,i #aai? ,,congress #a/ ,session ,h4 ,r4 #cfhd ,,9 ,,! ,,h\se ,,( ,,repres5tatives ,june #c1 #bjbe,mr4 ,graves 7= himself & ,ms4 ,budz9ski7 introduc$ ! foll[+ bill2 :i* 0 ref]r$ to ! ,committee on ,ways & ,means1 & 9 addition to ! ,committees on ,en]gy & ,comm]ce1 & ! ,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 ,z ( ,may #a1 #bjbe1 #aea rural hospitals h 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$ & ?irty-two 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 ,) ! #dcb 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$ic>e seque/ration = rural hospitals4,sec4 #ajb4 ,rev]s+ cuts to reimbursem5t ( bad debt = critical access hospitals 7,c,a,hs7 & rural hospitals4,sec4 #ajc4 ,p]man5tly ext5d+ paym5t levels = l[-volume hospitals & ,m$ic>e-dep5d5t hospitals 7,m,d,hs74,sec4 #ajd4 ,ext5d+ disproportionate %>e paym5ts = sole community hospitals & m$ic>e-dep5d5t hospitals4,sec4 #aje4 ,rebas+ t>get am\nts = ,m$ic>e-dep5d5t hospitals & sole community hospitals4,sec4 #ajf4 ,implem5t+ area wage index adju/m5ts4,subtitle ,b--,o!r rural providers,sec4 #aaa4 ,mak+ p]man5t increas$ ,m$ic>e paym5ts = gr\nd ambulance s]vices 9 rural areas4,sec4 #aab4 ,p]man5tly ext5d+ ,m$ic>e teleheal? s]vice enhancem5ts = f$]ally qualifi$ heal? c5t]s & rural heal? cl9ics4,sec4 #aac4 ,re/or+ ,/ate au?ority to waive ! #ce-mile rule = c]ta9 ,m$ic>e critical access hospital designations4,title ,,ii--,rural ,m$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 requirem5ts ) respect to inpati5t ,,cah s]vices4,sec4 #cjb4 ,elim9at+ hospitalization requirem5t = ext5d$ c>e s]vices furni%$ by c]ta9 hospitals4,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 7z def9$ 9 section #ahhf7;d77#a77;,b7 ( su* ,act7 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 at ! end ! 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+ 1 a critical access hospital aft] or 7,v74 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 ,p]man5tly 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$-- 7,a7 9 clause 7i71 by /rik+ 1 & be=e ,octob] #a1 #bjbe2 & 7,b7 9 clause 7ii77,,ii71 by /rik+ 1 & be=e ,octob] #a1 #bjbe4 7#b7 ,con=m+ am5dm5ts 7,a7 ,ext5sion ( t>get am\nt ,section #ahhf7;b77#c77;,d7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77;,d77 is am5d$-- 7i7 9 ! matt] prec$+ clause 7i71 by /rik+ 1 & be=e ,octob] #a1 #bjbe2 & 7ii7 9 clause 7iv71 by /rik+ ?r\gh fiscal ye> #bjbe & ins]t+ or a subsequ5t fiscal ye>4 7,b7 ,ext5d+ ! p]iod dur+ :i* hospitals c decl9e reclassification z urban ,section #aceja7;e77#b7 ( ! ,omnibus ,budget ,reconciliation ,act ( #aiic 7#db ,u4,s4,c4 #acieww note7 is am5d$ by /rik+ ?r\gh fiscal ye> #bjbe & ins]t+ 1 or 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$-- 7#a7 9 subp>agraph 7,b7-- 7,a7 9 ! subp>agraph head+1 by ins]t+ = fiscal ye>s #bjje ?r\gh #bjaj aft] increase2 & 7,b7 9 ! matt] prec$+ clause 7i71 by /rik+ & = dis*>ges occurr+ 9 fiscal ye> #bjbf & subsequ5t fiscal ye>s2 7#b7 9 subp>agraph 7,c77i7-- 7,a7 9 ! matt] prec$+ subclause 7,i71 by /rik+ ?r\gh #bjbe & ins]t+ & ea* subsequ5t fiscal ye>2 7,b7 9 subclause 7,,ii71 by add+ & at ! end2 7,c7 9 subclause 7,,iii7-- 7i7 by /rik+ fiscal ye>s #bjai ?r\gh #bjbe & ins]t+ fiscal ye> #bjai & ea* subsequ5t fiscal ye>2 & 7ii7 by /rik+ 2 & & ins]t+ a p]iod2 & 7,d7 by /rik+ subclause 7,,iv72 & 7#c7 9 subp>agraph 7,d7-- 7,a7 by am5d+ ! head+ to read z foll[s3 ,p]man5t ,applicable p]c5tage increase2 7,b7 9 ! matt] prec$+ clause 7i71 by /rik+ 9 fiscal ye>s #bjaa ?r\gh #bjbe & 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 #bjbe & ins]t+ fiscal ye> #bjai & ea* subsequ5t fiscal ye>4 #ajd4 ,ext5d+ disproportionate %>e paym5ts = sole community hospitals & m$ic>e-dep5d5t hospitals ,section #ahhf ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7 is am5d$-- 7#a7 9 subsection 7d77#e77;,f77i71 by ins]t+ 1 includ+1 ) respect to dis*>ges occurr+ 9 fiscal ye> #bjbf & ea* subsequ5t fiscal ye>1 a subsection 7d7 hospitals t is a sole community hospitals paid ! am\nt describ$ 9 subp>agraph 7,d77i77,i7 or a m$ic>e-dep5d5t1 small rural hospital paid ! am\nt describ$ 9 subp>agraph 7,g71 aft] subsection 7d7 hospital2 & 7#b7 9 subsection 7r77#b71 by ins]t+ 7includ+1 ) respect to fiscal ye> #bjbf & ea* subsequ5t fiscal ye>1 subsection 7d7 hospitals t are sole community hospitals or m$ic>e-dep5d5t1 small rural hospitals describ$ 9 subsection 7d77#e77;,f77i77 aft] su* subsection 7d7 hospitals4 #aje4 ,rebas+ t>get am\nts = ,m$ic>e-dep5d5t hospitals & sole community hospitals ,section #ahhf7;b77#c7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7b77#c77 is am5d$-- 7#a7 9 subp>agraph 7,k77i7-- 7,a7 9 subclause 7,i71 by ins]t+ 7or1 ) respect to dis*>ges occurr+ on or aft] ,octob] #a1 #bjbe1 ! #ab-mon? co/ report+ p]iod beg9n+ dur+ fiscal ye> #bjbd7 aft] fiscal ye> #bjjb2 & 7,b7 9 subclause 7,,ii71 by ins]t+ 7or1 ) respect to dis*>ges occurr+ on or aft] ,octob] #a1 #bjbe1 ! fir/ co/ report+ p]iod beg9n+ on or aft] su* date7 aft] ,octob] #a1 #bjjf2 & 7#b7 9 subp>agraph 7,l77ii7-- 7,a7 9 subclause 7,i71 by ins]t+ 7or1 ) respect to dis*>ges occurr+ on or aft] ,octob] #a1 #bjbe1 ! #ab-mon? co/ report+ p]iod beg9n+ dur+ fiscal ye> #bjbd7 aft] fiscal ye> #bjjf2 & 7,b7 9 subclause 7,,ii71 by ins]t+ 7or1 ) respect to dis*>ges occurr+ on or aft] ,octob] #a1 #bjbe1 ! fir/ co/ report+ p]iod beg9n+ on or aft] su* date7 aft] ,janu>y #a1 #bjji4 #ajf4 ,implem5t+ area wage index adju/m5ts 7a7 ,codification ( l[-,wage index hospital policy ,section #ahhf7;d77#c77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#c77;,e77 is am5d$ by add+ at ! end ! foll[+ new clause3 7v7 ,l[-wage hospitals ,= dis*>ges occurr+ on or aft] ,octob] #a1 #bjbe1 ! area wage index applicable "u ?is subp>agraph = a fiscal ye> to a hospital ) an area wage index bel[ ! #be? p]c5tile area wage index %all be increas$ by ( ! diff]5ce betwe5 ! o!rwise applicable f9al area wage index = su* fiscal ye> = su* hospital & ! #be? p]c5tile area wage index = su* fiscal ye> across all hospitals4 ,pursuant to ! f\r? s5t5ce ( clause 7i71 ! prec$+ s5t5ce %all be appli$ 9 a budget neutral mann]4 4 7b7 ,area wage adju/m5t = hospitals n locat$ 9 fronti] ,/ates 7#a7 ,hospital inpati5t s]vices ,section #ahhf7;d77#c77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#c77;,e771 z am5d$ by subsection 7a71 is fur!r am5d$ by add+ at ! end ! foll[+ new clause3 7vi7 ,floor on area wage index = hospitals 9 c]ta9 o!r areas 7,i7 ,9 g5]al ,= dis*>ges occurr+ on or aft] ,octob] #a1 #bjbe1 ! area wage index applicable "u ?is subp>agraph to any hospital :i* is n locat$ 9 a fronti] ,/ate 7z def9$ 9 clause 7iii77,,ii77 may n be less ?an #j4he4 7,,ii7 ,ensur+ budget neutrality ,9 ord] to ensure t ! aggregate paym5ts made "u ?is subsection = a fiscal ye> 7beg9n+ ) fiscal ye> #bjbf7 are n great] ?an ! aggregate paym5ts t w\ld h be5 made "u ?is subsection = su* fiscal ye> )\t ! application ( subclause 7,i71 z e/imat$ by ! ,secret>y1 ! ,secret>y %all e/abli% pursuant to rulemak+ a maximum area wage index to apply "u ?is subp>agraph to any hospital :i* is n locat$ 9 a fronti] ,/ate 7z def9$ 9 clause 7iii77,,ii774 7,,iii7 ,no impact = hospitals ) an area wage index betwe5 ! floor & ! maximum index ,subclauses 7,i7 & 7,,ii7 %all h no effect on ! area wage index applicable 9 a fiscal ye> to a hospital ) an area wage index t is great] ?an ! floor "u subclause 7,i7 b less ?an ! maximum area wage index e/abli%$ "u subclause 7,,ii7 = ! fiscal ye>4 4 7#b7 ,hospital outpati5t dep>tm5t s]vices ,section #ahcc7t7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciel7t771 is am5d$-- 7,a7 9 p>agraph 7#b77;,d71 by /rik+ p>agraph 7#ai7 & ins]t+ p>agraphs 7#ai7 & 7#bc72 & 7,b7 by add+ at ! end ! foll[+ new p>agraph3 7#bc7 ,floor on area wage adju/m5t factor = hospital outpati5t dep>tm5t s]vices 9 areas o!r ?an 9 fronti] /ates 7,a7 ,9 g5]al ,) respect to cov]$ ,,opd s]vices furni%$ on or aft] ,janu>y #a1 #bjbf1 ! area wage adju/m5t factor applicable "u ! paym5t sy/em e/abli%$ "u ?is subsection to any hospital outpati5t dep>tm5t :i* is n locat$ 9 a fronti] ,/ate 7z def9$ 9 section #ahhf7;d77#c77;,e77iii77,,ii77 may n be less ?an #j4he4 7,b7 ,ensur+ budget neutrality ,9 ord] to ensure t ! aggregate paym5ts made "u ?is subsection = a ye> 7beg9n+ ) #bjbf7 are n great] ?an ! aggregate paym5ts t w\ld h be5 made "u ?is subsection = su* ye> )\t ! application ( subp>agraph 7,a71 z e/imat$ by ! ,secret>y1 ! ,secret>y %all e/abli% pursuant to rulemak+ a maximum area wage adju/m5t factor to apply "u ! paym5t sy/em e/abli%$ "u ?is subsection to any hospital outpati5t dep>tm5t :i* is n locat$ 9 a fronti] ,/ate 7z def9$ 9 clause 7iii77,,ii774 7,c7 ,no impact = hospitals ) an area wage adju/m5t factor betwe5 ! floor & ! maximum factor ,subp>agraphs 7,a7 & 7,b7 %all h no effect on ! area wage adju/m5t factor applicable 9 a ye> to a hospital ) an area wage adju/m5t factor t is great] ?an ! floor "u subp>agraph 7,a7 b less ?an ! maximum area wage adju/m5t factor e/abli%$ "u subp>agraph 7,b7 = ! ye>4 4 7c7 ,con=m+ am5dm5ts ,section #ahhf7;d77#c77;,e7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acieww7d77#c77;,e771 z am5d$ by subsections 7a7 & 7b71 is fur!r am5d$-- 7#a7 9 clause 7i71 by /rik+ or 7iv7 & ins]t+ 7iv71 7v71 or 7vi72 7#b7 9 clause 7iii71 by adju/+ ! m>g9s ( su* clause #b ems to ! left2 & 7#c7 9 clause 7iv71 by adju/+ ! m>g9s ( su* clause #b ems to ! left4 ,b ,o!r rural provid]s #aaa4 ,mak+ p]man5t increas$ ,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$+ clause 7i71 by /rik+ 1 & be=e ,octob] #a1 #bjbe2 & 7,b7 9 clause 7i71 by /rik+ 1 & be=e ,octob] #a1 #bjbe4 #aab4 ,p]man5tly ext5d+ ,m$ic>e teleheal? s]vice enhancem5ts = f$]ally qualifi$ heal? c5t]s & rural heal? cl9ics ,section #ahcd7m77#h7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #aciem7m77#h77 is am5d$-- 7#a7 9 subp>agraph 7,a7-- 7,a7 9 ! matt] prec$+ clause 7i71 by /rik+ ,dur+ ! em]g5cy p]iod describ$ 9 section #aace7;g77#a77;,b7 &1 9 ! case t su* em]g5cy p]iod ends be=e ,decemb] #ca1 #bjbd1 dur+ ! p]iod beg9n+ on ! fir/ day aft] ! end ( su* em]g5cy p]iod & end+ on ,septemb] #cj1 #bjbe & ins]t+ ,beg9n+ on ! fir/ day ( ! em]g5cy p]iod describ$ 9 section #aace7;g77#a77;,b72 & 7,b7 9 clause 7ii71 by /rik+ det]m9$ "u subp>agraph 7,b7 & ins]t+ 1 = s]vices furni%$ dur+ ! p]iod beg9n+ on ! fir/ day ( ! em]g5cy p]iod describ$ 9 section #aace7;g77#a77;,b7 & end+ on ! date t is #fj days aft] ! date ( ! enactm5t ( ! ,save ,am]ica's ,rural ,hospitals ,act1 det]m9$ "u subp>agraph 7,b7 &1 = s]vices furni%$ aft] su* p]iod1 an am\nt equal to ! am\nt t su* c5t] or cl9ic w\ld h be5 paid "u ?is title _h su* s]vices be5 furni%$ )\t ! use ( a telecommunications sy/em2 & 7#b7 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 /rik+ dur+ ! p]iods = :i* subp>agraph 7,a7 applies & ins]t+ dur+ ! p]iod describ$ 9 subp>agraph 7,a77ii72 & 7,c7 by r$esignat+ clause 7ii7 z subp>agraph 7,c71 & adju/+ ! m>g9 accord+ly4 #aac4 ,re/or+ ,/ate au?ority to waive ! #ce-mile rule = c]ta9 ,m$ic>e critical access hospital designations 7a7 ,9 g5]al ,section #ahbj ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#d7 is am5d$-- 7#a7 9 subsection 7c77#b7-- 7,a7 9 subp>agraph 7,b77i7-- 7i7 9 subclause 7,i71 by /rik+ at ! end or2 7ii7 9 subclause 7,,ii71 by ins]t+ at ! end or2 & 7iii7 by add+ at ! end ! foll[+ new subclause3 7,,iii7 subject to subp>agraph 7,g71 is a hospital describ$ 9 subp>agraph 7,f7 & is c]tifi$ on or aft] ! date ( ! enactm5t ( ! ,save ,am]ica's ,rural ,hospitals ,act by ! ,/ate z be+ a necess>y provid] ( heal? c>e s]vices to resid5ts 9 ! area2 2 & 7,b7 by add+ at ! end ! foll[+ new subp>agraphs3 7,f7 ,hospital describ$ ,= purposes ( subp>agraph 7,b77i77,,iii71 a hospital describ$ 9 ?is subp>agraph is a hospital t-- 7i7 is a sole community hospital 7z def9$ 9 section #ahhf7;d77#e77;,d77iii771 a m$ic>e-dep5d5t1 small rural hospital 7z def9$ 9 section #ahhf7;d77#e77;,g77iv771 a l[-volume hospital t 9 #bjba receives a paym5t adju/m5t "u section #ahhf7;d77#ab71 a subsection 7d7 hospital 7z def9$ 9 section #ahhf7;d77#a77;,b77 t has few] ?an #ej b$s1 or1 subject to ! limitation "u subp>agraph 7,g77i77,i71 is a facility describ$ 9 subp>agraph 7,g77ii72 7ii7 is locat$ 9 a rural area1 z def9$ 9 section #ahhf7;d77#b77;,d72 7iii7 7,i7 is locat$-- 7aa7 9 a c\nty t has a p]c5tage ( individuals ) income t is bel[ #aej p]c5t ( ! pov]ty l9e t is high] ?an ! national or /atewide av]age 9 #bjbj2 or 7bb7 9 a heal? pr(essional %ortage area 7z def9$ 9 section #ccb7;a77#a77;,a7 ( ! ,public ,heal? ,s]vice ,act72 or 7,,ii7 has a p]c5tage ( inpati5t days ( individuals entitl$ to b5efits "u "p ,a ( ?is title1 enroll$ "u "p ,b ( ?is title1 or enroll$ "u a ,/ate plan "u title ,,xix t is high] ?an ! national or /atewide av]age 9 #bjai or #bjbj2 7iv7 subject to subp>agraph 7,g77ii77,,ii71 has atte/$ to ! ,secret>y #b consecutive ye>s ( negative op]at+ m>g9s prec$+ ! date ( c]tification describ$ 9 subp>agraph 7,b77i77,,iii72 & 7v7 submits to ! ,secret>y-- 7,i7 at su* "t & 9 su* mann] z ! ,secret>y may require1 an atte/ation outl9+ ! good gov]nance qualifications & /rategic plan = multi-ye> f9ancial solv5cy ( ! hospital2 & 7,,ii7 n lat] ?an #abj days aft] ! date on :i* ! ,secret>y issues f9al regulations pursuant to section #aac7;b7 ( ! ,save ,am]ica's ,rural ,hospitals ,act1 an application = c]tification ( ! facility z a critical access hospital4 7,g7 ,limitation on c]ta9 designations 7i7 ,9 g5]al ,! ,secret>y may n "u subsection 7e7 c]tify pursuant to a c]tification by a ,/ate "u subp>agraph 7,b77i77,,iii7-- 7,i7 m ?an a total ( #age facilities z critical access hospitals1 ( :i* n m ?an #bj p]c5t may be facilities describ$ 9 clause 7ii72 & 7,,ii7 )9 any "o ,/ate1 m ?an #aj facilities z critical access hospitals4 7ii7 ,facility describ$ 7,i7 ,9 g5]al ,a facility describ$ 9 ?is clause is a facility t z ( ! date ( enactm5t ( ?is subp>agraph met ! crit]ia = designation z a critical access hospital "u subp>agraph 7,b77i77,i74 7,,ii7 ,nonapplication ( c]ta9 crit]ia ,= purposes ( subp>agraph 7,b77i77,,iii71 ! crit]ia describ$ 9 subp>agraph 7,f77iv7 %all n apply ) respect to ! designation ( a facility describ$ 9 subclause 7,i74 2 & 7#b7 9 subsection 7e71 by ins]t+ 1 subject to subsection 7c77#b77;,g71 aft] ,! ,secret>y %all4 7b7 ,regulations ,n lat] ?an #abj days aft] ! date ( ! enactm5t ( ?is ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices %all issue f9al regulations to c>ry out ?is section4 7c7 ,cl>ification reg>d+ facilities t meet di/ance or o!r c]tification crit]ia ,no?+ 9 ?is section %all affect ! application ( crit]ia = designation z a critical access hospital describ$ 9 subclause 7,i7 or 7,,ii7 ( section #ahbj7;c77#b77;,b77i7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#d7;c77#b77;,b77i774 ,,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 requirem5ts ) respect to inpati5t ,,cah s]vices 7a7 ,physician c]tification requirem5t ,section #ahad7;a7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;f7a77 is am5d$-- 7#a7 9 p>agraph 7#f71 by add+ & at ! end2 7#b7 9 p>agraph 7#g77;,e71 by /rik+ 2 & & ins]t+ a p]iod2 & 7#c7 by /rik+ p>agraph 7#h74 7b7 ,av]age l5g? ( /ay requirem5t ,section #ahbj7;c77#b77;,b77iii7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;i-#d7;c77#b77;,b77iii77 is am5d$ by /rik+ = provid+ inpati5t c>e = a p]iod t does n exce$1 z det]m9$ on an annual1 av]age basis1 #if h\rs p] pati5t4 7c7 ,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 ,elim9at+ hospitalization requirem5t = ext5d$ c>e s]vices furni%$ by c]ta9 hospitals ,section #ahab7;f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie;d7f77 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#c7 ,! ,secret>y %all provide = cov]age "u subsection 7a77#b77;,b7 ( ext5d$ c>e s]vices 7t are n po/hospital ext5d$ c>e s]vices7 furni%$ on or aft] ! date t is #fj days aft] ! date ( ! enactm5t ( ?is p>agraph by a hospital describ$ 9 subsection 7b7 ( section #ahhc pursuant to an agreem5t "u su* section = su* a duration z ! ,secret>y det]m9es appropriate su* t ! cov]age ( su* s]vices = su* duration does n alt] ! acute c>e nature ( ! b5efit describ$ 9 subsection 7a77#b74 4 ,,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,d77 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