,,ii  #aaeth ,,congress  #ast ,session  
,s4 #aacj  ,,in ,,the ,,senate ,,of     
,,the ,,united ,,states  ,may #af1      
#bjag,mr4 ,grassley 7for himself1 ,ms4  
,klobuchar1 and ,mr4 ,gardner7          
introduced the following bill2 which was
 read twice and referred to the         
,committee on ,finance  ,a ,,bill  ,to  
amend title ,,xviii of the ,social      
,security ,act to create a sustainable  
future for rural healthcare4  #a4 ,short
 title ,this ,act may be cited as the   
,rural ,emergency ,acute ,care ,hospital
 ,act4  #b4 ,findings ,congress finds   
the following3 7#a7 ,according to the   
,university of ,north ,carolina's       
,center for ,health ,services ,research1
 #ee rural hospitals have closed in the 
,unites ,states since ,january #bjaj4   
7#b7 ,in #bjad1 i,vantage conducted a   
study for the ,national ,rural ,health  
,association and found #bhc hospitals at
 risk of closure based upon performance 
indicators that matched those facilities
 already forced to close in this decade4

  7#c7 ,researchers at the ,university  
of ,north ,carolina identified inpatient
 volume as a substantial contributing   
factor to the financial performance of  
rural hospitals1 with many of the       
at-risk hospitals having an average     
daily bed census of less than two4  7#d7
 ,adverse impacts to the local economy  
and the loss of timely access to        
emergency medical care are #b major     
effects of rural hospital closures4     
7#e7 ,according to the ,national ,center
 for ,rural ,health ,works1 the typical 
rural hospital creates over #adj jobs   
and generates #f1hjj1jjj in compensation
 while serving an average population of 
#ad1fjj4  7#f7 ,the #bjad i,vantage     
study estimates that the #bhc at-risk   
hospitals could result in the loss of   
#cf1jjj health care jobs1 #ej1jjj       
community jobs1 and #aj1fjj1jjj1jjj in  
gross domestic product4  7#g7 ,time is  
the most critical factor for achieving  
successful outcomes in emergency        
medicine1 and emergency medical         

clinicians refer to the time-sensitive  
period during which successful outcomes 
may be best achieved as the golden hour4
  7#h7 ,the ,national ,conference of    
,state ,legislatures states that #fj    
percent of trauma deaths in the ,united 
,states occur in rural areas1 where only
 #ae percent of the population is       
represented4  7#i7 ,the disproportionate
 percentage of trauma deaths in rural   
areas is likely attributable in large   
part to a combination of response time  
to the scene and distance to the nearest
 emergency room to stabilize trauma     
victims4  7#aj7 ,the percentage of      
trauma deaths occurring in rural areas  
could continue to increase as more rural
 hospitals close1 further limiting      
access to emergency services and        
requiring patients to travel longer     
distances to receive emergency medical  
care4  7#aa7 ,the creation of a rural   
emergency hospital designation under the
 ,medicare program will allow facilities
 in rural areas to provide emergency    

medical services without having to      
maintain inpatient beds4  7#ab7 ,in     
addition to providing emergency care1   
rural emergency hospitals could convert 
the space previously used for inpatient 
services to provide other medical       
services including1 but not limited to1 
observation care1 skilled nursing       
facility care1 infusion services1       
hemodialysis1 home health1 hospice1     
nursing home care1 population health1   
and telemedicine services4  #c4 ,rural  
emergency hospital program  7a7 ,in     
general  7#a7 ,rural emergency hospital 
and services defined ,section #ahfa of  
the ,social ,security ,act 7#db         
,u4,s4,c4 #aciex7 is amended-- 7,a7 in  
subsection 7e71 in the last sentence of 
the matter following paragraph 7#i71 by 
inserting or a rural emergency hospital 
7as defined in section #ahfa7;jjj77#a77 
before the period at the end2 and  7,b7 
by adding at the end the following      
subsection3  7jjj7 ,rural ,emergency    
,hospital2 ,rural ,emergency ,hospital  

,outpatient ,services  7#a7 ,the term   
rural emergency hospital means a        
facility that-- 7,a7 7i7 as of ,december
 #ca1 #bjaf--  7,i7 was a critical      
access hospital2 or  7,,ii7 was a       
hospital with not more than #ej beds    
located in a county 7or equivalent unit 
of local government7 in a rural area 7as
 defined in section #ahhf7;d77#b77;,d771
 or was a hospital with not more than   
#ej beds that was treated as being      
located in a rural area pursuant to     
section #ahhf7;d77#h77;,e72 or  7ii7 was
 a critical access hospital described in
 clause 7i77,i7 or a hospital described 
in clause 7i77,,ii7 that ceased         
operations during the period beginning  
on the date that is #e years prior to   
the date of the enactment of this       
subsection and ending on ,december #cj1 
#bjaf2  7,b7 provides #bd-;hour         
emergency medical care and observation  
care that does not exceed an annual per 
patient average of #bd hours or more    
than #a midnight2  7,c7 does not provide

 any acute care inpatient beds and has  
protocols in place for the timely       
transfer of patients who require acute  
care inpatient services or other        
inpatient services2  7,d7 has elected to
 be designated as a rural emergency     
hospital2  7,e7 has received approval to
 operate as a rural emergency hospital  
from the ,state under section           
#ahcd7v77#c77;,a72 and  7,f7 is         
certified by the ,secretary under       
section #ahcd7v77#c77;,b74  7#b7 ,the   
term rural emergency hospital outpatient
 services means medical and other health
 services furnished by a rural emergency
 hospital on an outpatient basis4  7#c7 
,nothing in this subsection or section  
#ahcd7v77#c7 shall be construed to      
prohibit a rural emergency hospital from
 providing extended care services4  4   
7#b7 ,payment for rural emergency       
hospital services  7,a7 ,in general     
,section #ahcc7;a7 of the ,social       
,security ,act 7#db ,u4,s4,c4 #aciel7a77
 is amended-- 7i7 in paragraph 7#h71 by 

striking and at the end2  7ii7 in       
paragraph 7#i71 by striking the period  
at the end and inserting 2 and2 and     
7iii7 by inserting after paragraph 7#i7 
the following new paragraph3  7#aj7 in  
the case of rural emergency hospital    
emergency services and services provided
 by a rural emergency hospital or other 
provider of ambulance services to       
transport patients who require acute    
care inpatient services or other        
inpatient services from such rural      
emergency hospital to a hospital or     
critical access hospital1 the amounts   
described in section #ahcd7v74  4  7,b7 
,payment amount ,section #ahcd of the   
,social ,security ,act 7#db ,u4,s4,c4   
#aciem7 is amended by adding at the end 
the following subsection3  7v7 ,payment 
rules relating to rural emergency       
hospitals  7#a7 ,payment for rural      
emergency hospital outpatient services  
7,a7 ,in general ,the amount of payment 
for rural emergency hospital outpatient 
services of a rural emergency hospital  

is equal to #aaj percent of the         
reasonable costs of providing such      
services4  7,b7 ,telehealth services    
,for purposes of this paragraph1 in     
determining the reasonable costs of     
providing rural emergency hospital      
outpatient services1 costs associated   
with having a backup physician available
 via a telecommunications system shall  
be considered reasonable costs4  7#b7   
,payment for transportation services    
,the amount of payment for services     
provided by a rural emergency hospital  
or other provider of ambulance services 
to transport patients who require acute 
care inpatient services or other        
inpatient services from such rural      
emergency hospital to a hospital or     
critical access hospital is equal to    
#aaj percent of the reasonable costs of 
providing such services4  7#c7          
,requirements for rural emergency       
hospitals  7,a7 ,state approval to      
operate as a rural emergency hospital   
,no payment shall be made under this    

subsection to a facility1 or to a       
provider of ambulance services providing
 transportation services from such      
facility1 unless the ,state in which the
 facility is located has approved the   
facility's designation as a rural       
emergency hospital4  7,b7 ,certification
 of rural emergency hospital  7i7 ,in   
general ,no payment shall be made under 
this subsection to a facility1 or to a  
provider of ambulance services providing
 transportation services from such      
facility1 unless the facility has been  
certified by the ,secretary as a rural  
emergency hospital4  7ii7 ,certification
 requirements ,the ,secretary shall     
certify a facility as a rural emergency 
hospital if the facility-- 7,i7 meets   
the criteria for rural emergency        
hospitals described in subparagraphs    
7,a7 through 7,e7 of section            
#ahfa7;jjj77#a72  7,,ii7 either-- 7aa7  
is verified by the ,american ,college of
 ,surgeons or a ,state as having the    
resources required of a level ,,iv      

trauma center or higher2 or  7bb7       
employs healthcare professionals that   
successfully completed within the       
preceding #d years-- 7,,aa7 the         
,advanced ,trauma ,life ,support ,course
 offered by the ,american ,college of   
,surgeons2 or 7,,bb7 another trauma     
training program for healthcare         
professionals that is accepted by a     
,state trauma system for certification  
purposes2  7,,iii7 has in effect a      
transfer agreement with a level ,i or   
level ,,ii trauma center2 and  7,,iv7   
meets such staff training and           
certification requirements as the       
,secretary may require4  7#d7           
,coinsurance  7,a7 ,in general ,the     
amount of payment for rural emergency   
hospital services or transportation     
services made to a rural emergency      
hospital or other provider of ambulance 
services under this subsection shall be 
reduced by the coinsurance amount       
described in subparagraph 7,b74  7,b7   
,coinsurance amount ,the coinsurance    

amount described in this subparagraph1  
with respect to an item or service      
provided by a rural emergency hospital  
or provider of ambulance services1 shall
 be calculated in the same manner as the
 coinsurance amount for an outpatient   
critical access hospital service is     
calculated under section #ahff7;a77#b74 
4  7b7 ,waiver of distance requirement  
for replacement ,c,a,hs2 subsequent     
redesignation of rural emergency        
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 subject to    
subparagraph 7,f71 before is located2   
and  7#b7 by adding at the end the      
following new subparagraphs3  7,f7      
,option to waive distance requirement   
,beginning on the date of the enactment 
of this subparagraph1 for every critical
 access hospital located in a ,state    
that is certified as a rural emergency  
hospital under section                  

#ahcd7v77#c77;,b71 the ,state shall have
 the option of waiving the distance     
requirement described in subparagraph   
7,b77i77,i7 with respect to another     
facility located in the ,state that is  
seeking designation as a critical access
 hospital under this paragraph4  7,g7   
,redesignation of a rural emergency     
hospital as a critical access hospital  
,a rural emergency hospital that was    
previously designated as a critical     
access hospital under this paragraph may
 elect to be redesignated as a critical 
access hospital 7in the same manner that
 the hospital was originally designated 
as a critical access hospital7 at any   
time1 subject to such conditions as the 
,secretary may establish4  4  7c7       
,studies and reports  7#a7 ,studies ,the
 ,secretary of ,health  ,human ,services
 shall conduct #c studies to evaluate   
the impact of rural emergency 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;,d7774 ,the   
,secretary shall conduct a study--  7,a7
 #b years after the date of the         
enactment of this ,act2  7,b7 #e years  
after the date of the enactment of this 
,act2 and  7,c7 #aj years after the date
 of the enactment of this ,act4  7#b7   
,reports ,not later than #f months after
 each date that the ,secretary of       
,health  ,human ,services is required to
 conduct a study under paragraph 7#a71  
the ,secretary shall submit a report to 
,congress containing the results of each
 such study4  7d7 ,effective date ,the  
amendments made by this section shall   
apply to items and services furnished on
 or after the date that is #a year after
 the date of the enactment of this ,act4
  #d4 ,inclusion of emergency medicine  
as health services under the ,national  
,health ,service ,corps ,section        
#cca7;a77#c77;,d7 of the ,public ,health
 ,service ,act 7#db ,u4,s4,c4           
#bed;d7a77#c77;,d77 is amended by       

inserting 1 and includes emergency      
medicine provided by physicians in a    
rural emergency hospital 7as defined in 
section #ahfa7;jjj7 of the ,social      
,security ,act7 before the period4  #e4 
,permitting hospitals with approved     
residency programs in emergency medicine
 to include time spent by interns and   
residents in the emergency department of
 a rural hospital in full-time          
equivalent count  7a7 ,indirect medical 
education ,section                      
#ahhf7;d77#e77;,b77iv7 of the ,social   
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#e77;,b77iv77 is amended by  
adding at the end the following new     
subclause3  7,,iii7 ,effective for      
discharges occurring on or after        
,october #a1 #bjag1 all of the time     
spent in patient care activities in the 
emergency department of a rural hospital
 by interns and residents in emergency  
medicine from a hospital with an        
approved medical residency training     
program 7as defined in subsection       

7h77#e77;,a77 in such specialty shall be
 included in determining the number of  
full-time equivalent interns and        
residents in such program if the        
hospital with such program incurs the   
costs of the stipends and fringe        
benefits of the interns or residents    
during the time the interns or residents
 spend in that rural hospital in        
accordance with subclause 7,,ii74 ,in   
this subclause1 the term rural hospital 
means a hospital that is located in a   
rural area 7as defined for purposes of  
paragraph 7#b77;,d774  4  7b7 ,direct   
medical education ,section              
#ahhf7;h77#d77;,e7 of the ,social       
,security ,act 7#db ,u4,s4,c4           
#acie7;h77#d77;,e77 is amended-- 7#a7 in
 clause 7ii71 by striking the period at 
the end and inserting 2 and2  7#b7 by   
inserting after clause 7ii7 the         
following new clause3  7iii7 effective  
for cost reporting periods beginning on 
or after ,july #a1 #bjag1 all of the    
time so spent in the emergency          

department of a rural hospital by       
residents in emergency medicine from a  
hospital with an approved medical       
residency training program in such      
specialty shall be counted towards the  
determination of full-time equivalency  
in such program if the hospital with    
such program bears all1 or substantially
 all1 of the costs of training such     
residents in the rural hospital4 ,in    
this subparagraph1 the term rural       
hospital means a hospital that is       
located in a rural area 7as defined for 
purposes of subsection 7d77#b77;,d774  2
 and  7#c7 by adding at the end the     
following new sentence3 ,for purposes of
 this subparagraph1 the emergency       
department of a rural hospital described
 in clause 7iii7 is a nonprovider       
setting44