I 
116TH CONGRESS 
2D SESSION 
H. R. 6962 
To amend title XI of the Social Security Act to expand the use of global 
payments to hospitals in rural areas. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 22, 2020 
Mr. CARTWRIGHT (for himself and Mr. YOUNG) introduced the following bill; 
which was referred to the Committee on Energy and Commerce, and in 
addition to the Committee on Ways and Means, for a period to be subse-
quently 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 title XI of the Social Security Act to expand 
the use of global payments to hospitals in rural areas. 
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 ‘‘Rural Hospital Sus-
tainability Act’’. 
SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) Approximately 10,000,000 individuals age 
65 and older live in rural America today. In fact, 
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one out of every 4 older adults lives in a small town 
or other rural area. 
(2) Residents of rural areas are more likely to 
be poorer, sicker, and have lower incomes compared 
to their urban counterparts. 
(3) According to the Office of Rural Health 
Policy, from 2005 to 2009, people living in rural 
areas had an average life expectancy of 76.8 years, 
a full two years less than their urban counterparts 
who had an average life expectancy of 78.8 years. 
(4) Many rural hospitals are located in areas 
where a majority of the population is age 65 and 
older and has Medicare coverage. 
(5) Certain State-based demonstrations to im-
prove payment models for rural hospitals show 
promise in improving healthcare, reducing costs, and 
integrating services for patients. 
(6) Experts and organizations suggest that 
transitioning rural hospitals to global payment sys-
tems would benefit patients, providers, and rural 
communities. 
SEC. 3. EXPANDING THE USE OF GLOBAL PAYMENTS TO 
HOSPITALS IN RURAL AREAS. 
Section 1115A(b)(2) of the Social Security Act (42 
U.S.C. 1315a(b)(2)) is amended— 
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(1) in subparagraph (B), by adding at the end 
the following new clause: 
‘‘(xxviii) National testing of a model 
for global payments to hospitals in rural 
areas as described in subparagraph (D).’’; 
and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(D) NATIONAL TESTING OF MODEL FOR 
GLOBAL
PAYMENTS
TO
HOSPITALS
IN
RURAL 
AREAS.—In the case where the Secretary selects 
the model described in clause (ii) of this sub-
paragraph for testing pursuant to clause (xxviii) 
of subparagraph (B), the following shall apply: 
‘‘(i) NATIONAL TESTING.— 
‘‘(I) IN
GENERAL.—Subject to 
subclause (II), the Secretary shall 
allow each State to develop and sub-
mit to the Secretary an application to 
begin testing such model in accord-
ance with this clause within 1 year of 
the date on which the model is se-
lected for such testing. 
‘‘(II) STATE
DESIGNATION
OF 
ENTITIES.—A State may designate an 
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entity or organization for purposes of 
developing and submitting an applica-
tion under subclause (I) with respect 
to the State, which may include the 
implementation of such model in the 
State. In the case where a State 
makes such a designation, with re-
spect to any activities covered by the 
designation, the entity or organization 
so designated shall be subject to any 
requirements applicable to the imple-
menting State under this subpara-
graph in the same manner as such re-
quirements are applicable to the im-
plementing State. 
‘‘(III) NO EFFECT ON ONGOING 
MODELS
OR
DEMONSTRATION 
PROJECTS.—Nothing in this subpara-
graph shall effect the testing of any 
model under this subsection or any 
demonstration project under this Act 
that is implemented prior to the date 
of the enactment of this subpara-
graph. 
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‘‘(ii) MODEL DESCRIBED.—The model 
described in this clause seeks to increase 
rural Americans’ access to quality care in 
order to improve health, while also reduc-
ing the growth of hospital expenditures 
across payers, including Medicare, and in-
creasing the financial viability of rural hos-
pitals to ensure continued access to care. 
Under this model, participating rural hos-
pitals would— 
‘‘(I) be paid based on all-payer 
global budget, a fixed amount that is 
set in advance for inpatient and out-
patient hospital-based services and 
paid monthly by Medicare fee-for-serv-
ice, State Medicaid plans, and all 
other participating payers; 
‘‘(II) deliberately redesign the de-
livery of care to improve quality of 
care and meet the needs of their local 
communities; 
‘‘(III) receive an upfront, fixed 
payment for infrastructure redesign, 
in an amount to be recovered over a 
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period of time as set forth by the Sec-
retary; 
‘‘(IV) receive annual global budg-
et payment adjustments based on an 
amount determined in conjunction 
with the Secretary; and 
‘‘(V) partner with non-hospital 
providers such as physicians, behav-
ioral health providers, schools, and 
community based organizations to cre-
ate a comprehensive care delivery sys-
tem. 
‘‘(iii) DEFINITIONS.—In this subpara-
graph: 
‘‘(I) IMPLEMENTING
STATE.— 
The term ‘implementing State’ means 
a State whose application to begin 
testing such model is approved by the 
Secretary under clause (i). 
‘‘(II) 
RURAL
HOSPITAL.—The 
term ‘rural hospital’ means the fol-
lowing: 
‘‘(aa) A critical access hos-
pital 
(as 
defined 
in 
section 
1861(mm)(1)). 
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‘‘(bb) A sole community hos-
pital 
(as 
defined 
in 
section 
1886(d)(5)(D)(iii)). 
‘‘(cc) A Medicare-dependent, 
small rural hospital (as defined 
in section 1886(d)(5)(G)(iv)). 
‘‘(dd) Any other hospital 
that is located in a rural area (as 
defined in section 1886(d)(2)(D)) 
or is treated as being located in 
a rural area pursuant to section 
1886(d)(8)(E). 
‘‘(iv) REQUIREMENTS
FOR
PARTICI-
PATING HOSPITALS.— 
‘‘(I) IN GENERAL.—In order to 
participate in the model in an imple-
menting 
State, 
a 
rural 
hospital 
must— 
‘‘(aa) subject to subclause 
(II), conduct a community health 
needs assessment survey to deter-
mine the condition and health 
needs in their community, includ-
ing those needs with respect to 
mental or behavioral health; and 
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‘‘(bb) following such assess-
ment survey, submit and, subject 
to clause (vi), receive approval of 
a Rural Hospital Transformation 
Plan (as described in clause (v)) 
from the implementing State and 
the Secretary. 
‘‘(II) EXCEPTION.—A rural hos-
pital meets the requirement described 
in subclause (I)(aa) if the rural hos-
pital has conducted a community 
health needs assessment survey during 
the preceding year for any purpose. 
‘‘(v) 
RURAL
HOSPITAL
TRANS-
FORMATION
PLAN
DESCRIBED.—A Rural 
Hospital Transformation Plan described in 
this clause, with respect to a rural hos-
pital, shall include the following informa-
tion: 
‘‘(I) Results of the community 
health needs assessment survey under 
clause (iv)(I)(aa) and an explanation 
of how the Transformation Plan suits 
the needs of the community. 
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