I 
115TH CONGRESS 
1ST SESSION H. R. 3224 
To amend title XVIII of the Social Security Act to clarify reasonable costs 
for critical access hospital payments under the Medicare program, and 
for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 13, 2017 
Mr. HARPER (for himself, Mr. LOEBSACK, Mr. KIND, Mr. KELLY of Mis-
sissippi, Mr. THOMPSON of Mississippi, Mr. PALAZZO, and Mr. PETER-
SON) introduced the following bill; which was referred to the Committee 
on Ways and Means, and in addition to the Committee on Energy and 
Commerce, for a period to be subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to clarify 
reasonable costs for critical access hospital payments 
under the Medicare program, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Critical Access and 
Rural Equity Act of 2017’’ or the ‘‘CARE Act of 2017’’. 
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SEC. 2. CLARIFYING REASONABLE COSTS FOR CRITICAL 
ACCESS HOSPITAL MEDICARE PAYMENTS. 
(a) INCLUSION OF CERTAIN COSTS AS REASONABLE 
COSTS.— 
(1) INPATIENT
CRITICAL
ACCESS
HOSPITAL 
SERVICES.—Section 1814(l) of the Social Security 
Act (42 U.S.C. 1395f(l)) is amended by adding at 
the end the following new paragraph: 
‘‘(6) In determining payment and reasonable 
costs under paragraph (1) for inpatient critical ac-
cess services, the Secretary shall recognize as allow-
able costs of the critical access hospital at least the 
following: 
‘‘(A) Costs of services that would be con-
sidered bona fide emergency services (as defined 
in section 1861(v)(1)(K)(ii)) if provided in a 
hospital emergency room, including professional 
services and any associated surgical on-call and 
standby costs. 
‘‘(B) Costs of a test or procedure per-
formed at a critical access hospital or an entity 
owned by the critical access hospital, including 
a clinical diagnostic laboratory test, mammo-
gram (as defined in section 354(a)(5) of the 
Public Health Service Act), colonoscopy, cardiac 
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stress test, pulmonary function test, echocardio-
gram, and bone density study. 
‘‘(C) Standby and on-call costs for certified 
registered nurse anesthetist services, regardless 
of the number of surgical procedures requiring 
anesthesia services and regardless of the num-
ber of full-time equivalent physicians. 
‘‘(D) Costs of services provided by the crit-
ical access hospital or satellite facility of the 
critical access hospital that improve the total 
health of communities, including immunization 
programs, health clinics, and medical homes. 
‘‘(E) Costs of services provided by an off- 
campus provider-based clinic described in sec-
tion 1820(c)(2)(F) of the critical access hos-
pital, regardless of distance of such clinic from 
a hospital or another critical access hospital.’’. 
(2) OUTPATIENT
CRITICAL
ACCESS
HOSPITAL 
SERVICES.—Section 1834(g) of the Social Security 
Act (42 U.S.C. 1395m(g)) is amended by adding at 
the end the following new paragraph: 
‘‘(6) COVERAGE
OF
CERTAIN
ADDITIONAL 
COSTS AS REASONABLE COSTS.—In determining the 
reasonable costs of outpatient critical access hospital 
services under paragraphs (1) and (2)(A), the Sec-
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retary shall recognize as allowable the costs de-
scribed in paragraph (6) of section 1814(l).’’. 
(3) 
CONFORMING
AMENDMENT.—Section 
1861(v)(7) of the Social Security Act (42 U.S.C. 
1395x(v)(7)) is amended by adding at the end the 
following new subparagraph: 
‘‘(E) For provisions further describing costs 
recognized as reasonable costs for inpatient and out-
patient critical access hospital services, see sections 
1814(l)(6) and 1834(g)(6).’’. 
(b) TREATMENT OF PROVIDER-BASED CLINICS OF 
CRITICAL ACCESS HOSPITALS.—Section 1820(c)(2) of the 
Social Security Act (42 U.S.C. 1395i–4(c)(2)) is amend-
ed— 
(1) in subparagraph (B)(i)(I), by striking ‘‘is 
located’’ and inserting ‘‘subject to subparagraph 
(E), is located’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(F) 
TREATMENT
OF
OFF-CAMPUS 
PROVIDER-BASED
CLINICS.—Subparagraph 
(B)(i)(I) shall not apply to an off-campus 
provider-based clinic (as described in section 
485.610 of title 45 of the Code of Federal Reg-
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ulations) of a facility designated as a critical 
access hospital.’’. 
(c) ALLOWING COORDINATION FOR PROVISION OF 
EMERGENCY SERVICES.—Section 1820(c)(2) of the Social 
Security Act (42 U.S.C. 1395i–4(c)(2)), as amended by 
subsection (b), is further amended— 
(1) in subparagraph (B)(ii), by striking 
‘‘makes’’ and inserting ‘‘subject to subparagraph 
(G), makes’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(G) ALLOWING COORDINATION FOR PRO-
VISION
OF
EMERGENCY
SERVICES.—The Sec-
retary may waive the requirements under sub-
paragraph (B)(ii), with respect to a facility, if 
such facility— 
‘‘(i) is located not more than 15 miles 
of another facility or hospital that has an 
emergency department that satisfies the 
requirement of subparagraph (B)(ii); and 
‘‘(ii) coordinates with such other facil-
ity or hospital with respect to furnishing 
24-hour emergency care services described 
in such subparagraph to the area served by 
such facility.’’. 
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(d) TREATMENT
OF MEDICAID PROVIDER TAXES 
FOR CRITICAL ACCESS HOSPITAL REASONABLE COSTS.— 
(1) INPATIENT
CRITICAL
ACCESS
HOSPITAL 
SERVICES.—Section 1814(l) of the Social Security 
Act (42 U.S.C. 1395f(l)), as amended by subsection 
(a)(1), is further amended by adding at the end the 
following new paragraph: 
‘‘(7)(A) In determining payment and reasonable 
costs under paragraph (1) for inpatient critical ac-
cess services— 
‘‘(i) with respect to a current permissible 
health care related tax imposed and paid by the 
critical access hospital for a cost reporting pe-
riod beginning before the date of enactment of 
this paragraph, the Secretary shall not, through 
recoupment or otherwise, disallow payment to 
the critical access hospital under this subsection 
on the basis that payments to the critical access 
hospital under this subsection offset some or all 
of the costs of such tax; and 
‘‘(ii) with respect to a current permissible 
health care related tax imposed and paid by the 
critical access hospital for a cost reporting pe-
riod beginning on or after the date of enact-
ment of this paragraph, the Secretary shall— 
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‘‘(I) assess the percentage of individ-
uals entitled to benefits under this part 
who are furnished inpatient critical access 
hospital services at such critical access 
hospital during such cost reporting period 
and who are also receiving medical assist-
ance under the Medicaid program under 
title XIX during such period; and 
‘‘(II) adjust payments under this sub-
section with respect to such services fur-
nished during such period in a manner 
specified by the Secretary based on such 
percentage to take into account such tax. 
‘‘(B) For purposes of this paragraph and sec-
tion 1834(g)(7), the term ‘current permissible health 
care related tax’ means a broad-based health care 
related tax (as defined in paragraph (3)(B) of such 
section) that is in effect prior to enactment of this 
paragraph and for which there is not in effect a hold 
harmless provision described in paragraph (4) of 
such section.’’. 
(2) OUTPATIENT
CRITICAL
ACCESS
HOSPITAL 
SERVICES.—Section 1834(g) of the Social Security 
Act (42 U.S.C. 1395m(g)), as amended by sub-
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section (a)(2), is further amended by adding at the 
end the following new paragraph: 
‘‘(7) TREATMENT
OF
MEDICAID
PROVIDER 
TAXES.—In determining payment for outpatient crit-
ical access hospital services under paragraphs (1) 
and (2), the provisions of paragraph (7) of section 
1814(l) shall apply to payment for such services 
under this subsection in the same manner as such 
provisions apply to payment for inpatient critical ac-
cess hospital services under section 1814(l), except 
that in applying subparagraph (B) of such para-
graph (7), the reference to ‘individuals entitled to 
benefits under this part’ shall be deemed a reference 
to ‘individuals enrolled under part B’.’’. 
Æ 
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