,,ii  #aagth ,,congress  #ast ,session  
,s4 #fdd  ,,in ,,the ,,senate ,,of ,,the
 ,,united ,,states  ,march #i1 #bjba,mr4
 ,durbin 7for himself and ,mr4          
,lankford7 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 restore ,state       
authority to waive for certain          
facilities the #ce-mile rule for        
designating critical access hospitals   
under the ,medicare program1 and for    
other purposes4  #a4 ,short title ,this 
,act may be cited as the ,rural         
,hospital ,closure ,relief ,act of      
#bjba4  #b4 ,restoring ,state authority 
to waive the #ce-mile rule for certain  
,medicare critical access hospital      
designations  7a7 ,in general ,section  
#ahbj of the ,social ,security ,act 7#db
 ,u4,s4,c4 #acie;i-#d7 is amended-- 7#a7
 in subsection 7c77#b7-- 7,a7 in        
subparagraph 7,b77i7-- 7i7 in subclause 
7,i71 by striking at the end or2  7ii7  

in subclause 7,,ii71 by inserting at the
 end or2 and  7iii7 by adding at the end
 the following new subclause3  7,,iii7  
subject to subparagraph 7,g71 is a      
hospital described in subparagraph 7,f7 
and is certified on or after the date of
 the enactment of the ,rural ,hospital  
,closure ,relief ,act of #bjba by the   
,state as being a necessary provider of 
health care services to residents in the
 area2  2 and  7,b7 by adding at the end
 the following new subparagraphs3  7,f7 
,hospital described ,for purposes of    
subparagraph 7,b77i77,,iii71 a hospital 
described in this subparagraph is a     
hospital that-- 7i7 is a sole community 
hospital 7as defined in section         
#ahhf7;d77#e77;,d77iii771 a medicare    
dependent1 small rural hospital 7as     
defined in section                      
#ahhf7;d77#e77;,g77iv771 a low-volume   
hospital that in #bjba receives a       
payment adjustment under section        
#ahhf7;d77#ab71 a subsection 7d7        
hospital 7as defined in section         

#ahhf7;d77#a77;,b77 that has fewer than 
#ej beds1 or1 subject to the limitation 
under subparagraph 7,g77i77,i71 is a    
facility described in subparagraph      
7,g77ii72  7ii7 is located in a rural   
area1 as defined in section             
#ahhf7;d77#b77;,d72  7iii7 7,i7 is      
located-- 7aa7 in a county that has a   
percentage of individuals with income   
that is below #aej percent of the       
poverty line that is higher than the    
national or statewide average in #bjbj2 
or  7bb7 in a health professional       
shortage area 7as defined in section    
#ccb7;a77#a77;,a7 of the ,public ,health
 ,service ,act72 or  7,,ii7 has a       
percentage of inpatient days of         
individuals entitled to benefits under  
part ,a of this title1 enrolled under   
part ,b of this title1 or enrolled under
 a ,state plan under title ,,xix that is
 higher than the national or statewide  
average in #bjai or #bjbj2  7iv7 subject
 to subparagraph 7,g77ii77,,ii71 has    
attested to the ,secretary two          

consecutive years of negative operating 
margins preceding the date of           
certification described in subparagraph 
7,b77i77,,iii72 and  7v7 submits to the 
,secretary-- 7,i7 at such time and in   
such manner as the ,secretary may       
require1 an attestation outlining the   
good governance qualifications and      
strategic plan for multi-year financial 
solvency of the hospital2 and  7,,ii7   
not later than #abj days after the date 
on which the ,secretary issues final    
regulations pursuant to section #b7;b7  
of the ,rural ,hospital ,closure ,relief
 ,act of #bjba1 an application for      
certification of the facility as a      
critical access hospital4  7,g7         
,limitation on certain designations  7i7
 ,in general ,the ,secretary may not    
under subsection 7e7 certify pursuant to
 a certification by a ,state under      
subparagraph 7,b77i77,,iii7-- 7,i7 more 
than a total of #age facilities as      
critical access hospitals1 of which not 
more than #bj percent may be facilities 

described in clause 7ii72 and  7,,ii7   
within any one ,state1 more than #aj    
facilities as critical access hospitals4
  7ii7 ,facility described  7,i7 ,in    
general ,a facility described in this   
clause is a facility that as of the date
 of enactment of this subparagraph met  
the criteria for designation as a       
critical access hospital under          
subparagraph 7,b77i77,i74  7,,ii7       
,nonapplication of certain criteria ,for
 purposes of subparagraph               
7,b77i77,,iii71 the criteria described  
in subparagraph 7,f77iv7 shall not apply
 with respect to the designation of a   
facility described in subclause 7,i74  2
 and  7#b7 in subsection 7e71 by        
inserting 1 subject to subsection       
7c77#b77;,g71 after ,the ,secretary     
shall4  7b7 ,regulations ,not later than
 #abj days after the date of the        
enactment of this ,act1 the ,secretary  
of ,health and ,human ,services shall   
issue final regulations to carry out    
this section4  7c7 ,clarification       

regarding facilities that meet distance 
or other certification criteria ,nothing
 in this section shall affect the       
application of criteria for designation 
as a critical access hospital described 
in subclause 7,i7 or 7,,ii7 section     
#ahbj7;c77#b77;,b77i7 of the ,social    
,security ,act 7#db ,u4,s4,c4           
#acie;i-#d7;c77#b77;,b77i774  #c4 ,,cmi 
testing of new rural hospital delivery  
and payment model ,section #aaae;,a of  
the ,social ,security ,act 7#db         
,u4,s4,c4 #acae;a7 is amended-- 7#a7 in 
subsection 7b77#b77;,a71 by adding at   
the end the following new sentence3     
8,the models selected under this        
subparagraph shall include the testing  
of a new rural hospital delivery and    
payment model 7or models71 as described 
in subsection 7h7402 and  7#b7 by adding
 at the end the following new           
subsection3  7h7 ,testing of new rural  
hospital delivery and payment model     
7#a7 ,in general  7,a7 ,testing ,the    
,secretary shall test the implementation

 of a new rural hospital delivery and   
payment model 7or models7 that the      
,secretary determines would promote     
financially sustainable ways to ensure  
patient access to care in rural         
communities1 which may include models   
under which such hospitals furnish      
outpatient emergency care services #bd  
hours a day1 #g days a week for which   
payment is made under title ,,xviii     
based on the amount determined under the
 prospective payment system for hospital
 outpatient department services under   
section #ahcc7t71 plus a fixed rate for 
the cost of furnishing the emergency    
services4  7,b7 ,promulgation of        
regulations ,not later than #c years    
after the date of the enactment of this 
subsection1 the ,secretary shall        
promulgate regulations to test a new    
rural hospital delivery and payment     
model 7or models7 described in          
subparagraph 7,a71 unless ,congress     
enacts legislation that establishes such
 a payment model 7or models7 prior to   

the promulgation of regulations pursuant
 to this subparagraph4  7#b7 ,transition
 ,effective beginning on the date on    
which the testing of a new rural        
hospital delivery and payment model 7or 
models7 described in paragraph 7#a77;,a7
 is implemented under this subsection or
 such a payment model 7or models7 is    
established through the enactment of    
legislation described in paragraph      
7#a77;,b71 the ,secretary shall provide 
a process under which-- 7,a7 all        
critical access hospitals may transition
 to such new model or models under this 
subsection2 and  7,b7 any facility that 
was designated as a critical access     
hospital pursuant to a certification by 
a ,state under section                  
#ahbj7;c77#b77;,b77i77,,iii7 may revert 
to the prospective payment model 7or    
models7 under which the facility        
received payment under title ,,xviii    
prior to being so designated4  4