# Patient Protection and Affordable Care Act/Title III/Subtitle B/Part II
## PART II--RURAL PROTECTIONS
### SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.

    (a) In General- Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended--
       (1) in subclause (II)--
          (A) in the first sentence, by striking `2010'and inserting `2011'; and
          (B) in the second sentence, by striking `or 2009' and inserting `, 2009, or 2010'; and
       (2) in subclause (III), by striking `January 1, 2010' and inserting `January 1, 2011'.
    (b) Permitting All Sole Community Hospitals To Be Eligible for Hold Harmless- Section 1833(t)(7)(D)(i)(III) of the Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)(III)) is amended by adding at the end the following new sentence: `In the case of covered OPD services furnished on or after January 1, 2010, and before January 1, 2011, the preceding sentence shall be applied without regard to the 100-bed limitation.'.

### SEC. 3122. EXTENSION OF MEDICARE REASONABLE COSTS PAYMENTS FOR CERTAIN CLINICAL DIAGNOSTIC LABORATORY TESTS FURNISHED TO HOSPITAL PATIENTS IN CERTAIN RURAL AREAS.

Section 416(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395l-4), as amended by section 105 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395l note) and section 107 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (42 U.S.C. 1395l note), is amended by inserting `or during the 1-year period beginning on July 1, 2010' before the period at the end.

### SEC. 3123. EXTENSION OF THE RURAL COMMUNITY HOSPITAL DEMONSTRATION PROGRAM.

    (a) One-year Extension- Section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2272) is amended by adding at the end the following new subsection:
             `(g) One-Year Extension of Demonstration Program-
                `(1) IN GENERAL- Subject to the succeeding provisions of this subsection, the Secretary shall conduct the demonstration program under this section for an additional 1-year period (in this section referred to as the `1-year extension period') that begins on the date immediately following the last day of the initial 5-year period under subsection (a)(5).
                `(2) EXPANSION OF DEMONSTRATION STATES- Notwithstanding subsection (a)(2), during the 1-year extension period, the Secretary shall expand the number of States with low population densities determined by the Secretary under such subsection to 20. In determining which States to include in such expansion, the Secretary shall use the same criteria and data that the Secretary used to determine the States under such subsection for purposes of the initial 5-year period.
                `(3) INCREASE IN MAXIMUM NUMBER OF HOSPITALS PARTICIPATING IN THE DEMONSTRATION PROGRAM- Notwithstanding subsection (a)(4), during the 1-year extension period, not more than 30 rural community hospitals may participate in the demonstration program under this section.
                `(4) NO AFFECT ON HOSPITALS IN DEMONSTRATION PROGRAM ON DATE OF ENACTMENT- In the case of a rural community hospital that is participating in the demonstration program under this section as of the last day of the initial 5-year period, the Secretary shall provide for the continued participation of such rural community hospital in the demonstration program during the 1-year extension period unless the rural community hospital makes an election, in such form and manner as the Secretary may specify, to discontinue such participation.'.
    (b) Conforming Amendments- Subsection (a)(5) of section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2272) is amended by inserting `(in this section referred to as the `initial 5-year period') and, as provided in subsection (g), for the 1-year extension period' after `5-year period'.
    (c) Technical Amendments-
       (1) Subsection (b) of section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2272) is amended--
          (A) in paragraph (1)(B)(ii), by striking `2)' and inserting `2))'; and
          (B) in paragraph (2), by inserting `cost' before `reporting period' the first place such term appears in each of subparagraphs (A) and (B).
       (2) Subsection (f)(1) of section 410A of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2272) is amended--
          (A) in subparagraph (A)(ii), by striking `paragraph (2)' and inserting `subparagraph (B)'; and
          (B) in subparagraph (B), by striking `paragraph (1)(B)' and inserting `subparagraph (A)(ii)'.

### SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT HOSPITAL (MDH) PROGRAM.

    (a) Extension of Payment Methodology- Section 1886(d)(5)(G) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(G)) is amended--
       (1) in clause (i), by striking `October 1, 2011' and inserting `October 1, 2012'; and
       (2) in clause (ii)(II), by striking `October 1, 2011' and inserting `October 1, 2012'.
    (b) Conforming Amendments-
       (1) EXTENSION OF TARGET AMOUNT- Section 1886(b)(3)(D) of the Social Security Act (42 U.S.C. 1395ww(b)(3)(D)) is amended--
          (A) in the matter preceding clause (i), by striking `October 1, 2011' and inserting `October 1, 2012'; and
          (B) in clause (iv), by striking `through fiscal year 2011' and inserting `through fiscal year 2012'.
       (2) PERMITTING HOSPITALS TO DECLINE RECLASSIFICATION- Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of 1993 (42 U.S.C. 1395ww note) is amended by striking `through fiscal year 2011' and inserting `through fiscal year 2012'.

### SEC. 3125. TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT HOSPITAL PAYMENT ADJUSTMENT FOR LOW-VOLUME HOSPITALS.

Section 1886(d)(12) of the Social Security Act (42 U.S.C. 1395ww(d)(12)) is amended--
       (1) in subparagraph (A), by inserting `or (D)' after `subparagraph (B)';
       (2) in subparagraph (B), in the matter preceding clause (i), by striking `The Secretary' and inserting `For discharges occurring in fiscal years 2005 through 2010 and for discharges occurring in fiscal year 2013 and subsequent fiscal years, the Secretary';
       (3) in subparagraph (C)(i)--
          (A) by inserting `(or, with respect to fiscal years 2011 and 2012, 15 road miles)' after `25 road miles'; and
          (B) by inserting `(or, with respect to fiscal years 2011 and 2012, 1,500 discharges of individuals entitled to, or enrolled for, benefits under part A)' after `800 discharges'; and
       (4) by adding at the end the following new subparagraph:
                   `(D) TEMPORARY APPLICABLE PERCENTAGE INCREASE- For discharges occurring in fiscal years 2011 and 2012, the Secretary shall determine an applicable percentage increase for purposes of subparagraph (A) using a continuous linear sliding scale ranging from 25 percent for low-volume hospitals with 200 or fewer discharges of individuals entitled to, or enrolled for, benefits under part A in the fiscal year to 0 percent for low-volume hospitals with greater than 1,500 discharges of such individuals in the fiscal year.'.

### SEC. 3126. IMPROVEMENTS TO THE DEMONSTRATION PROJECT ON COMMUNITY HEALTH INTEGRATION MODELS IN CERTAIN RURAL COUNTIES.

    (a) Removal of Limitation on Number of Eligible Counties Selected- Subsection (d)(3) of section 123 of the Medicare Improvements for Patients and Providers Act of 2008 (42 U.S.C. 1395i-4 note) is amended by striking `not more than 6'.
    (b) Removal of References to Rural Health Clinic Services and Inclusion of Physicians' Services in Scope of Demonstration Project- Such section 123 is amended--
       (1) in subsection (d)(4)(B)(i)(3), by striking subclause (III); and
       (2) in subsection (j)--
          (A) in paragraph (8), by striking subparagraph (B) and inserting the following:
                   `(B) Physicians' services (as defined in section 1861(q) of the Social Security Act (42 U.S.C. 1395x(q)).';
          (B) by striking paragraph (9); and
          (C) by redesignating paragraph (10) as paragraph (9).

### SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE PAYMENTS FOR HEALTH CARE PROVIDERS SERVING IN RURAL AREAS.

    (a) Study- The Medicare Payment Advisory Commission shall conduct a study on the adequacy of payments for items and services furnished by providers of services and suppliers in rural areas under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.). Such study shall include an analysis of--
       (1) any adjustments in payments to providers of services and suppliers that furnish items and services in rural areas;
       (2) access by Medicare beneficiaries to items and services in rural areas;
       (3) the adequacy of payments to providers of services and suppliers that furnish items and services in rural areas; and
       (4) the quality of care furnished in rural areas.
    (b) Report- Not later than January 1, 2011, the Medicare Payment Advisory Commission shall submit to Congress a report containing the results of the study conducted under subsection (a). Such report shall include recommendations on appropriate modifications to any adjustments in payments to providers of services and suppliers that furnish items and services in rural areas, together with recommendations for such legislation and administrative action as the Medicare Payment Advisory Commission determines appropriate.

### SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS HOSPITAL SERVICES.

    (a) In General- Subsections (g)(2)(A) and (l)(8) of section 1834 of the Social Security Act (42 U.S.C. 1395m) are each amended by inserting `101 percent of' before `the reasonable costs'.
    (b) Effective Date- The amendments made by subsection (a) shall take effect as if included in the enactment of section 405(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173; 117 Stat. 2266).

### SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE RURAL HOSPITAL FLEXIBILITY PROGRAM.

    (a) Authorization- Section 1820(j) of the Social Security Act (42 U.S.C. 1395i-4(j)) is amended--
       (1) by striking `2010, and for' and inserting `2010, for'; and
       (2) by inserting `and for making grants to all States under subsection (g), such sums as may be necessary in each of fiscal years 2011 and 2012, to remain available until expended' before the period at the end.
    (b) Use of Funds- Section 1820(g)(3) of the Social Security Act (42 U.S.C. 1395i-4(g)(3)) is amended--
       (1) in subparagraph (A), by inserting `and to assist such hospitals in participating in delivery system reforms under the provisions of and amendments made by the Patient Protection and Affordable Care Act, such as value-based purchasing programs, accountable care organizations under section 1899, the National pilot program on payment bundling under section 1866D, and other delivery system reform programs determined appropriate by the Secretary' before the period at the end; and
       (2) in subparagraph (E)--
          (A) by striking `, and to offset' and inserting `, to offset'; and
          (B) by inserting `and to participate in delivery system reforms under the provisions of and amendments made by the Patient Protection and Affordable Care Act, such as value-based purchasing programs, accountable care organizations under section 1899, the National pilot program on payment bundling under section 1866D, and other delivery system reform programs determined appropriate by the Secretary' before the period at the end.
    (c) Effective Date- The amendments made by this section shall apply to grants made on or after January 1, 2010.