,i #aaith ,,congress #ast ,session ,h4 ,r4 #cfhd ,,in ,,the ,,house ,,of ,,representatives ,june #c1 #bjbe,mr4 ,graves 7for himself and ,ms4 ,budzinski7 introduced the following bill2 which was referred to the ,committee on ,ways and ,means1 and in addition to the ,committees on ,energy and ,commerce1 and the ,budget1 for a period to be subsequently determined by the ,speaker1 in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned ,a ,,bill ,to amend titles ,,xviii and ,,xix of the ,social ,security ,act to provide for enhanced payments to rural health care providers under the ,medicare and ,medicaid programs1 and for other purposes4 #a4 ,short title2 table of contents 7a7 ,short title ,this ,act may be cited as the ,save ,america's ,rural ,hospitals ,act4 7b7 ,findings ,congress finds the following3 7#a7 ,more than #fj1jjj1jjj individuals in rural areas of the ,united ,states rely on rural hospitals and other providers as critical access points to health care4 7#b7 ,access to health care is essential to communities that ,americans living in rural areas call home4 7#c7 ,americans living in rural areas are older1 poorer1 and sicker than ,americans living in urban areas4 7#d7 ,as of ,may #a1 #bjbe1 #aea rural hospitals have closed in the ,united ,states1 according to the ,university of ,north ,carolina's ,cecil ,g4 ,sheps ,center for ,health ,services ,research1 and the rate of these closures is increasing4 7#e7 ,four hundred and thirty-two hospitals are operating at margins similar to those that have closed over the past decade4 ,of those1 #baf are considered most vulnerable to closure4 7#f7 ,rural ,medicare beneficiaries already face a number of challenges when trying to access health care services close to home1 including the weather1 geography1 and cultural1 social1 and language barriers4 7#g7 ,approximately sixty percent of all primary care health professional shortage areas are located in rural areas4 7#h7 ,seniors living in rural areas are forced to travel significant distances for care4 7#i7 ,on average1 trauma victims in rural areas must travel twice as far as victims in urban areas to the closest hospital1 and1 as a result1 #fj percent of trauma deaths occur in rural areas1 even though only #bj percent of ,americans live in rural areas4 7#aj7 ,with the #dcb hospitals on the brink of closure1 millions of ,americans living in rural areas are on the brink of losing access to the closest emergency room4 7c7 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title2 table of contents4,title ,i--,rural provider payment stabilization,subtitle ,a--,rural hospitals,sec4 #aja4 ,eliminating ,medicare sequestration for rural hospitals4,sec4 #ajb4 ,reversing cuts to reimbursement of bad debt for critical access hospitals 7,c,a,hs7 and rural hospitals4,sec4 #ajc4 ,permanently extending payment levels for low-volume hospitals and ,medicare-dependent hospitals 7,m,d,hs74,sec4 #ajd4 ,extending disproportionate share payments for sole community hospitals and medicare-dependent hospitals4,sec4 #aje4 ,rebasing target amounts for ,medicare-dependent hospitals and sole community hospitals4,sec4 #ajf4 ,implementing area wage index adjustments4,subtitle ,b--,other rural providers,sec4 #aaa4 ,making permanent increased ,medicare payments for ground ambulance services in rural areas4,sec4 #aab4 ,permanently extending ,medicare telehealth service enhancements for federally qualified health centers and rural health clinics4,sec4 #aac4 ,restoring ,state authority to waive the #ce-mile rule for certain ,medicare critical access hospital designations4,title ,,ii--,rural ,medicare beneficiary equity,sec4 #bja4 ,equalizing beneficiary copayments for services furnished by ,c,a,hs4,title ,,iii--,regulatory relief,sec4 #cja4 ,eliminating #if-;hour requirements with respect to inpatient ,,cah services4,sec4 #cjb4 ,eliminating hospitalization requirement for extended care services furnished by certain hospitals4,title ,,iv--,future of rural health care,sec4 #dja4 ,medicare rural hospital flexibility program grants4 ,i ,rural provider payment stabilization ,a ,rural hospitals #aja4 ,eliminating ,medicare sequestration for rural hospitals 7a7 ,in general ,section #bef7;d77#g7 of the ,balanced ,budget and ,emergency ,deficit ,control ,act of #aihe 7#b ,u4,s4,c4 #ijf7;d77#g77 is amended by adding at the end the following3 7,d7 ,rural hospitals ,payments under part ,a or part ,b of title ,,xviii of the ,social ,security ,act with respect to items and services furnished by a critical access hospital 7as defined in section #ahfa7mm77#a7 of such ,act71 a sole community hospital 7as defined in section #ahhf7;d77#e77;,d77iii7 of such ,act71 a medicare-dependent1 small rural hospital 7as defined in section #ahhf7;d77#e77;,g77iv7 of such ,act71 or a subsection 7d7 hospital 7as defined in section #ahhf7;d77#a77;,b7 of such ,act7 located in a rural area 7as defined in section #ahhf7;d77#b77;,d7 of such ,act74 4 7b7 ,applicability ,the amendment made by this section applies with respect to orders of sequestration effective on or after the date that is #fj days after the date of the enactment of this ,act4 #ajb4 ,reversing cuts to reimbursement of bad debt for critical access hospitals 7,c,a,hs7 and rural hospitals 7a7 ,rural hospitals ,section #ahfa7v77#a77,t77v7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7v77#a77,t77v77 is amended by inserting before the period at the end the following3 or1 in the case of a hospital located in a rural area1 by #ae percent of such amount otherwise allowable4 7b7 ,c,a,hs ,section #ahfa7v77#a77,w77ii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7v77#a77,w77ii77 is amended by inserting 1 a critical access hospital after or 7,v74 7c7 ,applicability ,the amendments made by this section apply with respect to cost reporting periods beginning more than #fj days after the date of the enactment of this ,act4 #ajc4 ,permanently extending payment levels for low-volume hospitals and ,medicare-dependent hospitals 7,m,d,hs7 7a7 ,extension of increased payments for ,m,d,hs 7#a7 ,extension of payment methodology ,section #ahhf7;d77#e77;,g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#e77;,g77 is amended-- 7,a7 in clause 7i71 by striking 1 and before ,october #a1 #bjbe2 and 7,b7 in clause 7ii77,,ii71 by striking 1 and before ,october #a1 #bjbe4 7#b7 ,conforming amendments 7,a7 ,extension of target amount ,section #ahhf7;b77#c77;,d7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,d77 is amended-- 7i7 in the matter preceding clause 7i71 by striking 1 and before ,october #a1 #bjbe2 and 7ii7 in clause 7iv71 by striking through fiscal year #bjbe and inserting or a subsequent fiscal year4 7,b7 ,extending the period during which hospitals can decline reclassification as urban ,section #aceja7;e77#b7 of the ,omnibus ,budget ,reconciliation ,act of #aiic 7#db ,u4,s4,c4 #acieww note7 is amended by striking through fiscal year #bjbe and inserting 1 or a subsequent fiscal year4 7b7 ,extension of increased payments for low-,volume hospitals ,section #ahhf7;d77#ab7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#ab77 is amended-- 7#a7 in subparagraph 7,b7-- 7,a7 in the subparagraph heading1 by inserting for fiscal years #bjje through #bjaj after increase2 and 7,b7 in the matter preceding clause 7i71 by striking and for discharges occurring in fiscal year #bjbf and subsequent fiscal years2 7#b7 in subparagraph 7,c77i7-- 7,a7 in the matter preceding subclause 7,i71 by striking through #bjbe and inserting and each subsequent fiscal year2 7,b7 in subclause 7,,ii71 by adding and at the end2 7,c7 in subclause 7,,iii7-- 7i7 by striking fiscal years #bjai through #bjbe and inserting fiscal year #bjai and each subsequent fiscal year2 and 7ii7 by striking 2 and and inserting a period2 and 7,d7 by striking subclause 7,,iv72 and 7#c7 in subparagraph 7,d7-- 7,a7 by amending the heading to read as follows3 ,permanent ,applicable percentage increase2 7,b7 in the matter preceding clause 7i71 by striking in fiscal years #bjaa through #bjbe and inserting in fiscal year #bjaa or a subsequent fiscal year2 and 7,c7 in clause 7ii71 by striking each of fiscal years #bjai through #bjbe and inserting fiscal year #bjai and each subsequent fiscal year4 #ajd4 ,extending disproportionate share payments for sole community hospitals and medicare-dependent hospitals ,section #ahhf of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7 is amended-- 7#a7 in subsection 7d77#e77;,f77i71 by inserting 1 including1 with respect to discharges occurring in fiscal year #bjbf and each subsequent fiscal year1 a subsection 7d7 hospitals that is a sole community hospitals paid the amount described in subparagraph 7,d77i77,i7 or a medicare-dependent1 small rural hospital paid the amount described in subparagraph 7,g71 after subsection 7d7 hospital2 and 7#b7 in subsection 7r77#b71 by inserting 7including1 with respect to fiscal year #bjbf and each subsequent fiscal year1 subsection 7d7 hospitals that are sole community hospitals or medicare-dependent1 small rural hospitals described in subsection 7d77#e77;,f77i77 after such subsection 7d7 hospitals4 #aje4 ,rebasing target amounts for ,medicare-dependent hospitals and sole community hospitals ,section #ahhf7;b77#c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77 is amended-- 7#a7 in subparagraph 7,k77i7-- 7,a7 in subclause 7,i71 by inserting 7or1 with respect to discharges occurring on or after ,october #a1 #bjbe1 the #ab-month cost reporting period beginning during fiscal year #bjbd7 after fiscal year #bjjb2 and 7,b7 in subclause 7,,ii71 by inserting 7or1 with respect to discharges occurring on or after ,october #a1 #bjbe1 the first cost reporting period beginning on or after such date7 after ,october #a1 #bjjf2 and 7#b7 in subparagraph 7,l77ii7-- 7,a7 in subclause 7,i71 by inserting 7or1 with respect to discharges occurring on or after ,october #a1 #bjbe1 the #ab-month cost reporting period beginning during fiscal year #bjbd7 after fiscal year #bjjf2 and 7,b7 in subclause 7,,ii71 by inserting 7or1 with respect to discharges occurring on or after ,october #a1 #bjbe1 the first cost reporting period beginning on or after such date7 after ,january #a1 #bjji4 #ajf4 ,implementing area wage index adjustments 7a7 ,codification of low-,wage index hospital policy ,section #ahhf7;d77#c77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#c77;,e77 is amended by adding at the end the following new clause3 7v7 ,low-wage hospitals ,for discharges occurring on or after ,october #a1 #bjbe1 the area wage index applicable under this subparagraph for a fiscal year to a hospital with an area wage index below the #beth percentile area wage index shall be increased by of the difference between the otherwise applicable final area wage index for such fiscal year for such hospital and the #beth percentile area wage index for such fiscal year across all hospitals4 ,pursuant to the fourth sentence of clause 7i71 the preceding sentence shall be applied in a budget neutral manner4 4 7b7 ,area wage adjustment for hospitals not located in frontier ,states 7#a7 ,hospital inpatient services ,section #ahhf7;d77#c77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#c77;,e771 as amended by subsection 7a71 is further amended by adding at the end the following new clause3 7vi7 ,floor on area wage index for hospitals in certain other areas 7,i7 ,in general ,for discharges occurring on or after ,october #a1 #bjbe1 the area wage index applicable under this subparagraph to any hospital which is not located in a frontier ,state 7as defined in clause 7iii77,,ii77 may not be less than #j4he4 7,,ii7 ,ensuring budget neutrality ,in order to ensure that the aggregate payments made under this subsection for a fiscal year 7beginning with fiscal year #bjbf7 are not greater than the aggregate payments that would have been made under this subsection for such fiscal year without the application of subclause 7,i71 as estimated by the ,secretary1 the ,secretary shall establish pursuant to rulemaking a maximum area wage index to apply under this subparagraph to any hospital which is not located in a frontier ,state 7as defined in clause 7iii77,,ii774 7,,iii7 ,no impact for hospitals with an area wage index between the floor and the maximum index ,subclauses 7,i7 and 7,,ii7 shall have no effect on the area wage index applicable in a fiscal year to a hospital with an area wage index that is greater than the floor under subclause 7,i7 but less than the maximum area wage index established under subclause 7,,ii7 for the fiscal year4 4 7#b7 ,hospital outpatient department services ,section #ahcc7t7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t771 is amended-- 7,a7 in paragraph 7#b77;,d71 by striking paragraph 7#ai7 and inserting paragraphs 7#ai7 and 7#bc72 and 7,b7 by adding at the end the following new paragraph3 7#bc7 ,floor on area wage adjustment factor for hospital outpatient department services in areas other than in frontier states 7,a7 ,in general ,with respect to covered ,,opd services furnished on or after ,january #a1 #bjbf1 the area wage adjustment factor applicable under the payment system established under this subsection to any hospital outpatient department which is not located in a frontier ,state 7as defined in section #ahhf7;d77#c77;,e77iii77,,ii77 may not be less than #j4he4 7,b7 ,ensuring budget neutrality ,in order to ensure that the aggregate payments made under this subsection for a year 7beginning with #bjbf7 are not greater than the aggregate payments that would have been made under this subsection for such year without the application of subparagraph 7,a71 as estimated by the ,secretary1 the ,secretary shall establish pursuant to rulemaking a maximum area wage adjustment factor to apply under the payment system established under this subsection to any hospital outpatient department which is not located in a frontier ,state 7as defined in clause 7iii77,,ii774 7,c7 ,no impact for hospitals with an area wage adjustment factor between the floor and the maximum factor ,subparagraphs 7,a7 and 7,b7 shall have no effect on the area wage adjustment factor applicable in a year to a hospital with an area wage adjustment factor that is greater than the floor under subparagraph 7,a7 but less than the maximum area wage adjustment factor established under subparagraph 7,b7 for the year4 4 7c7 ,conforming amendments ,section #ahhf7;d77#c77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#c77;,e771 as amended by subsections 7a7 and 7b71 is further amended-- 7#a7 in clause 7i71 by striking or 7iv7 and inserting 7iv71 7v71 or 7vi72 7#b7 in clause 7iii71 by adjusting the margins of such clause #b ems to the left2 and 7#c7 in clause 7iv71 by adjusting the margins of such clause #b ems to the left4 ,b ,other rural providers #aaa4 ,making permanent increased ,medicare payments for ground ambulance services in rural areas ,section #ahcd7l77#ac7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7l77#ac77 is amended-- 7#a7 in the paragraph heading1 by striking ,temporary increase and inserting ,increase2 and 7#b7 in subparagraph 7,a7-- 7,a7 in the matter preceding clause 7i71 by striking 1 and before ,october #a1 #bjbe2 and 7,b7 in clause 7i71 by striking 1 and before ,october #a1 #bjbe4 #aab4 ,permanently extending ,medicare telehealth service enhancements for federally qualified health centers and rural health clinics ,section #ahcd7m77#h7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciem7m77#h77 is amended-- 7#a7 in subparagraph 7,a7-- 7,a7 in the matter preceding clause 7i71 by striking ,during the emergency period described in section #aace7;g77#a77;,b7 and1 in the case that such emergency period ends before ,december #ca1 #bjbd1 during the period beginning on the first day after the end of such emergency period and ending on ,september #cj1 #bjbe and inserting ,beginning on the first day of the emergency period described in section #aace7;g77#a77;,b72 and 7,b7 in clause 7ii71 by striking determined under subparagraph 7,b7 and inserting 1 for services furnished during the period beginning on the first day of the emergency period described in section #aace7;g77#a77;,b7 and ending on the date that is #fj days after the date of the enactment of the ,save ,america's ,rural ,hospitals ,act1 determined under subparagraph 7,b7 and1 for services furnished after such period1 an amount equal to the amount that such center or clinic would have been paid under this title had such services been furnished without the use of a telecommunications system2 and 7#b7 in subparagraph 7,b7-- 7,a7 by striking payment rule and all that follows through ,the ,secretary shall and inserting payment rule4--,the ,secretary shall2 7,b7 by striking during the periods for which subparagraph 7,a7 applies and inserting during the period described in subparagraph 7,a77ii72 and 7,c7 by redesignating clause 7ii7 as subparagraph 7,c71 and adjusting the margin accordingly4 #aac4 ,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 ,save ,america's ,rural ,hospitals ,act 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 #b 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 #aac7;b7 of the ,save ,america's ,rural ,hospitals ,act1 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 of section #ahbj7;c77#b77;,b77i7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#d7;c77#b77;,b77i774 ,,ii ,rural ,medicare beneficiary equity #bja4 ,equalizing beneficiary copayments for services furnished by ,c,a,hs 7a7 ,in general ,section #ahff7;a77#b77;,a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;cc7a77#b77;,a77 is amended by adding at the end the following3 ,in the case of outpatient critical access hospital services for which payment is made under section #ahcd7;g71 clause 7ii7 of the first sentence shall be applied by substituting #bj percent of the lesser of the actual charge or the payment basis under this part for such services if the critical access hospital were treated as a hospital for #bj per centum of the reasonable charges for such items and services44 7b7 ,applicability ,the amendment made by this section applies with respect to services furnished during a year that begins more than #fj days after the date of the enactment of this ,act4 ,,iii ,regulatory relief #cja4 ,eliminating #if-;hour requirements with respect to inpatient ,,cah services 7a7 ,physician certification requirement ,section #ahad7;a7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77 is amended-- 7#a7 in paragraph 7#f71 by adding and at the end2 7#b7 in paragraph 7#g77;,e71 by striking 2 and and inserting a period2 and 7#c7 by striking paragraph 7#h74 7b7 ,average length of stay requirement ,section #ahbj7;c77#b77;,b77iii7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#d7;c77#b77;,b77iii77 is amended by striking for providing inpatient care for a period that does not exceed1 as determined on an annual1 average basis1 #if hours per patient4 7c7 ,applicability ,the amendments made by this section apply with respect to services furnished during a year that begins more than #fj days after the date of the enactment of this ,act4 #cjb4 ,eliminating hospitalization requirement for extended care services furnished by certain hospitals ,section #ahab7;f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;d7f77 is amended by adding at the end the following new paragraph3 7#c7 ,the ,secretary shall provide for coverage under subsection 7a77#b77;,b7 of extended care services 7that are not posthospital extended care services7 furnished on or after the date that is #fj days after the date of the enactment of this paragraph by a hospital described in subsection 7b7 of section #ahhc pursuant to an agreement under such section for such a duration as the ,secretary determines appropriate such that the coverage of such services for such duration does not alter the acute care nature of the benefit described in subsection 7a77#b74 4 ,,iv ,future of rural health care #dja4 ,medicare rural hospital flexibility program grants ,section #ahbj7;g7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#d7;g77 is amended-- 7#a7 in paragraph 7#a7-- 7,a7 in subparagraph 7,c71 by striking and at the end2 7,b7 in subparagraph 7,d71 by striking the period at the end and inserting a semicolon2 and 7,c7 by adding at the end the following new subparagraphs3 7,e7 rural emergency hospitals providing support for critical access hospitals to convert to rural emergency hospitals to stabilize hospital emergency services in their communities2 and 7,f7 supporting certified rural health clinics for maintaining and building business operations1 increasing financial indicators1 addressing population health1 transforming services1 and providing linkages and services for behavioral health and substance use disorders responding to public health emergencies4 2 7#b7 by redesignating paragraphs 7#c7 through 7#g7 as paragraphs 7#d7 through 7#h71 respectively2 7#c7 after paragraph 7#b71 by inserting the following new paragraph3 7#c7 ,activities to support carrying out ,,flex grants ,the ,secretary may award grants or cooperative agreements to entities that submit to the ,secretary applications1 at such time and in such form and manner and containing such information as the ,secretary specifies1 for purposes of supporting ,states and hospitals in carrying out the activities under this subsection by providing technical assistance1 data analysis1 and evaluation efforts4 2 7#d7 in paragraph 7#d71 as redesignated-- 7,a7 in subparagraph 7,a71 by inserting ,state ,offices of ,rural ,health on behalf of eligible hospitals and after award grants to2 7,b7 by amending subparagraph 7,c7 to read as follows3 7,c7 ,application ,the ,state ,office of ,rural ,health shall submit an application1 on behalf of eligible rural hospitals1 to the ,secretary on or before such date and in such form and manner as the ,secretary specifies4 2 7,c7 by amending subparagraph 7,d71 to read as follows3 7,d7 ,amount of grant ,a grant to a hospital under this paragraph shall be determined on an equal national distribution so that each hospital receives the same amount of support related to the funds appropriated4 2 7,d7 by amending subparagraph 7,e71 to read as follows3 7,e7 ,use of funds ,state ,offices of ,rural ,health and eligible hospitals may use the funds received through a grant under this paragraph for the purchase of computer software and hardware2 the education and training of hospital staff on billing1 operational1 quality improvement and related value-focused efforts2 and other delivery system reform programs determined appropriate by the ,secretary4 2 and 7#e7 by adding at the end the following new paragraph3 7#i7 ,rural ,health ,transformation ,grants 7,a7 ,grants ,the ,secretary may award #e-year grants to ,state ,offices of ,rural ,health and to eligible rural health care providers 7as defined in subparagraph 7,d77 on the transition to new models1 including rural emergency hospitals1 extended stay clinics1 freestanding emergency departments1 rural health clinics1 and integration of behavioral1 oral health services1 telehealth and other transformational models relevant to rural providers as such providers evolve to better meet community needs and the changing health care environment4 7,b7 ,application ,an applicable rural health care provider1 in partnership with the ,state ,office of ,rural ,health in the ,state in which the rural health care provider seeking a grant under this paragraph is located1 shall submit an application to the ,secretary on or before such date and in such form and manner as the ,secretary specifies4 7,c7 ,additional requirements ,the ,secretary may not award a grant under this paragraph to an eligible rural health care provider unless-- 7i7 local organizations or the ,state in which the hospital is located provides support 7either direct or in kind72 and there are letters of support from key ,state payers such as ,medicaid and private insurance2 and 7ii7 the applicant describes in detail how the transition of the health care provider or providers will better meet local needs and be sustainable4 7,d7 ,eligible rural health care provider defined ,for purposes of this paragraph1 the term eligible rural health care provider includes a critical access hospital1 a certified rural health clinic1 a rural nursing home1 skilled nursing facility1 emergency care provider1 or other entity identified by the ,secretary4 ,an eligible rural health care provider may include other entities applying on behalf of a group of providers such as a ,state ,office of ,rural ,health1 a ,state or local health care authority1 a rural health network1 or other entity identified by the ,secretary4 4