II 

117TH CONGRESS 

1ST SESSION S. 644 

To amend title XVIII of the Social Security Act to restore State authority 

to waive for certain facilities the 35-mile rule for designating critical 

access hospitals under the Medicare program, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

MARCH 9, 2021 

Mr. DURBIN (for himself and Mr. LANKFORD) introduced the following bill; 

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 35- 

mile rule for designating critical access hospitals under 

the Medicare program, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Rural Hospital Closure 

5 Relief Act of 2021’’. 


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1 SEC. 2. RESTORING STATE AUTHORITY TO WAIVE THE 35- 

2 MILE RULE FOR CERTAIN MEDICARE CRIT3 ICAL ACCESS HOSPITAL DESIGNATIONS. 

4 (a) IN GENERAL.—Section 1820 of the Social Secu5 rity Act (42 U.S.C. 1395i–4) is amended— 

6 (1) in subsection (c)(2)— 

7 (A) in subparagraph (B)(i)— 

8 (i) in subclause (I), by striking at the 

9 end ‘‘or’’; 

10 (ii) in subclause (II), by inserting at 

11 the end ‘‘or’’; and 

12 (iii) by adding at the end the fol13 lowing new subclause: 

14 ‘‘(III) subject to subparagraph 

15 (G), is a hospital described in sub16 paragraph (F) and is certified on or 

17 after the date of the enactment of the 

18 Rural Hospital Closure Relief Act of 

19 2021 by the State as being a nec20 essary provider of health care services 

21 to residents in the area;’’; and 

22 (B) by adding at the end the following new 

23 subparagraphs: 

24 ‘‘(F) HOSPITAL DESCRIBED.—For pur25 poses of subparagraph (B)(i)(III), a hospital 


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1 described in this subparagraph is a hospital 

2 that— 

3 ‘‘(i) is a sole community hospital (as 

4 defined in section 1886(d)(5)(D)(iii)), a 

5 medicare dependent, small rural hospital 

6 (as defined in section 1886(d)(5)(G)(iv)), a 

7 low-volume hospital that in 2021 receives a 

8 payment adjustment under section 

9 1886(d)(12), a subsection (d) hospital (as 

10 defined in section 1886(d)(1)(B)) that has 

11 fewer than 50 beds, or, subject to the limi12 tation under subparagraph (G)(i)(I), is a 

13 facility described in subparagraph (G)(ii); 

14 ‘‘(ii) is located in a rural area, as de15 fined in section 1886(d)(2)(D); 

16 ‘‘(iii)(I) is located— 

17 ‘‘(aa) in a county that has a per18 centage of individuals with income 

19 that is below 150 percent of the pov20 erty line that is higher than the na21 tional or statewide average in 2020; 

22 or 

23 ‘‘(bb) in a health professional 

24 shortage area (as defined in section 


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1 332(a)(1)(A) of the Public Health 

2 Service Act); or 

3 ‘‘(II) has a percentage of inpatient 

4 days of individuals entitled to benefits 

5 under part A of this title, enrolled under 

6 part B of this title, or enrolled under a 

7 State plan under title XIX that is higher 

8 than the national or statewide average in 

9 2019 or 2020; 

10 ‘‘(iv) subject to subparagraph 

11 (G)(ii)(II), has attested to the Secretary 

12 two consecutive years of negative operating 

13 margins preceding the date of certification 

14 described in subparagraph (B)(i)(III); and 

15 ‘‘(v) submits to the Secretary— 

16 ‘‘(I) at such time and in such 

17 manner as the Secretary may require, 

18 an attestation outlining the good gov19 ernance qualifications and strategic 

20 plan for multi-year financial solvency 

21 of the hospital; and 

22 ‘‘(II) not later than 120 days 

23 after the date on which the Secretary 

24 issues final regulations pursuant to 

25 section 2(b) of the Rural Hospital 


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1 Closure Relief Act of 2021, an appli2 cation for certification of the facility 

3 as a critical access hospital. 

4 ‘‘(G) LIMITATION ON CERTAIN DESIGNA5 TIONS.— 

6 ‘‘(i) IN GENERAL.—The Secretary 

7 may not under subsection (e) certify pur8 suant to a certification by a State under 

9 subparagraph (B)(i)(III)— 

10 ‘‘(I) more than a total of 175 fa11 cilities as critical access hospitals, of 

12 which not more than 20 percent may 

13 be facilities described in clause (ii); 

14 and 

15 ‘‘(II) within any one State, more 

16 than 10 facilities as critical access 

17 hospitals. 

18 ‘‘(ii) FACILITY DESCRIBED.— 

19 ‘‘(I) IN GENERAL.—A facility de20 scribed in this clause is a facility that 

21 as of the date of enactment of this 

22 subparagraph met the criteria for des23 ignation as a critical access hospital 

24 under subparagraph (B)(i)(I). 


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1 ‘‘(II) NONAPPLICATION OF CER2 TAIN CRITERIA.—For purposes of 

3 subparagraph (B)(i)(III), the criteria 

4 described in subparagraph (F)(iv) 

5 shall not apply with respect to the 

6 designation of a facility described in 

7 subclause (I).’’; and 

8 (2) in subsection (e), by inserting ‘‘, subject to 

9 subsection (c)(2)(G),’’ after ‘‘The Secretary shall’’. 

10 (b) REGULATIONS.—Not later than 120 days after 

11 the date of the enactment of this Act, the Secretary of 

12 Health and Human Services shall issue final regulations 

13 to carry out this section. 

14 (c) CLARIFICATION REGARDING FACILITIES THAT

15 MEET DISTANCE OR OTHER CERTIFICATION CRITERIA.— 

16 Nothing in this section shall affect the application of cri17 teria for designation as a critical access hospital described 

18 in subclause (I) or (II) section 1820(c)(2)(B)(i) of the So19 cial Security Act (42 U.S.C. 1395i–4(c)(2)(B)(i)). 

20 SEC. 3. CMI TESTING OF NEW RURAL HOSPITAL DELIVERY 

21 AND PAYMENT MODEL. 

22 Section 1115A of the Social Security Act (42 U.S.C. 

23 1315a) is amended— 

24 (1) in subsection (b)(2)(A), by adding at the 

25 end the following new sentence: ‘‘The models seVerDate Sep 11 2014 19:35 Apr 04, 2021 Jkt 019200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S644.IS S644

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1 lected under this subparagraph shall include the 

2 testing of a new rural hospital delivery and payment 

3 model (or models), as described in subsection (h).’’; 

4 and 

5 (2) by adding at the end the following new sub6 section: 

7 ‘‘(h) TESTING OF NEW RURAL HOSPITAL DELIVERY

8 AND PAYMENT MODEL.— 

9 ‘‘(1) IN GENERAL.— 

10 ‘‘(A) TESTING.—The Secretary shall test 

11 the implementation of a new rural hospital de12 livery and payment model (or models) that the 

13 Secretary determines would promote financially 

14 sustainable ways to ensure patient access to 

15 care in rural communities, which may include 

16 models under which such hospitals furnish out17 patient emergency care services 24 hours a day, 

18 7 days a week for which payment is made 

19 under title XVIII based on the amount deter20 mined under the prospective payment system 

21 for hospital outpatient department services 

22 under section 1833(t), plus a fixed rate for the 

23 cost of furnishing the emergency services. 

24 ‘‘(B) PROMULGATION OF REGULATIONS.— 

25 Not later than 3 years after the date of the enVerDate Sep 11 2014 19:35 Apr 04, 2021 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S644.IS S644

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1 actment of this subsection, the Secretary shall 

2 promulgate regulations to test a new rural hos3 pital delivery and payment model (or models) 

4 described in subparagraph (A), unless Congress 

5 enacts legislation that establishes such a pay6 ment model (or models) prior to the promulga7 tion of regulations pursuant to this subpara8 graph. 

9 ‘‘(2) TRANSITION.—Effective beginning on the 

10 date on which the testing of a new rural hospital de11 livery and payment model (or models) described in 

12 paragraph (1)(A) is implemented under this sub13 section or such a payment model (or models) is es14 tablished through the enactment of legislation de15 scribed in paragraph (1)(B), the Secretary shall pro16 vide a process under which— 

17 ‘‘(A) all critical access hospitals may tran18 sition to such new model or models under this 

19 subsection; and 

20 ‘‘(B) any facility that was designated as a 

21 critical access hospital pursuant to a certifi22 cation by a State under section 

23 1820(c)(2)(B)(i)(III) may revert to the prospec24 tive payment model (or models) under which 


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1 the facility received payment under title XVIII 

2 prior to being so designated.’’. 

Æ 


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