,,ii  #aai? ,,congress  #a/ ,session    
,s4 #ejb  ,,9 ,,! ,,s5ate ,,( ,,!       
,,unit$ ,,/ates  ,febru>y #aj1 #bjbe,mr4
 ,durb9 7= himself1 ,mr4 ,lank=d1 & ,ms4
 ,smi?7 introduc$ ! foll[+ bill2 :i* 0  
read twice & ref]r$ to ! ,committee on  
,f9ance  ,a ,,bill  ,to am5d title      
,,xviii ( ! ,social ,security ,act to   
re/ore ,/ate au?ority to waive = c]ta9  
facilities ! #ce-mile rule = designat+  
critical access hospitals "u ! ,m$ic>e  
program1 & = o!r purposes4  #a4 ,%ort   
title ,?is ,act may be cit$ z ! ,rural  
,hospital ,closure ,relief ,act ( #bjbe4
  #b4 ,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+ or at !  
end2  7ii7 9 subclause 7,,ii71 by ins]t+
 or at ! end2 &  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$1 on or aft] ! date ( ! enactm5t 
( ! ,rural ,hospital ,closure ,relief   
,act ( #bjbe1 & be=e ! date t is #i ye>s
 aft] ! date ( enactm5t ( ?is subclause1
 by ! ,/ate z be+ a necess>y provid] (  
heal? c>e s]vices to resid5ts 9 ! area2 
2 &  7,b7 by add+ at ! end ! foll[+ new 
subp>agraphs3  7,f7 ,hospital describ$  
,= 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 or a subsection 7d7     
hospital 7z def9$ 9 section             
#ahhf7;d77#a77;,b772  7ii7 is locat$ 9 a
 rural area1 z def9$ 9 section          
#ahhf7;d77#b77;,d71 or a rural c5sus    
tract ( a metropolitan /ati/ical area 7z

 det]m9$ "u ! mo/ rec5t modification ( !
 ,goldsmi? ,modification1 orig9ally     
publi%$ 9 ! ,f$]al ,regi/] on ,febru>y  
#bg1 #aiib 7#eg ,f$4 ,reg4 #fgbe772     
7iii7 7,i7 is locat$-- 7aa7 9 a c\nty t 
has a p]c5tage ( individuals ) income at
 or bel[ ! ,f$]al pov]ty level 9 #bjbc  
or #bjbd t is high] ?an ! national or   
/atewide av]age 9 t ye>2 or  7bb7 9 a   
heal? pr(essional %ortage area 7z def9$ 
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 title 
9 #bjbc or #bjbd t is high] ?an !       
national or /atewide av]age 9 t ye>2    
7iv7 has atte/$ to ! ,secret>y t !      
hospital-- 7,i7 0 op]at+ z ( ! date (   
enactm5t ( ?is subp>agraph2 &  7,,ii7 _h
 #b consecutive ye>s ( negative op]at+  
m>g9s prec$+ ! date ( c]tification      
describ$ 9 subp>agraph 7,b77i77,,iii71 z
 def9$ by ! ,secret>y 9 ! regulations or
 program in/ruction issu$ pursuant to   
section #b7;b7 ( ! ,rural ,hospital     

,closure ,relief ,act ( #bjbe2 &  7v7   
submits to ! ,secret>y1 at su* "t & 9   
su* mann] z ! ,secret>y may require1 an 
application = c]tification ( ! facility 
z a critical access hospital1 includ+ an
 atte/ation outl9+-- 7,i7 ! good        
gov]nance qualifications & /rategic plan
 = multi-ye> f9ancial solv5cy ( !       
hospital2 &  7,,ii7 ! hospital's        
commitm5t to op5 & ma9ta91 = ! duration 
( ! hospital's designation z a critical 
access hospital "u ?is section1 a new   
s]vice l9e or exp&$ s]vice capacity = a 
s]vice t is 9 high dem& or limit$ supply
 9 ! hospital's s]vice area 7det]m9$    
bas$ on ! hospital's mo/ rec5t community
 heal? ne$s assessm5t "u section        
#eja7r77#c7 ( ! ,int]nal ,rev5ue ,code (
 #aihf 7or o!r comp>able assessm5t771   
su* z ob/etrics or behavioral heal? c>e 
s]vices4  7,g7 ,limitation on c]ta9     
designations  7i7 ,9 g5]al ,subject to  
clauses 7ii7 & 7iii71 ! ,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 (   
#abj facilities z critical access       
hospitals2 &  7,,ii7 )9 any "o ,/ate1 m 
?an #e facilities z critical access     
hospitals4  7ii7 ,process ,! ,secret>y  
%all foll[ ! foll[+ process 9 c>ry+ out 
clause 7i7 ) respect to ea* ye> 9 :i* ! 
,secret>y det]m9es t ! limitation "u    
clause 7i77,i7 has n be5 rea*$3 7,i7    
,initial assessm5t ,! ,secret>y %all    
conduct an initial assessm5t ( ! total  
numb] ( hospitals describ$ 9 p>agraph   
7#b77;,f74  7,,ii7 ,initial allocation  
,( ! total numb] ( designations         
available "u clause 7i71 ! ,secret>y    
%all allocate #a = a hospital 9 ea*     
,/ate t ! ,secret>y det]m9es 7bas$ on ! 
initial assessm5t "u subclause 7,i77 has
 "o or m hospitals describ$ 9 p>agraph  
7#b77;,f74  7,,iii7 ,rema9+ allocation  
,( ! total numb] ( designations         
available "u clause 7i71 aft]           
application ( subclause 7,,ii71 !       
,secret>y %all allocate ! rema9+ numb]  
on a proportional basis bas$ on ! total 

numb] ( hospitals describ$ 9 p>agraph   
7#b77;,f7 9 ea* ,/ate t are eligible 7z 
det]m9$ bas$ on ! initial assessm5t "u  
subclause 7,i774  7iii7 ,sunset         
,effective beg9n+ on ! date t is #i ye>s
 aft] ! date ( enactm5t ( ?is           
subp>agraph1 ! ,secret>y may n c]tify a 
hospital z a critical access hospital   
pursuant to a c]tification by a ,/ate "u
 subp>agraph 7,b77i77,,iii74  7,h7      
,in=mation submission requirem5ts =     
hospitals c]tifi$ pursuant to ,rural    
,hospital ,closure ,relief ,act  7i7 ,9 
g5]al ,a critical access hospital t is  
c]tifi$ "u subsection 7e7 pursuant to a 
c]tification by a ,/ate "u subp>agraph  
7,b77i77,,iii7 %all submit to !         
,secret>y ! foll[+ at a "t1 & 9 a mann]1
 specifi$ by ! ,secret>y3 7,i7 ,reports 
,reports conta9+ su* in=mation z !      
,secret>y may specify ) respect to items
 & s]vices furni%$ z "p ( ! new s]vice  
l9e or exp&$ s]vice capacity = a s]vice 
z describ$ 9 ! atte/ation submitt$ by ! 
critical access hospital "u subp>agraph 

7,f77v77,,ii74 ,to ! ext5t practicable1 
! ,secret>y %all align su* report+ ) o!r
 report+ requirem5ts applicable to      
critical access hospitals "u ?is        
subsection4  7,,ii7 ,notice ,if !       
critical access hospital mat]ially      
*anges ! new s]vice l9e or exp&$        
capacity = a s]vice z s describ$1 notice
 ( su* *anges along ) a plan to         
satisfactorily ma9ta9 access to c>e 7z  
det]m9$ by ! ,secret>y74  7ii7          
,revocation ( c]tification =            
noncompliance ,if ! ,secret>y det]m9es t
 a critical access hospital describ$ 9  
clause 7i7 has fail$ to submit an annual
 report requir$ "u subclause 7,i7 ( su* 
clause or a notice requir$ "u subclause 
7,,ii7 ( su* clause1 ! ,secret>y may1 z 
! ,secret>y det]m9es appropriate1 revoke
 ! c]tification ( ! critical access     
hospital "u subsection 7e74  2 &  7#b7 9
 subsection 7e71 by ins]t+ 1 subject to 
subsection 7c77#b77;,g71 aft] ,!        
,secret>y %all4  7b7 ,implem5tation ,n  
lat] ?an #a ye> aft] ! date ( ! enactm5t

 ( ?is ,act1 ! ,secret>y ( ,heal? &     
,human ,s]vices %all issue f9al         
regulations or program in/ruction to    
c>ry out subsection 7a74  7c7           
,cl>ification reg>d+ facilities t meet  
di/ance or o!r crit]ia & application (  
o!r crit]ia ,no?+ 9 ?is section %all    
affect-- 7#a7 ! 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;,b77i772 or  7#b7 ! 
application ( crit]ia = designation z a 
critical access hospital describ$ 9     
clauses 7ii7 ?r\gh 7v7 ( section        
#ahbj7;c77#b77;,b7 ( ! ,social ,security
 ,act 7#db ,u4,s4,c4                    
#acie;i-#d7;c77#b77;,b774  7d7 ,,gao    
/udy & report  7#a7 ,/udy ,! ,comptroll]
 ,g5]al ( ! ,unit$ ,/ates 79 ?is section
 ref]r$ to z ! ,comptroll] ,g5]al7 %all 
conduct a /udy on ! implem5tation ( !   
am5dm5ts made by subsection 7a74 ,to !  
ext5t su* data are available & reliable1

 su* /udy %all include-- 7,a7 an        
analysis (-- 7i7 ! *>act]i/ics (        
facilities designat$ z critical access  
hospitals pursuant to section           
#ahbj7;c77#b77;,b77i77,,iii7 ( ! ,social
 ,security ,act1 z add$ by subsection   
7a72  7ii7 an analysis ( ! f9ancial     
/atus & outlook = su* facilities bas$ on
 _! designation z a critical access     
hospital pursuant to su* section2 &     
7iii7 an analysis ( any increase 9      
exp5ditures "u ! ,m$ic>e program "u     
title ,,xviii ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #acie et seq47 z a      
result ( su* designation1 relative to ! 
expect$ basel9e exp5ditures "u ! ,m$ic>e
 program if su* facilities _h n receiv$ 
su* designation2 &  7,b7 an assessm5t ( 
:e!r ! au?ority to designate facilities 
z critical access hospitals pursuant to 
su* section #ahbj7;c77#b77;,b77i77,,iii7
 promotes access to c>e 9 rural areas4  
7#b7 ,report ,n lat] ?an #f ye>s aft] ! 
date ( ! enactm5t ( ?is ,act1 !         
,comptroll] ,g5]al %all submit to       

,congress a report conta9+ ! results ( !
 /udy conduct$ "u subsection 7a71 toge!r
 ) recomm5dations = su* legislation &   
adm9i/rative action z ! ,comptroll]     
,g5]al det]m9es appropriate4  #c4       
,med,p,a,c /udy & report on paym5t      
sy/ems = rural hospitals  7a7 ,/udy ,!  
,m$ic>e ,paym5t ,advisory ,commission 79
 ?is section ref]r$ to z ! ,commission7 
%all conduct a /udy1 us+ data f #bjah   
?r\gh #bjbh1 on paym5t sy/ems = rural   
hospitals "u ! ,m$ic>e program "u title 
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie et seq474 ,su* /udy %all
 include an analysis (-- 7#a7 facilities
 designat$ z critical access hospitals  
pursuant to section                     
#ahbj7;c77#b77;,b77i77,,iii7 ( ! ,social
 ,security ,act1 z add$ by section      
#b7;a72  7#b7 features ( paym5t sy/ems =
 rural hospitals1 includ+ value-bas$    
paym5t sy/ems1 t w\ld-- 7,a7 ensure     
f9ancial su/a9ability = ! ,m$ic>e       
program2 &  7,b7 pres]ve access to c>e =
 ,m$ic>e b5efici>ies2 &  7#c7 if !      

,commission recomm5ds any new paym5t    
sy/em = rural hospitals "u ! ,m$ic>e    
program1 to ! ext5t feasible1 ! impacts 
( transition f exi/+ paym5t sy/ems to   
su* new paym5t sy/em4  7b7 ,report ,n   
lat] ?an #h ye>s aft] ! date ( enactm5t 
( ?is ,act1 ! ,commission %all submit to
 ,congress a report on ! /udy conduct$  
"u subsection 7a71 toge!r )             
recomm5dations = su* legislation &      
adm9i/rative action z ! ,commission     
det]m9es appropriate4  7c7 ,def9ition ( 
rural hospital ,9 ?is section1 ! t]m    
rural hospital means-- 7#a7 a critical  
access hospital 7z def9$ 9 section      
#ahfa7mm77#a7 ( ! ,social ,security ,act
 7#db ,u4,s4,c4 #aciex7mm77#a7772  7#b7 
a subsection 7d7 hospital 7z def9$ 9    
section #ahhf7;d77#a77;,b7 ( ! ,social  
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#a77;,b777 t is locat$ 9 a   
rural c5sus tract ( a metropolitan      
/ati/ical area 7z det]m9$ "u ! mo/ rec5t
 modification ( ! ,goldsmi?             
,modification1 orig9ally publi%$ 9 !    

,f$]al ,regi/] on ,febru>y #bg1 #aiib   
7#eg ,f$4 ,reg4 #fgbe772  7#c7 a sole   
community hospital 7z def9$ 9 section   
#ahhf7;d77#e77;,d77iii77 ( ! ,social    
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#e77;,d77iii7772  7#d7 a     
m$ic>e dep5d5t1 small rural hospital 7z 
def9$ 9 section #ahhf7;d77#e77;,g77iv7 (
 ! ,social ,security ,act 7#db ,u4,s4,c4
 #acieww7d77#e77;,g77iv7772 &  7#e7 a   
l[-volume hospital 7z def9$ 9 section   
#ahhf7;d77#ab77;,c77i7 ( ! ,social      
,security ,act 7#db ,u4,s4,c4           
#acieww7d77#ab77;,c77i7774  #d4 ,sunset 
,n lat] ?an #i ye>s aft] ! date (       
enactm5t ( ?is ,act1 ! ,secret>y %all   
e/abli% a me*anism & provide guidance & 
te*nical assi/ance "u :i* any facility t
 0 designat$ z a critical access        
hospital pursuant to a c]tification by a
 ,/ate "u section                       
#ahbj7;c77#b77;,b77i77,,iii7 ( ! ,social
 ,security ,act1 z add$ by section      
#b7;a71 may transition )9 #a ye> to "o (
 ! foll[+ paym5t models3 7#a7 ,su* new  

model or models recomm5d$ by ! ,m$ic>e  
,paym5t ,advisory ,commission 9 ! report
 submitt$ "u section #c4  7#b7 ,!       
prospective paym5t model 7or models7 "u 
:i* ! facility receiv$ paym5t "u title  
,,xviii ( ! ,social ,security ,act 7#db 
,u4,s4,c4 #acie et seq47 prior to be+ s 
designat$ pursuant to su* c]tification4 
7#c7 ,paym5t z a rural em]g5cy hospital 
"u section #ahcd7x7 ( ! ,social         
,security ,act 7#db ,u4,s4,c4           
#aciem7x774