,,ii  #aaf? ,,congress  #a/ ,session    
,s4 #baeg  ,,9 ,,! ,,s5ate ,,( ,,!      
,,unit$ ,,/ates  ,july #ah1 #bjai,mr4   
,casey introduc$ ! foll[+ bill2 :i* 0   
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d title ,,xi 
( ! ,social ,security ,act to exp& ! use
 ( global paym5ts to hospitals 9 rural  
areas4  #a4 ,%ort title ,?is ,act may be
 cit$ z ! ,rural ,hospital ,su/a9ability
 ,act4  #b4 ,f9d+s ,congress makes !    
foll[+ f9d+s3 7#a7 ,approximately       
#aj1jjj1jjj individuals age #fe & old]  
live 9 rural ,am]ica today4 ,9 fact1 #a 
out ( e #d old] adults lives 9 a small  
t[n or o!r rural area4  7#b7 ,resid5ts (
 rural areas are m likely to be poor]1  
sick]1 & h l[] incomes comp>$ to _!     
urban c\nt]p>ts4  7#c7 ,accord+ to !    
,(fice ( ,rural ,heal? ,policy1 f #bjje 
to #bjji1 p liv+ 9 rural areas _h an    
av]age life expectancy ( #gf4h ye>s1 a  
full two ye>s less ?an _! urban         
c\nt]p>ts :o _h an av]age life          
expectancy ( #gh4h ye>s4  7#d7 ,_m rural

 hospitals are locat$ 9 areas :]e a     
majority ( ! population is age #fe &    
old] & has ,m$ic>e cov]age4  7#e7 ,c]ta9
 ,/ate-bas$ demon/rations to improve    
paym5t models = rural hospitals %[      
promise 9 improv+ heal?c>e1 r$uc+ co/s1 
& integrat+ s]vices = pati5ts4  7#f7    
,exp]ts & organizations sugge/ t        
transition+ rural hospitals to global   
paym5t sy/ems w\ld b5efit pati5ts1      
provid]s1 & rural communities4  #c4     
,exp&+ ! use ( global paym5ts to        
hospitals 9 rural areas ,section        
#aaae;,a7b77#b7 ( ! ,social ,security   
,act 7#db ,u4,s4,c4 #acae;a7b77#b77 is  
am5d$-- 7#a7 9 subp>agraph 7,b71 by add+
 at ! end ! foll[+ new clause3  7xxviii7
 ,national te/+ ( a model = global      
paym5ts to hospitals 9 rural areas z    
describ$ 9 subp>agraph 7,d74  2 &  7#b7 
by add+ at ! end ! foll[+ new           
subp>agraph3  7,d7 ,national te/+ (     
model = global paym5ts to hospitals 9   
rural areas ,9 ! case :]e ! ,secret>y   
selects ! model describ$ 9 clause 7ii7 (

 ?is subp>agraph = te/+ pursuant to     
clause 7xxviii7 ( subp>agraph 7,b71 !   
foll[+ %all apply3  7i7 ,national te/+  
7,i7 ,9 g5]al ,subject to subclause     
7,,ii71 ! ,secret>y %all all[ ea* ,/ate 
to develop & submit to ! ,secret>y an   
application to beg9 te/+ su* model 9    
accordance ) ?is clause )9 #a ye> ( !   
date on :i* ! model is select$ = su*    
te/+4  7,,ii7 ,/ate designation (       
entities ,a ,/ate may designate an      
entity or organization = purposes (     
develop+ & submitt+ an application "u   
subclause 7,i7 ) respect to ! ,/ate1 :i*
 may include ! implem5tation ( su* model
 9 ! ,/ate4 ,9 ! case :]e a ,/ate makes 
su* a designation1 ) respect to any     
activities cov]$ by ! designation1 !    
entity or organization s designat$ %all 
be subject to any requirem5ts applicable
 to ! implem5t+ ,/ate "u ?is subp>agraph
 9 ! same mann] z su* requirem5ts are   
applicable to ! implem5t+ ,/ate4        
7,,iii7 ,no effect on ongo+ models or   
demon/ration projects ,no?+ 9 ?is       

subp>agraph %all effect ! te/+ ( any    
model "u ?is subsection or any          
demon/ration project "u ?is ,act t is   
implem5t$ prior to ! date ( ! enactm5t (
 ?is subp>agraph4  7ii7 ,model describ$ 
,! model describ$ 9 ?is clause seeks to 
increase rural ,am]icans' access to     
quality c>e 9 ord] to improve heal?1    
:ile also r$uc+ ! gr[? ( hospital       
exp5ditures across pay]s1 includ+       
,m$ic>e1 & increas+ ! f9ancial viability
 ( rural hospitals to ensure cont9u$    
access to c>e4 ,"u ?is model1 p>ticipat+
 rural hospitals w\ld--  7,i7 be paid   
bas$ on all-pay] global budget1 a fix$  
am\nt t is set 9 advance = inpati5t &   
outpati5t hospital-bas$ s]vices & paid  
mon?ly by ,m$ic>e fee-=-s]vice1 ,/ate   
,m$icaid plans1 & all o!r p>ticipat+    
pay]s2  7,,ii7 delib]ately r$esign !    
deliv]y ( c>e to improve quality ( c>e &
 meet ! ne$s ( _! local communities2    
7,,iii7 receive an upfront1 fix$ paym5t 
= infra/ructure r$esign1 9 an am\nt to  
be recov]$ ov] a p]iod ( "t z set =? by 

! ,secret>y2  7,,iv7 receive annual     
global budget paym5t adju/m5ts bas$ on  
an am\nt det]m9$ 9 conjunction ) !      
,secret>y2 &  7,v7 p>tn] ) non-hospital 
provid]s su* z physicians1 behavioral   
heal? provid]s1 s*ools1 & community bas$
 organizations to create a compreh5sive 
c>e deliv]y sy/em4  7iii7 ,def9itions ,9
 ?is subp>agraph3 7,i7 ,implem5t+ ,/ate 
,! t]m implem5t+ ,/ate means a ,/ate ^: 
application to beg9 te/+ su* model is   
approv$ by ! ,secret>y "u clause 7i74   
7,,ii7 ,rural hospital ,! t]m rural     
hospital means ! foll[+3 7aa7 ,a        
critical access hospital 7z def9$ 9     
section #ahfa7mm77#a774  7bb7 ,a sole   
community hospital 7z def9$ 9 section   
#ahhf7;d77#e77;,d77iii774  7cc7 ,a      
m$ic>e-dep5d5t1 small rural hospital 7z 
def9$ 9 section #ahhf7;d77#e77;,g77iv774
  7dd7 ,any o!r hospital t is locat$ 9 a
 rural area 7z def9$ 9 section          
#ahhf7;d77#b77;,d77 or is treat$ z be+  
locat$ 9 a rural area pursuant to       
section #ahhf7;d77#h77;,e74  7iv7       

,requirem5ts = p>ticipat+ hospitals     
7,i7 ,9 g5]al ,9 ord] to p>ticipate 9 ! 
model 9 an implem5t+ ,/ate1 a rural     
hospital mu/-- 7aa7 subject to subclause
 7,,ii71 conduct a community heal? ne$s 
assessm5t survey to det]m9e ! condition 
& heal? ne$s 9 _! community1 includ+ ^? 
ne$s ) respect to m5tal or behavioral   
heal?2 &  7bb7 foll[+ su* assessm5t     
survey1 submit &1 subject to clause     
7vi71 receive approval ( a ,rural       
,hospital ,trans=mation ,plan 7z        
describ$ 9 clause 7v77 f ! implem5t+    
,/ate & ! ,secret>y4  7,,ii7 ,exception 
,a rural hospital meets ! requirem5t    
describ$ 9 subclause 7,i77aa7 if ! rural
 hospital has conduct$ a community heal?
 ne$s assessm5t survey dur+ ! prec$+ ye>
 = any purpose4  7v7 ,rural ,hospital   
,trans=mation ,plan describ$ ,a ,rural  
,hospital ,trans=mation ,plan describ$ 9
 ?is clause1 ) respect to a rural       
hospital1 %all include ! foll[+         
in=mation3  7,i7 ,results ( ! community 
heal? ne$s assessm5t survey "u clause   

7iv77,i77aa7 & an explanation ( h[ !    
,trans=mation ,plan suits ! ne$s ( !    
community4  7,,ii7 ,! population (      
individuals :o w be s]v$ by ! rural     
hospital "u ! model4  7,,iii7 ,! types (
 s]vices t w be includ$ 9 ! global      
paym5t "u ! model4  7,,iv7 ,h[ ! rural  
hospital int5ds to improve quality &    
heal? outcomes "u ! model1 includ+ :i*  
population heal? outcomes ! hospital w  
assess on an annual basis4  7,v7 ,h[ !  
rural hospital w a*ieve pati5t engagem5t
 & involvem5t 9 ! model4  7,,vi7 ,h[ !  
rural hospital w id5tify1 p>tn] )1 & pay
 o!r entities p>ticipat+ 9 ! model4     
7,,vii7 ,h[ private pay]s w be includ$ 9
 ! model4  7,,viii7 ,plans to acc\nt =  
any m>ket %>e *anges "u ! model4  7,,ix7
 ,h[ access to prev5tive c>e w be       
increas$ "u ! model4  7,x7 ,h[ ! rural  
hospital w su/a9 ! *anges made "u !     
model4  7,,xi7 ,h[ sav+s "u ! model w   
accrue to ! ,m$ic>e program "u title    
,,xviii4  7,,xii7 ,any o!r in=mation    
requir$ by ! implem5t+ ,/ate or !       

,secret>y4  7vi7 ,opportunity = public  
comm5t ,9 ord] = ! ,secret>y or an      
implem5t+ ,/ate to approve a ,rural     
,hospital ,trans=mation ,plan "u clause 
7iv71 ! ,secret>y 9 consultation ) !    
implem5t+ ,/ate1 %all--  7,i7 provide ! 
public ) a mean+ful opportunity1 z      
det]m9$ by ! ,secret>y1 to provide      
comm5ts on ! plan2 &  7,,ii7 make a     
summ>y ( comm5ts provid$ available to ! 
public on ! ,int]net website ( ! ,c5t]s 
= ,m$ic>e  ,m$icaid ,s]vices4  7vii7    
,te*nical assi/ance ,! ,secret>y %all   
designate an entity to provide te*nical 
assi/ance to p>ticipat+ rural hospitals 
z !y r$esign ! c>e !y deliv] "u ! model4
  7viii7 ,acc\nt+ = unc]ta9ty ,9 ord] = 
implem5t+ ,/ates & p>ticipat+ rural     
hospitals to receive unanticipat$       
additional res\rces ne$$ to implem5t !  
model1 ! ,secret>y %all e/abli%         
proc$ures = implem5t+ ,/ates &          
p>ticipat+ rural hospitals to submit to 
! ,secret>y a reque/ = additional       
res\rces1 %\ld v>iations 9 s]vices      

outside ( normally plann$ volume occur  
or %\ld new te*nologies be develop$1 or 
9 su* o!r circum/ances z ! ,secret>y    
det]m9es appropriate4  7ix7 ,monitor+   
outcomes ,! ,secret>y1 9 conjunction )  
implem5t+ ,/ates & p>ticipat+ rural     
hospitals1 %all develop a plan to--     
7,i7 id5tify1 us+ a p>ticipat+ rural    
hospital's approv$ ,rural ,hospital     
,trans=mation ,plan describ$ 9 clause   
7v71 ! relevant local population (      
pati5ts attributable to ! hospital1 !   
data po9ts ! hospital may ne$ to guide  
c>e r$esign = t population1 & h[ !      
hospital may use su* data2  7,,ii7      
annually monitor outcomes "u ! model1   
:i* may include f9ancial1 quality1      
access1 & utilization outcomes2  7,,iii7
 annually monitor ! specific population 
heal? outcomes li/$ 9 ! approv$ ,rural  
,hospital ,trans=mation ,plan ( ea*     
p>ticipat+ rural hospital pursuant to   
clause 7v77,,iv72 &  7,,iv7 any o!r     
outcomes z det]m9$ by ! ,secret>y4  7x7 
,risk mitigation ,z "p ( ! model1 !     

,secret>y1 9 conjunction ) implem5t+    
,/ates & p>ticipat+ rural hospitals1    
%all develop appropriate me*anisms to   
mitigate risks1 includ+ ! use (         
re9surance4  7xi7 ,report+ requirem5ts  
7,i7 ,report to ,secret>y ,an implem5t+ 
,/ate1 z a condition ( implem5t+ !      
model1 %all p>tn] ) an indep5d5t entity 
to report to ! ,secret>y on ! ability ( 
a p>ticipat+ rural hospital to c>ry out 
! ,rural ,hospital ,trans=mation ,plan  
describ$ 9 clause 7v74  7,,ii7 ,report  
to ,congress ,n less frequ5tly ?an e #e 
ye>s 7= ! duration ( ! implem5tation ( !
 model "u ?is subp>agraph71 ! ,secret>y 
%all submit to ,congress a report on !  
implem5tation ( ! model "u ?is          
subp>agraph4 ,! report %all include be/ 
practices = future implem5tation ef=ts &
 any o!r in=mation ! ,secret>y det]m9es 
appropriate1 includ+ ! in=mation report$
 "u subclause 7,i71 toge!r )            
recomm5dations = su* legislation &      
adm9i/rative action z ! ,secret>y       
det]m9es appropriate4  7xii7 ,fund+ ,!  

,secret>y %all allocate funds made      
available "u subsection 7f77#a7 to      
design1 implem5t1 evaluate1 & report on 
! model describ$ 9 clause 7ii7 9        
accordance ) ?is subp>agraph4  4