #bieg  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,june #bj1 #bjag,mr4  
,graves ( ,miss\ri 7= himself & ,mr4    
,loebsack7 introduc$ ! foll[+ bill2 :i* 
0 ref]r$ to ! ,committee on ,en]gy &    
,comm]ce1 & 9 addition to ! ,committees 
on ,ways & ,means1 & ! ,budget1 = a     
p]iod to be subsequ5tly det]m9$ by !    
,speak]1 9 ea* case = consid]ation ( su*
 provisions z fall )9 ! jurisdiction ( !
 committee conc]n$  ,a ,,bill  ,to am5d 
titles ,,xviii & ,,xix ( ! ,social      
,security ,act to provide = enhanc$     
paym5ts to rural heal? c>e provid]s "u !
 ,m$ic>e & ,m$icaid programs1 & = o!r   
purposes4  #a4 ,%ort title2 table (     
cont5ts  7a7 ,%ort title ,?is ,act may  
be cit$ z ! ,save ,rural ,hospitals     
,act4  7b7 ,f9d+s ,congress f9ds !      
foll[+3  7#a7 ,m ?an #fj1jjj1jjj        
individuals 9 rural areas ( ! ,unit$    
,/ates rely on rural hospitals & o!r    
provid]s z critical access po9ts to     
heal? c>e4  7#b7 ,access to heal? c>e is

 ess5tial to communities t ,am]icans    
liv+ 9 rural areas call home4  7#c7     
,am]icans liv+ 9 rural areas are old]1  
poor]1 & sick] ?an ,am]icans liv+ 9     
urban areas4  7#d7 ,f ,janu>y #bjaj     
until ,janu>y #a1 #bjag1 #hj rural      
hospitals h clos$ 9 ! ,unit$ ,/ates1    
accord+ to ! ,univ]sity ( ,nor?         
,c>ol9a's ,cecil ,g4 ,%eps ,c5t] =      
,heal? ,s]vices ,rese>*1 & ! rate ( ^!  
closures is increas+4  7#e7 ,six hundr$ 
& sev5ty-?ree hospitals are at risk (   
clos+1 accord+ to i,vantage's ,hospital 
,/r5g? ,,index /udy1 & su* clos+s w\ld  
impact #aa1gjj1jjj pati5t enc\nt]s1     
#ii1jjj community jobs w\ld be lo/1     
#acg1jjj heal?c>e jobs w\ld be lo/1 &   
#bgg1jjj1jjj1jjj w\ld be lo/ f ! gross  
dome/ic product 7ov] #aj ye>s74  7#f7   
,rural ,m$ic>e b5efici>ies already face 
a numb] ( *all5ges :5 try+ to access    
heal? c>e s]vices close to home1 includ+
 ! wea!r1 geography1 & cultural1 social1
 & language b>ri]s4  7#g7 ,sev5ty-sev5  
p]c5t ( rural c\nties 9 ! ,unit$ ,/ates 

are designat$ z prim>y c>e heal?        
pr(essional %ortage areas :ile #i p]c5t 
h no physicians at all4  7#h7 ,s5iors   
liv+ 9 rural areas are =c$ to travel    
significant di/ances = c>e4  7#i7 ,on   
av]age1 trauma victims 9 rural areas mu/
 travel twice z f> z victims 9 urban    
areas to ! close/ hospital1 &1 z a      
result1 #fj p]c5t ( trauma dea?s occur 9
 rural areas1 ev5 ?\gh only #bj p]c5t ( 
,am]icans live 9 rural areas4  7#aj7 ,) 
! #fgc hospitals on ! br9k ( closure1   
#aa1gjj1jjj ,am]icans liv+ 9 rural areas
 are on ! br9k ( los+ access to ! close/
 em]g5cy room4  7c7 ,table ( cont5ts ,! 
table ( cont5ts ( ?is ,act is z foll[s3 
,sec4 #a4 ,%ort title2 table ( cont5ts4 
,title ,i--,rural provid] paym5t        
/abilization ,subtitle ,a--,rural       
hospitals ,sec4 #aja4 ,elim9at+ ,m$ic>e 
seque/ration = rural hospitals4 ,sec4   
#ajb4 ,rev]s+ cuts to reimbursem5t ( bad
 debt = critical access hospitals       
7,c,a,hs7 & rural hospitals4 ,sec4 #ajc4
 ,ext5d+ paym5t levels = l[-volume      

hospitals & ,m$ic>e-dep5d5t hospitals   
7,m,d,hs74 ,sec4 #ajd4 ,re9/at+ revis$  
diagnosis-relat$ gr\p paym5ts = ,m,d,hs 
& sole community hospitals 7,s,c,hs74   
,sec4 #aje4 ,re9/at+ hold h>mless       
treatm5t = hospital outpati5t s]vices = 
,s,c,hs4 ,sec4 #ajf4 ,delay+ application
 ( p5alties = failure to be a mean+ful  
electronic heal? record us]4 ,sec4 #ajg4
 ,elim9at+ rural ,m$ic>e & ,m$icaid     
disproportionate %>e hospital paym5t    
r$uctions4 ,subtitle ,b--,o!r rural     
provid]s ,sec4 #aaa4 ,mak+ p]man5t      
increas$ ,m$ic>e paym5ts = gr\nd        
ambulance s]vices 9 rural areas4 ,sec4  
#aab4 ,ext5d+ ,m$icaid prim>y c>e       
paym5ts4 ,title ,,ii--,rural ,m$ic>e    
b5efici>y equity ,sec4 #bja4 ,equaliz+  
b5efici>y copaym5ts = s]vices furni%$ by
 ,c,a,hs4 ,title ,,iii--,regulatory     
relief ,sec4 #cja4 ,elim9at+ #if-;h\r   
physician c]tification requirem5t )     
respect to inpati5t ,,cah s]vices4 ,sec4
 #cjb4 ,rebas+ sup]vision requirem5ts4  
,sec4 #cjc4 ,re=m+ practices ( recov]y  

audit contractors "u ,m$ic>e4 ,title    
,,iv--,future ( rural heal? c>e ,sec4   
#dja4 ,community outpati5t hospital     
program4 ,sec4 #djb4 ,grant fund+ to    
assi/ rural hospitals4 ,sec4 #djc4      
,,cmmi demon/ration ( %>$ sav+s 9 rural 
hospitals4  ,i ,rural provid] paym5t    
/abilization  ,a ,rural hospitals  #aja4
 ,elim9at+ ,m$ic>e seque/ration = rural 
hospitals  7a7 ,9 g5]al ,section        
#bef7;d77#g7 ( ! ,balanc$ ,budget &     
,em]g5cy ,deficit ,control ,act ( #aihe 
7#b ,u4,s4,c4 #ijf7;d77#g77 is am5d$ by 
add+ at ! end ! foll[+3  7,d7 ,rural    
hospitals ,paym5ts "u "p ,a or "p ,b (  
title ,,xviii ( ! ,social ,security ,act
 ) respect to items & s]vices furni%$ by
 a critical access hospital 7z def9$ 9  
section #ahfa7mm77#a7 ( su* ,act71 a    
sole community hospital 7z def9$ 9      
section #ahhf7;d77#e77;,d77iii7 ( su*   
,act71 a m$ic>e-dep5d5t small rural     
hospital 7z def9$ 9 section             
#ahhf7;d77#e77;,g77iv7 ( su* ,act71 or a
 subsection 7d7 hospital locat$ 9 a     

rural area 7z def9$ 9 section           
#ahhf7;d77#b77;,d7 ( su* ,act74  4  7b7 
,applicability ,! am5dm5t made by ?is   
section applies ) respect to ord]s (    
seque/ration effective on or aft] ! date
 t is #fj days aft] ! date ( ! enactm5t 
( ?is ,act4  #ajb4 ,rev]s+ cuts to      
reimbursem5t ( bad debt = critical      
access hospitals 7,c,a,hs7 & rural      
hospitals  7a7 ,rural hospitals ,section
 #ahfa7v77#a77,t77v7 ( ! ,social        
,security ,act 7#db ,u4,s4,c4           
#aciex7v77#a77,t77v77 is am5d$ by ins]t+
 be=e ! p]iod ! foll[+3 or1 9 ! case ( a
 hospital locat$ 9 a rural area1 by #cj 
p]c5t ( su* am\nt o!rwise all[able4  7b7
 ,c,a,hs ,section #ahfa7v77#a77,w77ii7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #aciex7v77#a77,w77ii77 is am5d$ by     
ins]t+ aft] or 7,v7 ! foll[+3 1 a       
critical access hospital4  7c7          
,applicability ,! am5dm5ts made by ?is  
section apply ) respect to co/ report+  
p]iods beg9n+ m ?an #fj days aft] ! date
 ( ! enactm5t ( ?is ,act4  #ajc4 ,ext5d+

 paym5t levels = l[-volume hospitals &  
,m$ic>e-dep5d5t hospitals 7,m,d,hs7  7a7
 ,ext5sion ( increas$ paym5ts = ,m,d,hs 
7#a7 ,ext5sion ( paym5t me?odology      
,section #ahhf7;d77#e77;,g7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#e77;,g771 z am5d$ by section
 #bje7;a7 ( ! ,m$ic>e ,access & ,,*ip   
,reau?orization ,act ( #bjae1 is am5d$--
  7,a7 9 clause 7i71 by /rik+ 1 & be=e  
,octob] #a1 #bjag2 &  7,b7 9 clause     
7ii77,,ii71 by /rik+ 1 & be=e ,octob]   
#a1 #bjag4  7#b7 ,con=m+ am5dm5ts  7,a7 
,ext5sion ( t>get am\nt ,section        
#ahhf7;b77#c77;,d7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acieww7b77#c77;,d771 z am5d$ by section
 #bje7;b7 ( ! ,m$ic>e ,access & ,,*ip   
,reau?orization ,act ( #bjae1 is am5d$--
  7i7 9 ! matt] prec$+ clause 7i71 by   
/rik+ 1 & be=e ,octob] #a1 #bjag2 &     
7ii7 9 clause 7iv71 by /rik+ dur+ fiscal
 ye> #aiih ?r\gh fiscal ye> #bjag &     
ins]t+ dur+ or aft] fiscal ye> #aiih4   
7,b7 ,ext5d+ ! p]iod dur+ :i* hospitals 

c decl9e reclassification z urban       
,section #aceja7;e77#b7 ( ! ,omnibus    
,budget ,reconciliation ,act ( #aiic    
7#db ,u4,s4,c4 #acieww note71 z am5d$ by
 section #bje7;b7 ( ! ,m$ic>e ,access & 
,,*ip ,reau?orization ,act ( #bjae1 is  
am5d$--  7i7 by ins]t+ aft] #bjag !     
foll[+3 or a subsequ5t fiscal ye>2 &    
7ii7 9 subp>agraph 7,c71 by ins]t+ aft] 
su* reclassification ! foll[+3 dur+ !   
#a-ye> p]iod t beg9s on ! date ( !      
notification ( ! hospital "u subp>agraph
 7,a74  7b7 ,ext5sion ( ,increas$       
,paym5ts = ,l[-,volume ,hospitals       
,section #ahhf7;d77#ab7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#ab771 z am5d$ by section    
#bjd ( ! ,m$ic>e ,access & ,,*ip        
,reau?orization ,act ( #bjae1 is am5d$--
  7#a7 9 subp>agraph 7,b7-- 7,a7 9 !    
head+1 by ins]t+ aft] increase ! foll[+3
 ?r\gh fiscal ye> #bjaj2 &  7,b7 by     
/rik+ & = dis*>ges occurr+ 9 fiscal ye> 
#bjah & subsequ5t fiscal ye>s2  7#b7 9  
subp>agraph 7,c77i7--  7,a7 by /rik+ #be

 road miles 7or1 ) respect to fiscal    
ye>s #bjaa ?r\gh #bjag1 #ae road miles7 
& ins]t+ #ae road miles2 &  7,b7 by     
/rik+ 7or1 ) respect to fiscal ye>s     
#bjaa ?r\gh #bjag1 #a1fjj dis*>ges (    
individuals entitl$ to1 or enroll$ =1   
b5efits "u "p ,a7 & ins]t+ or #a1fjj    
dis*>ges ( individuals entitl$ to1 or   
enroll$ =1 b5efits "u "p ,a2 &  7#c7 9  
subp>agraph 7,d7-- 7,a7 by am5d+ ! head+
 to read z foll[s3 ,applicable p]c5tage 
increase aft] fiscal ye> #bjaj2 &  7,b7 
by /rik+ 9 fiscal ye>s #bjaa ?r\gh #bjag
 & ins]t+ 9 fiscal ye> #bjaa & ea*      
subsequ5t fiscal ye>4  #ajd4 ,re9/at+   
revis$ diagnosis-relat$ gr\p paym5ts =  
,m,d,hs & sole community hospitals      
7,s,c,hs7  7a7 ,paym5ts = ,m,d,hs &     
,s,c,hs = ,value-,bas$ ,inc5tive        
,programs ,section                      
#ahhf7o77#g77;,d77ii77,i7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#acieww7o77#g77;,d77ii77,i77 is am5d$ by
 ins]t+ or aft] fiscal ye> #bjah aft]   
#bjac4  7b7 ,paym5ts = ,m,d,hs & ,s,c,hs

 "u hospital readmissions r$uction      
program ,section #ahhf7q77#b77;,b77i7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#acieww7q77#b77;,b77i77 is am5d$ by     
ins]t+ or aft] fiscal ye> #bjah aft]    
#bjac4  #aje4 ,re9/at+ hold h>mless     
treatm5t = hospital outpati5t s]vices = 
,s,c,hs ,section #ahcc7t77#g77;,d77i7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciel7t77#g77;,d77i77 is am5d$-- 7#a7 9
 ! head+1 by /rik+ ,tempor>y & ins]t+   
,p]man5t2  7#b7 9 subclause 7,,ii7--    
7,a7 9 ! fir/ s5t5ce1 by ins]t+ or on or
 aft] ,janu>y #a1 #bjah1 aft] ,janu>y   
#a1 #bjac12 &  7,b7 9 ! second s5t5ce1  
by ins]t+ 1 or dur+ or aft] #bjah aft]  
or #bjab2 &  7#c7 9 subclause 7,,iii71 9
 ! fir/ s5t5ce1 by ins]t+ or on or aft] 
,janu>y #a1 #bjah1 aft] ,janu>y #a1     
#bjac14  #ajf4 ,delay+ application (    
p5alties = failure to be a mean+ful     
electronic heal? record us]  7a7 ,9     
g5]al ,section                          
#ahhf7;b77#c77;,b77ix77,i7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           

#acieww7b77#c77;,b77ix77,i77 is am5d$ by
 add+ at ! end ! foll[+3 ,9 ! case ( a  
hospital locat$ 9 a rural area1 ea*     
fiscal ye> ref]r$ to 9 ! fir/ s5t5ce (  
?is subclause %all be appli$ z if x 7 a 
ref]5ce to ! ye> t is #d fiscal ye>s    
lat]44  7b7 ,applicability ,! am5dm5t   
made by ?is section applies ) respect   
fiscal ye>s beg9n+ aft] ! date ( !      
enactm5t ( ?is ,act4  #ajg4 ,elim9at+   
rural ,m$ic>e & ,m$icaid                
disproportionate %>e hospital paym5t    
r$uctions  7a7 ,m$ic>e ,section         
#ahhf7r77#a7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #acieww7r77#a77 is am5d$ 
by ins]t+ be=e #be p]c5t ! foll[+3      
7unless su* hospital is locat$ 9 a rural
 area1 z def9$ 9 subsection             
7d77#b77;,d774  7b7 ,m$icaid ,section   
#aibc7;f77#c7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4#acifr-#d7;f77#c77 is    
am5d$-- 7#a7 9 subp>agraph 7,a7 by /rik+
 subp>agraph 7,e7 & ins]t+ subp>agraphs 
7,e7 & 7,f72 &  7#b7 by add+ at ! end ! 
foll[+3  7,f7 ,increase 9 allotm5ts &   

paym5ts = rural hospitals  7i7          
,allotm5ts ,subject to clause 7iii7 &   
not)/&+ subp>agraphs 7,b71 7,c71 & 7,e71
 ! ,,d% allotm5t = a ,/ate ) respect to 
a fiscal ye> t w\ld be det]m9$ "u ?is   
p>agraph = ! ,/ate = ! fiscal ye> if ?is
 subp>agraph did n apply1 %all be       
increas$ by ! product (--  7,i7 !       
r$uction ( su* ,/ate's ,,d% allotm5t "u 
p>agraph 7#g77;,a77i77,i7 = su* fiscal  
ye>2 &  7,,ii7 ! p]c5tage ( individuals 
9 ! ,/ate :o receive m$ical assi/ance "u
 a ,/ate plan "u ?is title & :o live 9 a
 rural area 7z def9$ 9 section          
#ahhf7;d77#b77;,d77 ( ! ,/ate4  7ii7    
,paym5ts ,subject to clause 7iii71 !    
paym5ts made to a ,/ate "u section      
#aijc7;a7 = ea* cal5d> qu>t] %all be    
increas$ by ! product (--  7,i7 !       
r$uction su* ,/ate's ,,d% allotm5t "u   
p>agraph 7#g77;,a77i77,,ii7 = su* fiscal
 ye>2 &  7,,ii7 ! p]c5tage ( individuals
 9 ! ,/ate :o receive m$ical assi/ance  
"u a ,/ate plan "u ?is title & :o live 9
 a rural area 7z def9$ 9 section        

#ahhf7;d77#b77;,d77 ( ! ,/ate4  7iii7   
,supplem5t1 n supplant ,a ,/ate may only
 receive an increas$ allotm5t "u clause 
7i7 or an increas$ paym5t "u clause 7ii7
 if su* ,/ate provides su* assurances z 
! ,secret>y may require t any funds made
 available to su* ,/ate pursuant to su* 
clauses %all be us$ to supplem5t1 & n   
supplant1 am\nts paid "u ?is section to 
hospitals 9 ! ,/ate t are locat$ 9 rural
 areas 7z def9$ 9 section               
#ahhf7;d77#b77;,d774  4  7c7            
,applicability ,! am5dm5ts made by ?is  
section apply ) respect to fiscal ye>   
#bjah & ea* subsequ5t fiscal ye>4  ,b   
,o!r rural provid]s  #aaa4 ,mak+ p]man5t
 increas$ ,m$ic>e paym5ts = gr\nd       
ambulance s]vices 9 rural areas ,section
 #ahcd7l77#ac7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciem7l77#ac77 is  
am5d$-- 7#a7 by /rik+ ,tempor>y increase
 & ins]t+ ,increase2 &  7#b7 9          
subp>agraph 7,a7-- 7,a7 9 ! matt] prec$+
 clause 7i71 by /rik+ 1 & be=e ,janu>y  
#a1 #bjah2 &  7,b7 9 clause 7i71 by     

/rik+ 1 & be=e ,janu>y #a1 #bjah4  #aab4
 ,ext5d+ ,m$icaid prim>y c>e paym5ts    
7a7 ,9 g5]al ,section                   
#aijb7;a77#ac77;,c7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#acif;a7a77#ac77;,c77 is am5d$ by ins]t+
 aft] #bjad ! foll[+3 7or 9 ! case ( a  
prim>y c>e s]vices furni%$ by a         
physician locat$ 9 a rural area1 z def9$
 9 section #ahhf7;d77#b77;,d71 furni%$ 9
 any ye>74  7b7 ,applicability  7#a7 ,9 
g5]al ,except z provid$ 9 p>agraph 7#b71
 ! am5dm5t made by ?is section applies  
to s]vices furni%$ 9 a ye> beg9n+ on or 
aft] ! date ( ! enactm5t ( ?is ,act4    
7#b7 ,exception if /ate legislation     
requir$ ,9 ! case ( a ,/ate plan =      
m$ical assi/ance "u title ,,xix ( !     
,social ,security ,act :i* ! ,secret>y (
 ,heal? & ,human ,s]vices det]m9es      
requires ,/ate legislation 7o!r ?an     
legislation appropriat+ funds7 9 ord] = 
! plan to meet ! additional requirem5t  
impos$ by ! am5dm5t made by ?is section1
 ! ,/ate plan %all n be reg>d$ z fail+  

to comply ) ! requirem5ts ( su* title   
solely on ! basis ( its failure to meet 
?is additional requirem5t be=e ! fir/   
day ( ! fir/ cal5d> qu>t] beg9n+ aft] ! 
close ( ! fir/ regul> session ( ! ,/ate 
legislature t beg9s aft] ! date ( !     
enactm5t ( ?is ,act4 ,= purposes ( !    
previ\s s5t5ce1 9 ! case ( a ,/ate t has
 a #b-ye> legislative session1 ea* ye> (
 su* session %all be deem$ to be a      
sep>ate regul> session ( ! ,/ate        
legislature4  ,,ii ,rural ,m$ic>e       
b5efici>y equity  #bja4 ,equaliz+       
b5efici>y copaym5ts = s]vices furni%$ by
 ,c,a,hs  7a7 ,9 g5]al ,section         
#ahff7;a77#b77;,a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;cc7a77#b77;,a77 is am5d$ by add+  
at ! end ! foll[+3 ,9 ! case ( outpati5t
 critical access hospital s]vices = :i* 
paym5t is made "u section #ahcd7;g71    
clause 7ii7 ( ! fir/ s5t5ce %all be     
appli$ by sub/itut+ #bj p]c5t ( ! less] 
( ! actual *>ge or ! paym5t basis "u ?is
 "p = su* s]vices if ! critical access  

hospital 7 treat$ z a hospital = #bj p] 
c5tum ( ! reasonable *>ge = su* items & 
s]vices44  7b7 ,applicability ,! am5dm5t
 made by ?is section applies ) respect  
to s]vices furni%$ dur+ a ye> t beg9s m 
?an #fj days aft] ! date ( ! enactm5t ( 
?is ,act4  ,,iii ,regulatory relief     
#cja4 ,elim9at+ #if-;h\r physician      
c]tification requirem5t ) respect to    
inpati5t ,,cah s]vices  7a7 ,9 g5]al    
,section #ahad7;a7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acie;f7a77 is     
am5d$-- 7#a7 9 p>agraph 7#f71 by add+ & 
at ! end2  7#b7 9 p>agraph 7#g77;,e71 by
 /rik+ 2 & & ins]t+ a p]iod2 &  7#c7 by 
/rik+ p>agraph 7#h74  7b7 ,applicability
 ,! am5dm5ts made by ?is section apply )
 respect to s]vices furni%$ dur+ a ye> t
 beg9s m ?an #fj days aft] ! date ( !   
enactm5t ( ?is ,act4  #cjb4 ,rebas+     
sup]vision requirem5ts  7a7 ,!rapeutic  
hospital outpati5t s]vices  7#a7        
,sup]vision requirem5ts ,section #ahcc (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #aciel7 is am5d$ by add+ at ! end !    

foll[+3  7aa7 ,physician sup]vision     
requirem5ts = !rapeutic hospital        
outpati5t s]vices  7#a7 ,g5]al          
sup]vision = !rapeutic s]vices ,except z
 may be provid$ "u p>agraph 7#b71 ins(> 
z ! ,secret>y requires ! sup]vision by a
 physician or a non-physician           
practition] = paym5t = !rapeutic        
hospital outpati5t s]vices 7z def9$ 9   
p>agraph 7#e77;,a77 furni%$ "u ?is "p1  
su* requirem5t %all be met if su*       
s]vices are furni%$ "u ! g5]al          
sup]vision 7z def9$ 9 p>agraph          
7#e77;,b77 ( ! physician or             
non-physician practition]1 z ! case may 
be4  7#b7 ,exceptions process =         
high-risk or complex m$ical s]vices     
requir+ a direct level ( sup]vision     
7,a7 ,9 g5]al ,subject to ! succe$+     
provisions ( ?is p>agraph1 ! ,secret>y  
%all e/abli% a process = ! designation (
 !rapeutic hospital outpati5t s]vices   
furni%$ "u ?is "p t1 by reason (        
complexity or high risk1 require--  7i7 
direct sup]vision 7z def9$ 9 p>agraph   

7#e77;,c77 = ! entire s]vice2 or  7ii7  
direct sup]vision dur+ ! initiation ( ! 
s]vice foll[$ by g5]al sup]vision = !   
rema9d] ( ! s]vice4  7,b7 ,consultation 
) cl9ical exp]ts  7i7 ,9 g5]al ,"u !    
process e/abli%$ "u subp>agraph 7,a71   
be=e ! designation ( any !rapeutic      
hospital outpati5t s]vice = :i* direct  
sup]vision may be requir$ "u ?is "p1 !  
,secret>y %all consult ) a panel (      
outside exp]ts describ$ 9 clause 7ii7 to
 advise ! ,secret>y ) respect to ea* su*
 designation4  7ii7 ,advisory panel on  
sup]vision ( !rapeutic hospital         
outpati5t s]vices ,= purposes ( clause  
7i71 a panel ( outside exp]ts describ$ 9
 ?is clause is a panel appo9t$ by !     
,secret>y1 bas$ on nom9ations submitt$  
by hospital1 rural heal?1 & m$ical      
organizations repres5t+ physicians1     
non-physician practition]s1 & hospital  
adm9i/rators1 z ! case may be1 t meets !
 foll[+ requirem5ts3  7,i7 ,composition 
,! panel %all be compos$ ( at lea/ #ae  
physicians & non-physician practition]s 

:o furni% !rapeutic hospital outpati5t  
s]vices = :i* paym5t is made "u ?is "p &
 :o collectively repres5t ! m$ical      
specialties t furni% su* s]vices1 & ( #d
 hospital adm9i/rators ( hospitals      
locat$ 9 rural areas 7z def9$ 9 section 
#ahhf7;d77#b77;,d77 or critical access  
hospitals4  7,,ii7 ,practical exp]i5ce  
requir$ = physicians & non-physician    
practition]s ,dur+ ! #ab-mon? p]iod     
prec$+ appo9tm5t to ! panel by !        
,secret>y1 ea* physician or             
non-physician practition] describ$ 9    
subclause 7,i7 %all h furni%$ !rapeutic 
hospital outpati5t s]vices = :i* paym5t 
0 made "u ?is "p4  7,,iii7 ,m9imum rural
 repres5tation requirem5t = physicians &
 non-physician practition]s ,n less ?an 
#ej p]c5t ( ! memb]%ip ( ! panel t is   
compris$ ( physicians & non-physician   
practition]s %all be physicians or      
non-physician practition]s describ$ 9   
subclause 7,i7 :o practice 9 rural areas
 7z def9$ 9 section #ahhf7;d77#b77;,d77 
or :o furni% su* s]vices 9 critical     

access hospitals4  7iii7 ,application ( 
,,faca ,! ,f$]al ,advisory ,committee   
,act 7#e ,u4,s4,c4 #b ,app471 o!r ?an   
section #ad ( su* ,act1 %all apply to ! 
panel ( outside exp]ts appo9t$ by !     
,secret>y "u clause 7ii74  7,c7 ,special
 rule = outpati5t critical access       
hospital s]vices ,ins(> z a !rapeutic   
outpati5t hospital s]vice t is an       
outpati5t critical access hospital      
s]vice is designat$ z requir+ direct    
sup]vision "u ! process e/abli%$ "u     
subp>agraph 7,a71 ! ,secret>y %all deem 
! critical access hospital furni%+ t    
s]vice z hav+ met ! requirem5t = direct 
sup]vision = t s]vice if1 :5 furni%+ su*
 s]vice1 ! critical access hospital     
meets ! /&>d = p]sonnel requir$ z a     
condition ( p>ticipation "u section     
#dhe4fah7;d7 ( title #db1 ,code ( ,f$]al
 ,regulations 7z 9 effect on ! date ( ! 
enactm5t ( ?is subsection74  7,d7       
,consid]ation ( compliance burd5s ,"u ! 
process e/abli%$ "u subp>agraph 7,a71 ! 
,secret>y %all take into acc\nt ! impact

 on hospitals & critical access         
hospitals 9 comply+ ) requirem5ts =     
direct sup]vision 9 ! furni%+ (         
!rapeutic hospital outpati5t s]vices1   
includ+ hospital res\rces1 availability 
( hospital-privileg$ physicians1        
specialty physicians1 & non-physician   
practition]s1 & adm9i/rative burd5s4    
7,e7 ,requirem5t = notice & comm5t      
rulemak+ ,"u ! process e/abli%$ "u      
subp>agraph 7,a71 ! ,secret>y %all only 
designate !rapeutic hospital outpati5t  
s]vices requir+ direct sup]vision "u ?is
 "p ?r\gh propos$ & f9al rulemak+ t     
provides = public notice & opportunity =
 comm5t4  7,f7 ,rule ( con/ruction ,no?+
 9 ?is subsection %all be con/ru$ z     
au?oriz+ ! ,secret>y to apply or require
 any level ( sup]vision o!r ?an g5]al or
 direct sup]vision ) respect to !       
furni%+ ( !rapeutic hospital outpati5t  
s]vices4  7#c7 ,initial li/ ( designat$ 
s]vices ,! ,secret>y %all include 9 !   
propos$ & f9al regulation = paym5t =    
hospital outpati5t s]vices = #bjah "u   

?is "p a li/ ( initial !rapeutic        
hospital outpati5t s]vices1 if any1     
designat$ "u ! process e/abli%$ "u      
p>agraph 7#b77;,a7 z requir+ direct     
sup]vision "u ?is "p4  7#d7 ,direct     
sup]vision by non-physician practition]s
 = c]ta9 hospital outpati5t s]vices     
p]mitt$  7,a7 ,9 g5]al ,subject to !    
succe$+ provisions ( ?is subsection1 a  
non-physician practition] may directly  
sup]vise ! furni%+ (--  7i7 !rapeutic   
hospital outpati5t s]vices "u ?is "p1   
includ+ c>diac rehabilitation s]vices   
7"u section #ahfa7;eee77#a771 int5sive  
c>diac rehabilitation s]vices 7"u       
section #ahfa7;eee77#d771 & pulmon>y    
rehabilitation s]vices 7"u section      
#ahfa7;fff77#a772 &  7ii7 ^? hospital   
outpati5t diagno/ic s]vices 7describ$ 9 
section #ahfa7s77#b77;,c77 t require    
direct sup]vision "u ! fee s*$ule       
e/abli%$ "u section #ahdh4  7,b7        
,requirem5ts ,subp>agraph 7,a7 %all     
apply ins(> z ! non-physician           
practition] involv$ meets ! foll[+      

requirem5ts3  7i7 ,scope ( practice ,!  
non-physician practition] is act+ )9 !  
scope ( practice "u ,/ate law applicable
 to ! practition]4  7ii7 ,additional    
requirem5ts ,! non-physician practition]
 meets su* requirem5ts z ! ,secret>y may
 specify4  7#e7 ,def9itions ,9 ?is      
subsection3  7,a7 ,!rapeutic hospital   
outpati5t s]vices ,! t]m !rapeutic      
hospital outpati5t s]vices means        
hospital s]vices describ$ 9 section     
#ahfa7s77#b77;,b7 furni%$ by a hospital 
or critical access hospital & includes--
  7i7 c>diac rehabilitation s]vices &   
int5sive c>diac rehabilitation s]vices  
7z def9$ 9 p>agraphs 7#a7 & 7#d71       
respectively1 ( section #ahfa7;eee772 & 
7ii7 pulmon>y rehabilitation s]vices 7z 
def9$ 9 section #ahfa7;fff77#a774  7,b7 
,g5]al sup]vision  7i7 ,ov]all direction
 & control ( physician ,subject to      
clause 7ii71 ) respect to ! furni%+ (   
!rapeutic hospital outpati5t s]vices =  
:i* paym5t may be made "u ?is "p1 ! t]m 
g5]al sup]vision means su* s]vices t are

 furni%$ "u ! ov]all direction & control
 ( a physician or non-physician         
practition]1 z ! case may be4  7ii7     
,pres5ce n requir$ ,= purposes ( clause 
7i71 ! pres5ce ( a physician or         
non-physician practition] is n requir$  
dur+ ! p]=mance ( ! proc$ure involv$4   
7,c7 ,direct sup]vision  7i7 ,provision 
( assi/ance & direction ,subject to     
clause 7ii71 ) respect to ! furni%+ (   
!rapeutic hospital outpati5t s]vices =  
:i* paym5t may be made "u ?is "p1 ! t]m 
direct sup]vision means t a physician or
 non-physician practition]1 z ! case may
 be1 is imm$iately available 7includ+ by
 telephone or o!r means7 to furni%      
assi/ance & direction ?r\gh\t ! furni%+ 
( su* s]vices4 ,su* t]m includes1 )     
respect to ! furni%+ ( a !rapeutic      
hospital outpati5t s]vice = :i* paym5t  
may be made "u ?is "p1 direct sup]vision
 dur+ ! initiation ( ! s]vice foll[$ by 
g5]al sup]vision = ! rema9d] ( ! s]vice 
7z describ$ 9 p>agraph 7#b77;,a77ii774  
7ii7 ,pres5ce 9 room n requir$ ,=       

purposes ( clause 7i71 a physician or   
non-physician practition]1 z ! case may 
be1 is n requir$ to be pres5t 9 ! room  
dur+ ! p]=mance ( ! proc$ure involv$ or 
)9 any o!r physical b\nd>y z long z !   
physician or non-physician practition]1 
z ! case may be1 is imm$iately          
available4  7,d7 ,non-physician         
practition] def9$ ,! t]m non-physician  
practition] means an individual :o-- 7i7
 is a physician assi/ant1 a nurse       
practition]1 a cl9ical nurse speciali/1 
a cl9ical social work]1 a cl9ical       
psy*ologi/1 a c]tifi$ nurse midwife1 or 
a c]tifi$ regi/]$ nurse ane/heti/1 &    
includes su* o!r practition]s z !       
,secret>y may specify2 &  7ii7 ) respect
 to ! furni%+ ( !rapeutic outpati5t     
hospital s]vices1 meets ! requirem5ts ( 
p>agraph 7#d77;,b74  4  7#b7 ,con=m+    
am5dm5t ,section #ahfa7;eee77#b77;,b7 ( 
! ,social ,security ,act 7#db ,u4,s4,c4 
#aciex7eee77#b77;,b77 is am5d$ by ins]t+
 1 & a non-physician practition] 7z     
def9$ 9 section #ahcc7;aa77#e77;,d77 may

 sup]vise ! furni%+ ( su* items &       
s]vices 9 ! hospital aft] 9 ! case (    
items & s]vices furni%$ "u su* a program
 9 a hospital1 su* availability %all be 
presum$4  7b7 ,prohibition on           
retroactive en=cem5t ( revis$           
int]pretation  7#a7 ,repeal ( regulatory
 cl>ification ,! re/atem5t &            
cl>ification "u ! f9al rulemak+ *anges  
to ! ,m$ic>e hospital outpati5t         
prospective paym5t sy/em & cal5d> ye>   
#bjji paym5t rates 7publi%$ 9 ! ,f$]al  
,regi/] on ,novemb] #ah1 #bjjh1 #gc ,f$4
 ,reg4 #fhgjb ?r\gh #fhgjd7 ) respect to
 requirem5ts = direct sup]vision by     
physicians = !rapeutic hospital         
outpati5t s]vices 7z def9$ 9 p>agraph   
7#c77 = purposes ( paym5t = su* s]vices 
"u ! ,m$ic>e program %all h no =ce or   
effect 9 law4  7#b7 ,hold h>mless ,a    
hospital or critical access hospital t  
furni%es !rapeutic hospital outpati5t   
s]vices dur+ ! p]iod beg9n+ on ,janu>y  
#a1 #bjja1 & end+ on ! lat] ( ,decemb]  
#ca1 #bjag1 or ! date on :i* ! f9al     

regulation promulgat$ by ! ,secret>y (  
,heal? & ,human ,s]vices to c>ry out ?is
 section takes effect1 = :i* a claim =  
paym5t is made "u "p ,b ( title ,,xviii 
( ! ,social ,security ,act %all n be    
subject to any civil or crim9al action  
or p5alty "u ,f$]al law = failure to    
meet sup]vision requirem5ts "u !        
regulation describ$ 9 p>agraph 7#a71 "u 
program manuals1 or o!rwise4  7#c7      
,!rapeutic hospital outpati5t s]vices   
def9$ ,9 ?is subsection1 ! t]m !rapeutic
 hospital outpati5t s]vices means m$ical
 & o!r heal? s]vices furni%$ by a       
hospital or critical access hospital t  
are--  7,a7 hospital s]vices describ$ 9 
subsection 7s77#b77;,b7 ( section #ahfa 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #aciex72  7,b7 c>diac         
rehabilitation s]vices or int5sive      
c>diac rehabilitation s]vices 7z def9$ 9
 p>agraphs 7#a7 & 7#d71 respectively1 ( 
subsection 7eee7 ( su* section72 or     
7,c7 pulmon>y rehabilitation s]vices 7z 
def9$ 9 subsection 7fff77#a7 ( su*      

section74  #cjc4 ,re=m+ practices (     
recov]y audit contractors "u ,m$ic>e    
7a7 ,elim9ation ( cont+5cy fee paym5t   
sy/em ,section #ahic7;h7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acie;ddd7h771 z am5d$ by section       
#eje7;b7 ( ! ,m$ic>e ,access & ,,*ip    
,reau?orization ,act ( #bjae1 is am5d$--
  7#a7 9 p>agraph 7#a71 by ins]t+ 1 =   
recov]y activities conduct$ dur+ a      
fiscal ye> be=e fiscal ye> #bjaf aft]   
,"u ! contracts2 &  7#b7 by add+ at !   
end ! foll[+ new p>agraph3  7#aa7       
,paym5t = recov]y activities p]=m$ aft] 
fiscal ye> #bjag  7,a7 ,9 g5]al ,"u !   
contracts1 subject to subp>agraphs 7,b7 
& 7,c71 paym5t %all be made to recov]y  
audit contractors = recov]y activities  
conduct$ dur+ fiscal ye> #bjah & ea*    
fiscal ye> !reaft] 9 ! same mann]1 & f !
 same am\nts1 z paym5t is made to       
eligible entities "u contracts ent]$    
into = recov]y activities conduct$ dur+ 
fiscal ye> #bjae "u subsection 7a74     
7,b7 ,prohibition on inc5tive paym5ts   

,"u ! contracts1 paym5t made to a       
recov]y audit contractor = recov]y      
activities conduct$ dur+ fiscal ye>     
#bjah or any fiscal ye> !reaft] may n   
include any inc5tive paym5ts4  7,c7     
,p]=mance acc\ntability  7i7 ,9 g5]al   
,"u ! contracts1 paym5t made to a       
recov]y audit contractor = recov]y      
activities conduct$ dur+ fiscal ye>     
#bjah or any fiscal ye> !reaft] %all1 9 
! case t ! contractor has a complex     
audit d5ial ov]turn rate at ! end ( su* 
fiscal ye> 7z calculat$ "u ! me?odology 
describ$ 9 clause 7iv77 t is 4#a or     
great]1 be r$uc$ 9 an am\nt det]m9$ 9   
accordance ) clause 7ii74  7ii7 ,paym5t 
r$uctions  7,i7 ,slid+ scale ( am\nt (  
r$uctions ,! ,secret>y %all e/abli%1 =  
purposes ( det]m9+ ! am\nt ( a r$uction 
9 paym5t to a recov]y audit contractor  
"u clause 7i7 = recov]y activities      
conduct$ dur+ fiscal ye>1 a l9e> slid+  
scale ( paym5t r$uctions = recov]y audit
 contractors = su* fiscal ye>4 ,"u su*  
l9e> slid+ scale1 ! am\nt ( su* a       

r$uction 9 paym5t to a recov]y audit    
contractor = a fiscal ye> %all be       
calculat$ 9 a mann] t provides = su*    
r$uction to be great] ?an ! r$uction =  
su* fiscal ye> = recov]y audit          
contractors t h complex audit d5ial     
ov]turn rates at ! end ( su* fiscal ye> 
7z calculat$ "u ! me?odology describ$ 9 
clause 7iv77 t are l[] ?an ! complex    
audit d5ial ov]turn rate ( ! contractor 
at ! end ( su* fiscal ye> 7z s          
calculat$74  7,,ii7 ,mann] ( collect+   
r$uction ,! ,secret>y may assess &      
collect ! r$uctions 9 paym5t to recov]y 
audit contractors "u clause 7i7 9 su*   
mann] z ! ,secret>y may specify 7su* z  
by r$uc+ ! am\nt paid to ! contractor = 
recov]y activities conduct$ dur+ a      
fiscal ye> or by assess+ ! r$uction z a 
sep>ate p5alty paym5t to be paid to !   
,secret>y by ! contractor ) respect to  
ea* complex audit d5ial issu$ by !      
contractor t is ov]turn$ on appeal74    
7iii7 ,tim+ ( det]m9ations ( paym5t     
r$uctions ,! ,secret>y %all1 ) respect  

to a recov]y audit contractor1 det]m9e n
 lat] ?an six mon?s aft] ! end ( a      
fiscal ye>--  7,i7 :e!r to r$uce paym5t 
to ! recov]y audit contractor "u clause 
7i7 = recov]y activities conduct$ dur+  
su* fiscal ye>2 &  7,,ii7 9 ! case t !  
,secret>y det]m9es to s r$uce paym5t to 
! contractor1 ! am\nt ( su* paym5t      
r$uction4  7iv7 ,me?odology =           
calculation ( ov]turn$ complex audit    
d5ial ov]turn rate  7,i7 ,calculation ( 
ov]turn rate ,! ,secret>y %all calculate
 a complex audit d5ial ov]turn rate = a 
recov]y audit contractor = a fiscal ye> 
by--  7aa7 det]m9+1 ) respect to !      
contract ent]$ into "u p>agraph 7#a7 by 
! contractor1 ! numb] ( complex audit   
d5ials issu$ by ! contractor "u !       
contract 7includ+ d5ials issu$ be=e su* 
fiscal ye> & dur+ su* fiscal ye>7 t are 
ov]turn$ on appeal2 &  7bb7 divid+ !    
numb] det]m9$ "u item 7aa7 by ! numb] ( 
complex audit d5ials issu$ by !         
contractor "u su* contract 7includ+     
d5ials issu$ be=e su* fiscal ye> & dur+ 

su* fiscal ye>74  7,,ii7 ,fairness &    
transp>5cy ,! ,secret>y %all calculate !
 p]c5tage describ$ 9 subclause 7,i7 9 a 
fair & transp>5t mann]4  7,,iii7        
,acc\nt+ = subsequ5tly ov]turn$ appeals 
,! ,secret>y %all calculate ! p]c5tage  
describ$ 9 subclause 7,i7 9 a mann] t   
acc\nts = ! likelihood t complex audit  
d5ials issu$ by ! contractor = su*      
fiscal ye> w be ov]turn$ on appeal 9 a  
subsequ5t fiscal ye>4  7,,iv7 ,complex  
audit d5ial def9$ ,9 ?is subp>agraph1 ! 
t]m complex audit d5ial means a d5ial by
 a recov]y audit contractor ( a claim = 
paym5t "u ?is title submitt$ by a       
hospital1 psy*iatric hospital1 or       
critical access hospital t is s d5i$ by 
! contractor aft] ! contractor has--    
7aa7 reque/$ t ! hospital1 psy*iatric   
hospital1 or critical access hospital1 9
 ord] to support su* claim = paym5t1    
provide support+ m$ical records to !    
contractor2 &  7bb7 review$ su* m$ical  
records 9 ord] to det]m9e :e!r an       
improp] paym5t has be5 made to !        

hospital1 psy*iatric hospital1 or       
critical access hospital = su* claim4   
7,v7 ,ov]turn$ on appeal def9$ ,9 ?is   
subp>agraph1 ! t]m ov]turn$ on appeal   
means1 ) respect to a complex audit     
d5ial1 a d5ial t is ov]turn$ on appeal  
at ! reconsid]ation level1 !            
r$et]m9ation level1 or ! adm9i/rative   
law judge he>+ level4  7,d7 ,application
 to exi/+ contracts ,n lat] ?an #fj days
 aft] ! date ( ! enactm5t ( ?is         
p>agraph1 ! ,secret>y %all modify1 z    
necess>y1 ea* contract "u p>agraph 7#a7 
t ! ,secret>y ent]$ into prior to su*   
date ( enactm5t 9 ord] to ensure t      
paym5t ) respect to recov]y activities  
conduct$ "u su* contract is made 9      
accordance ) ! requirem5ts describ$ 9   
?is p>agraph4  4  7b7 ,elim9ation (     
,"o-,ye> ,timely ,fil+ ,limit ,to       
,rebill ,"p ,b ,claims  7#a7 ,9 g5]al   
,section #ahdb7;b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4 #acieu7b77 is am5d$
 by add+ at ! end ! foll[+ new p>agraph3
  7#bj7 ,exception to ! "o-ye> timely   

fil+ limit = c]ta9 rebill$ claims  7,a7 
,9 g5]al ,9 ! case ( a claim submitt$ "u
 ?is "p by a hospital 7z def9$ 9        
subp>agraph 7,b77i77 = hospital s]vices 
) respect to :i* !re 0 a previ\s claim  
submitt$ "u "p ,a z inpati5t hospital   
s]vices or inpati5t critical access     
hospital s]vices t 0 d5i$ by a m$ic>e   
contractor 7z def9$ 9 subp>agraph       
7,b77ii77 because ( a det]m9ation t !   
inpati5t admission 0 n m$ically         
reasonable & necess>y "u section        
#ahfb7;a77#a77;,a71 ! deadl9e describ$ 9
 ?is p>agraph is #ahj days aft] ! date (
 ! f9al d5ial ( su* claim "u "p ,a4     
7,b7 ,def9itions ,9 ?is p>agraph3 7i7   
,hospital ,! t]m hospital has ! mean+   
giv5 su* t]m 9 section #ahfa7;e7 &      
includes a psy*iatric hospital 7z def9$ 
9 section #ahfa7;f77 & a critical access
 hospital 7z def9$ 9 section            
#ahfa7mm77#a774  7ii7 ,m$ic>e contractor
 ,! t]m m$ic>e contractor has ! mean+   
giv5 su* t]m "u section #ahhi7;g71 &    
includes a recov]y audit contractor ) a 

contract "u section #ahic7;h74  7iii7   
,f9al d5ial ,! t]m f9al d5ial means--   
7,i7 9 ! case t a hospital elects n to  
appeal a d5ial describ$ 9 subp>agraph   
7,a7 by a m$ic>e contractor1 ! date (   
su* d5ial2 or  7,,ii7 9 ! case t a      
hospital elects to appeal a su* a d5ial1
 ! date on :i* su* appeal is exhau/$4  4
  7#b7 ,con=m+ am5dm5ts  7,a7 ,section  
#ahce7;a77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acien7a77#a77 is am5d$ 
by ins]t+ or1 9 ! case ( a claim        
describ$ 9 section #ahdb7;b77#bj71 n    
lat] ?an ! deadl9e describ$ 9 su*       
p>agraph aft] ! date ( s]vice4  7,b7    
,section #ahdb7;b77#c77;,b7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#acieu7b77#c77;,b77 is am5d$ 9 ! flu%   
language foll[+ clause 7ii7 by ins]t+   
or1 9 ! case ( a claim describ$ 9       
section #ahdb7;b77#bj71 n lat] ?an !    
deadl9e describ$ 9 su* p>agraph aft] !  
date ( s]vice4  7#c7 ,applicability ,!  
am5dm5ts made by ?is subsection apply to
 claims submitt$ "u "p ,b ( title       

,,xviii ( ! ,social ,security ,act =    
hospital s]vices = :i* !re 0 a previ\s  
claim submitt$ "u "p ,a z inpati5t      
hospital s]vices or inpati5t critical   
access hospital s]vices t 0 subject to a
 f9al d5ial 7z def9$ 9 p>agraph         
7#bj77;,b77iii7 ( section #ahdb7;b7 (   
su* ,act 7#db ,u4,s4,c4 #acieu7b777 on  
or aft] ! date ( ! enactm5t ( ?is ,act4 
7c7 ,m$ical docum5tation consid]$ =     
m$ical necessity reviews ( claims =     
inpati5t hospital s]vices ,section      
#ahfb7;a7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciey7a77 is am5d$ by   
add+ at ! end ! foll[+ new s5t5ce3 ,a   
det]m9ation "u p>agraph 7#a7 ( :e!r     
inpati5t hospital s]vices or inpati5t   
critical access hospital s]vices furni%$
 to an individual on or aft] ! date ( ! 
enactm5t ( ?is s5t5ce are reasonable &  
necess>y %all be bas$ solely ^u         
in=mation available to ! admitt+        
physician at ! "t ( ! inpati5t admission
 ( ! individual = su* inpati5t s]vices1 
z docum5t$ 9 ! m$ical record44  ,,iv    

,future ( rural heal? c>e  #dja4        
,community outpati5t hospital program   
7a7 ,9 g5]al  7#a7 ,community outpati5t 
hospital & qualifi$ outpati5t s]vices   
def9$ ,section #ahfa ( ! ,social        
,security ,act 7#db ,u4,s4,c4 #aciex7 is
 am5d$-- 7,a7 9 ! la/ s5t5ce (          
subsection 7e71 by ins]t+ be=e ! p]iod  
at ! end or a community outpati5t       
hospital 7z def9$ 9 subsection          
7iii77#a772 &  7,b7 by add+ at ! end !  
foll[+3  7iii7 ,community outpati5t     
hospital  7#a7 ,! t]m community         
outpati5t hospital means a facility t-- 
7,a7 at any "t dur+ ! p]iod beg9n+ on ! 
date t is #e ye>s be=e ! date ( !       
enactm5t ( ?is subsection & end+ on     
,decemb] #ca1 #bjaf1 0 a critical access
 hospital1 or is a hospital ) n m ?an   
#ej b$s t is--  7i7 locat$ 9 a rural    
area 7z def9$ 9 section                 
#ahhf7;d77#b77;,d772 or  7ii7 treat$ z  
be+ locat$ 9 a rural area "u section    
#ahhf7;d77#h77;,e72  7,b7 provides      
em]g5cy m$ical c>e & obs]vation c>e     

available on a #bd-;h\r basis2  7,c7 )  
respect to cont9u\s c>e = an individual1
 does n provide c>e ov] two or m        
consecutive midnights2  7,d7 does n     
provide any acute c>e inpati5t b$s & has
 protocols 9 place = ! timely transf] ( 
pati5ts :o require o!r inpati5t s]vices2
  7,e7 has ! res\rces requir$ ( a level 
,,iv or high] trauma c5t] 7z v]ifi$ by !
 ,am]ican ,college ( ,surgeons or o!r   
means specifi$ by ! ,secret>y71 or has  
available = consultation on a #bd-;h\r  
basis a heal? c>e pr(essional :o        
successfully complet$ ! ,advanc$ ,trauma
 ,life ,support ,c\rse (f]$ by !        
,am]ican ,college ( ,surgeons 7or an    
equival5t c\rse z det]m9$ by !          
,secret>y7 )9 ! prec$+ #d ye>s2  7,f7   
has 9 effect a transf] agreem5t ) a     
level ,i or level ,,ii trauma c5t]      
designat$ "u section #abca7a7 ( !       
,public ,heal? ,s]vice ,act2  7,g7 meets
 ! requirem5ts ( subsection             
7aa77#b77;,i72  7,h7 has be5 approv$ by 
! ,/ate 9 :i* ! facility is locat$ =    

treatm5t z a community outpati5t        
hospital2  7,i7 notifies ! ,secret>y at 
su* "t & 9 su* mann] z ! ,secret>y may  
require ( ! int5t ( su* facility to be  
designat$ z a community outpati5t       
facility2 &  7,j7 meets su* /aff tra9+ &
 c]tification requirem5ts z ! ,secret>y 
may require4  7#b7 ,no?+ 9 ?is          
subsection or section #ahcd7r7 %all be  
con/ru$ to prohibit a community         
outpati5t hospital f hav+ an agreem5t "u
 section #ahhc = ! provision ( ext5d$   
c>e s]vices4  7#c7 ,unless ! context    
o!rwise requires1 a ref]5ce to a        
community outpati5t hospital 9 ?is title
 %all be deem$ to also be a ref]5ce to a
 critical access hospital4  7jjj7       
,qualifi$ outpati5t s]vices ,! t]m      
qualifi$ outpati5t s]vices means m$ical 
& o!r heal? s]vices furni%$ on an       
outpati5t basis by a community outpati5t
 hospital1 rural heal? cl9ic 7z def9$ 9 
section #ahfa7;aa77#b771 f$]ally        
qualifi$ heal? c5t] 7z def9$ 9 section  
#ahfa7;aa77#d771 or an entity c]tifi$ by

 ! ,heal? ,res\rces & ,s]vices          
,adm9i/ration z a f$]ally qualifi$ heal?
 c5t] look-alike1 includ+1 = individuals
 :o require s]vices f a hospital or     
critical access hospital1 transportation
 s]vices f su* community outpati5t      
hospital to a hospital or critical      
access hospital4  4  7#b7 ,paym5t =     
qualifi$ outpati5t s]vices ,section     
#ahcd ( ! ,social ,security ,act 7#db   
,u4,s4,c4 #aciem7 is am5d$ by add+ at ! 
end ! foll[+3  7r7 ,paym5t = qualifi$   
outpati5t s]vices  7#a7 ,9 g5]al ,!     
am\nt ( paym5t = qualifi$ outpati5t     
s]vices is equal to #aje p]c5t ( !      
reasonable co/s ( provid+ su* s]vices4  
7#b7 ,teleheal? s]vices z reasonable    
co/s ,= purposes ( ?is subsection1 )    
respect to qualifi$ outpati5t s]vices1  
co/s reasonably associat$ ) hav+ a      
backup physician available via a        
telecommunications sy/em %all be        
consid]$ reasonable co/s4  4  7b7 ,waiv]
 ( di/ance requirem5t = replacem5t      
,c,a,hs2 subsequ5t r$esignation (       

community outpati5t 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+ 1    
subject to subp>agraph 7,f71 be=e is    
locat$2 &  7#b7 by add+ at ! end !      
foll[+3  7,f7 ,option to waive di/ance  
requirem5t ,! ,/ate may waive ! di/ance 
requirem5t describ$ 9 subp>agraph       
7,b77i77,i7 ) respect to a facility     
locat$ 9 ! ,/ate t is seek+ designation 
z a critical access hospital "u ?is     
p>agraph if ! total numb] ( waiv]s = su*
 facilities does n exce$ ! numb] (      
facilities t are critical access        
hospitals )\t su* a waiv]4  7,g7        
,r$esignation ( a critical access       
hospital z a community outpati5t        
hospital ,a community outpati5t hospital
 may elect to be r$esignat$ z a         
community outpati5t hospital by notify+ 
! ,secret>y at ! same "t & 9 ! same     
mann] z notifications "u section        
#ahfa7;iii77#a77;,i7 if su* community   

outpati5t hospital--  7i7 meets !       
requirem5ts 9 p>agraphs 7#a7 & 7#c7 (   
section #ahbj7;e72 &  7ii7 0 designat$ z
 a critical access hospital "u ?is      
p>agraph on ! date t ! ,secret>y fir/   
consid]$ su* community outpati5t        
hospital to be a community outpati5t    
hospital4  4  7c7 ,con=m+ am5dm5ts  7#a7
 ,reasonable co/ = ,c,o,hs ,section     
#ahfa7v77#g7 ( ! ,social ,security ,act 
7#db ,u4,s4,c4 #aciex7v77#g77 is am5d$  
by add+ at ! end ! foll[+3  7,e7 ,=     
additional items includ$ 9 reasonable   
co/ = community outpati5t hospitals & = 
det]m9ation ( paym5t am\nts = qualifi$  
outpati5t s]vices1 see section #ahcd7r74
  4  7#b7 ,c,o,hs z cov]$ s]vices       
,section #ahcb7;a77#b77;,h7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4           
#aciek7a77#b77;,h77 is am5d$ by ins]t+ &
 qualifi$ outpati5t s]vices 7z def9$ 9  
section #ahfa7;iii77#b77 be=e !         
semicolon4  7#c7 ,,coh paym5ts ,section 
#ahcc7;a7 ( ! ,social ,security ,act    
7#db ,u4,s4,c4 #aciel7a77 is am5d$--    

7,a7 9 p>agraph 7#h71 by /rik+ 2 &2     
7,b7 9 p>agraph 7#i71 by /rik+ ! p]iod  
at ! end & ins]t+ 2 &2 &  7,c7 by ins]t+
 aft] p>agraph 7#i7 ! foll[+3  7#aj7 9 !
 case ( qualifi$ outpati5t s]vices1 !   
am\nts describ$ 9 section #ahcd7r74  4  
7#d7 ,effective date ,! am5dm5ts made by
 ?is subsection %all apply to items &   
s]vices furni%$ on or aft] ! fir/ day ( 
! fir/ cal5d> ye> beg9n+ m ?an #a ye>   
aft] ! date ( ! enactm5t ( ?is ,act4    
7d7 ,reports ,! ,secret>y ( ,heal? &    
,human ,s]vices %all submit to ,congress
 ?ree reports on ! impact ( community   
outpati5t 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
 #acieww7d77#b77;,d777 z foll[s3  7#a7  
,initial report ,an initial report      
approximately #b ye>s aft] ! date ( !   
enactm5t ( ?is ,act4  7#b7 ,int]im      
report ,an int]im report approximately  
#e ye>s aft] ! date ( ! enactm5t ( ?is  
,act4  7#c7 ,f9al report ,a f9al report 

approximately #aj ye>s aft] ! date ( !  
enactm5t ( ?is ,act4  #djb4 ,grant fund+
 to assi/ rural hospitals ,section      
#ccj;,a ( ! ,public ,heal? ,s]vice ,act 
7#db ,u4,s4,c4 #bed;c7 is am5d$--  7#a7 
9 subsection 7b7-- 7,a7 9 p>agraph 7#a71
 by /rik+ ,director specifi$ 9          
subsection 7d7 & ins]t+ ,director ( !   
,(fice ( ,rural ,heal? ,policy ( !      
,heal? ,res\rces & ,s]vices             
,adm9i/ration2 &  7,b7 by add+ at ! end 
! foll[+3  7#f7 ,eligible rural hospital
 ,! t]m eligible rural hospital means-- 
7,a7 a hospital 7z def9$ 9 section      
#ahfa7;e7 ( ! ,social ,security ,act7   
t-- 7i7 has few] ?an #ej b$s2 &  7ii7 is
 locat$ 9 a rural area 7z def9$ 9       
section #ahhf7;d77#b77;,d7 ( su* ,act7  
or treat$ z be+ locat$ 9 a rural area   
pursuant to section #ahhf7;d77#h77;,e7 (
 su* ,act2  7,b7 a community outpati5t  
hospital 7z def9$ 9 section #ahfa7;iii7 
( su* ,act72 or  7,c7 a critical access 
hospital 7z def9$ 9 section #ahfa7mm7 ( 
su* ,act74  2 &  7#b7 by add+ at ! end !

 foll[+3  7i7 ,quality improvem5t &     
compliance grants = eligible rural      
hospitals  7#a7 ,grants ,! ,director may
 aw>d grants to eligible rural hospitals
 to assi/ su* hospitals ) report+ on    
quality & to prep>e su* hospitals to    
transition to value-bas$ reimbursem5t4  
7#b7 ,applications ,to be eligible to   
receive a grant "u ?is subsection1 an   
eligible rural hospital %all prep>e &   
submit to ! ,secret>y an application1 at
 su* "t1 9 su* mann]1 & conta9+ su*     
in=mation z ! ,secret>y may require1    
includ+ a description (--  7,a7 h[ !    
eligible rural hospital w use ! funds   
provid$ "u ! grant2 &  7,b7 h[ ! project
 w be evaluat$4  7#c7 ,au?orization (   
appropriations ,!re is au?oriz$ to be   
appropriat$ = ea* fiscal ye> 7beg9n+ )  
fiscal ye> #bjai7 #ab1jjj1jjj to c>ry   
out ?is subsection4  7j7 ,outrea* grants
 = rural hospital population heal?  7#a7
 ,grants ,to help eligible rural        
hospitals meet a specific community ne$ 
id5tifi$ 9 a community ne$s assessm5t1 !

 ,director may aw>d grants to eligible  
rural hospitals4  7#b7 ,limitation on   
size ( grants to ,c,o,hs ,! ,secret>y   
may n aw>d m ?an #fej1jjj ea* fiscal ye>
 to a community outpati5t hospital t is 
describ$ 9 subsection 7b77#f77;,b74     
7#c7 ,applications ,to be eligible to   
receive a grant "u ?is subsection1 an   
eligible rural hospital %all prep>e &   
submit to ! ,secret>y an application1 at
 su* "t1 9 su* mann]1 & conta9+ su*     
in=mation z ! ,secret>y may require1    
includ+--  7,a7 a description ( h[ !    
eligible rural hospital w use ! funds   
provid$ "u ! grant2  7,b7 ! results (   
community ne$s assessm5t t id5tifi$ !   
specific community ne$ describ$ 9       
p>agraph 7#a72 &  7,c7 a description (  
h[ ! project w be evaluat$4  7#d7       
,au?orization ( appropriations ,!re is  
au?oriz$ to be appropriat$ = ea* fiscal 
ye> 7beg9n+ ) fiscal ye> #bjai7--  7,a7 
#ae1jjj1jjj = grants to eligible rural  
hospitals describ$ 9 subp>agraphs 7,a7 &
 7,c7 ( subsection 7b77#f72 &  7,b7     

#ej1jjj1jjj = grants to eligible rural  
hospitals describ$ 9 subp>agraph 7,b7 ( 
su* subsection4  7k7 ,,ems ,grant ,fund+
  7#a7 ,grants ,! ,director may aw>d    
grants to eligible rural hospitals to   
develop & implem5t /rategies to develop 
successful em]g5cy m$ical s]vices       
programs t meet community ne$s1 provide 
quality c>e1 & address work=ce & fund+  
problems4  7#b7 ,applications ,to be    
eligible to receive a grant "u ?is      
subsection1 an eligible rural hospital  
%all prep>e & submit to ! ,secret>y an  
application1 at su* "t1 9 su* mann]1 &  
conta9+ su* in=mation z ! ,secret>y may 
require1 includ+ a description (--  7,a7
 h[ ! eligible rural hospital w use !   
funds provid$ "u ! grant2  7,b7 any     
multi/ate collaborations involv$ 9 us+  
su* funds2 &  7,c7 h[ ! use ( funds w be
 evaluat$4  7#c7 ,au?orization (        
appropriations ,!re is au?oriz$ to be   
appropriat$ = ea* fiscal ye> 7beg9n+ )  
fiscal ye> #bjai7 #b1jjj1jjj to c>ry out
 ?is subsection4  4  #djc4 ,,cmmi       

demon/ration ( %>$ sav+s 9 rural        
hospitals ,section #aaae;,a7b77#b77;,b7 
( ! ,social ,security ,act 7#db         
,u4,s4,c4 #acae;a7b77#b77;,b77 is am5d$ 
by add+ at ! end ! foll[+3  7xxv7       
,promot+ great] %>$ sav+s ) hospitals   
locat$ 9 rural areas1 ) critical access 
hospitals 7z def9$ 9 section            
#ahfa7mm77#a771 & ) community outpati5t 
hospitals 7z def9$ 9 section            
#ahfa7;iii77#a774  4