,i  #aae? ,,congress  #b;d ,session  ,h4
 ,r4 #efgh  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,may #g1 #bjah,ms4    
,j5k9s ( ,kansas 7= h]self1 ,mr4 ,k9d1 &
 ,ms4 ,sewell ( ,alabama7 introduc$ !   
foll[+ bill2 :i* 0 ref]r$ to !          
,committee on ,ways & ,means1 & 9       
addition to ! ,committee on ,en]gy &    
,comm]ce1 = 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 title ,,xviii ( !     
,social ,security ,act to provide =     
cov]age ( rural em]g5cy m$ical c5t]     
s]vices "u ! ,m$ic>e program1 & = o!r   
purposes4  #a4 ,%ort title ,?is ,act may
 be cit$ z ! ,rural ,em]g5cy ,m$ical    
,c5t] ,act ( #bjah or ! ,,remc ,act (   
#bjah4  #b4 ,m$ic>e rural em]g5cy m$ical
 c5t]s & s]vices  7a7 ,9 g5]al  7#a7    
,rural em]g5cy m$ical c5t] & 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 m$ical c5t]
 7z def9$ 9 subsection 7jjj77#a77 be=e !
 p]iod at ! end2 &  7,b7 by add+ at !   
end ! foll[+ subsection3  7jjj7 ,rural  
,em]g5cy ,m$ical ,c5t]2 ,rural ,em]g5cy 
,m$ical ,c5t] ,s]vices  7#a7 ,! t]m     
rural em]g5cy m$ical c5t] means a       
facility t-- 7,a7 7i7 z ( ! date ( !    
enactm5t ( ?is subsection--  7,i7 0 a   
critical access hospital2 or  7,,ii7 0 a
 hospital ) n m ?an #ej b$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 ! date ( ! enactm5t
 ( ?is subsection2  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 may include a unit ( ! facility t  
is lic5s$ z a di/9ct "p skill$ nurs+    
facility2  7,d7 does n provide any acute
 c>e inpati5t b$s & has protocols 9     
place = ! timely transf] ( pati5ts :o   
require acute c>e inpati5t s]vices or   
o!r inpati5t s]vices2  7,e7 provides = !
 transport ( pati5ts :o require acute   
c>e inpati5t s]vices or o!r inpati5t    
s]vices f ! rural em]g5cy m$ical c5t] to
 a hospital or critical access hospital1
 ei!r by ! rural em]g5cy m$ical c5t]'s  
ambulance s]vice provid] or ?r\gh ano!r 
ambulance s]vice suppli]2  7,f7 has     
elect$ to be designat$ z a rural em]g5cy
 m$ical c5t]2  7,g7 has be5 lic5s$ by1  
or receiv$ approval to op]ate z a       
qualifi$ em]g5cy m$ical c5t] f1 ! ,/ate 
"u p>agraph 7#c72 &  7,h7 is c]tifi$ by 
! ,secret>y "u p>agraph 7#d74  7#b7 7,a7
 ,! t]m rural em]g5cy m$ical c5t]       
s]vices means m$ical & o!r heal? s]vices

 furni%$ by a rural em]g5cy m$ical c5t] 
on an outpati5t basis4  7,b7 ,su* t]m   
%all include ext5d$ c>e s]vices 7z def9$
 9 subsection 7h77 subject to su*       
requirem5ts z ! ,secret>y may specify4  
7#c7 ,a facility may n op]ate z a rural 
em]g5cy m$ical c5t] unless ! facility-- 
7,a7 is locat$ 9 a ,/ate t provides = ! 
lic5s+ ( em]g5cy m$ical c5t]s "u ,/ate  
or applicable local law2 &  7,b7  7i7 is
 lic5s$ pursuant to su* law2 or  7ii7 is
 approv$ by ! ag5cy ( su* ,/ate or      
locality responsible = lic5s+ hospitals1
 z meet+ ! /&>ds e/abli%$ = su* lic5s+4 
7#d7 ,! ,secret>y %all c]tify a facility
 z a rural em]g5cy m$ical c5t] if !     
facility-- 7,a7 meets ! crit]ia = rural 
em]g5cy m$ical c5t] describ$ 9          
subp>agraphs 7,a7 ?r\gh 7,g7 ( p>agraph 
7#a72  7,b7 has 9 effect a transf]      
agreem5t ) a level ,i or level ,,ii     
trauma c5t]2 &  7,c7 meets su* /aff     
tra9+ & c]tification requirem5ts z !    
,secret>y may require4  7#e7 ,a facility
 c]tifi$ by ! ,secret>y z a rural       

em]g5cy m$ical c5t] %all be deem$ to be 
a critical access hospital = purposes ( 
section #bef;b ( title #db1 ,unit$      
,/ates ,code4  4  7#b7 ,paym5t = rural  
em]g5cy m$ical c5t] s]vices  7,a7 ,9    
g5]al ,section #ahcc7;a7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4 #aciel7a77
 is am5d$-- 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 m$ical c5t] s]vices1      
s]vices provid$ by a rural em]g5cy      
m$ical c5t] ambulance s]vice provid] or 
ano!r ambulance s]vice suppli] to       
transport pati5ts :o require acute c>e  
inpati5t s]vices or o!r inpati5t s]vices
 f su* rural em]g5cy m$ical c5t] to a   
hospital or critical access hospital1 & 
ext5d$ c>e s]vices furni%$ by a rural   
em]g5cy m$ical c5t]1 ! am\nts describ$ 9
 section #ahcd7w74  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  7w7 ,paym5t rules relat+ to
 rural em]g5cy m$ical c5t]s  7#a7       
,paym5t = rural em]g5cy m$ical c5t]     
outpati5t s]vices ,! am\nt ( paym5t =   
rural em]g5cy m$ical c5t] s]vices ( a   
rural em]g5cy m$ical c5t] is det]m9$ z  
foll[s3  7,a7 ,facility fee ,) respect  
to facility s]vices 7o!r ?an s]vices =  
:i* paym5t is made "u subp>agraph 7,b771
 ! sum ( ! foll[+3  7i7 ,,opps rate ,!  
am\nt ( paym5t t w\ld o!rwise apply "u  
section #ahcc7t7 = cov]$ ,,opd s]vices  
7z def9$ 9 section #ahcc7t77#a77;,b7    
7o!r ?an clause 7ii7 ( su* section774   
7ii7 ,additional fee ,an additional     
facility paym5t 9 an am\nt det]m9$      
appropriate by ! ,secret>y t acc\nts = !
 fix$ co/s ( ! rural em]g5cy m$ical c5t]
 9 furni%+ rural em]g5cy m$ical c5t]    
s]vices & ! l[ volume ( s]vices provid$ 
by su* c5t]4  7,b7 ,pr(essional s]vices 
,) respect to pr(essional s]vices1 !    
am\nt ( paym5t t w\ld o!rwise be made "u
 ?is "p 7o!r ?an "u section             

#ahcc7t77#ba77 = su* s]vices4  7#b7     
,paym5t = transportation s]vices ,!     
am\nt ( paym5t = s]vices provid$ by a   
rural em]g5cy m$ical c5t] ambulance     
s]vice provid] or ano!r ambulance s]vice
 suppli] to transport pati5ts :o require
 acute c>e inpati5t s]vices or o!r      
inpati5t s]vices f su* rural em]g5cy    
m$ical c5t] to a hospital or critical   
access hospital is equal to #aje p]c5t (
 ! am\nt o!rwise payable = su* s]vices 9
 su* area "u section #ahcd7l74  7#c7    
,paym5t = ext5d$ c>e s]vices ,! am\nt ( 
paym5t = ext5d$ c>e s]vices furni%$ by a
 rural em]g5cy m$ical c5t] t is lic5s$ &
 approv$ to furni% su* ext5d$ c>e       
s]vices is equal to #aaj p]c5t ( ! am\nt
 ( paym5t t w\ld o!rwise be made = cov]$
 skill$ nurs+ facility s]vices "u       
section #ahhh7;e7 = ! ye> involv$ )\t   
reg>d to section #ahhh7;h74  4  7b7     
,conditions ( p>ticipation ,section     
#ahff7;a77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie;cc7a77#a77 is     
am5d$-- 7#a7 9 subp>agraph 7,x71 by     

/rik+ at ! end &2  7#b7 9 ! subp>agraph 
7,y71 by /rik+ at ! end ! p]iod & ins]t+
 a comma2 &  7#c7 by ins]t+ aft]        
subp>agraph 7,y7 ! foll[+ new           
subp>agraph3  7,z7 9 ! case ( a rural   
em]g5cy m$ical c5t]1 to meet requirem5ts
 applicable to critical access hospitals
 "u ?is title1 o!r ?an--  7i7           
requirem5ts relat+ to a ,m$ic>e rural   
hospital flexibility program "u section 
#ahbj7;c71 includ+ /ate designation ( a 
facility z a critical access hospital & 
crit]ia = su* designation "u p>agraph   
7#b7 ( su* section2  7ii7 requirem5ts   
relat+ to critical access hospitals &   
rural heal? networks "u section         
#ahbj7;d72  7iii7 c]tification by !     
,secret>y z a critical access hospital  
"u section #ahbj7;e72  7iv7 requirem5ts 
relat+ to ! provision ( inpati5t        
hospital s]vices or acute c>e b$s by a  
hospital or critical access hospital "u 
?is section1 includ+ "u--  7,i7 p>agraph
 7#a77;,g7 ( ?is subsection 7relat+ to  
c]ta9 paym5t re/rictions = inpati5t     

hospital s]vices72 &  7,,ii7 p>agraph   
7#a77,t7 ( ?is subsection 7relat+ to    
data submission requirem5ts = inpati5t  
hospital s]vices = purposes ( !         
l[-volume adju/m5t72 &  7v7 su* o!rs    
provisions ( law or regulation1 includ+ 
provisions "u ,"p ,b & ,"p ,e1 z !      
,secret>y may specify4  4  7c7 ,treatm5t
 z teleheal? orig9at+ site ,section     
#ahcd7m77#d77;,c77ii7 ( ! ,social       
,security ,act 7#db ,u4,s4,c4           
#aciem7m77#d77;,c77ii77 is am5d$ by add+
 at ! end ! foll[+ new subclause3       
7,,ix7 ,a rural em]g5cy m$ical c5t] 7z  
def9$ 9 section #ahfa7;jjj77#a774  4    
7d7 ,waiv] ( di/ance requirem5t =       
replacem5t ,c,a,hs2 subsequ5t           
r$esignation ( rural em]g5cy m$ical c5t]
 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    
m$ical c5t] "u section #ahfa7;jjj77#d71 
! ,/ate %all h ! option ( waiv+ !       
di/ance requirem5t describ$ 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$esignation ( a rural em]g5cy m$ical  
c5t] z a critical access hospital ,a    
rural em]g5cy m$ical c5t] t 0 previ\sly 
designat$ 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  7e7 ,con=m+
 am5dm5t ,section #ahfa7u7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4 #aciex7u77
 is am5d$ by ins]t+ rural em]g5cy m$ical
 c5t]1 aft] critical access hospital14  

7f7 ,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