I 
118TH CONGRESS 
2D SESSION 
H. R. 9128 
To amend title XVIII of the Social Security Act to establish a designation 
for territorial safety net hospitals, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 24, 2024 
Mr. SABLAN (for himself and Mr. MOYLAN) 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 com-
mittee concerned 
A BILL 
To amend title XVIII of the Social Security Act to establish 
a designation for territorial safety net hospitals, 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 ‘‘Supporting Territorial 
Safety Net Hospitals Act’’. 
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SEC. 2. DESIGNATION FOR TERRITORIAL SAFETY NET HOS-
PITALS. 
(a) TERRITORIAL
SAFETY
NET
HOSPITAL
DE-
FINED.—Section 1861 of the Social Security Act (42 
U.S.C. 1395x) is amended by adding at the end the fol-
lowing new subsection: 
‘‘(nnn) TERRITORIAL SAFETY NET HOSPITAL.— 
‘‘(1) The term ‘territorial safety net hospital’ 
means a hospital (as defined in subsection (e)) that 
is located in the Northern Mariana Islands, Amer-
ican Samoa, Guam, or the Virgin Islands. 
‘‘(2) The term ‘inpatient territorial safety net 
hospital services’ means items and services, fur-
nished to an inpatient of a territorial safety net hos-
pital by such facility, that would be inpatient hos-
pital services if furnished to an inpatient of a hos-
pital by a hospital. 
‘‘(3) The term ‘outpatient territorial safety net 
hospital services’ means medical and other health 
services furnished by a territorial safety net hospital 
on an outpatient basis.’’. 
(b) PAYMENT FOR INPATIENT TERRITORIAL SAFETY 
NET HOSPITAL SERVICES.— 
(1) IN GENERAL.—Section 1814 of the Social 
Security Act (42 U.S.C. 1395f) is amended— 
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(A) in subsection (b), by inserting ‘‘other 
than a territorial safety net hospital providing 
inpatient territorial safety net hospital serv-
ices,’’ after ‘‘critical access hospital providing 
inpatient critical access hospital services,’’; and 
(B) by adding at the end the following new 
subsection: 
‘‘(m) PAYMENT FOR INPATIENT TERRITORIAL SAFE-
TY NET HOSPITAL SERVICES.—The amount of payment 
under this part for inpatient territorial safety net hospital 
services is equal to 101 percent of the reasonable costs 
of the territorial safety net hospital in providing such serv-
ices.’’. 
(2) SCOPE OF BENEFITS.—Section 1812(a)(1) 
of the Social Security Act (42 U.S.C. 1395d(a)(1)) 
is amended by striking ‘‘or inpatient critical access 
hospital services’’ and inserting ‘‘, inpatient critical 
access hospital services, or inpatient territorial safe-
ty net hospital services’’. 
(3) DEDUCTIBLES AND COINSURANCE.—Section 
1813 of the Social Security Act (42 U.S.C. 1395e) 
is amended— 
(A) in subsection (a)(1), by striking ‘‘or in-
patient critical access hospital services’’ each 
place it appears and inserting ‘‘, inpatient crit-
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ical access hospital services, or inpatient terri-
torial safety net hospital services’’; and 
(B) in subsection (b)(3)— 
(i) in subparagraph (A), by striking 
‘‘or inpatient critical access hospital serv-
ices’’ and inserting ‘‘, inpatient critical ac-
cess hospital services, or inpatient terri-
torial safety net hospital services’’; and 
(ii) in subparagraph (B), by inserting 
‘‘, inpatient territorial safety net hospital 
services,’’ after ‘‘inpatient critical access 
hospital services’’. 
(4) PAYMENT TO PROVIDERS OF SERVICES.— 
Section 1815(e)(2) of the Social Security Act (42 
U.S.C. 1395g(e)(2)) is amended— 
(A) in subparagraph (D), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (E), by inserting 
‘‘and’’ after the semicolon at the end; and 
(C) by adding at the end the following new 
subparagraph: 
‘‘(F) inpatient territorial safety net hos-
pital services;’’. 
(5) ADMINISTRATION
OF
PART
A.—Section 
1816(c)(2)(C) of the Social Security Act (42 U.S.C. 
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1395h(c)(2)(C)) is amended by inserting ‘‘territorial 
safety net hospital,’’ after ‘‘critical access hospital,’’. 
(c) PAYMENT FOR OUTPATIENT TERRITORIAL SAFE-
TY NET HOSPITAL SERVICES.— 
(1) IN GENERAL.—Section 1834 of the Social 
Security Act (42 U.S.C. 1395m) is amended by add-
ing at the end the following new subsection: 
‘‘(aa) PAYMENT
FOR OUTPATIENT TERRITORIAL 
SAFETY NET HOSPITAL SERVICES.— 
‘‘(1) IN
GENERAL.—The amount of payment 
for outpatient territorial safety net hospital services 
of a territorial safety net hospital is equal to 101 
percent of the reasonable costs of the hospital in 
providing such services, unless the hospital makes 
the election under paragraph (2). 
‘‘(2) ELECTION OF COST-BASED HOSPITAL OUT-
PATIENT SERVICE PAYMENT PLUS FEE SCHEDULE 
FOR PROFESSIONAL SERVICES.—A territorial safety 
net hospital may elect to be paid for outpatient terri-
torial safety net hospital services amounts equal to 
the sum of the following, less the amount that such 
hospital may charge as described in section 
1866(a)(2)(A): 
‘‘(A) FACILITY FEE.—With respect to fa-
cility services, not including any services for 
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which payment may be made under subpara-
graph (B), 101 percent of the reasonable costs 
of the territorial safety net hospital in providing 
such services. 
‘‘(B) FEE SCHEDULE FOR PROFESSIONAL 
SERVICES.—With respect to professional serv-
ices otherwise included within outpatient terri-
torial safety net hospital services, 115 percent 
of such amounts as would otherwise be paid 
under this part if such services were not in-
cluded in outpatient territorial safety net hos-
pital services. Subsections (x) and (y) of section 
1833 shall not be taken into account in deter-
mining the amounts that would otherwise be 
paid pursuant to the preceding sentence. 
The Secretary may not require, as a condition for 
applying subparagraph (B) with respect to a terri-
torial safety net hospital, that each physician or 
other practitioner providing professional services in 
the hospital must assign billing rights with respect 
to such services, except that such subparagraph shall 
not apply to those physicians and practitioners who 
have not assigned such billing rights. 
‘‘(3) DISREGARDING CHARGES.—The payment 
amounts under this subsection shall be determined 
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without regard to the amount of the customary or 
other charge. 
‘‘(4) TREATMENT
OF
CLINICAL
DIAGNOSTIC 
LABORATORY
SERVICES.—No coinsurance, deduct-
ible, copayment, or other cost-sharing otherwise ap-
plicable under this part shall apply with respect to 
clinical diagnostic laboratory services furnished as 
an outpatient territorial safety net hospital service. 
Nothing in this title shall be construed as providing 
for payment for clinical diagnostic laboratory serv-
ices furnished as part of outpatient territorial safety 
net hospital services, other than on the basis de-
scribed in this subsection. For purposes of the pre-
ceding sentence and section 1861(nnn)(3), clinical 
diagnostic laboratory services furnished by a terri-
torial safety net hospital shall be treated as being 
furnished as part of outpatient critical access serv-
ices without regard to whether the individual with 
respect to whom such services are furnished is phys-
ically present in the territorial safety net hospital, or 
in a skilled nursing facility or a clinic (including a 
rural health clinic) that is operated by a territorial 
safety net hospital, at the time the specimen is col-
lected. 
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‘‘(5) COVERAGE OF COSTS FOR CERTAIN ON- 
CALL
EMERGENCY
ROOM
PROVIDERS.—In deter-
mining the reasonable costs of outpatient territorial 
safety net hospital services under paragraphs (1) 
and (2)(A), the Secretary shall recognize as allow-
able costs, amounts (as defined by the Secretary) for 
reasonable compensation and related costs for physi-
cians, physician assistants, nurse practitioners, and 
clinical nurse specialists who are on-call (as defined 
by the Secretary) to provide emergency services but 
who are not present on the premises of the terri-
torial safety net hospital involved, and are not other-
wise furnishing services covered under this title and 
are not on-call at any other provider or facility.’’. 
(2) SCOPE OF BENEFITS.—Section 1832(a)(2) 
of the Social Security Act (42 U.S.C. 1395k(a)(2)) 
is amended— 
(A) in subparagraph (I), by striking ‘‘; 
and’’ and inserting a semicolon; 
(B) in subparagraph (J), by striking the 
period at the end and inserting ‘‘; and’’; and 
(C) by adding at the end the following new 
subparagraph: 
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‘‘(K) outpatient territorial safety net hos-
pital 
services 
(as 
defined 
in 
section 
1861(nnn)(3)).’’. 
(3) PAYMENT OF BENEFITS.—Section 1833 of 
the Social Security Act (42 U.S.C. 1395l) is amend-
ed— 
(A) in subsection (a)— 
(i) in paragraph (9), by striking ‘‘; 
and’’ and inserting a semicolon; 
(ii) in paragraph (10), by striking the 
period at the end and inserting ‘‘; and’’; 
and 
(iii) by inserting after paragraph (10) 
the following new paragraph: 
‘‘(11) in the case of outpatient territorial safety 
net hospital services, the amounts described in sec-
tion 1834(aa).’’; 
(B) in subsection (h)(5)(A)(iii), by insert-
ing ‘‘territorial safety net hospital,’’ after ‘‘crit-
ical access hospital,’’; 
(C) in subsection (i)(1)(A), by inserting 
‘‘territorial safety net hospital,’’ after ‘‘critical 
access hospital,’’; 
(D) in subsection (l)(5)— 
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(i) in subparagraph (A), by inserting 
‘‘territorial safety net hospital,’’ after 
‘‘critical access hospital,’’ in each place it 
appears; and 
(ii) in subparagraph (B), by striking 
‘‘or critical access hospital’’ in each place 
it appears and inserting ‘‘, critical access 
hospital, or territorial safety net hospital’’ 
in each such place; 
(E) in subsection (r)— 
(i) in paragraph (1), by inserting 
‘‘territorial safety net hospital,’’ after 
‘‘critical access hospital’’; and 
(ii) in paragraph (2), by striking ‘‘or 
critical access hospital’’ and inserting ‘‘, 
critical access hospital, or territorial safety 
net hospital’’; and 
(F) in subsection (cc)(2), by adding at the 
end the following new subparagraph: 
‘‘(F) Section 1834(aa), with respect to an 
outpatient territorial safety net hospital serv-
ice.’’. 
(4) PAYMENT FOR AMBULANCE SERVICES FUR-
NISHED
BY
A
TERRITORIAL
SAFETY
NET
HOS-
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PITAL.—Section 1834(l)(8) of the Social Security 
Act (42 U.S.C. 1395m(l)(8)) is amended— 
(A) in the heading, by inserting ‘‘AND TER-
RITORIAL
SAFETY
NET
HOSPITALS’’ 
after 
‘‘CRITICAL ACCESS HOSPITALS’’; 
(B) in subparagraph (A), by inserting ‘‘or 
a territorial safety net hospital (as defined in 
section 1861(nnn))’’ after ‘‘(as defined in sec-
tion 1861(mm)(1))’’; 
(C) in subparagraph (B), by inserting ‘‘or 
a territorial safety net hospital’’ after ‘‘critical 
access hospital’’; and 
(D) by amending the flush left text fol-
lowing subparagraph (B) to read as follows: 
‘‘but only if the critical access hospital, territorial 
safety net hospital, or entity is the only provider or 
supplier of ambulance services that is located within 
a 35-mile drive of such critical access hospital or ter-
ritorial safety net hospital.’’. 
(d) CONFORMING AMENDMENTS.— 
(1) TITLE XI.— 
(A) CIVIL
MONETARY
PENALTIES.—Sec-
tion 1128A(b)(1) of the Social Security Act (42 
U.S.C. 1320a–7a(b)(1)) is amended by striking 
‘‘or a critical access hospital’’ in each place it 
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appears and inserting ‘‘, critical access hospital, 
or territorial safety net hospital’’ in each such 
place. 
(B) CRIMINAL PENALTIES FOR ACTS IN-
VOLVING FEDERAL HEALTH CARE PROGRAMS.— 
Section 1128B(c) of the Social Security Act (42 
U.S.C. 1320a–7b(c)) is amended by inserting 
‘‘territorial safety net hospital,’’ after ‘‘critical 
access hospital,’’. 
(C) 
NONPROFIT
HOSPITAL
PHILAN-
THROPY.—Section 1134 of the Social Security 
Act (42 U.S.C. 1320b–4) is amended in the 
matter preceding paragraph (1) by striking ‘‘or 
critical access hospitals’’ in each place it ap-
pears and inserting ‘‘, critical access hospitals, 
or territorial safety net hospitals’’ in each such 
place. 
(D) HOSPITAL
PROTOCOLS
FOR
ORGAN 
PROCUREMENT
AND
STANDARDS
FOR
ORGAN 
PROCUREMENT AGENCIES.—Section 1138 of the 
Social Security Act (42 U.S.C. 1320b–8) is 
amended by striking ‘‘or critical access hos-
pital’’ in each place it appears and inserting ‘‘, 
critical access hospital, or territorial safety net 
hospital’’ in each such place. 
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(2) TITLE XVIII.— 
(A) DEFINITION OF A HOSPITAL.—Section 
1861(e) of the Social Security Act (42 U.S.C. 
1395x(e)) is amended in the flush left matter at 
the end by striking ‘‘or a rural emergency hos-
pital (as defined in subsection (kkk)(2))’’ and 
inserting ‘‘, a rural emergency hospital (as de-
fined in subsection (kkk)(2)), or a territorial 
safety net hospital (as defined in subsection 
(nnn)(1))’’. 
(B) DEFINITION OF PROVIDER OF SERV-
ICES.—Section 1861(u) of the Social Security 
Act (42 U.S.C. 1395x(u)) is amended by insert-
ing ‘‘territorial safety net hospital,’’ after ‘‘crit-
ical access hospital,’’. 
(C) 
DEFINITION
OF
REASONABLE 
COSTS.—Section 1861(v)(1)(S)(ii)(III) of the 
Social 
Security 
Act 
(42 
U.S.C. 
1395x(v)(1)(S)(ii)(III)) is amended by striking 
‘‘or a critical access hospital (as defined in sec-
tion 1861(mm)(1))’’ and inserting ‘‘, a critical 
access 
hospital 
(as 
defined 
in 
section 
1861(mm)(1)), or a territorial safety net hos-
pital (as defined in subsection (nnn) of such 
section)’’. 
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(D) DEFINITION
OF
ARRANGEMENTS.— 
Section 1861(w) of the Social Security Act (42 
U.S.C. 1395x(w)) is amended— 
(i) in paragraph (1), by inserting 
‘‘territorial safety net hospital,’’ after 
‘‘critical access hospital,’’; and 
(ii) in paragraph (2), by striking ‘‘or 
critical access hospital’’ in each place it ap-
pears and inserting ‘‘, critical access hos-
pital, or territorial safety net hospital’’ in 
each such place. 
(E) DEFINITION OF POST-INSTITUTIONAL 
HOME
HEALTH
SERVICES; 
HOME
HEALTH 
SPELL OF ILLNESS.—Section 1861(tt) of the 
Social Security Act (42 U.S.C. 1395x(tt)) is 
amended— 
(i) in paragraph (1)(A), by striking 
‘‘or critical access hospital’’ and inserting 
‘‘, critical access hospital, or territorial 
safety net hospital’’; and 
(ii) in paragraph (2)(B), by striking 
‘‘or critical access hospital’’ and inserting 
‘‘, critical access hospital, or territorial 
safety net hospital’’. 
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(F) EXCLUSION
FROM
COVERAGE.—Sec-
tion 1862(a)(14) of the Social Security Act (42 
U.S.C. 1395y(a)(14)) is amended by striking 
‘‘or critical access hospital’’ in each place it ap-
pears and inserting ‘‘, critical access hospital, 
or territorial safety net hospital’’ in each such 
place. 
(G) USE OF STATE AGENCIES TO DETER-
MINE COMPLIANCE BY PROVIDERS OF SERVICES 
WITH CONDITIONS OF PARTICIPATION.—Section 
1864 of the Social Security Act (42 U.S.C. 
1395aa) is amended— 
(i) in subsection (a), by inserting ‘‘ter-
ritorial safety net hospital, as defined in 
section 1861(nnn)(1),’’ after ‘‘a critical ac-
cess 
hospital, 
as 
defined 
in 
section 
1861(mm)(1),’’; and 
(ii) by adding at the end the following 
new subparagraph: 
‘‘(f) For purposes of this section, the term ‘State’ 
means the 50 States and includes the District of Colum-
bia, Puerto Rico, the Virgin Islands, Guam, American 
Samoa, and the Northern Mariana Islands.’’. 
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(H) AGREEMENTS
WITH
PROVIDERS
OF 
SERVICES.—Section 1866(a) of the Social Secu-
rity Act (42 U.S.C. 1395cc(a)) is amended— 
(i) in paragraph (1)— 
(I) in subparagraph (F)(ii), by 
inserting ‘‘territorial safety net hos-
pitals,’’ after ‘‘critical access hos-
pitals,’’; 
(II) in subparagraph (H), by 
striking ‘‘and in the case of critical 
access hospitals which provide critical 
access hospital services’’ and inserting 
‘‘, in the case of critical access hos-
pitals which provide critical access 
hospital services, and in the case of 
territorial safety net hospitals which 
provide territorial safety net hospital 
services’’; 
(III) in subparagraph (I), by in-
serting ‘‘territorial safety net hos-
pital,’’ after ‘‘critical access hospital,’’ 
in each place it appears; 
(IV) in subparagraph (N), by in-
serting ‘‘territorial safety net hos-
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pital,’’ after ‘‘critical access hospital,’’ 
in each place it appears; 
(V) in subparagraph (T), by 
striking ‘‘and critical access hospitals’’ 
and inserting ‘‘, critical access hos-
pitals, and territorial safety net hos-
pitals’’; and 
(VI) in subparagraph (Y), by 
striking ‘‘or critical access hospital’’ 
each place it appears and inserting ‘‘, 
critical access hospital, or territorial 
safety net hospital’’ in each such 
place; and 
(ii) in paragraph (3)— 
(I) in subparagraph (A), by in-
serting ‘‘territorial safety net hos-
pital,’’ after ‘‘critical access hospital,’’; 
(II) in subparagraph (B), by in-
serting ‘‘territorial safety net hos-
pital,’’ after ‘‘critical access hospital,’’ 
in each place it appears; and 
(III) in subparagraph (C)(ii)(II), 
by inserting ‘‘territorial safety net 
hospitals,’’ after ‘‘critical access hos-
pitals,’’ in each place it appears. 
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(I) EXAMINATION
AND
TREATMENT
FOR 
EMERGENCY MEDICAL CONDITIONS AND WOMEN 
IN
LABOR.—Section 1867(e)(5) of the Social 
Security Act (42 U.S.C. 1395dd(e)(5)) is 
amended by inserting ‘‘, territorial safety net 
hospital (as defined in section 1861(nnn)(1)),’’ 
after ‘‘(as defined in section 1861(mm)(1))’’. 
(J) HOSPITAL PROVIDERS OF EXTENDED 
CARE SERVICES.—Section 1883(a)(3) of the So-
cial Security Act (42 U.S.C. 1395tt(a)(3)) is 
amended by inserting ‘‘or a territorial safety 
net hospital’’ after ‘‘critical access hospital’’. 
(K) PAYMENT TO SKILLED NURSING FA-
CILITIES
FOR
ROUTINE
CARE.—Section 
1888(e)(6)(B) of the Social Security Act (42 
U.S.C. 1395yy(e)(6)(B)) is amended— 
(i) in clause (i), by inserting ‘‘or a 
territorial safety net hospital’’ after ‘‘crit-
ical access hospital’’; and 
(ii) in clause (ii), by inserting ‘‘or a 
territorial safety net hospital’’ after ‘‘crit-
ical access hospital’’. 
(L) STANDARDIZED
POST-ACUTE
CARE 
(PAC) ASSESSMENT DATA FOR QUALITY, PAY-
MENT, AND
DISCHARGE
PLANNING.—Section 
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1899B of the Social Security Act (42 U.S.C. 
1395lll) is amended— 
(i) in subsection (c)(1)(E)— 
(I) in clause (i), by striking ‘‘or 
critical access hospital’’ and inserting 
‘‘, critical access hospital, or terri-
torial safety net hospital’’; and 
(II) in clause (ii), by inserting 
‘‘territorial safety net hospital,’’ after 
‘‘critical access hospital,’’; and 
(ii) in subsection (i)(1)— 
(I) in the first sentence, by strik-
ing ‘‘and critical access hospitals’’ and 
inserting ‘‘, critical access hospitals, 
and territorial safety net hospitals’’; 
and 
(II) in the third sentence, by in-
serting ‘‘territorial safety net hos-
pitals,’’ after ‘‘critical access hos-
pitals,’’. 
SEC. 3. INCLUSION OF TERRITORIAL SAFETY NET HOS-
PITALS AS 340B COVERED ENTITIES. 
Section 340B(a)(4) of the Public Health Service Act 
(42 U.S.C. 256b(a)(4)) is amended by adding at the end 
the following new subparagraph: 
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‘‘(P) An entity that is a territorial safety 
net hospital (as defined in section 1861(nnn) of 
the Social Security Act), and that meets the re-
quirements of subparagraph (L)(i).’’. 
SEC. 4. ELIMINATING MEDICARE SEQUESTRATION FOR 
TERRITORIAL SAFETY NET HOSPITALS. 
(a) ELIMINATING MEDICARE SEQUESTRATION FOR 
TERRITORIAL SAFETY NET HOSPITALS.— 
(1) IN
GENERAL.—Section 256(d)(7) of the 
Balanced Budget and Emergency Deficit Control 
Act of 1985 (2 U.S.C. 906(d)(7)) is amended by 
adding at the end the following: 
‘‘(D) TERRITORIAL
SAFETY
NET
HOS-
PITALS.—Payments under part A or part B of 
title XVIII of the Social Security Act with re-
spect to items and services furnished by a terri-
torial safety net hospital (as defined in section 
1861(nnn)(1) of such Act).’’. 
(2) APPLICABILITY.—The amendment made by 
this section applies with respect to orders of seques-
tration effective on or after the date that is 60 days 
after the date of the enactment of this Act. 
(b) REVERSING CUTS TO REIMBURSEMENT OF BAD 
DEBT FOR TERRITORIAL SAFETY NET HOSPITALS.— 
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(1) TERRITORIAL
SAFETY
NET
HOSPITALS.— 
Section 1861(v)(1)(W)(ii) of the Social Security Act 
(42 U.S.C. 1395x(v)(1)(W)(ii)) is amended by in-
serting after ‘‘or (V)’’ the following: ‘‘, a territorial 
safety net hospital’’. 
(2) APPLICABILITY.—The amendments made 
by this section apply with respect to cost reporting 
periods beginning more than 60 days after the date 
of the enactment of this Act. 
Æ 
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