I

103D CONGRESS

1ST SESSION H. R. 536

To amend title XVIII of the Social Security Act to extend and revise programs

to assist rural hospitals under part A of the medicare program.

IN THE HOUSE OF REPRESENTATIVES

JANUARY 21, 1993

Mr. ROBERTS introduced the following bill; which was referred jointly to the

Committees on Ways and Means and Energy and Commerce

A BILL

To amend title XVIII of the Social Security Act to extend

and revise programs to assist rural hospitals under part

A of the medicare program.

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; REFERENCES IN ACT.

4 (a) SHORT TITLE.—This Act may be cited as the

5 ‘‘Medicare Rural Hospital Amendments of 1993’’.

6 (b) REFERENCES IN ACT.—Except as otherwise spe7 cifically provided, whenever in this Act, an amendment is

8 expressed in terms of an amendment to or repeal of a sec9 tion or other provision, the reference shall be considered
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1 to be made to that section or other provision of the Social

2 Security Act.

3 SEC. 2. ESSENTIAL ACCESS COMMUNITY HOSPITAL (EACH)

4 AMENDMENTS.

5 (a) INCREASING NUMBER OF PARTICIPATING

6 STATES.—Section 1820(a)(1) (42 U.S.C. 1395i–4(a)(1))

7 is amended by striking ‘‘7’’ and inserting ‘‘9’’.

8 (b) TREATMENT OF INPATIENT HOSPITAL SERVICES

9 PROVIDED IN RURAL PRIMARY CARE HOSPITALS.—

10 (1) IN GENERAL.—Section 1820(f)(1)(F) (42

11 U.S.C. 1395i–4(f)(1)(F)) is amended to read as fol12 lows:

13 ‘‘(F) subject to paragraph (4), provides not

14 more than 6 inpatient beds (meeting such con15 ditions as the Secretary may establish) for pro16 viding inpatient care to patients requiring sta17 bilization before discharge or transfer to a hos18 pital, except that the facility may not provide

19 any inpatient hospital services—

20 ‘‘(i) to any patient whose attending

21 physician does not certify that the patient

22 may reasonably be expected to be dis23 charged or transferred to a hospital within

24 72 hours of admission to the facility; or
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1 ‘‘(ii) consisting of surgery or any

2 other service requiring the use of general

3 anesthesia (other than surgical procedures

4 specified by the Secretary under section

5 1833(i)(1)(A)), unless the attending physi6 cian certifies that the risk associated with

7 transferring the patient to a hospital for

8 such services outweighs the benefits of

9 transferring the patient to a hospital for

10 such services.’’.

11 (2) LIMITATION ON AVERAGE LENGTH OF

12 STAY.—Section 1820(f) (42 U.S.C. 1395i–4(f)) is

13 amended by adding at the end the following new

14 paragraph:

15 ‘‘(4) LIMITATION ON AVERAGE LENGTH OF IN16 PATIENT STAYS.—The Secretary may terminate a

17 designation of a rural primary care hospital under

18 paragraph (1) if the Secretary finds that the average

19 length of stay for inpatients at the facility during

20 the previous year in which the designation was in ef21 fect exceeded 72 hours. In determining the compli22 ance of a facility with the requirement of the pre23 vious sentence, there shall not be taken into account

24 periods of stay of inpatients in excess of 72 hours

25 to the extent such periods exceed 72 hours because
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1 transfer to a hospital is precluded because of inclem2 ent weather or other emergency conditions.’’.

3 (3) CONFORMING AMENDMENT.—Section

4 1814(a)(8) (42 U.S.C. 1395f(a)(8)) is amended by

5 striking ‘‘such services’’ and all that follows and in6 serting ‘‘the individual may reasonably be expected

7 to be discharged or transferred to a hospital within

8 72 hours after admission to the rural primary care

9 hospital.’’.

10 (4) GAO REPORTS.—Not later than 2 years

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

12 Comptroller General shall submit reports to Con13 gress on—

14 (A) the application of the requirements

15 under section 1820(f) of the Social Security Act

16 (as amended by this subsection) that rural pri17 mary care hospitals provide inpatient care only

18 to those individuals whose attending physicians

19 certify may reasonably be expected to be dis20 charged within 72 hours after admission and

21 maintain an average length of inpatient stay

22 during a year that does not exceed 72 hours;

23 and

24 (B) the extent to which such requirements

25 have resulted in such hospitals providing inpa-
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1 tient care beyond their capabilities or have lim2 ited the ability of such hospitals to provide

3 needed services.

4 (c) DESIGNATION OF HOSPITALS.—

5 (1) PERMITTING DESIGNATION OF HOSPITALS

6 LOCATED IN URBAN AREAS.—

7 (A) IN GENERAL.—Section 1820 (42

8 U.S.C. 1395i–4) is amended—

9 (i) by striking paragraph (1) of sub10 section (e) and redesignating paragraphs

11 (2) through (6) as paragraphs (1) through

12 (5); and

13 (ii) in subsection (e)(1)(A) (as redes14 ignated by subparagraph (A))—

15 (I) by striking ‘‘is located’’ and

16 inserting ‘‘except in the case of a hos17 pital located in an urban area, is lo18 cated’’,

19 (II) by striking ‘‘, (ii)’’ and in20 serting ‘‘or (ii)’’,

21 (III) by striking ‘‘or (iii)’’ and all

22 that follows through ‘‘section,’’, and

23 (IV) in subsection (i)(1)(B), by

24 striking ‘‘paragraph (3)’’ and insert25 ing ‘‘paragraph (2)’’.
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1 (B) NO CHANGE IN MEDICARE PROSPEC2 TIVE PAYMENT.—Section 1886(d)(5)(D) (42

3 U.S.C. 1395ww(d)(5)(D)) is amended—

4 (i) in clause (iii)(III), by inserting ‘‘lo5 cated in a rural area and’’ after ‘‘that is’’,

6 and

7 (ii) in clause (v), by inserting ‘‘located

8 in a rural area and’’ after ‘‘in the case of

9 a hospital’’.

10 (2) PERMITTING HOSPITALS LOCATED IN AD11 JOINING STATES TO PARTICIPATE IN STATE PRO12 GRAM.—

13 (A) IN GENERAL.—Section 1820 (42

14 U.S.C. 1395i–4) is amended—

15 (i) by redesignating subsection (k) as

16 subsection (l); and

17 (ii) by inserting after subsection (j)

18 the following new subsection:

19 ‘‘(k) ELIGIBILITY OF HOSPITALS NOT LOCATED IN

20 PARTICIPATING STATES.—Notwithstanding any other

21 provision of this section—

22 ‘‘(1) for purposes of including a hospital or fa23 cility as a member institution of a rural health net24 work, a State may designate a hospital or facility

25 that is not located in the State as an essential access
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1 community hospital or a rural primary care hospital

2 if the hospital or facility is located in an adjoining

3 State and is otherwise eligible for designation as

4 such a hospital;

5 ‘‘(2) the Secretary may designate a hospital or

6 facility that is not located in a State receiving a

7 grant under subsection (a)(1) as an essential access

8 community hospital or a rural primary care hospital

9 if the hospital or facility is a member institution of

10 a rural health network of a State receiving a grant

11 under such subsection; and

12 ‘‘(3) a hospital or facility designated pursuant

13 to this subsection shall be eligible to receive a grant

14 under subsection (a)(2).’’.

15 (B) CONFORMING AMENDMENTS.—(i) Sec16 tion 1820(c)(1) (42 U.S.C. 1395i–4(c)(1)) is

17 amended by striking ‘‘paragraph (3)’’ and in18 serting ‘‘paragraph (3) or subsection (k)’’.

19 (ii) Paragraphs (1)(A) and (2)(A) of sec20 tion 1820(i) (42 U.S.C. 1395i–4(i)) are each

21 amended—

22 (I) in clause (i), by striking ‘‘(a)(1)’’

23 and inserting ‘‘(a)(1) (except as provided

24 in subsection (k))’’, and
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1 (II) in clause (ii), by striking ‘‘sub2 paragraph (B)’’ and inserting ‘‘subpara3 graph (B) or subsection (k)’’.

4 (d) SKILLED NURSING SERVICES IN RURAL PRIMARY

5 CARE HOSPITALS.—Section 1820(f)(3) (42 U.S.C. 1395i–

6 4(f)(3)) is amended by striking ‘‘because the facility’’ and

7 all that follows and inserting the following: ‘‘because, at

8 the time the facility applies to the State for designation

9 as a rural primary care hospital, there is in effect an

10 agreement between the facility and the Secretary under

11 section 1883 under which the facility’s inpatient hospital

12 facilities are used for the furnishing of extended care serv13 ices, except that the number of beds used for the furnish14 ing of such services may not exceed the total number of

15 licensed inpatient beds at the time the facility applies to

16 the State for such designation (minus the number of inpa17 tient beds used for providing inpatient care pursuant to

18 paragraph (1)(F)). For purposes of the previous sentence,

19 the number of beds of the facility used for the furnishing

20 of extended care services shall not include any beds of a

21 unit of the facility that is licensed as a distinct-part skilled

22 nursing facility at the time the facility applies to the State

23 for designation as a rural primary care hospital.’’.

24 (e) PAYMENT FOR OUTPATIENT RURAL PRIMARY

25 CARE HOSPITAL SERVICES.—Section 1834(g)(1) (42
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1 U.S.C. 1395m(g)(1)) is amended by adding at the end the

2 following:

3 ‘‘The amount of payment shall be determined under

4 either method without regard to the amount of the

5 customary or other charge.’’.

6 (f) CLARIFICATION OF PHYSICIAN STAFFING RE7 QUIREMENT FOR RURAL PRIMARY CARE HOSPITALS.—

8 Section 1820(f)(1)(H) (42 U.S.C. 1395i–4(f)(1)(H)) is

9 amended by striking the period and inserting the follow10 ing: ‘‘, except that in determining whether a facility meets

11 the requirements of this subparagraph, subparagraphs (E)

12 and (F) of that paragraph shall be applied as if any ref13 erence to a ‘physician’ is a reference to a physician as de14 fined in section 1861(r)(1).’’.

15 (g) TECHNICAL AMENDMENTS RELATING TO PART

16 A DEDUCTIBLE, COINSURANCE, AND SPELL OF ILL17 NESS.—(1) Section 1812(a)(1) (42 U.S.C. 1395d(a)(1))

18 is amended—

19 (A) by striking ‘‘inpatient hospital services’’ the

20 first place it appears and inserting ‘‘inpatient hos21 pital services or inpatient rural primary care hos22 pital services’’;

23 (B) by striking ‘‘inpatient hospital services’’ the

24 second place it appears and inserting ‘‘such serv25 ices’’; and
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1 (C) by striking ‘‘and inpatient rural primary

2 care hospital services’’.

3 (2) Sections 1813(a) and 1813(b)(3)(A) (42 U.S.C.

4 1395e(a), 1395e(b)(3)(A)) are each amended by striking

5 ‘‘inpatient hospital services’’ each place it appears and in6 serting ‘‘inpatient hospital services or inpatient rural pri7 mary care hospital services’’.

8 (3) Section 1813(b)(3)(B) (42 U.S.C.

9 1395e(b)(3)(B)) is amended by striking ‘‘inpatient hos10 pital services’’ and inserting ‘‘inpatient hospital services,

11 inpatient rural primary care hospital services’’.

12 (4) Section 1861(a) (42 U.S.C. 1395x(a)) is amend13 ed—

14 (A) in paragraphs (1), by striking ‘‘inpatient

15 hospital services’’ and inserting ‘‘inpatient hospital

16 services, inpatient rural primary care hospital serv17 ices’’; and

18 (B) in paragraph (2), by striking ‘‘hospital’’

19 and inserting ‘‘hospital or rural primary care hos20 pital’’.

21 (h) AUTHORIZATION OF APPROPRIATIONS.—Section

22 1820(k) (42 U.S.C. 1395i–4(k)) is amended by striking

23 ‘‘1990, 1991, and 1992’’ and inserting ‘‘1990 through

24 1995’’.
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1 (i) EFFECTIVE DATE.—The amendments made by

2 this section shall take effect on the date of the enactment

3 of this Act.

4 SEC. 3. REAUTHORIZATION OF RURAL TRANSITION GRANT

5 PROGRAM.

6 Section 4005(e)(9) of the Omnibus Budget Reconcili7 ation Act of 1987 is amended—

8 (1) by striking ‘‘1989 and’’ and inserting

9 ‘‘1989,’’; and

10 (2) by striking ‘‘1992’’ and inserting ‘‘1992

11 and $30,000,000 for each of fiscal years 1993

12 through 1997’’.

13 SEC. 4. REGIONAL REFERRAL CENTERS.

14 (a) EXTENSION THROUGH FISCAL YEAR 1994.—Sec15 tion 6003(d) of the Omnibus Budget Reconciliation Act

16 of 1989 (42 U.S.C. 1395ww note) is amended by striking

17 ‘‘October 1, 1992’’ and inserting ‘‘October 1, 1994’’.

18 (b) PERMITTING HOSPITALS TO DECLINE RECLASSI19 FICATION.—If any hospital fails to qualify as a rural refer20 ral center under section 1886(d)(5)(C) of the Social Secu21 rity Act as a result of a decision by the Medicare Geo22 graphic Classification Review Board under section

23 1886(d)(10) of such Act to reclassify the hospital as being

24 located in an urban area for fiscal year 1994, the Sec25 retary of Health and Human Services shall—
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1 (1) notify such hospital of such failure to qual2 ify,

3 (2) provide an opportunity for such hospital to

4 decline such reclassification, and

5 (3) if the hospital declines such reclassification,

6 administer the Social Security Act (other than sec7 tion 1886(d)(8)(D)) for fiscal year 1994 as if the

8 decision by the Review Board had not occurred.

9 SEC. 5. MEDICARE-DEPENDENT, SMALL RURAL HOSPITALS.

10 (a) IN GENERAL.—Section 1886(d)(5)(G) (42 U.S.C.

11 1395ww(d)(5)(G)) is amended—

12 (1) by amending clause (i) to read as follows:

13 ‘‘(i) In the case of a subsection (d) hospital which

14 is a medicare-dependent, small rural hospital, payment

15 under paragraph (1)(A) for discharges occurring before

16 October 1, 1994, shall be equal to the sum of the amount

17 determined under clause (ii) and the amount determined

18 under paragraph (1)(A)(iii).’’;

19 (2) by redesignating clauses (ii) and (iii) as

20 clauses (iii) and (iv); and

21 (3) by inserting after clause (i) the following

22 new clause:

23 ‘‘(ii) The amount determined under this clause is—

24 ‘‘(I) for discharges occurring during the first 3

25 12-month cost reporting periods that begin on or
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1 after April 1, 1990, the amount by which the hos2 pital’s target amount for the cost reporting period

3 (as defined in subsection (b)(3)(D)) exceeds the

4 amount determined under paragraph (1)(A)(iii); and

5 ‘‘(II) for discharges occurring during any subse6 quent cost reporting period (or portion thereof), 50

7 percent of the amount by which the hospital’s target

8 amount for the cost reporting period (as defined in

9 subsection (b)(3)(D)) exceeds the amount deter10 mined under paragraph (1)(A)(iii).’’.

11 (b) PERMITTING HOSPITALS TO DECLINE RECLASSI12 FICATION.—If any hospital fails to qualify as a medicare13 dependent, small rural hospital under section

14 1886(d)(5)(G)(i) of the Social Security Act as a result of

15 a decision by the Medicare Geographic Classification Re16 view Board under section 1886(d)(10) of such Act to re17 classify the hospital as being located in an urban area for

18 fiscal year 1994, the Secretary of Health and Human

19 Services shall—

20 (1) notify such hospital of such failure to qual21 ify,

22 (2) provide an opportunity for such hospital to

23 decline such reclassification, and

24 (3) if the hospital declines such reclassification,

25 administer the Social Security Act (other than sec-
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1 tion 1886(d)(8)(D)) for fiscal year 1994 as if the

2 decision by the Review Board had not occurred.

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