I 

117TH CONGRESS 

2D SESSION H. R. 6400 

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 

JANUARY 13, 2022 

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 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. Creation of reporting requirements for provider-based rural health 

clinics. 

TITLE II—RURAL MEDICARE BENEFICIARY EQUITY 

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

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-de17 pendent, small rural hospital (as defined in secVerDate Sep 11 2014 23:58 Jan 19, 2022 Jkt 029200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H6400.IH H6400

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1 tion 1886(d)(5)(G)(iv) of such Act), or a sub2 section (d) hospital located in a rural area (as 

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

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

5 section applies with respect to orders of sequestration ef6 fective on or after the date that is 60 days after the date 

7 of the enactment of this Act. 

8 SEC. 102. REVERSING CUTS TO REIMBURSEMENT OF BAD 

9 DEBT FOR CRITICAL ACCESS HOSPITALS 

10 (CAHS) AND RURAL HOSPITALS. 

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

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

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

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

15 percent of such amount otherwise allowable’’. 

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

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

18 by inserting after ‘‘or (V)’’ the following: ‘‘, a critical ac19 cess hospital’’. 

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

21 section apply with respect to cost reporting periods begin22 ning more than 60 days after the date of the enactment 

23 of this Act. 


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1 SEC. 103. EXTENDING PAYMENT LEVELS FOR LOW-VOLUME 

2 HOSPITALS AND MEDICARE-DEPENDENT 

3 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, 2022’’; and 

11 (B) in clause (ii)(II), by striking ‘‘, and be12 fore October 1, 2022’’. 

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 2022’’; and 

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

22 ‘‘through fiscal year 2022’’ 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 2022’’ 

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 2023 and subsequent fiscal years’’; 

15 (2) in subparagraph (C)(i)— 

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

17 by striking ‘‘through 2022’’ 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 2022’’ 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: ‘‘APPLICABLE PERCENTAGE INCREASE

7 AFTER FISCAL YEAR 2010’’; 

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

9 striking ‘‘in fiscal years 2011 through 2022’’ 

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 2022’’ 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 2021’’ 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 2021’’ 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, 2022,’’ after ‘‘January 

13 1, 2013,’’; and 

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

15 and during or after 2022’’ after ‘‘or 2012’’; and 

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

17 inserting ‘‘and on or after January 1, 2022,’’ 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, 2023’’; and 

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

8 January 1, 2023’’. 

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 inserting ‘‘Beginning 

2 on the first day of the emergency period described 

3 in section 1135(g)(1)(B)’’; 

4 (3) in subparagraph (A)(ii), by striking ‘‘deter5 mined under subparagraph (B)’’ and inserting ‘‘de6 termined, for services furnished during the emer7 gency period described in section 1135(g)(1)(B), 

8 under subparagraph (B) and, for services furnished 

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

10 that such center or clinic would have been paid 

11 under this title had such service been furnished 

12 without the use of a telecommunications system’’; 

13 and 

14 (4) in subparagraph (B)— 

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

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

17 inserting ‘‘PAYMENT RULE.—The Secretary 

18 shall’’; and 

19 (B) by redesignating clause (ii) as sub20 paragraph (C) and moving such subparagraph 

21 as so redesignated 2 ems to the left. 

22 SEC. 114. CREATION OF REPORTING REQUIREMENTS FOR 

23 PROVIDER-BASED RURAL HEALTH CLINICS. 

24 (a) IN GENERAL.—Not later than two years after the 

25 date of the enactment of this Act, the Secretary of Health 


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1 and Human Services (in this section referred to as the 

2 ‘‘Secretary’’) shall, taking into account the recommenda3 tions made pursuant to subsection (b), implement a vol4 untary Medicare provider-based rural health clinic quality 

5 reporting program, in accordance with this section, under 

6 which— 

7 (1) provider-based rural health clinics estab8 lished on or after January 1, 2021, may voluntarily 

9 comply with reporting requirements described in 

10 subsection (b)(2); and 

11 (2) payments under title XVIII to such clinics 

12 complying with such requirements are provided in 

13 accordance with subsection (d). 

14 (b) CONSULTATION.—Not later than one year after 

15 the date of the enactment of this Act, the Secretary, acting 

16 through the Administrator for Centers for Medicare & 

17 Medicaid Services, the Federal Office of Rural Health Pol18 icy, and the Agency for Healthcare Research and Quality, 

19 shall consult with relevant stakeholders— 

20 (1) to review rural health clinic data collection 

21 processes and quality measurers identified for rural 

22 health clinics by the National Quality Forum and 

23 other national quality-monitoring systems; and 

24 (2) to make recommendations to the Secretary 

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1 retary to implement under the eligible professional 

2 Merit-based Incentive Payment System under sec3 tion 1848(q) of the Social Security Act (42 U.S.C. 

4 1395w–4) for provider-based rural health clinics es5 tablished on or after January 1, 2021. 

6 (c) COLLABORATION.—In implementing the vol7 untary Medicare provider-based rural health clinic quality 

8 reporting program, the Secretary shall consult with a di9 verse group of rural health clinic stakeholders, which shall 

10 include— 

11 (1) the National Quality Forum, or such other 

12 standard-setting organizations specified by the Sec13 retary; 

14 (2) relevant State and local public agencies, in15 cluding State offices of rural health; 

16 (3) established provider-based rural health clin17 ics, including those in the application process; 

18 (4) small rural hospitals with 50 beds or less; 

19 (5) organizations representing provider-based 

20 rural health clinics; and 

21 (6) organizations representing rural health care. 

22 (d) CONDITIONS.—Under the voluntary Medicare 

23 provider-based rural health clinic quality reporting pro24 gram the Secretary shall provide that in the case of a pro25 vider-based rural health clinic described in subsection 


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1 (a)(1) that voluntarily complies with the reporting require2 ments described in subsection (b)(2), with respect to a 

3 year— 

4 (1) reimbursement rates under title XVIII of 

5 the Social Security Act for rural health services fur6 nished by such clinic during such year shall be con7 sistent with reimbursement rates under such title for 

8 such services furnished by a provider-based rural 

9 health clinic established before December 31, 2020; 

10 and 

11 (2) the provisions of section 1833(f)(3) of such 

12 Act (42 U.S.C. 1395l(f)(3)) shall not apply with re13 spect to such clinic and such year. 

14 (e) GRANTS FOR TECHNICAL ASSISTANCE.— 

15 (1) IN GENERAL.—Section 1820(g)(3) of the 

16 Social Security Act (42 U.S.C. 1395i–4(g)(3)) is 

17 amended— 

18 (A) in subparagraph (A)— 

19 (i) by striking ‘‘Balanced Budget Act 

20 of 1997 and’’ and inserting ‘‘Balanced 

21 Budget Act of 1997,’’; and 

22 (ii) by inserting before the period at 

23 the end the following: ‘‘, and to provide to 

24 such small rural hospitals that participate 

25 in the voluntary Medicare provider-based 


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1 rural health clinic quality reporting pro2 gram established pursuant to section 114 

3 of the Save America’s Rural Hospitals Act 

4 technical assistance necessary to so partici5 pate in such program’’; and 

6 (B) in subparagraph (E)— 

7 (i) by striking ‘‘and to participate in 

8 delivery system reforms’’ and inserting ‘‘, 

9 to participate in delivery system reforms’’; 

10 and 

11 (ii) by inserting before the period at 

12 the end the following: ‘‘, and in the case of 

13 small rural hospitals that participate in the 

14 voluntary Medicare provider-based rural 

15 health clinic quality reporting program es16 tablished pursuant to section 114 of the 

17 Save America’s Rural Hospitals Act, for 

18 technical assistance necessary to so partici19 pate in such program’’. 

20 (2) FUNDING.—In addition to amounts other21 wise made available for grants under section 

22 1820(g)(3) of the Social Security Act, there is ap23 propriated to the Secretary of Health and Human 

24 Services, out of any monies in the Treasury not oth25 erwise appropriated, $15,000,000 for the period of 


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1 fiscal years 2022 through 2026 to provide grants 

2 under such section to small rural hospitals that par3 ticipate in the voluntary Medicare provider-based 

4 rural health clinic quality reporting program estab5 lished pursuant to this section for technical assist6 ance necessary to so participate in such program. 

7 TITLE II—RURAL MEDICARE 

8 BENEFICIARY EQUITY 

9 SEC. 201. EQUALIZING BENEFICIARY COPAYMENTS FOR 

10 SERVICES FURNISHED BY CAHS. 

11 (a) IN GENERAL.—Section 1866(a)(2)(A) of the So12 cial Security Act (42 U.S.C. 1395cc(a)(2)(A)) is amended 

13 by adding at the end the following: ‘‘In the case of out14 patient critical access hospital services for which payment 

15 is made under section 1834(g), clause (ii) of the first sen16 tence shall be applied by substituting ‘20 percent of the 

17 lesser of the actual charge or the payment basis under 

18 this part for such services if the critical access hospital 

19 were treated as a hospital’ for ‘20 per centum of the rea20 sonable charges for such items and services’.’’. 

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

22 section applies with respect to services furnished during 

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

24 the enactment of this Act. 


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1 TITLE III—REGULATORY RELIEF 

2 SEC. 301. ELIMINATING 96-HOUR PHYSICIAN CERTIFI3 CATION REQUIREMENT WITH RESPECT TO 

4 INPATIENT CAH SERVICES. 

5 (a) IN GENERAL.—Section 1814(a) of the Social Se6 curity Act (42 U.S.C. 1395f(a)) is amended— 

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

8 end; 

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

10 and inserting a period; and 

11 (3) by striking paragraph (8). 

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

13 section apply with respect to services furnished during a 

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

15 enactment of this Act. 

16 SEC. 302. REBASING SUPERVISION REQUIREMENTS. 

17 (a) THERAPEUTIC HOSPITAL OUTPATIENT SERV18 ICES.— 

19 (1) SUPERVISION REQUIREMENTS.—Section 

20 1833 of the Social Security Act (42 U.S.C. 1395l) 

21 is amended by adding at the end the following new 

22 subsection: 

23 ‘‘(ee) PHYSICIAN SUPERVISION REQUIREMENTS FOR

24 THERAPEUTIC HOSPITAL OUTPATIENT SERVICES.— 


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1 ‘‘(1) GENERAL SUPERVISION FOR THERAPEUTIC

2 SERVICES.—Except as may be provided under para3 graph (2), insofar as the Secretary requires the su4 pervision by a physician or a non-physician practi5 tioner for payment for therapeutic hospital out6 patient services (as defined in paragraph (5)(A)) 

7 furnished under this part, such requirement shall be 

8 met if such services are furnished under the general 

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

10 physician or non-physician practitioner, as the case 

11 may be. 

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

13 COMPLEX MEDICAL SERVICES REQUIRING A DIRECT

14 LEVEL OF SUPERVISION.— 

15 ‘‘(A) IN GENERAL.—Subject to the suc16 ceeding provisions of this paragraph, the Sec17 retary shall establish a process for the designa18 tion of therapeutic hospital outpatient services 

19 furnished under this part that, by reason of 

20 complexity or high risk, require— 

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

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

23 ‘‘(ii) direct supervision during the ini24 tiation of the service followed by general 


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1 supervision for the remainder of the serv2 ice. 

3 ‘‘(B) CONSULTATION WITH CLINICAL EX4 PERTS.— 

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

6 established under subparagraph (A), before 

7 the designation of any therapeutic hospital 

8 outpatient service for which direct super9 vision may be required under this part, the 

10 Secretary shall consult with a panel of out11 side experts described in clause (ii) to ad12 vise the Secretary with respect to each 

13 such designation. 

14 ‘‘(ii) ADVISORY PANEL ON SUPER15 VISION OF THERAPEUTIC HOSPITAL OUT16 PATIENT SERVICES.—For purposes of 

17 clause (i), a panel of outside experts de18 scribed in this clause is a panel appointed 

19 by the Secretary, based on nominations 

20 submitted by hospital, rural health, and 

21 medical organizations representing physi22 cians, non-physician practitioners, and hos23 pital administrators, as the case may be, 

24 that meets the following requirements: 


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1 ‘‘(I) COMPOSITION.—The panel 

2 shall be composed of at least 15 phy3 sicians and non-physician practi4 tioners who furnish therapeutic hos5 pital outpatient services for which 

6 payment is made under this part and 

7 who collectively represent the medical 

8 specialties that furnish such services, 

9 and of 4 hospital administrators of 

10 hospitals located in rural areas (as de11 fined in section 1886(d)(2)(D)) or 

12 critical access hospitals. 

13 ‘‘(II) PRACTICAL EXPERIENCE

14 REQUIRED FOR PHYSICIANS AND NON15 PHYSICIAN PRACTITIONERS.—During 

16 the 12-month period preceding ap17 pointment to the panel by the Sec18 retary, each physician or non-physi19 cian practitioner described in sub20 clause (I) shall have furnished thera21 peutic hospital outpatient services for 

22 which payment was made under this 

23 part. 

24 ‘‘(III) MINIMUM RURAL REP25 RESENTATION REQUIREMENT FOR


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1 PHYSICIANS AND NON-PHYSICIAN

2 PRACTITIONERS.—Not less than 50 

3 percent of the membership of the 

4 panel that is comprised of physicians 

5 and non-physician practitioners shall 

6 be physicians or non-physician practi7 tioners described in subclause (I) who 

8 practice in rural areas (as defined in 

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

10 such services in critical access hos11 pitals. 

12 ‘‘(iii) APPLICATION OF FACA.—The 

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

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

15 shall apply to the panel of outside experts 

16 appointed by the Secretary under clause 

17 (ii). 

18 ‘‘(C) SPECIAL RULE FOR OUTPATIENT

19 CRITICAL ACCESS HOSPITAL SERVICES.—Inso20 far as a therapeutic outpatient hospital service 

21 that is an outpatient critical access hospital 

22 service is designated as requiring direct super23 vision under the process established under sub24 paragraph (A), the Secretary shall deem the 

25 critical access hospital furnishing that service 


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1 as having met the requirement for direct super2 vision for that service if, when furnishing such 

3 service, the critical access hospital meets the 

4 standard for personnel required as a condition 

5 of participation under section 485.618(d) of 

6 title 42, Code of Federal Regulations (as in ef7 fect on the date of the enactment of this sub8 section). 

9 ‘‘(D) CONSIDERATION OF COMPLIANCE

10 BURDENS.—Under the process established 

11 under subparagraph (A), the Secretary shall 

12 take into account the impact on hospitals and 

13 critical access hospitals in complying with re14 quirements for direct supervision in the fur15 nishing of therapeutic hospital outpatient serv16 ices, including hospital resources, availability of 

17 hospital-privileged physicians, specialty physi18 cians, and non-physician practitioners, and ad19 ministrative burdens. 

20 ‘‘(E) REQUIREMENT FOR NOTICE AND

21 COMMENT RULEMAKING.—Under the process 

22 established under subparagraph (A), the Sec23 retary shall only designate therapeutic hospital 

24 outpatient services requiring direct supervision 

25 under this part through proposed and final 


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1 rulemaking that provides for public notice and 

2 opportunity for comment. 

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

4 in this subsection shall be construed as author5 izing the Secretary to apply or require any level 

6 of supervision other than general or direct su7 pervision with respect to the furnishing of 

8 therapeutic hospital outpatient services. 

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

10 The Secretary shall include in the proposed and final 

11 regulation for payment for hospital outpatient serv12 ices for 2022 under this part a list of initial thera13 peutic hospital outpatient services, if any, designated 

14 under the process established under paragraph 

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

16 part. 

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

18 PRACTITIONERS FOR CERTAIN HOSPITAL OUT19 PATIENT SERVICES PERMITTED.— 

20 ‘‘(A) IN GENERAL.—Subject to the suc21 ceeding provisions of this subsection, a non-phy22 sician practitioner may directly supervise the 

23 furnishing of— 

24 ‘‘(i) therapeutic hospital outpatient 

25 services under this part, including cardiac 


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1 rehabilitation services (under section 

2 1861(eee)(1)), intensive cardiac rehabilita3 tion services (under section 1861(eee)(4)), 

4 and pulmonary rehabilitation services 

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

6 ‘‘(ii) those hospital outpatient diag7 nostic services (described in section 

8 1861(s)(2)(C)) that require direct super9 vision under the fee schedule established 

10 under section 1848. 

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

12 shall apply insofar as the non-physician practi13 tioner involved meets the following require14 ments: 

15 ‘‘(i) SCOPE OF PRACTICE.—The non16 physician practitioner is acting within the 

17 scope of practice under State law applica18 ble to the practitioner. 

19 ‘‘(ii) ADDITIONAL REQUIREMENTS.— 

20 The non-physician practitioner meets such 

21 requirements as the Secretary may specify. 

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

23 ‘‘(A) THERAPEUTIC HOSPITAL OUT24 PATIENT SERVICES.—The term ‘therapeutic 

25 hospital outpatient services’ means hospital 


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1 services described in section 1861(s)(2)(B) fur2 nished by a hospital or critical access hospital 

3 and includes— 

4 ‘‘(i) cardiac rehabilitation services and 

5 intensive cardiac rehabilitation services (as 

6 defined in paragraphs (1) and (4), respec7 tively, of section 1861(eee)); and 

8 ‘‘(ii) pulmonary rehabilitation services 

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

10 ‘‘(B) GENERAL SUPERVISION.— 

11 ‘‘(i) OVERALL DIRECTION AND CON12 TROL OF PHYSICIAN.—Subject to clause 

13 (ii), with respect to the furnishing of 

14 therapeutic hospital outpatient services for 

15 which payment may be made under this 

16 part, the term ‘general supervision’ means 

17 such services that are furnished under the 

18 overall direction and control of a physician 

19 or non-physician practitioner, as the case 

20 may be. 

21 ‘‘(ii) PRESENCE NOT REQUIRED.—For 

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

23 physician or non-physician practitioner is 

24 not required during the performance of the 

25 procedure involved. 


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1 ‘‘(C) DIRECT SUPERVISION.— 

2 ‘‘(i) PROVISION OF ASSISTANCE AND

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

4 respect to the furnishing of therapeutic 

5 hospital outpatient services for which pay6 ment may be made under this part, the 

7 term ‘direct supervision’ means that a phy8 sician or non-physician practitioner, as the 

9 case may be, is immediately available (in10 cluding by telephone or other means) to 

11 furnish assistance and direction through12 out the furnishing of such services. Such 

13 term includes, with respect to the fur14 nishing of a therapeutic hospital outpatient 

15 service for which payment may be made 

16 under this part, direct supervision during 

17 the initiation of the service followed by 

18 general supervision for the remainder of 

19 the service (as described in paragraph 

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

21 ‘‘(ii) PRESENCE IN ROOM NOT RE22 QUIRED.—For purposes of clause (i), a 

23 physician or non-physician practitioner, as 

24 the case may be, is not required to be 

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1 ance of the procedure involved or within 

2 any other physical boundary as long as the 

3 physician or non-physician practitioner, as 

4 the case may be, is immediately available. 

5 ‘‘(D) NON-PHYSICIAN PRACTITIONER DE6 FINED.—The term ‘non-physician practitioner’ 

7 means an individual who— 

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

9 practitioner, a clinical nurse specialist, a 

10 clinical social worker, a clinical psycholo11 gist, a certified nurse midwife, or a cer12 tified registered nurse anesthetist, and in13 cludes such other practitioners as the Sec14 retary may specify; and 

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

16 therapeutic outpatient hospital services, 

17 meets the requirements of paragraph 

18 (4)(B).’’. 

19 (2) CONFORMING AMENDMENT.—Section 

20 1861(eee)(2)(B) of the Social Security Act (42 

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

22 and a non-physician practitioner (as defined in sec23 tion 1833(cc)(5)(D)) may supervise the furnishing of 

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

25 the case of items and services furnished under such 


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1 a program in a hospital, such availability shall be 

2 presumed’’. 

3 (b) PROHIBITION ON RETROACTIVE ENFORCEMENT

4 OF REVISED INTERPRETATION.— 

5 (1) REPEAL OF REGULATORY CLARIFICA6 TION.—The restatement and clarification under the 

7 final rulemaking changes to the Medicare hospital 

8 outpatient prospective payment system and calendar 

9 year 2009 payment rates (published in the Federal 

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

11 68702 through 68704) with respect to requirements 

12 for direct supervision by physicians for therapeutic 

13 hospital outpatient services (as defined in paragraph 

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

15 the Medicare program shall have no force or effect 

16 in law. 

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

18 access hospital that furnishes therapeutic hospital 

19 outpatient services during the period beginning on 

20 January 1, 2001, and ending on the later of Decem21 ber 31, 2021, or the date on which the final regula22 tion promulgated by the Secretary of Health and 

23 Human Services to carry out this section takes ef24 fect, for which a claim for payment is made under 

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


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1 not be subject to any civil or criminal action or pen2 alty under Federal law for failure to meet super3 vision requirements under the regulation described 

4 in paragraph (1), under program manuals, or other5 wise. 

6 (3) THERAPEUTIC HOSPITAL OUTPATIENT

7 SERVICES DEFINED.—In this subsection, the term 

8 ‘‘therapeutic hospital outpatient services’’ means 

9 medical and other health services furnished by a 

10 hospital or critical access hospital that are— 

11 (A) hospital services described in sub12 section (s)(2)(B) of section 1861 of the Social 

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

14 (B) cardiac rehabilitation services or inten15 sive cardiac rehabilitation services (as defined 

16 in paragraphs (1) and (4), respectively, of sub17 section (eee) of such section); or 

18 (C) pulmonary rehabilitation services (as 

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

20 SEC. 303. REFORMING PRACTICES OF RECOVERY AUDIT 

21 CONTRACTORS UNDER MEDICARE. 

22 (a) ELIMINATION OF CONTINGENCY FEE PAYMENT

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

24 U.S.C. 1395ddd(h)) is amended— 


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1 (1) in paragraph (1), by inserting ‘‘, for recov2 ery activities conducted during a fiscal year before 

3 fiscal year 2022’’ after ‘‘Under the contracts’’; and 

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

5 paragraph: 

6 ‘‘(11) PAYMENT FOR RECOVERY ACTIVITIES

7 PERFORMED AFTER FISCAL YEAR 2021.— 

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

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

10 shall be made to recovery audit contractors for 

11 recovery activities conducted during fiscal year 

12 2022 and each fiscal year thereafter in the 

13 same manner, and from the same amounts, as 

14 payment is made to eligible entities under con15 tracts entered into for recovery activities con16 ducted during fiscal year 2021 under subsection 

17 (a). 

18 ‘‘(B) PROHIBITION ON INCENTIVE PAY19 MENTS.—Under the contracts, payment made 

20 to a recovery audit contractor for recovery ac21 tivities conducted during fiscal year 2022 or 

22 any fiscal year thereafter may not include any 

23 incentive payments. 

24 ‘‘(C) PERFORMANCE ACCOUNTABILITY.— 


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1 ‘‘(i) IN GENERAL.—Under the con2 tracts, payment made to a recovery audit 

3 contractor for recovery activities conducted 

4 during fiscal year 2022 or any fiscal year 

5 thereafter shall, in the case that the con6 tractor has a complex audit denial overturn 

7 rate at the end of such fiscal year (as cal8 culated under the methodology described in 

9 clause (iv)) that is 0.1 or greater, be re10 duced in an amount determined in accord11 ance with clause (ii). 

12 ‘‘(ii) PAYMENT REDUCTIONS.— 

13 ‘‘(I) SLIDING SCALE OF AMOUNT

14 OF REDUCTIONS.—The Secretary 

15 shall establish, for purposes of deter16 mining the amount of a reduction in 

17 payment to a recovery audit con18 tractor under clause (i) for recovery 

19 activities conducted during fiscal year, 

20 a linear sliding scale of payment re21 ductions for recovery audit contrac22 tors for such fiscal year. Under such 

23 linear sliding scale, the amount of 

24 such a reduction in payment to a re25 covery audit contractor for a fiscal 


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1 year shall be calculated in a manner 

2 that provides for such reduction to be 

3 greater than the reduction for such 

4 fiscal year for recovery audit contrac5 tors that have complex audit denial 

6 overturn rates at the end of such fis7 cal year (as calculated under the 

8 methodology described in clause (iv)) 

9 that are lower than the complex audit 

10 denial overturn rate of the contractor 

11 at the end of such fiscal year (as so 

12 calculated). 

13 ‘‘(II) MANNER OF COLLECTING

14 REDUCTION.—The Secretary may as15 sess and collect the reductions in pay16 ment to recovery audit contractors 

17 under clause (i) in such manner as 

18 the Secretary may specify (such as by 

19 reducing the amount paid to the con20 tractor for recovery activities con21 ducted during a fiscal year or by as22 sessing the reduction as a separate 

23 penalty payment to be paid to the 

24 Secretary by the contractor with re25 spect to each complex audit denial 


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1 issued by the contractor that is over2 turned on appeal). 

3 ‘‘(iii) TIMING OF DETERMINATIONS OF

4 PAYMENT REDUCTIONS.—The Secretary 

5 shall, with respect to a recovery audit con6 tractor, determine not later than six 

7 months after the end of a fiscal year— 

8 ‘‘(I) whether to reduce payment 

9 to the recovery audit contractor under 

10 clause (i) for recovery activities con11 ducted during such fiscal year; and 

12 ‘‘(II) in the case that the Sec13 retary determines to so reduce pay14 ment to the contractor, the amount of 

15 such payment reduction. 

16 ‘‘(iv) METHODOLOGY FOR CALCULA17 TION OF OVERTURNED COMPLEX AUDIT

18 DENIAL OVERTURN RATE.— 

19 ‘‘(I) CALCULATION OF OVERTURN

20 RATE.—The Secretary shall calculate 

21 a complex audit denial overturn rate 

22 for a recovery audit contractor for a 

23 fiscal year by— 

24 ‘‘(aa) determining, with re25 spect to the contract entered into 


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1 under paragraph (1) by the con2 tractor, the number of complex 

3 audit denials issued by the con4 tractor under the contract (in5 cluding denials issued before such 

6 fiscal year and during such fiscal 

7 year) that are overturned on ap8 peal; and 

9 ‘‘(bb) dividing the number 

10 determined under item (aa) by 

11 the number of complex audit de12 nials issued by the contractor 

13 under such contract (including 

14 denials issued before such fiscal 

15 year and during such fiscal year). 

16 ‘‘(II) FAIRNESS AND TRANS17 PARENCY.—The Secretary shall cal18 culate the percentage described in 

19 subclause (I) in a fair and trans20 parent manner. 

21 ‘‘(III) ACCOUNTING FOR SUBSE22 QUENTLY OVERTURNED APPEALS.— 

23 The Secretary shall calculate the per24 centage described in subclause (I) in a 

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1 hood that complex audit denials 

2 issued by the contractor for such fis3 cal year will be overturned on appeal 

4 in a subsequent fiscal year. 

5 ‘‘(IV) COMPLEX AUDIT DENIAL

6 DEFINED.—In this subparagraph, the 

7 term ‘complex audit denial’ means a 

8 denial by a recovery audit contractor 

9 of a claim for payment under this title 

10 submitted by a hospital, psychiatric 

11 hospital, or critical access hospital 

12 that is so denied by the contractor 

13 after the contractor has— 

14 ‘‘(aa) requested that the 

15 hospital, psychiatric hospital, or 

16 critical access hospital, in order 

17 to support such claim for pay18 ment, provide supporting medical 

19 records to the contractor; and 

20 ‘‘(bb) reviewed such medical 

21 records in order to determine 

22 whether an improper payment 

23 has been made to the hospital, 

24 psychiatric hospital, or critical 

25 access hospital for such claim. 


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1 ‘‘(V) OVERTURNED ON APPEAL

2 DEFINED.—In this subparagraph, the 

3 term ‘overturned on appeal’ means, 

4 with respect to a complex audit de5 nial, a denial that is overturned on 

6 appeal at the reconsideration level, the 

7 redetermination level, or the adminis8 trative law judge hearing level. 

9 ‘‘(D) APPLICATION TO EXISTING CON10 TRACTS.—Not later than 60 days after the date 

11 of the enactment of this paragraph, the Sec12 retary shall modify, as necessary, each contract 

13 under paragraph (1) that the Secretary entered 

14 into prior to such date of enactment in order to 

15 ensure that payment with respect to recovery 

16 activities conducted under such contract is 

17 made in accordance with the requirements de18 scribed in this paragraph.’’. 

19 (b) ELIMINATION OF ONE-YEAR TIMELY FILING

20 LIMIT TO REBILL PART B CLAIMS.— 

21 (1) IN GENERAL.—Section 1842(b) of the So22 cial Security Act (42 U.S.C. 1395u(b)) is amended 

23 by adding at the end the following new paragraph: 

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

25 FILING LIMIT FOR CERTAIN REBILLED CLAIMS.— 


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

2 submitted under this part by a hospital (as de3 fined in subparagraph (B)(i)) for hospital serv4 ices with respect to which there was a previous 

5 claim submitted under part A as inpatient hos6 pital services or inpatient critical access hos7 pital services that was denied by a medicare 

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

9 because of a determination that the inpatient 

10 admission was not medically reasonable and 

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

12 deadline described in this paragraph is 180 

13 days after the date of the final denial of such 

14 claim under part A. 

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

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

17 has the meaning given such term in section 

18 1861(e) and includes a psychiatric hospital 

19 (as defined in section 1861(f)) and a crit20 ical access hospital (as defined in section 

21 1861(mm)(1)). 

22 ‘‘(ii) MEDICARE CONTRACTOR.—The 

23 term ‘medicare contractor’ has the mean24 ing given such term under section 1889(g), 


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1 and includes a recovery audit contractor 

2 with a contract under section 1893(h). 

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

4 denial’ means— 

5 ‘‘(I) in the case that a hospital 

6 elects not to appeal a denial described 

7 in subparagraph (A) by a medicare 

8 contractor, the date of such denial; or 

9 ‘‘(II) in the case that a hospital 

10 elects to appeal a such a denial, the 

11 date on which such appeal is ex12 hausted.’’. 

13 (2) CONFORMING AMENDMENTS.— 

14 (A) Section 1835(a)(1) of the Social Secu15 rity Act (42 U.S.C. 1395n(a)(1)) is amended by 

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

17 in section 1842(b)(20), not later than the dead18 line described in such paragraph’’ after ‘‘the 

19 date of service’’. 

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

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

22 amended in the flush language following clause 

23 (ii) by inserting ‘‘or, in the case of a claim de24 scribed in section 1842(b)(20), not later than 


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1 the deadline described in such paragraph’’ after 

2 ‘‘the date of service’’. 

3 (3) APPLICABILITY.—The amendments made 

4 by this subsection apply to claims submitted under 

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

6 hospital services for which there was a previous 

7 claim submitted under part A as inpatient hospital 

8 services or inpatient critical access hospital services 

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

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

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

12 the enactment of this Act. 

13 (c) MEDICAL DOCUMENTATION CONSIDERED FOR

14 MEDICAL NECESSITY REVIEWS OF CLAIMS FOR INPA15 TIENT HOSPITAL SERVICES.—Section 1862(a) of the So16 cial Security Act (42 U.S.C. 1395y(a)) is amended by add17 ing at the end the following new sentence: ‘‘A determina18 tion under paragraph (1) of whether inpatient hospital 

19 services or inpatient critical access hospital services fur20 nished to an individual on or after the date of the enact21 ment of this sentence are reasonable and necessary shall 

22 be based solely upon information available to the admit23 ting physician at the time of the inpatient admission of 

24 the individual for such inpatient services, as documented 

25 in the medical record.’’. 


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1 TITLE IV—FUTURE OF RURAL 

2 HEALTH CARE 

3 SEC. 401. MEDICARE RURAL HOSPITAL FLEXIBILITY PRO4 GRAM GRANTS. 

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

6 1395i–4(g)) is amended— 

7 (1) in paragraph (1)— 

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

9 ‘‘and’’ at the end; 

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

11 period at the end and inserting a semicolon; 

12 and 

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

14 subparagraphs: 

15 ‘‘(E) rural emergency hospitals providing 

16 support for critical access hospitals to convert 

17 to rural emergency hospitals to stabilize hos18 pital emergency services in their communities; 

19 and 

20 ‘‘(F) supporting certified rural health clin21 ics for maintaining and building business oper22 ations, increasing financial indicators, address23 ing population health, transforming services, 

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1 ioral health and substance use disorders re2 sponding to public health emergencies.’’; 

3 (2) by redesignating paragraphs (3) through 

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

5 (3) after paragraph (2), by inserting the fol6 lowing new paragraph: 

7 ‘‘(3) ACTIVITIES TO SUPPORT CARRYING OUT

8 FLEX GRANTS.—The Secretary may award grants or 

9 cooperative agreements to entities that submit to the 

10 Secretary applications, at such time and in such 

11 form and manner and containing such information 

12 as the Secretary specifies, for purposes of supporting 

13 States and hospitals in carrying out the activities 

14 under this subsection by providing technical assist15 ance, data analysis, and evaluation efforts.’’; 

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

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

18 ‘‘State Offices of Rural Health on behalf of eli19 gible hospitals’’ after ‘‘award grants to’’; 

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

21 as follows: 

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

23 Rural Health shall submit an application, on 

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1 retary on or before such date and in such form 

2 and manner as the Secretary specifies.’’; 

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

4 read as follows: 

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

6 hospital under this paragraph shall be deter7 mined on an equal national distribution so that 

8 each hospital receives the same amount of sup9 port related to the funds appropriated.’’; 

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

11 read as follows: 

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

13 Rural Health and eligible hospitals may use the 

14 funds received through a grant under this para15 graph for the purchase of computer software 

16 and hardware; the education and training of 

17 hospital staff on billing, operational, quality im18 provement and related value-focused efforts; 

19 and other delivery system reform programs de20 termined appropriate by the Secretary.’’; and 

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

22 paragraph: 

23 ‘‘(9) RURAL HEALTH TRANSFORMATION

24 GRANTS.— 


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

2 5-year grants to State Offices of Rural Health 

3 and to eligible rural health care providers (as 

4 defined in subparagraph (E)) on the transition 

5 to new models, including rural emergency hos6 pitals, extended stay clinics, freestanding emer7 gency departments, rural health clinics, and in8 tegration of behavioral, oral health services, 

9 telehealth and other transformational models 

10 relevant to rural providers as such providers 

11 evolve to better meet community needs and the 

12 changing health care environment. 

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

14 health care provider, in partnership with the 

15 State Office of Rural Health in the State in 

16 which the rural health care provider seeking a 

17 grant under this paragraph is located, shall 

18 submit an application to the Secretary on or be19 fore such date and in such form and manner as 

20 the Secretary specifies. 

21 ‘‘(C) ADDITIONAL REQUIREMENTS.—The 

22 Secretary may not award a grant under this 

23 paragraph to an eligible rural health care pro24 vider unless— 


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

2 which the hospital is located provides sup3 port (either direct or in kind); and there 

4 are letters of support from key State pay5 ers such as Medicaid and private insur6 ance; and 

7 ‘‘(ii) the applicant describes in detail 

8 how the transition of the health care pro9 vider or providers will better meet local 

10 needs and be sustainable. 

11 ‘‘(D) ELIGIBLE RURAL HEALTH CARE PRO12 VIDER DEFINED.—For purposes of this para13 graph, the term ‘eligible rural health care pro14 vider’ includes a critical access hospital, a cer15 tified rural health clinic, a rural nursing home, 

16 skilled nursing facility, emergency care pro17 vider, or other entity identified by the Sec18 retary. An eligible rural health care provider 

19 may include other entities applying on behalf of 

20 a group of providers such as a State Office of 

21 Rural Health, a State or local health care au22 thority, a rural health network, or other entity 

23 identified by the Secretary.’’. 

Æ 


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