,i  #aag? ,,congress  #b;d ,session  ,h4
 ,r4 #fdjj  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,janu>y #ac1 #bjbb,mr4
 ,graves ( ,miss\ri 7= himself & ,mr4   
,huffman7 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 ,am]ica's ,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 ,betwe5 ,janu>y #bjaj
 & ,janu>y #a1 #bjba1 #acg rural        
hospitals 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 ,f\r hundr$ 
& fifty-?ree hospitals are op]at+ at    
m>g9s simil> to ^? t h clos$ ov] ! pa/  
decade4 ,( ^?1 #baf are consid]$ mo/    
vuln]able to closure4  7#f7 ,rural      
,m$ic>e b5efici>ies already face a numb]
 ( *all5ges :5 try+ to access heal? c>e 
s]vices close to home1 includ+ ! wea!r1 
geography1 & cultural1 social1 &        
language b>ri]s4  7#g7 ,approximately   
sixty p]c5t ( all prim>y c>e heal?      
pr(essional %ortage areas are locat$ 9  
rural areas4  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 ,) ! #dec hospitals 
on ! br9k ( closure1 millions (         
,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               
stabilization,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,subtitle ,b--,o!r    
rural providers,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,sec4 #aac4 ,mak+ p]man5t       
,m$ic>e teleheal? s]vice enhancem5ts =  
f$]ally qualifi$ heal? c5t]s & rural    
heal? cl9ics4,sec4 #aad4 ,creation (    
report+ requirem5ts = provid]-bas$ rural
 heal? cl9ics4,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$ic>e4,title           
,,iv--,future ( rural heal? care,sec4   
#dja4 ,m$ic>e rural hospital flexibility
 program grants4  ,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$ic>e-dep5d5t1 small rural   
hospital 7z def9$ 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 #ae 
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;,g77 is am5d$-- 7,a7 9  

clause 7i71 by /rik+ 1 & be=e ,octob]   
#a1 #bjbb2 &  7,b7 9 clause 7ii77,,ii71 
by /rik+ 1 & be=e ,octob] #a1 #bjbb4    
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;,d77 is       
am5d$-- 7i7 9 ! matt] prec$+ clause 7i71
 by /rik+ 1 & be=e ,octob] #a1 #bjbb2 & 
7ii7 9 clause 7iv71 by /rik+ ?r\gh      
fiscal ye> #bjbb & ins]t+ or a subsequ5t
 fiscal ye>4  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 note7 is   
am5d$ by /rik+ fiscal ye> #bjjj ?r\gh   
fiscal ye> #bjbb & ins]t+ a subsequ5t   
fiscal ye>4  7b7 ,ext5sion ( ,increas$  
,paym5ts = ,l[-,volume ,hospitals       
,section #ahhf7;d77#ab7 ( ! ,social     
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#ab77 is am5d$-- 7#a7 9      
subp>agraph 7,b7-- 7,a7 9 ! head]1 by   
ins]t+ = fiscal ye>s #bjje ?r\gh #bjaj  

aft] increase2 &  7,b7 9 ! matt] prec$+ 
clause 7i71 by /rik+ & = dis*>ges       
occurr+ 9 fiscal ye> #bjbc & subsequ5t  
fiscal ye>s2  7#b7 9 subp>agraph        
7,c77i7-- 7,a7 9 ! matt] prec$+         
subclause 7,i71 by /rik+ ?r\gh #bjbb &  
ins]t+ & ea* subsequ5t fiscal ye>2  7,b7
 9 subclause 7,,ii71 by add+ at ! end &2
  7,c7 9 subclause 7,,iii7-- 7i7 by     
/rik+ fiscal ye>s #bjai ?r\gh #bjbb &   
ins]t+ fiscal ye> #bjai & ea* subsequ5t 
fiscal ye>2 &  7ii7 by /rik+ 2 & &      
ins]t+ a p]iod2 &  7,d7 by /rik+        
subclause 7,,iv72 &  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 9 ! matt]  
prec$+ clause 7i71 by /rik+ 9 fiscal    
ye>s #bjaa ?r\gh #bjbb & ins]t+ 9 fiscal
 ye> #bjaa or a subsequ5t fiscal ye>2 & 
7,c7 9 clause 7ii71 by /rik+ ea* (      
fiscal ye>s #bjai ?r\gh #bjbb & ins]t+  
fiscal ye> #bjai & ea* subsequ5t fiscal 
ye>4  #ajd4 ,re9/at+ revis$             
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+ & aft] fiscal ye> #bjba 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+ & aft] fiscal ye> #bjba 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+ & on or 
aft] ,janu>y #a1 #bjbb1 aft] ,janu>y #a1
 #bjac12 &  7,b7 9 ! second s5t5ce1 by  
ins]t+ 1 & dur+ or aft] #bjbb aft] or   
#bjab2 &  7#c7 9 subclause 7,,iii71 9 ! 

fir/ s5t5ce1 by ins]t+ & on or aft]     
,janu>y #a1 #bjbb1 aft] ,janu>y #a1     
#bjac14  ,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 9 !     
p>agraph head+1 by /rik+ ,tempor>y      
increase & ins]t+ ,increase2 &  7#b7 9  
subp>agraph 7,a7-- 7,a7 9 ! matt] prec$+
 clause 7i71 by /rik+ 1 & be=e ,janu>y  
#a1 #bjbc2 &  7,b7 9 clause 7i71 by     
/rik+ 1 & be=e ,janu>y #a1 #bjbc4  #aab4
 ,ext5d+ ,m$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 7or1 9 ! case (   
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  #aac4 ,mak+ p]man5t       

,m$ic>e teleheal? s]vice enhancem5ts =  
f$]ally qualifi$ heal? c5t]s & rural    
heal? cl9ics ,p>agraph 7#h7 ( section   
#ahcd7m7 ( ! ,social ,security ,act 7#db
 ,u4,s4,c4 #aciem7m77 is am5d$-- 7#a7 9 
! p>agraph head+1 be /rik+ dur+ em]g5cy 
p]iod2  7#b7 9 ! matt] prec$+           
subp>agraph 7,a71 by /rik+ ,dur+ !      
em]g5cy p]iod describ$ 9 section        
#aace7;g77#a77;,b7 & ins]t+ ,beg9n+ on !
 fir/ day ( ! em]g5cy p]iod describ$ 9  
section #aace7;g77#a77;,b72  7#c7 9     
subp>agraph 7,a77ii71 by /rik+ det]m9$  
"u subp>agraph 7,b7 & ins]t+ det]m9$1 = 
s]vices furni%$ dur+ ! em]g5cy p]iod    
describ$ 9 section #aace7;g77#a77;,b71  
"u subp>agraph 7,b7 &1 = s]vices furni%$
 aft] su* p]iod1 z an am\nt equal to !  
am\nt t su* c5t] or cl9ic w\ld h be5    
paid "u ?is title _h su* s]vice be5     
furni%$ )\t ! use ( a telecommunications
 sy/em2 &  7#d7 9 subp>agraph 7,b7--    
7,a7 by /rik+ paym5t rule & all t foll[s
 ?r\gh ,! ,secret>y %all & ins]t+ paym5t
 rule4--,! ,secret>y %all2 &  7,b7 by   

r$esignat+ clause 7ii7 z subp>agraph    
7,c7 & mov+ su* subp>agraph z s         
r$esignat$ #b ems to ! left4  #aad4     
,creation ( report+ requirem5ts =       
provid]-bas$ rural heal? cl9ics  7a7 ,9 
,g5]al ,n lat] ?an two ye>s aft] ! date 
( ! enactm5t ( ?is ,act1 ! ,secret>y (  
,heal? & ,human ,s]vices 79 ?is section 
ref]r$ to z ! ,secret>y7 %all1 tak+ into
 acc\nt ! recomm5dations made pursuant  
to subsection 7b71 implem5t a volunt>y  
,m$ic>e provid]-bas$ rural heal? cl9ic  
quality report+ program1 9 accordance ) 
?is section1 "u :i*-- 7#a7 provid]-bas$ 
rural heal? cl9ics e/abli%$ on or aft]  
,janu>y #a1 #bjba1 may volunt>ily comply
 ) report+ requirem5ts describ$ 9       
subsection 7b77#b72 &  7#b7 paym5ts "u  
title ,,xviii to su* cl9ics comply+ )   
su* requirem5ts are provid$ 9 accordance
 ) subsection 7d74  7b7 ,consultation ,n
 lat] ?an "o ye> aft] ! date ( !        
enactm5t ( ?is ,act1 ! ,secret>y1 act+  
?r\gh ! ,adm9i/rator = ,c5t]s = ,m$ic>e 
,m$icaid ,s]vices1 ! ,f$]al ,(fice (    

,rural ,heal? ,policy1 & ! ,ag5cy =     
,heal?c>e ,rese>* & ,quality1 %all      
consult ) relevant /akehold]s-- 7#a7 to 
review rural heal? cl9ic data collection
 processes & quality measur]s id5tifi$ =
 rural heal? cl9ics by ! ,national      
,quality ,=um & o!r national            
quality-monitor+ sy/ems2 &  7#b7 to make
 recomm5dations to ! ,secret>y =        
volunt>y report+ requirem5ts = !        
,secret>y to implem5t "u ! eligible     
pr(essional ,m]it-bas$ ,inc5tive ,paym5t
 ,sy/em "u section #ahdh7q7 ( ! ,social 
,security ,act 7#db ,u4,s4,c4 #aciew-#d7
 = provid]-bas$ rural heal? cl9ics      
e/abli%$ on or aft] ,janu>y #a1 #bjba4  
7c7 ,collaboration ,9 implem5t+ !       
volunt>y ,m$ic>e provid]-bas$ rural     
heal? cl9ic quality report+ program1 !  
,secret>y %all consult ) a div]se gr\p (
 rural heal? cl9ic /akehold]s1 :i* %all 
include-- 7#a7 ! ,national ,quality     
,=um1 or su* o!r /&>d-sett+             
organizations specifi$ by ! ,secret>y2  
7#b7 relevant ,/ate & local public      

ag5cies1 includ+ ,/ate (fices ( rural   
heal?2  7#c7 e/abli%$ provid]-bas$ rural
 heal? cl9ics1 includ+ ^? 9 !           
application process2  7#d7 small rural  
hospitals ) #ej b$s or less2  7#e7      
organizations repres5t+ provid]-bas$    
rural heal? cl9ics2 &  7#f7             
organizations repres5t+ rural heal? c>e4
  7d7 ,conditions ,"u ! volunt>y ,m$ic>e
 provid]-bas$ rural heal? cl9ic quality 
report+ program ! ,secret>y %all provide
 t 9 ! case ( a provid]-bas$ rural heal?
 cl9ic describ$ 9 subsection 7a77#a7 t  
volunt>ily complies ) ! report+         
requirem5ts describ$ 9 subsection       
7b77#b71 ) respect to a ye>-- 7#a7      
reimbursem5t rates "u title ,,xviii ( ! 
,social ,security ,act = rural heal?    
s]vices furni%$ by su* cl9ic dur+ su*   
ye> %all be consi/5t ) reimbursem5t     
rates "u su* title = su* s]vices furni%$
 by a provid]-bas$ rural heal? cl9ic    
e/abli%$ be=e ,decemb] #ca1 #bjbj2 &    
7#b7 ! provisions ( section             
#ahcc7;f77#c7 ( su* ,act 7#db ,u4,s4,c4 

#aciel7f77#c77 %all n apply ) respect to
 su* cl9ic & su* ye>4  7e7 ,grants =    
te*nical assi/ance  7#a7 ,9 g5]al       
,section #ahbj7;g77#c7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acie;i-#d7;g77#c77 is am5d$-- 7,a7 9   
subp>agraph 7,a7-- 7i7 by /rik+ ,balanc$
 ,budget ,act ( #aiig & & ins]t+        
,balanc$ ,budget ,act ( #aiig12 &  7ii7 
by ins]t+ be=e ! p]iod at ! end !       
foll[+3 1 & to provide to su* small     
rural hospitals t p>ticipate 9 !        
volunt>y ,m$ic>e provid]-bas$ rural     
heal? cl9ic quality report+ program     
e/abli%$ pursuant to section #aad ( !   
,save ,am]ica's ,rural ,hospitals ,act  
te*nical assi/ance necess>y to s        
p>ticipate 9 su* program2 &  7,b7 9     
subp>agraph 7,e7-- 7i7 by /rik+ & to    
p>ticipate 9 deliv]y sy/em re=ms &      
ins]t+ 1 to p>ticipate 9 deliv]y sy/em  
re=ms2 &  7ii7 by ins]t+ be=e ! p]iod at
 ! end ! foll[+3 1 & 9 ! case ( small   
rural hospitals t p>ticipate 9 !        
volunt>y ,m$ic>e provid]-bas$ rural     

heal? cl9ic quality report+ program     
e/abli%$ pursuant to section #aad ( !   
,save ,am]ica's ,rural ,hospitals ,act1 
= te*nical assi/ance necess>y to s      
p>ticipate 9 su* program4  7#b7 ,fund+  
,9 addition to am\nts o!rwise made      
available = grants "u section           
#ahbj7;g77#c7 ( ! ,social ,security     
,act1 !re is appropriat$ to ! ,secret>y 
( ,heal? & ,human ,s]vices1 out ( any   
monies 9 ! ,treasury n o!rwise          
appropriat$1 #ae1jjj1jjj = ! p]iod (    
fiscal ye>s #bjbb ?r\gh #bjbf to provide
 grants "u su* section to small rural   
hospitals t p>ticipate 9 ! volunt>y     
,m$ic>e provid]-bas$ rural heal? cl9ic  
quality report+ program e/abli%$        
pursuant to ?is section = te*nical      
assi/ance necess>y to s p>ticipate 9 su*
 program4  ,,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  
*>ges = 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[+ new subsection3  7ee7 ,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 = #bjbb "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;cc77#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$ic>e program %all h no =ce or   
effect 9 law4  7#b7 ,hold h>mless ,a    
hospital or critical access hospital t  
furni%es !rapeutic hospital outpati5t   
s]vices dur+ ! p]iod beg9n+ on ,janu>y  
#a1 #bjja1 & end+ on ! lat] ( ,decemb]  
#ca1 #bjba1 or ! date on :i* ! f9al     
regulation promulgat$ 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$ic>e    
7a7 ,elim9ation ( cont+5cy fee paym5t   
sy/em ,section #ahic7;h7 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acie;ddd7h77 is am5d$-- 7#a7 9 p>agraph
 7#a71 by ins]t+ 1 = recov]y activities 
conduct$ dur+ a fiscal ye> be=e fiscal  
ye> #bjbb aft] ,"u ! contracts2 &  7#b7 
by add+ at ! end ! foll[+ new p>agraph3 
7#aa7 ,paym5t = recov]y activities p]=m$
 aft] fiscal ye> #bjba  7,a7 ,9 g5]al   
,"u ! contracts1 subject to p>agraphs   
7,b7 & 7,c71 paym5t %all be made to     
recov]y audit contractors = recov]y     
activities conduct$ dur+ fiscal ye>     
#bjbb & 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> #bjba "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>     
#bjbb 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>     
#bjbb 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 #j4a 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$ical record44  ,,iv    
,future ( rural heal? c>e  #dja4 ,m$ic>e
 rural hospital flexibility program     
grants ,section #ahbj7;g7 ( ! ,social   
,security ,act 7#db ,u4,s4,c4           
#acie;i-#d7;g77 is am5d$-- 7#a7 9       
p>agraph 7#a7-- 7,a7 9 subp>agraph 7,c71
 by /rik+ & at ! end2  7,b7 9           
subp>agraph 7,d71 by /rik+ ! p]iod at ! 
end & ins]t+ a semicolon2 &  7,c7 by    
add+ at ! end ! foll[+ new subp>agraphs3
  7,e7 rural em]g5cy hospitals provid+  
support = critical access hospitals to  
conv]t to rural em]g5cy hospitals to    
/abilize hospital em]g5cy s]vices 9 _!  
communities2 &  7,f7 support+ c]tifi$   
rural heal? cl9ics = ma9ta9+ & build+   
bus9ess op]ations1 increas+ f9ancial    
indicators1 address+ population heal?1  
trans=m+ s]vices1 & provid+ l9kages &   
s]vices = behavioral heal? & sub/ance   

use disord]s respond+ to public heal?   
em]g5cies4  2  7#b7 by r$esignat+       
p>agraphs 7#c7 ?r\gh 7#g7 z p>agraphs   
7#d7 ?r\gh 7#h71 respectively2  7#c7    
aft] p>agraph 7#b71 by ins]t+ ! foll[+  
new p>agraph3  7#c7 ,activities to      
support c>ry+ out ,,flex grants ,!      
,secret>y may aw>d grants or coop]ative 
agreem5ts to entities t submit to !     
,secret>y applications1 at su* "t & 9   
su* =m & mann] & conta9+ su* in=mation z
 ! ,secret>y specifies1 = purposes (    
support+ ,/ates & hospitals 9 c>ry+ out 
! activities "u ?is subsection by       
provid+ te*nical assi/ance1 data        
analysis1 & evaluation ef=ts4  2  7#d7 9
 p>agraph 7#d71 z r$esignat$-- 7,a7 9   
subp>agraph 7,a71 by ins]t+ ,/ate       
,(fices ( ,rural ,heal? on behalf (     
eligible hospitals aft] aw>d grants to2 
7,b7 by am5d+ subp>agraph 7,c7 to read z
 foll[s3  7,c7 ,application ,! ,/ate    
,(fice ( ,rural ,heal? %all submit an   
application1 on behalf ( eligible rural 
hospitals1 to ! ,secret>y on or be=e su*

 date & 9 su* =m & mann] z ! ,secret>y  
specifies4  2  7,c7 by am5d+ subp>agraph
 7,d71 to read z foll[s3  7,d7 ,am\nt ( 
grant ,a grant to a hospital "u ?is     
p>agraph %all be det]m9$ on an equal    
national di/ribution s t ea* hospital   
receives ! same am\nt ( support relat$  
to ! funds appropriat$4  2  7,d7 by     
am5d+ subp>agraph 7,e71 to read z       
foll[s3  7,e7 ,use ( funds ,/ate ,(fices
 ( ,rural ,heal? & eligible hospitals   
may use ! funds receiv$ ?r\gh a grant "u
 ?is p>agraph = ! pur*ase ( comput]     
s(tw>e & h>dw>e2 ! education & tra9+ (  
hospital /aff on bill+1 op]ational1     
quality improvem5t & relat$ value-focus$
 ef=ts2 & o!r deliv]y sy/em re=m        
programs det]m9$ appropriate by !       
,secret>y4  2 &  7#e7 by add+ at ! end !
 foll[+ new p>agraph3  7#i7 ,rural      
,heal? ,trans=mation ,grants  7,a7      
,grants ,! ,secret>y may aw>d #e-ye>    
grants to ,/ate ,(fices ( ,rural ,heal? 
& to eligible rural heal? c>e provid]s  
7z def9$ 9 subp>agraph 7,e77 on !       

transition to new models1 includ+ rural 
em]g5cy hospitals1 ext5d$ /ay cl9ics1   
free/&+ em]g5cy dep>tm5ts1 rural heal?  
cl9ics1 & integration ( behavioral1 oral
 heal? s]vices1 teleheal? & o!r         
trans=mational models relevant to rural 
provid]s z su* provid]s evolve to bett] 
meet community ne$s & ! *ang+ heal? c>e 
environm5t4  7,b7 ,application ,an      
applicable rural heal? c>e provid]1 9   
p>tn]%ip ) ! ,/ate ,(fice ( ,rural      
,heal? 9 ! ,/ate 9 :i* ! rural heal? c>e
 provid] seek+ a grant "u ?is p>agraph  
is locat$1 %all submit an application to
 ! ,secret>y on or be=e su* date & 9 su*
 =m & mann] z ! ,secret>y specifies4    
7,c7 ,additional requirem5ts ,!         
,secret>y may n aw>d a grant "u ?is     
p>agraph to an eligible rural heal? c>e 
provid] unless-- 7i7 local organizations
 or ! ,/ate 9 :i* ! hospital is locat$  
provides support 7ei!r direct or 9 k9d72
 & !re are lett]s ( support f key ,/ate 
pay]s su* z ,m$icaid & private          
insurance2 &  7ii7 ! applicant describes

 9 detail h[ ! transition ( ! heal? c>e 
provid] or provid]s w bett] meet local  
ne$s & be su/a9able4  7,d7 ,eligible    
rural heal? c>e provid] def9$ ,=        
purposes ( ?is p>agraph1 ! t]m eligible 
rural heal? c>e provid] includes a      
critical access hospital1 a c]tifi$     
rural heal? cl9ic1 a rural nurs+ home1  
skill$ nurs+ facility1 em]g5cy c>e      
provid]1 or o!r entity id5tifi$ by !    
,secret>y4 ,an eligible rural heal? c>e 
provid] may include o!r entities apply+ 
on behalf ( a gr\p ( provid]s su* z a   
,/ate ,(fice ( ,rural ,heal?1 a ,/ate or
 local heal? c>e au?ority1 a rural heal?
 network1 or o!r entity id5tifi$ by !   
,secret>y4  4