I 

118TH CONGRESS 

1ST SESSION H. R. 833 

To amend titles XVIII and XIX of the Social Security Act to provide for 

enhanced payments to rural health care providers under the Medicare 

and Medicaid programs, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

FEBRUARY 6, 2023 

Mr. GRAVES of Missouri (for himself and Mr. HUFFMAN) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and the 

Budget, for a period to be subsequently determined by the Speaker, in 

each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend titles XVIII and XIX of the Social Security Act 

to provide for enhanced payments to rural health care 

providers under the Medicare and Medicaid programs, 

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; TABLE OF CONTENTS. 

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

5 ‘‘Save America’s Rural Hospitals Act’’. 

6 (b) FINDINGS.—Congress finds the following: 


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1 (1) More than 60,000,000 individuals in rural 

2 areas of the United States rely on rural hospitals 

3 and other providers as critical access points to 

4 health care. 

5 (2) Access to health care is essential to commu6 nities that Americans living in rural areas call home. 

7 (3) Americans living in rural areas are older, 

8 poorer, and sicker than Americans living in urban 

9 areas. 

10 (4) Between January 2010 and January 1, 

11 2021, 137 rural hospitals closed in the United 

12 States, according to the University of North Caro13 lina’s Cecil G. Sheps Center for Health Services Re14 search, and the rate of these closures is increasing. 

15 (5) Four hundred and fifty-three hospitals are 

16 operating at margins similar to those that have 

17 closed over the past decade. Of those, 216 are con18 sidered most vulnerable to closure. 

19 (6) Rural Medicare beneficiaries already face a 

20 number of challenges when trying to access health 

21 care services close to home, including the weather, 

22 geography, and cultural, social, and language bar23 riers. 


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1 (7) Approximately sixty percent of all primary 

2 care health professional shortage areas are located 

3 in rural areas. 

4 (8) Seniors living in rural areas are forced to 

5 travel significant distances for care. 

6 (9) On average, trauma victims in rural areas 

7 must travel twice as far as victims in urban areas 

8 to the closest hospital, and, as a result, 60 percent 

9 of trauma deaths occur in rural areas, even though 

10 only 20 percent of Americans live in rural areas. 

11 (10) With the 453 hospitals on the brink of clo12 sure, millions of Americans living in rural areas are 

13 on the brink of losing access to the closest emer14 gency room. 

15 (c) TABLE OF CONTENTS.—The table of contents of 

16 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—RURAL PROVIDER PAYMENT STABILIZATION 

Subtitle A—Rural Hospitals 

Sec. 101. Eliminating Medicare sequestration for rural hospitals. 

Sec. 102. Reversing cuts to reimbursement of bad debt for critical access hospitals (CAHs) and rural hospitals. 

Sec. 103. Extending permanently payment levels for low-volume hospitals and 

Medicare-dependent hospitals (MDHs). 

Sec. 104. Reinstating revised diagnosis-related group payments for MDHs and 

sole community hospitals (SCHs). 

Sec. 105. Reinstating hold harmless treatment for hospital outpatient services 

for SCHs. 

Subtitle B—Other Rural Providers 

Sec. 111. Making permanent increased Medicare payments for ground ambulance services in rural areas. 

Sec. 112. Extending Medicaid primary care payments. 


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Sec. 113. Making permanent Medicare telehealth service enhancements for federally qualified health centers and rural health clinics. 

Sec. 114. Restoring State authority to waive the 35-mile rule for certain Medicare critical access hospital designations. 

Sec. 115. CMI testing of new rural hospital delivery and payment model. 

TITLE II—RURAL MEDICARE BENEFICIARY EQUITY 

Sec. 201. Equalizing beneficiary copayments for services furnished by CAHs. 

Sec. 202. Removing supervision of certified registered nurse anesthetists. 

Sec. 203. CRNA services as a Medicaid-required benefit. 

TITLE III—REGULATORY RELIEF 

Sec. 301. Eliminating 96-hour physician certification requirement with respect 

to inpatient CAH services. 

Sec. 302. Rebasing supervision requirements. 

Sec. 303. Reforming practices of recovery audit contractors under Medicare. 

TITLE IV—FUTURE OF RURAL HEALTH CARE 

Sec. 401. Medicare rural hospital flexibility program grants. 

1 TITLE I—RURAL PROVIDER 

2 PAYMENT STABILIZATION 

3 Subtitle A—Rural Hospitals 

4 SEC. 101. ELIMINATING MEDICARE SEQUESTRATION FOR 

5 RURAL HOSPITALS. 

6 (a) IN GENERAL.—Section 256(d)(7) of the Balanced 

7 Budget and Emergency Deficit Control Act of 1985 (2 

8 U.S.C. 906(d)(7)) is amended by adding at the end the 

9 following: 

10 ‘‘(D) RURAL HOSPITALS.—Payments 

11 under part A or part B of title XVIII of the So12 cial Security Act with respect to items and serv13 ices furnished by a critical access hospital (as 

14 defined in section 1861(mm)(1) of such Act), a 

15 sole community hospital (as defined in section 

16 1886(d)(5)(D)(iii) of such Act), a medicare-deVerDate Sep 11 2014 00:42 Mar 03, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H833.IH H833

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1 pendent, small rural hospital (as defined in sec2 tion 1886(d)(5)(G)(iv) of such Act), or a sub3 section (d) hospital located in a rural area (as 

4 defined in section 1886(d)(2)(D) of such Act).’’. 

5 (b) APPLICABILITY.—The amendment made by this 

6 section applies with respect to orders of sequestration ef7 fective on or after the date that is 60 days after the date 

8 of the enactment of this Act. 

9 SEC. 102. REVERSING CUTS TO REIMBURSEMENT OF BAD 

10 DEBT FOR CRITICAL ACCESS HOSPITALS 

11 (CAHS) AND RURAL HOSPITALS. 

12 (a) RURAL HOSPITALS.—Section 1861(v)(1)(T)(v) of 

13 the Social Security Act (42 U.S.C. 1395x(v)(1)(T)(v)) is 

14 amended by inserting before the period the following: ‘‘or, 

15 in the case of a hospital located in a rural area, by 15 

16 percent of such amount otherwise allowable’’. 

17 (b) CAHS.—Section 1861(v)(1)(W)(ii) of the Social 

18 Security Act (42 U.S.C. 1395x(v)(1)(W)(ii)) is amended 

19 by inserting after ‘‘or (V)’’ the following: ‘‘, a critical ac20 cess hospital’’. 

21 (c) APPLICABILITY.—The amendments made by this 

22 section apply with respect to cost reporting periods begin23 ning more than 60 days after the date of the enactment 

24 of this Act. 


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1 SEC. 103. EXTENDING PERMANENTLY PAYMENT LEVELS 

2 FOR LOW-VOLUME HOSPITALS AND MEDI3 CARE-DEPENDENT HOSPITALS (MDHS). 

4 (a) EXTENSION OF INCREASED PAYMENTS FOR

5 MDHS.— 

6 (1) EXTENSION OF PAYMENT METHODOLOGY.— 

7 Section 1886(d)(5)(G) of the Social Security Act (42 

8 U.S.C. 1395ww(d)(5)(G)) is amended— 

9 (A) in clause (i), by striking ‘‘, and before 

10 October 1, 2024’’; and 

11 (B) in clause (ii)(II), by striking ‘‘, and be12 fore October 1, 2024’’. 

13 (2) CONFORMING AMENDMENTS.— 

14 (A) EXTENSION OF TARGET AMOUNT.— 

15 Section 1886(b)(3)(D) of the Social Security 

16 Act (42 U.S.C. 1395ww(b)(3)(D)) is amend17 ed— 

18 (i) in the matter preceding clause (i), 

19 by striking ‘‘, and before October 1, 

20 2024’’; and 

21 (ii) in clause (iv), by striking 

22 ‘‘through fiscal year 2024’’ and inserting 

23 ‘‘or a subsequent fiscal year’’. 

24 (B) EXTENDING THE PERIOD DURING

25 WHICH HOSPITALS CAN DECLINE RECLASSI26 FICATION AS URBAN.—Section 13501(e)(2) of 


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1 the Omnibus Budget Reconciliation Act of 1993 

2 (42 U.S.C. 1395ww note) is amended by strik3 ing ‘‘fiscal year 2000 through fiscal year 2024’’ 

4 and inserting ‘‘a subsequent fiscal year’’. 

5 (b) EXTENSION OF INCREASED PAYMENTS FOR LOW6 VOLUME HOSPITALS.—Section 1886(d)(12) of the Social 

7 Security Act (42 U.S.C. 1395ww(d)(12)) is amended— 

8 (1) in subparagraph (B)— 

9 (A) in the header, by inserting ‘‘for fiscal 

10 years 2005 through 2010’’ after ‘‘increase’’; 

11 and 

12 (B) in the matter preceding clause (i), by 

13 striking ‘‘and for discharges occurring in fiscal 

14 year 2025 and subsequent fiscal years’’; 

15 (2) in subparagraph (C)(i)— 

16 (A) in the matter preceding subclause (I), 

17 by striking ‘‘through 2024’’ and inserting ‘‘and 

18 each subsequent fiscal year’’; 

19 (B) in subclause (II), by adding at the end 

20 ‘‘and’’; 

21 (C) in subclause (III)— 

22 (i) by striking ‘‘fiscal years 2019 

23 through 2024’’ and inserting ‘‘fiscal year 

24 2019 and each subsequent fiscal year’’; 

25 and 


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1 (ii) by striking ‘‘; and’’ and inserting 

2 a period; and 

3 (D) by striking subclause (IV); and 

4 (3) in subparagraph (D)— 

5 (A) by amending the heading to read as 

6 follows: ‘‘PERMANENT APPLICABLE PERCENT7 AGE INCREASE’’; 

8 (B) in the matter preceding clause (i), by 

9 striking ‘‘in fiscal years 2011 through 2024’’ 

10 and inserting ‘‘in fiscal year 2011 or a subse11 quent fiscal year’’; and 

12 (C) in clause (ii), by striking ‘‘each of fis13 cal years 2019 through 2024’’ and inserting 

14 ‘‘fiscal year 2019 and each subsequent fiscal 

15 year’’. 

16 SEC. 104. REINSTATING REVISED DIAGNOSIS-RELATED 

17 GROUP PAYMENTS FOR MDHS AND SOLE 

18 COMMUNITY HOSPITALS (SCHS). 

19 (a) PAYMENTS FOR MDHS AND SCHS FOR VALUE20 BASED INCENTIVE PROGRAMS.—Section 

21 1886(o)(7)(D)(ii)(I) of the Social Security Act (42 U.S.C. 

22 1395ww(o)(7)(D)(ii)(I)) is amended by inserting ‘‘and 

23 after fiscal year 2022’’ after ‘‘2013’’. 

24 (b) PAYMENTS FOR MDHS AND SCHS UNDER HOS25 PITAL READMISSIONS REDUCTION PROGRAM.—Section 


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1 1886(q)(2)(B)(i) of the Social Security Act (42 U.S.C. 

2 1395ww(q)(2)(B)(i)) is amended by inserting ‘‘and after 

3 fiscal year 2022’’ after ‘‘2013’’. 

4 SEC. 105. REINSTATING HOLD HARMLESS TREATMENT FOR 

5 HOSPITAL OUTPATIENT SERVICES FOR SCHS. 

6 Section 1833(t)(7)(D)(i) of the Social Security Act 

7 (42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 

8 (1) in the heading, by striking ‘‘TEMPORARY’’ 

9 and inserting ‘‘PERMANENT’’; 

10 (2) in subclause (II)— 

11 (A) in the first sentence, by inserting ‘‘and 

12 on or after January 1, 2023,’’ after ‘‘January 

13 1, 2013,’’; and 

14 (B) in the second sentence, by inserting ‘‘, 

15 and during or after 2023’’ after ‘‘or 2012’’; and 

16 (3) in subclause (III), in the first sentence, by 

17 inserting ‘‘and on or after January 1, 2023,’’ after 

18 ‘‘January 1, 2013,’’. 

19 Subtitle B—Other Rural Providers 

20 SEC. 111. MAKING PERMANENT INCREASED MEDICARE 

21 PAYMENTS FOR GROUND AMBULANCE SERV22 ICES IN RURAL AREAS. 

23 Section 1834(l)(13) of the Social Security Act (42 

24 U.S.C. 1395m(l)(13)) is amended— 


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1 (1) in the paragraph heading, by striking 

2 ‘‘TEMPORARY INCREASE’’ and inserting ‘‘IN3 CREASE’’; and 

4 (2) in subparagraph (A)— 

5 (A) in the matter preceding clause (i), by 

6 striking ‘‘, and before January 1, 2025’’; and 

7 (B) in clause (i), by striking ‘‘, and before 

8 January 1, 2025’’. 

9 SEC. 112. EXTENDING MEDICAID PRIMARY CARE PAY10 MENTS. 

11 (a) IN GENERAL.—Section 1902(a)(13)(C) of the So12 cial Security Act (42 U.S.C. 1396a(a)(13)(C)) is amended 

13 by inserting after ‘‘2014’’ the following: ‘‘(or, in the case 

14 of primary care services furnished by a physician located 

15 in a rural area, as defined in section 1886(d)(2)(D), fur16 nished in any year)’’. 

17 (b) APPLICABILITY.— 

18 (1) IN GENERAL.—Except as provided in para19 graph (2), the amendment made by this section ap20 plies to services furnished in a year beginning on or 

21 after the date of the enactment of this Act. 

22 (2) EXCEPTION IF STATE LEGISLATION RE23 QUIRED.—In the case of a State plan for medical as24 sistance under title XIX of the Social Security Act 

25 which the Secretary of Health and Human Services 


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1 determines requires State legislation (other than leg2 islation appropriating funds) in order for the plan to 

3 meet the additional requirement imposed by the 

4 amendment made by this section, the State plan 

5 shall not be regarded as failing to comply with the 

6 requirements of such title solely on the basis of its 

7 failure to meet this additional requirement before 

8 the first day of the first calendar quarter beginning 

9 after the close of the first regular session of the 

10 State legislature that begins after the date of the en11 actment of this Act. For purposes of the previous 

12 sentence, in the case of a State that has a 2-year 

13 legislative session, each year of such session shall be 

14 deemed to be a separate regular session of the State 

15 legislature. 

16 SEC. 113. MAKING PERMANENT MEDICARE TELEHEALTH 

17 SERVICE ENHANCEMENTS FOR FEDERALLY 

18 QUALIFIED HEALTH CENTERS AND RURAL 

19 HEALTH CLINICS. 

20 Paragraph (8) of section 1834(m) of the Social Secu21 rity Act (42 U.S.C. 1395m(m)) is amended— 

22 (1) in the paragraph heading, be striking ‘‘DUR23 ING EMERGENCY PERIOD’’; 

24 (2) in the matter preceding subparagraph (A), 

25 by striking ‘‘During the emergency period described 


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1 in section 1135(g)(1)(B) and, in the case that such 

2 emergency period ends before December 31, 2024, 

3 during the period beginning on the first day after 

4 the end of such emergency period and ending on De5 cember 31, 2024’’ and inserting ‘‘Beginning on the 

6 first day of the emergency period described in sec7 tion 1135(g)(1)(B)’’; 

8 (3) in subparagraph (A)(ii), by striking ‘‘deter9 mined under subparagraph (B)’’ and inserting ‘‘de10 termined, for services furnished during the emer11 gency period described in section 1135(g)(1)(B), 

12 under subparagraph (B) and, for services furnished 

13 after such period, as an amount equal to the amount 

14 that such center or clinic would have been paid 

15 under this title had such service been furnished 

16 without the use of a telecommunications system’’; 

17 and 

18 (4) in subparagraph (B)— 

19 (A) by striking ‘‘PAYMENT RULE’’ and all 

20 that follows through ‘‘The Secretary shall’’ and 

21 inserting ‘‘PAYMENT RULE.—The Secretary 

22 shall’’; and 

23 (B) by redesignating clause (ii) as sub24 paragraph (C) and moving such subparagraph 

25 as so redesignated 2 ems to the left. 


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1 SEC. 114. 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 Save America’s Rural Hospitals Act 

19 by the State as being a necessary pro20 vider of health care services to resi21 dents 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 114(b) of the Save America’s 


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1 Rural Hospitals Act, an application 

2 for certification of the facility as a 

3 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) of section 1820(c)(2)(B)(i) of the 

19 Social Security Act (42 U.S.C. 1395i–4(c)(2)(B)(i)). 

20 SEC. 115. CMI TESTING OF NEW RURAL HOSPITAL DELIV21 ERY 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 

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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.— 

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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.’’. 

3 TITLE II—RURAL MEDICARE 

4 BENEFICIARY EQUITY 

5 SEC. 201. EQUALIZING BENEFICIARY COPAYMENTS FOR 

6 SERVICES FURNISHED BY CAHS. 

7 (a) IN GENERAL.—Section 1866(a)(2)(A) of the So8 cial Security Act (42 U.S.C. 1395cc(a)(2)(A)) is amended 

9 by adding at the end the following: ‘‘In the case of out10 patient critical access hospital services for which payment 

11 is made under section 1834(g), clause (ii) of the first sen12 tence shall be applied by substituting ‘20 percent of the 

13 lesser of the actual charge or the payment basis under 

14 this part for such services if the critical access hospital 

15 were treated as a hospital’ for ‘20 per centum of the rea16 sonable charges for such items and services’.’’. 

17 (b) APPLICABILITY.—The amendment made by this 

18 section applies with respect to services furnished during 

19 a year that begins more than 60 days after the date of 

20 the enactment of this Act. 

21 SEC. 202. REMOVING SUPERVISION OF CERTIFIED REG22 ISTERED NURSE ANESTHETISTS. 

23 Section 1861(bb)(2) of the Social Security Act (42 

24 U.S.C. 1395x(bb)(2)) is amended— 


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1 (1) in the second sentence, by inserting ‘‘, but 

2 may not require that certified registered nurse anes3 thetists provide services under the supervision of a 

4 physician’’ after ‘‘certification of nurse anes5 thetists’’; and 

6 (2) in the third sentence, by inserting ‘‘under 

7 the supervision of an anesthesiologist’’ after ‘‘an an8 esthesiologist assistant’’. 

9 SEC. 203. CRNA SERVICES AS A MEDICAID-REQUIRED BEN10 EFIT. 

11 (a) IN GENERAL.—Section 1905(a)(5) of the Social 

12 Security Act (42 U.S.C. 1396d(a)(5)) is amended— 

13 (1) by striking ‘‘and (B)’’ and inserting ‘‘(B)’’; 

14 and 

15 (2) by inserting before the semicolon at the end 

16 the following: ‘‘, and (C) services furnished by a cer17 tified registered nurse anesthetist (as defined in sec18 tion 1861(bb)(2)), which such certified registered 

19 nurse anesthetist is authorized to perform under 

20 State law (or the State regulatory mechanism as 

21 provided by State law)’’. 

22 (b) PAYMENT.—Section 1902(a) of the Social Secu23 rity Act (42 U.S.C. 1396d(a)) is amended— 

24 (1) in paragraph (86), by striking ‘‘and’’ at the 

25 end; 


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1 (2) in paragraph (87), by striking the period 

2 and inserting ‘‘; and’’; and 

3 (3) by inserting after paragraph (87) the fol4 lowing new paragraph: 

5 ‘‘(88) provide for payment for the services of a 

6 certified registered nurse anesthetist (as defined in 

7 section 1861(bb)(1)) in amounts no lower than the 

8 amounts, using the same methodology, used for pay9 ment for amounts under section 1833(a)(1)(H).’’. 

10 TITLE III—REGULATORY RELIEF 

11 SEC. 301. ELIMINATING 96-HOUR PHYSICIAN CERTIFI12 CATION REQUIREMENT WITH RESPECT TO 

13 INPATIENT CAH SERVICES. 

14 (a) IN GENERAL.—Section 1814(a) of the Social Se15 curity Act (42 U.S.C. 1395f(a)) is amended— 

16 (1) in paragraph (6), by adding ‘‘and’’ at the 

17 end; 

18 (2) in paragraph (7)(E), by striking ‘‘; and’’ 

19 and inserting a period; and 

20 (3) by striking paragraph (8). 

21 (b) APPLICABILITY.—The amendments made by this 

22 section apply with respect to services furnished during a 

23 year that begins more than 60 days after the date of the 

24 enactment of this Act. 


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1 SEC. 302. REBASING SUPERVISION REQUIREMENTS. 

2 (a) THERAPEUTIC HOSPITAL OUTPATIENT SERV3 ICES.— 

4 (1) SUPERVISION REQUIREMENTS.—Section 

5 1833 of the Social Security Act (42 U.S.C. 1395l) 

6 is amended by adding at the end the following new 

7 subsection: 

8 ‘‘(ee) PHYSICIAN SUPERVISION REQUIREMENTS FOR

9 THERAPEUTIC HOSPITAL OUTPATIENT SERVICES.— 

10 ‘‘(1) GENERAL SUPERVISION FOR THERAPEUTIC

11 SERVICES.—Except as may be provided under para12 graph (2), insofar as the Secretary requires the su13 pervision by a physician or a non-physician practi14 tioner for payment for therapeutic hospital out15 patient services (as defined in paragraph (5)(A)) 

16 furnished under this part, such requirement shall be 

17 met if such services are furnished under the general 

18 supervision (as defined in paragraph (5)(B)) of the 

19 physician or non-physician practitioner, as the case 

20 may be. 

21 ‘‘(2) EXCEPTIONS PROCESS FOR HIGH-RISK OR

22 COMPLEX MEDICAL SERVICES REQUIRING A DIRECT

23 LEVEL OF SUPERVISION.— 

24 ‘‘(A) IN GENERAL.—Subject to the suc25 ceeding provisions of this paragraph, the Sec26 retary shall establish a process for the designaVerDate Sep 11 2014 00:42 Mar 03, 2023 Jkt 039200 PO 00000 Frm 00023 Fmt 6652 Sfmt 6201 E:\BILLS\H833.IH H833

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1 tion of therapeutic hospital outpatient services 

2 furnished under this part that, by reason of 

3 complexity or high risk, require— 

4 ‘‘(i) direct supervision (as defined in 

5 paragraph (5)(C)) for the entire service; or 

6 ‘‘(ii) direct supervision during the ini7 tiation of the service followed by general 

8 supervision for the remainder of the serv9 ice. 

10 ‘‘(B) CONSULTATION WITH CLINICAL EX11 PERTS.— 

12 ‘‘(i) IN GENERAL.—Under the process 

13 established under subparagraph (A), before 

14 the designation of any therapeutic hospital 

15 outpatient service for which direct super16 vision may be required under this part, the 

17 Secretary shall consult with a panel of out18 side experts described in clause (ii) to ad19 vise the Secretary with respect to each 

20 such designation. 

21 ‘‘(ii) ADVISORY PANEL ON SUPER22 VISION OF THERAPEUTIC HOSPITAL OUT23 PATIENT SERVICES.—For purposes of 

24 clause (i), a panel of outside experts de25 scribed in this clause is a panel appointed 


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1 by the Secretary, based on nominations 

2 submitted by hospital, rural health, and 

3 medical organizations representing physi4 cians, non-physician practitioners, and hos5 pital administrators, as the case may be, 

6 that meets the following requirements: 

7 ‘‘(I) COMPOSITION.—The panel 

8 shall be composed of at least 15 phy9 sicians and non-physician practi10 tioners who furnish therapeutic hos11 pital outpatient services for which 

12 payment is made under this part and 

13 who collectively represent the medical 

14 specialties that furnish such services, 

15 and of 4 hospital administrators of 

16 hospitals located in rural areas (as de17 fined in section 1886(d)(2)(D)) or 

18 critical access hospitals. 

19 ‘‘(II) PRACTICAL EXPERIENCE

20 REQUIRED FOR PHYSICIANS AND NON21 PHYSICIAN PRACTITIONERS.—During 

22 the 12-month period preceding ap23 pointment to the panel by the Sec24 retary, each physician or non-physi25 cian practitioner described in subVerDate Sep 11 2014 00:42 Mar 03, 2023 Jkt 039200 PO 00000 Frm 00025 Fmt 6652 Sfmt 6201 E:\BILLS\H833.IH H833

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1 clause (I) shall have furnished thera2 peutic hospital outpatient services for 

3 which payment was made under this 

4 part. 

5 ‘‘(III) MINIMUM RURAL REP6 RESENTATION REQUIREMENT FOR

7 PHYSICIANS AND NON-PHYSICIAN

8 PRACTITIONERS.—Not less than 50 

9 percent of the membership of the 

10 panel that is composed of physicians 

11 and non-physician practitioners shall 

12 be physicians or non-physician practi13 tioners described in subclause (I) who 

14 practice in rural areas (as defined in 

15 section 1886(d)(2)(D)) or who furnish 

16 such services in critical access hos17 pitals. 

18 ‘‘(iii) APPLICATION OF FACA.—The 

19 Federal Advisory Committee Act (5 U.S.C. 

20 2 App.), other than section 14 of such Act, 

21 shall apply to the panel of outside experts 

22 appointed by the Secretary under clause 

23 (ii). 

24 ‘‘(C) SPECIAL RULE FOR OUTPATIENT

25 CRITICAL ACCESS HOSPITAL SERVICES.—InsoVerDate Sep 11 2014 00:42 Mar 03, 2023 Jkt 039200 PO 00000 Frm 00026 Fmt 6652 Sfmt 6201 E:\BILLS\H833.IH H833

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1 far as a therapeutic outpatient hospital service 

2 that is an outpatient critical access hospital 

3 service is designated as requiring direct super4 vision under the process established under sub5 paragraph (A), the Secretary shall deem the 

6 critical access hospital furnishing that service 

7 as having met the requirement for direct super8 vision for that service if, when furnishing such 

9 service, the critical access hospital meets the 

10 standard for personnel required as a condition 

11 of participation under section 485.618(d) of 

12 title 42, Code of Federal Regulations (as in ef13 fect on the date of the enactment of this sub14 section). 

15 ‘‘(D) CONSIDERATION OF COMPLIANCE

16 BURDENS.—Under the process established 

17 under subparagraph (A), the Secretary shall 

18 take into account the impact on hospitals and 

19 critical access hospitals in complying with re20 quirements for direct supervision in the fur21 nishing of therapeutic hospital outpatient serv22 ices, including hospital resources, availability of 

23 hospital-privileged physicians, specialty physi24 cians, and non-physician practitioners, and ad25 ministrative burdens. 


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1 ‘‘(E) REQUIREMENT FOR NOTICE AND

2 COMMENT RULEMAKING.—Under the process 

3 established under subparagraph (A), the Sec4 retary shall only designate therapeutic hospital 

5 outpatient services requiring direct supervision 

6 under this part through proposed and final 

7 rulemaking that provides for public notice and 

8 opportunity for comment. 

9 ‘‘(F) RULE OF CONSTRUCTION.—Nothing 

10 in this subsection shall be construed as author11 izing the Secretary to apply or require any level 

12 of supervision other than general or direct su13 pervision with respect to the furnishing of 

14 therapeutic hospital outpatient services. 

15 ‘‘(3) INITIAL LIST OF DESIGNATED SERVICES.— 

16 The Secretary shall include in the proposed and final 

17 regulation for payment for hospital outpatient serv18 ices for 2022 under this part a list of initial thera19 peutic hospital outpatient services, if any, designated 

20 under the process established under paragraph 

21 (2)(A) as requiring direct supervision under this 

22 part. 

23 ‘‘(4) DIRECT SUPERVISION BY NON-PHYSICIAN

24 PRACTITIONERS FOR CERTAIN HOSPITAL OUT25 PATIENT SERVICES PERMITTED.— 


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1 ‘‘(A) IN GENERAL.—Subject to the suc2 ceeding provisions of this subsection, a non-phy3 sician practitioner may directly supervise the 

4 furnishing of— 

5 ‘‘(i) therapeutic hospital outpatient 

6 services under this part, including cardiac 

7 rehabilitation services (under section 

8 1861(eee)(1)), intensive cardiac rehabilita9 tion services (under section 1861(eee)(4)), 

10 and pulmonary rehabilitation services 

11 (under section 1861(fff)(1)); and 

12 ‘‘(ii) those hospital outpatient diag13 nostic services (described in section 

14 1861(s)(2)(C)) that require direct super15 vision under the fee schedule established 

16 under section 1848. 

17 ‘‘(B) REQUIREMENTS.—Subparagraph (A) 

18 shall apply insofar as the non-physician practi19 tioner involved meets the following require20 ments: 

21 ‘‘(i) SCOPE OF PRACTICE.—The non22 physician practitioner is acting within the 

23 scope of practice under State law applica24 ble to the practitioner. 


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1 ‘‘(ii) ADDITIONAL REQUIREMENTS.— 

2 The non-physician practitioner meets such 

3 requirements as the Secretary may specify. 

4 ‘‘(5) DEFINITIONS.—In this subsection: 

5 ‘‘(A) THERAPEUTIC HOSPITAL OUT6 PATIENT SERVICES.—The term ‘therapeutic 

7 hospital outpatient services’ means hospital 

8 services described in section 1861(s)(2)(B) fur9 nished by a hospital or critical access hospital 

10 and includes— 

11 ‘‘(i) cardiac rehabilitation services and 

12 intensive cardiac rehabilitation services (as 

13 defined in paragraphs (1) and (4), respec14 tively, of section 1861(eee)); and 

15 ‘‘(ii) pulmonary rehabilitation services 

16 (as defined in section 1861(fff)(1)). 

17 ‘‘(B) GENERAL SUPERVISION.— 

18 ‘‘(i) OVERALL DIRECTION AND CON19 TROL OF PHYSICIAN.—Subject to clause 

20 (ii), with respect to the furnishing of 

21 therapeutic hospital outpatient services for 

22 which payment may be made under this 

23 part, the term ‘general supervision’ means 

24 such services that are furnished under the 

25 overall direction and control of a physician 


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1 or non-physician practitioner, as the case 

2 may be. 

3 ‘‘(ii) PRESENCE NOT REQUIRED.—For 

4 purposes of clause (i), the presence of a 

5 physician or non-physician practitioner is 

6 not required during the performance of the 

7 procedure involved. 

8 ‘‘(C) DIRECT SUPERVISION.— 

9 ‘‘(i) PROVISION OF ASSISTANCE AND

10 DIRECTION.—Subject to clause (ii), with 

11 respect to the furnishing of therapeutic 

12 hospital outpatient services for which pay13 ment may be made under this part, the 

14 term ‘direct supervision’ means that a phy15 sician or non-physician practitioner, as the 

16 case may be, is immediately available (in17 cluding by telephone or other means) to 

18 furnish assistance and direction through19 out the furnishing of such services. Such 

20 term includes, with respect to the fur21 nishing of a therapeutic hospital outpatient 

22 service for which payment may be made 

23 under this part, direct supervision during 

24 the initiation of the service followed by 

25 general supervision for the remainder of 


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1 the service (as described in paragraph 

2 (2)(A)(ii)). 

3 ‘‘(ii) PRESENCE IN ROOM NOT RE4 QUIRED.—For purposes of clause (i), a 

5 physician or non-physician practitioner, as 

6 the case may be, is not required to be 

7 present in the room during the perform8 ance of the procedure involved or within 

9 any other physical boundary as long as the 

10 physician or non-physician practitioner, as 

11 the case may be, is immediately available. 

12 ‘‘(D) NON-PHYSICIAN PRACTITIONER DE13 FINED.—The term ‘non-physician practitioner’ 

14 means an individual who— 

15 ‘‘(i) is a physician assistant, a nurse 

16 practitioner, a clinical nurse specialist, a 

17 clinical social worker, a clinical psycholo18 gist, a certified nurse midwife, or a cer19 tified registered nurse anesthetist, and in20 cludes such other practitioners as the Sec21 retary may specify; and 

22 ‘‘(ii) with respect to the furnishing of 

23 therapeutic outpatient hospital services, 

24 meets the requirements of paragraph 

25 (4)(B).’’. 


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1 (2) CONFORMING AMENDMENT.—Section 

2 1861(eee)(2)(B) of the Social Security Act (42 

3 U.S.C. 1395x(eee)(2)(B)) is amended by inserting ‘‘, 

4 and a non-physician practitioner (as defined in sec5 tion 1833(cc)(5)(D)) may supervise the furnishing of 

6 such items and services in the hospital’’ after ‘‘in 

7 the case of items and services furnished under such 

8 a program in a hospital, such availability shall be 

9 presumed’’. 

10 (b) PROHIBITION ON RETROACTIVE ENFORCEMENT

11 OF REVISED INTERPRETATION.— 

12 (1) REPEAL OF REGULATORY CLARIFICA13 TION.—The restatement and clarification under the 

14 final rulemaking changes to the Medicare hospital 

15 outpatient prospective payment system and calendar 

16 year 2009 payment rates (published in the Federal 

17 Register on November 18, 2008, 73 Fed. Reg. 

18 68702 through 68704) with respect to requirements 

19 for direct supervision by physicians for therapeutic 

20 hospital outpatient services (as defined in paragraph 

21 (3)) for purposes of payment for such services under 

22 the Medicare program shall have no force or effect 

23 in law. 

24 (2) HOLD HARMLESS.—A hospital or critical 

25 access hospital that furnishes therapeutic hospital 


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1 outpatient services during the period beginning on 

2 January 1, 2001, and ending on the later of Decem3 ber 31, 2021, or the date on which the final regula4 tion promulgated by the Secretary of Health and 

5 Human Services to carry out this section takes ef6 fect, for which a claim for payment is made under 

7 part B of title XVIII of the Social Security Act shall 

8 not be subject to any civil or criminal action or pen9 alty under Federal law for failure to meet super10 vision requirements under the regulation described 

11 in paragraph (1), under program manuals, or other12 wise. 

13 (3) THERAPEUTIC HOSPITAL OUTPATIENT

14 SERVICES DEFINED.—In this subsection, the term 

15 ‘‘therapeutic hospital outpatient services’’ means 

16 medical and other health services furnished by a 

17 hospital or critical access hospital that are— 

18 (A) hospital services described in sub19 section (s)(2)(B) of section 1861 of the Social 

20 Security Act (42 U.S.C. 1395x); 

21 (B) cardiac rehabilitation services or inten22 sive cardiac rehabilitation services (as defined 

23 in paragraphs (1) and (4), respectively, of sub24 section (eee) of such section); or 


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1 (C) pulmonary rehabilitation services (as 

2 defined in subsection (fff)(1) of such section). 

3 SEC. 303. REFORMING PRACTICES OF RECOVERY AUDIT 

4 CONTRACTORS UNDER MEDICARE. 

5 (a) ELIMINATION OF CONTINGENCY FEE PAYMENT

6 SYSTEM.—Section 1893(h) of the Social Security Act (42 

7 U.S.C. 1395ddd(h)) is amended— 

8 (1) in paragraph (1), by inserting ‘‘, for recov9 ery activities conducted during a fiscal year before 

10 fiscal year 2023’’ after ‘‘Under the contracts’’; and 

11 (2) by adding at the end the following new 

12 paragraph: 

13 ‘‘(11) PAYMENT FOR RECOVERY ACTIVITIES

14 PERFORMED AFTER FISCAL YEAR 2022.— 

15 ‘‘(A) IN GENERAL.—Under the contracts, 

16 subject to paragraphs (B) and (C), payment 

17 shall be made to recovery audit contractors for 

18 recovery activities conducted during fiscal year 

19 2022 and each fiscal year thereafter in the 

20 same manner, and from the same amounts, as 

21 payment is made to eligible entities under con22 tracts entered into for recovery activities con23 ducted during fiscal year 2022 under subsection 

24 (a). 


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1 ‘‘(B) PROHIBITION ON INCENTIVE PAY2 MENTS.—Under the contracts, payment made 

3 to a recovery audit contractor for recovery ac4 tivities conducted during fiscal year 2023 or 

5 any fiscal year thereafter may not include any 

6 incentive payments. 

7 ‘‘(C) PERFORMANCE ACCOUNTABILITY.— 

8 ‘‘(i) IN GENERAL.—Under the con9 tracts, payment made to a recovery audit 

10 contractor for recovery activities conducted 

11 during fiscal year 2023 or any fiscal year 

12 thereafter shall, in the case that the con13 tractor has a complex audit denial overturn 

14 rate at the end of such fiscal year (as cal15 culated under the methodology described in 

16 clause (iv)) that is 0.1 or greater, be re17 duced in an amount determined in accord18 ance with clause (ii). 

19 ‘‘(ii) PAYMENT REDUCTIONS.— 

20 ‘‘(I) SLIDING SCALE OF AMOUNT

21 OF REDUCTIONS.—The Secretary 

22 shall establish, for purposes of deter23 mining the amount of a reduction in 

24 payment to a recovery audit con25 tractor under clause (i) for recovery 


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1 activities conducted during fiscal year, 

2 a linear sliding scale of payment re3 ductions for recovery audit contrac4 tors for such fiscal year. Under such 

5 linear sliding scale, the amount of 

6 such a reduction in payment to a re7 covery audit contractor for a fiscal 

8 year shall be calculated in a manner 

9 that provides for such reduction to be 

10 greater than the reduction for such 

11 fiscal year for recovery audit contrac12 tors that have complex audit denial 

13 overturn rates at the end of such fis14 cal year (as calculated under the 

15 methodology described in clause (iv)) 

16 that are lower than the complex audit 

17 denial overturn rate of the contractor 

18 at the end of such fiscal year (as so 

19 calculated). 

20 ‘‘(II) MANNER OF COLLECTING

21 REDUCTION.—The Secretary may as22 sess and collect the reductions in pay23 ment to recovery audit contractors 

24 under clause (i) in such manner as 

25 the Secretary may specify (such as by 


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1 reducing the amount paid to the con2 tractor for recovery activities con3 ducted during a fiscal year or by as4 sessing the reduction as a separate 

5 penalty payment to be paid to the 

6 Secretary by the contractor with re7 spect to each complex audit denial 

8 issued by the contractor that is over9 turned on appeal). 

10 ‘‘(iii) TIMING OF DETERMINATIONS OF

11 PAYMENT REDUCTIONS.—The Secretary 

12 shall, with respect to a recovery audit con13 tractor, determine not later than six 

14 months after the end of a fiscal year— 

15 ‘‘(I) whether to reduce payment 

16 to the recovery audit contractor under 

17 clause (i) for recovery activities con18 ducted during such fiscal year; and 

19 ‘‘(II) in the case that the Sec20 retary determines to so reduce pay21 ment to the contractor, the amount of 

22 such payment reduction. 

23 ‘‘(iv) METHODOLOGY FOR CALCULA24 TION OF OVERTURNED COMPLEX AUDIT

25 DENIAL OVERTURN RATE.— 


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1 ‘‘(I) CALCULATION OF OVERTURN

2 RATE.—The Secretary shall calculate 

3 a complex audit denial overturn rate 

4 for a recovery audit contractor for a 

5 fiscal year by— 

6 ‘‘(aa) determining, with re7 spect to the contract entered into 

8 under paragraph (1) by the con9 tractor, the number of complex 

10 audit denials issued by the con11 tractor under the contract (in12 cluding denials issued before such 

13 fiscal year and during such fiscal 

14 year) that are overturned on ap15 peal; and 

16 ‘‘(bb) dividing the number 

17 determined under item (aa) by 

18 the number of complex audit de19 nials issued by the contractor 

20 under such contract (including 

21 denials issued before such fiscal 

22 year and during such fiscal year). 

23 ‘‘(II) FAIRNESS AND TRANS24 PARENCY.—The Secretary shall cal25 culate the percentage described in 


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1 subclause (I) in a fair and trans2 parent manner. 

3 ‘‘(III) ACCOUNTING FOR SUBSE4 QUENTLY OVERTURNED APPEALS.— 

5 The Secretary shall calculate the per6 centage described in subclause (I) in a 

7 manner that accounts for the likeli8 hood that complex audit denials 

9 issued by the contractor for such fis10 cal year will be overturned on appeal 

11 in a subsequent fiscal year. 

12 ‘‘(IV) COMPLEX AUDIT DENIAL

13 DEFINED.—In this subparagraph, the 

14 term ‘complex audit denial’ means a 

15 denial by a recovery audit contractor 

16 of a claim for payment under this title 

17 submitted by a hospital, psychiatric 

18 hospital, or critical access hospital 

19 that is so denied by the contractor 

20 after the contractor has— 

21 ‘‘(aa) requested that the 

22 hospital, psychiatric hospital, or 

23 critical access hospital, in order 

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1 ment, provide supporting medical 

2 records to the contractor; and 

3 ‘‘(bb) reviewed such medical 

4 records in order to determine 

5 whether an improper payment 

6 has been made to the hospital, 

7 psychiatric hospital, or critical 

8 access hospital for such claim. 

9 ‘‘(V) OVERTURNED ON APPEAL

10 DEFINED.—In this subparagraph, the 

11 term ‘overturned on appeal’ means, 

12 with respect to a complex audit de13 nial, a denial that is overturned on 

14 appeal at the reconsideration level, the 

15 redetermination level, or the adminis16 trative law judge hearing level. 

17 ‘‘(D) APPLICATION TO EXISTING CON18 TRACTS.—Not later than 60 days after the date 

19 of the enactment of this paragraph, the Sec20 retary shall modify, as necessary, each contract 

21 under paragraph (1) that the Secretary entered 

22 into prior to such date of enactment in order to 

23 ensure that payment with respect to recovery 

24 activities conducted under such contract is 


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1 made in accordance with the requirements de2 scribed in this paragraph.’’. 

3 (b) ELIMINATION OF ONE-YEAR TIMELY FILING

4 LIMIT TO REBILL PART B CLAIMS.— 

5 (1) IN GENERAL.—Section 1842(b) of the So6 cial Security Act (42 U.S.C. 1395u(b)) is amended 

7 by adding at the end the following new paragraph: 

8 ‘‘(20) EXCEPTION TO THE ONE-YEAR TIMELY

9 FILING LIMIT FOR CERTAIN REBILLED CLAIMS.— 

10 ‘‘(A) IN GENERAL.—In the case of a claim 

11 submitted under this part by a hospital (as de12 fined in subparagraph (B)(i)) for hospital serv13 ices with respect to which there was a previous 

14 claim submitted under part A as inpatient hos15 pital services or inpatient critical access hos16 pital services that was denied by a medicare 

17 contractor (as defined in subparagraph (B)(ii)) 

18 because of a determination that the inpatient 

19 admission was not medically reasonable and 

20 necessary under section 1862(a)(1)(A), the 

21 deadline described in this paragraph is 180 

22 days after the date of the final denial of such 

23 claim under part A. 

24 ‘‘(B) DEFINITIONS.—In this paragraph: 


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1 ‘‘(i) HOSPITAL.—The term ‘hospital’ 

2 has the meaning given such term in section 

3 1861(e) and includes a psychiatric hospital 

4 (as defined in section 1861(f)) and a crit5 ical access hospital (as defined in section 

6 1861(mm)(1)). 

7 ‘‘(ii) MEDICARE CONTRACTOR.—The 

8 term ‘medicare contractor’ has the mean9 ing given such term under section 1889(g), 

10 and includes a recovery audit contractor 

11 with a contract under section 1893(h). 

12 ‘‘(iii) FINAL DENIAL.—The term ‘final 

13 denial’ means— 

14 ‘‘(I) in the case that a hospital 

15 elects not to appeal a denial described 

16 in subparagraph (A) by a medicare 

17 contractor, the date of such denial; or 

18 ‘‘(II) in the case that a hospital 

19 elects to appeal such a denial, the 

20 date on which such appeal is ex21 hausted.’’. 

22 (2) CONFORMING AMENDMENTS.— 

23 (A) Section 1835(a)(1) of the Social Secu24 rity Act (42 U.S.C. 1395n(a)(1)) is amended by 

25 inserting ‘‘or, in the case of a claim described 


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1 in section 1842(b)(20), not later than the dead2 line described in such paragraph’’ after ‘‘the 

3 date of service’’. 

4 (B) Section 1842(b)(3)(B) of the Social 

5 Security Act (42 U.S.C. 1395u(b)(3)(B)) is 

6 amended in the flush language following clause 

7 (ii) by inserting ‘‘or, in the case of a claim de8 scribed in section 1842(b)(20), not later than 

9 the deadline described in such paragraph’’ after 

10 ‘‘the date of service’’. 

11 (3) APPLICABILITY.—The amendments made 

12 by this subsection apply to claims submitted under 

13 part B of title XVIII of the Social Security Act for 

14 hospital services for which there was a previous 

15 claim submitted under part A as inpatient hospital 

16 services or inpatient critical access hospital services 

17 that was subject to a final denial (as defined in 

18 paragraph (20)(B)(iii) of section 1842(b) of such 

19 Act (42 U.S.C. 1395u(b)) on or after the date of the 

20 enactment of this Act. 

21 (c) MEDICAL DOCUMENTATION CONSIDERED FOR

22 MEDICAL NECESSITY REVIEWS OF CLAIMS FOR INPA23 TIENT HOSPITAL SERVICES.—Section 1862(a) of the So24 cial Security Act (42 U.S.C. 1395y(a)) is amended by add25 ing at the end the following new sentence: ‘‘A determinaVerDate Sep 11 2014 00:42 Mar 03, 2023 Jkt 039200 PO 00000 Frm 00044 Fmt 6652 Sfmt 6201 E:\BILLS\H833.IH H833

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1 tion under paragraph (1) of whether inpatient hospital 

2 services or inpatient critical access hospital services fur3 nished to an individual on or after the date of the enact4 ment of this sentence are reasonable and necessary shall 

5 be based solely upon information available to the admit6 ting physician at the time of the inpatient admission of 

7 the individual for such inpatient services, as documented 

8 in the medical record.’’. 

9 TITLE IV—FUTURE OF RURAL 

10 HEALTH CARE 

11 SEC. 401. MEDICARE RURAL HOSPITAL FLEXIBILITY PRO12 GRAM GRANTS. 

13 Section 1820(g) of the Social Security Act (42 U.S.C. 

14 1395i–4(g)) is amended— 

15 (1) in paragraph (1)— 

16 (A) in subparagraph (C), by striking 

17 ‘‘and’’ at the end; 

18 (B) in subparagraph (D), by striking the 

19 period at the end and inserting a semicolon; 

20 and 

21 (C) by adding at the end the following new 

22 subparagraphs: 

23 ‘‘(E) rural emergency hospitals providing 

24 support for critical access hospitals to convert 

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1 pital emergency services in their communities; 

2 and 

3 ‘‘(F) supporting certified rural health clin4 ics for maintaining and building business oper5 ations, increasing financial indicators, address6 ing population health, transforming services, 

7 and providing linkages and services for behav8 ioral health and substance use disorders re9 sponding to public health emergencies.’’; 

10 (2) by redesignating paragraphs (3) through 

11 (7) as paragraphs (4) through (8), respectively; 

12 (3) after paragraph (2), by inserting the fol13 lowing new paragraph: 

14 ‘‘(3) ACTIVITIES TO SUPPORT CARRYING OUT

15 FLEX GRANTS.—The Secretary may award grants or 

16 cooperative agreements to entities that submit to the 

17 Secretary applications, at such time and in such 

18 form and manner and containing such information 

19 as the Secretary specifies, for purposes of supporting 

20 States and hospitals in carrying out the activities 

21 under this subsection by providing technical assist22 ance, data analysis, and evaluation efforts.’’; 

23 (4) in paragraph (4), as redesignated— 


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1 (A) in subparagraph (A), by inserting 

2 ‘‘State Offices of Rural Health on behalf of eli3 gible hospitals’’ after ‘‘award grants to’’; 

4 (B) by amending subparagraph (C) to read 

5 as follows: 

6 ‘‘(C) APPLICATION.—The State Office of 

7 Rural Health shall submit an application, on 

8 behalf of eligible rural hospitals, to the Sec9 retary on or before such date and in such form 

10 and manner as the Secretary specifies.’’; 

11 (C) by amending subparagraph (D), to 

12 read as follows: 

13 ‘‘(D) AMOUNT OF GRANT.—A grant to a 

14 hospital under this paragraph shall be deter15 mined on an equal national distribution so that 

16 each hospital receives the same amount of sup17 port related to the funds appropriated.’’; 

18 (D) by amending subparagraph (E), to 

19 read as follows: 

20 ‘‘(E) USE OF FUNDS.—State Offices of 

21 Rural Health and eligible hospitals may use the 

22 funds received through a grant under this para23 graph for the purchase of computer software 

24 and hardware; the education and training of 

25 hospital staff on billing, operational, quality imVerDate Sep 11 2014 00:42 Mar 03, 2023 Jkt 039200 PO 00000 Frm 00047 Fmt 6652 Sfmt 6201 E:\BILLS\H833.IH H833

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1 provement and related value-focused efforts; 

2 and other delivery system reform programs de3 termined appropriate by the Secretary.’’; and 

4 (5) by adding at the end the following new 

5 paragraph: 

6 ‘‘(9) RURAL HEALTH TRANSFORMATION

7 GRANTS.— 

8 ‘‘(A) GRANTS.—The Secretary may award 

9 5-year grants to State Offices of Rural Health 

10 and to eligible rural health care providers (as 

11 defined in subparagraph (E)) on the transition 

12 to new models, including rural emergency hos13 pitals, extended stay clinics, freestanding emer14 gency departments, rural health clinics, and in15 tegration of behavioral, oral health services, 

16 telehealth and other transformational models 

17 relevant to rural providers as such providers 

18 evolve to better meet community needs and the 

19 changing health care environment. 

20 ‘‘(B) APPLICATION.—An applicable rural 

21 health care provider, in partnership with the 

22 State Office of Rural Health in the State in 

23 which the rural health care provider seeking a 

24 grant under this paragraph is located, shall 

25 submit an application to the Secretary on or beVerDate Sep 11 2014 00:42 Mar 03, 2023 Jkt 039200 PO 00000 Frm 00048 Fmt 6652 Sfmt 6201 E:\BILLS\H833.IH H833

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1 fore such date and in such form and manner as 

2 the Secretary specifies. 

3 ‘‘(C) ADDITIONAL REQUIREMENTS.—The 

4 Secretary may not award a grant under this 

5 paragraph to an eligible rural health care pro6 vider unless— 

7 ‘‘(i) local organizations or the State in 

8 which the hospital is located provides sup9 port (either direct or in kind); and there 

10 are letters of support from key State pay11 ers such as Medicaid and private insur12 ance; and 

13 ‘‘(ii) the applicant describes in detail 

14 how the transition of the health care pro15 vider or providers will better meet local 

16 needs and be sustainable. 

17 ‘‘(D) ELIGIBLE RURAL HEALTH CARE PRO18 VIDER DEFINED.—For purposes of this para19 graph, the term ‘eligible rural health care pro20 vider’ includes a critical access hospital, a cer21 tified rural health clinic, a rural nursing home, 

22 skilled nursing facility, emergency care pro23 vider, or other entity identified by the Sec24 retary. An eligible rural health care provider 

25 may include other entities applying on behalf of 


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•HR 833 IH

1 a group of providers such as a State Office of 

2 Rural Health, a State or local health care au3 thority, a rural health network, or other entity 

4 identified by the Secretary.’’. 

Æ 


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