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 fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, 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 jurisdic-
tion 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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Save America’s Rural Hospitals Act’’. 
(b) FINDINGS.—Congress finds the following: 
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(1) More than 60,000,000 individuals in rural 
areas of the United States rely on rural hospitals 
and other providers as critical access points to 
health care. 
(2) Access to health care is essential to commu-
nities that Americans living in rural areas call home. 
(3) Americans living in rural areas are older, 
poorer, and sicker than Americans living in urban 
areas. 
(4) Between January 2010 and January 1, 
2021, 137 rural hospitals closed in the United 
States, according to the University of North Caro-
lina’s Cecil G. Sheps Center for Health Services Re-
search, and the rate of these closures is increasing. 
(5) Four hundred and fifty-three hospitals are 
operating at margins similar to those that have 
closed over the past decade. Of those, 216 are con-
sidered most vulnerable to closure. 
(6) Rural Medicare beneficiaries already face a 
number of challenges when trying to access health 
care services close to home, including the weather, 
geography, and cultural, social, and language bar-
riers. 
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(7) Approximately sixty percent of all primary 
care health professional shortage areas are located 
in rural areas. 
(8) Seniors living in rural areas are forced to 
travel significant distances for care. 
(9) On average, trauma victims in rural areas 
must travel twice as far as victims in urban areas 
to the closest hospital, and, as a result, 60 percent 
of trauma deaths occur in rural areas, even though 
only 20 percent of Americans live in rural areas. 
(10) With the 453 hospitals on the brink of clo-
sure, millions of Americans living in rural areas are 
on the brink of losing access to the closest emer-
gency room. 
(c) TABLE OF CONTENTS.—The table of contents of 
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 hos-
pitals (CAHs) and rural hospitals. 
Sec. 103. Extending payment levels for low-volume hospitals and Medicare-de-
pendent 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 ambu-
lance services in rural areas. 
Sec. 112. Extending Medicaid primary care payments. 
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Sec. 113. Making permanent Medicare telehealth service enhancements for fed-
erally 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. 
TITLE I—RURAL PROVIDER 
PAYMENT STABILIZATION 
Subtitle A—Rural Hospitals 
SEC. 101. ELIMINATING MEDICARE SEQUESTRATION FOR 
RURAL HOSPITALS. 
(a) 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) 
RURAL
HOSPITALS.—Payments 
under part A or part B of title XVIII of the So-
cial Security Act with respect to items and serv-
ices furnished by a critical access hospital (as 
defined in section 1861(mm)(1) of such Act), a 
sole community hospital (as defined in section 
1886(d)(5)(D)(iii) of such Act), a Medicare-de-
pendent, small rural hospital (as defined in sec-
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tion 1886(d)(5)(G)(iv) of such Act), or a sub-
section (d) hospital located in a rural area (as 
defined in section 1886(d)(2)(D) of such Act).’’. 
(b) APPLICABILITY.—The amendment made by this 
section applies with respect to orders of sequestration ef-
fective on or after the date that is 60 days after the date 
of the enactment of this Act. 
SEC. 102. REVERSING CUTS TO REIMBURSEMENT OF BAD 
DEBT FOR CRITICAL ACCESS HOSPITALS 
(CAHS) AND RURAL HOSPITALS. 
(a) RURAL HOSPITALS.—Section 1861(v)(1)(T)(v) of 
the Social Security Act (42 U.S.C. 1395x(v)(1)(T)(v)) is 
amended by inserting before the period the following: ‘‘or, 
in the case of a hospital located in a rural area, by 15 
percent of such amount otherwise allowable’’. 
(b) CAHS.—Section 1861(v)(1)(W)(ii) of the Social 
Security Act (42 U.S.C. 1395x(v)(1)(W)(ii)) is amended 
by inserting after ‘‘or (V)’’ the following: ‘‘, a critical ac-
cess hospital’’. 
(c) APPLICABILITY.—The amendments made by this 
section apply with respect to cost reporting periods begin-
ning more than 60 days after the date of the enactment 
of this Act. 
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(ii) by striking ‘‘; and’’ and inserting 
a period; and 
(D) by striking subclause (IV); and 
(3) in subparagraph (D)— 
(A) by amending the heading to read as 
follows: ‘‘APPLICABLE PERCENTAGE INCREASE 
AFTER FISCAL YEAR 2010’’; 
(B) in the matter preceding clause (i), by 
striking ‘‘in fiscal years 2011 through 2022’’ 
and inserting ‘‘in fiscal year 2011 or a subse-
quent fiscal year’’; and 
(C) in clause (ii), by striking ‘‘each of fis-
cal years 2019 through 2022’’ and inserting 
‘‘fiscal year 2019 and each subsequent fiscal 
year’’. 
SEC. 104. REINSTATING REVISED DIAGNOSIS-RELATED 
GROUP PAYMENTS FOR MDHS AND SOLE 
COMMUNITY HOSPITALS (SCHS). 
(a) PAYMENTS FOR MDHS AND SCHS FOR VALUE- 
BASED
INCENTIVE
PROGRAMS.—Section 
1886(o)(7)(D)(ii)(I) of the Social Security Act (42 U.S.C. 
1395ww(o)(7)(D)(ii)(I)) is amended by inserting ‘‘and 
after fiscal year 2021’’ after ‘‘2013’’. 
(b) PAYMENTS FOR MDHS AND SCHS UNDER HOS-
PITAL READMISSIONS REDUCTION PROGRAM.—Section 
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1886(q)(2)(B)(i) of the Social Security Act (42 U.S.C. 
1395ww(q)(2)(B)(i)) is amended by inserting ‘‘and after 
fiscal year 2021’’ after ‘‘2013’’. 
SEC. 105. REINSTATING HOLD HARMLESS TREATMENT FOR 
HOSPITAL OUTPATIENT SERVICES FOR SCHS. 
Section 1833(t)(7)(D)(i) of the Social Security Act 
(42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 
(1) in the heading, by striking ‘‘TEMPORARY’’ 
and inserting ‘‘PERMANENT’’; 
(2) in subclause (II)— 
(A) in the first sentence, by inserting ‘‘and 
on or after January 1, 2022,’’ after ‘‘January 
1, 2013,’’; and 
(B) in the second sentence, by inserting ‘‘, 
and during or after 2022’’ after ‘‘or 2012’’; and 
(3) in subclause (III), in the first sentence, by 
inserting ‘‘and on or after January 1, 2022,’’ after 
‘‘January 1, 2013,’’. 
Subtitle B—Other Rural Providers 
SEC. 111. MAKING PERMANENT INCREASED MEDICARE 
PAYMENTS FOR GROUND AMBULANCE SERV-
ICES IN RURAL AREAS. 
Section 1834(l)(13) of the Social Security Act (42 
U.S.C. 1395m(l)(13)) is amended— 
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(1) in the paragraph heading, by striking 
‘‘TEMPORARY
INCREASE’’ and inserting ‘‘IN-
CREASE’’; and 
(2) in subparagraph (A)— 
(A) in the matter preceding clause (i), by 
striking ‘‘, and before January 1, 2023’’; and 
(B) in clause (i), by striking ‘‘, and before 
January 1, 2023’’. 
SEC. 112. EXTENDING MEDICAID PRIMARY CARE PAY-
MENTS. 
(a) IN GENERAL.—Section 1902(a)(13)(C) of the So-
cial Security Act (42 U.S.C. 1396a(a)(13)(C)) is amended 
by inserting after ‘‘2014’’ the following: ‘‘(or, in the case 
of primary care services furnished by a physician located 
in a rural area, as defined in section 1886(d)(2)(D), fur-
nished in any year)’’. 
(b) APPLICABILITY.— 
(1) IN GENERAL.—Except as provided in para-
graph (2), the amendment made by this section ap-
plies to services furnished in a year beginning on or 
after the date of the enactment of this Act. 
(2) EXCEPTION
IF
STATE
LEGISLATION
RE-
QUIRED.—In the case of a State plan for medical as-
sistance under title XIX of the Social Security Act 
which the Secretary of Health and Human Services 
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determines requires State legislation (other than leg-
islation appropriating funds) in order for the plan to 
meet the additional requirement imposed by the 
amendment made by this section, the State plan 
shall not be regarded as failing to comply with the 
requirements of such title solely on the basis of its 
failure to meet this additional requirement before 
the first day of the first calendar quarter beginning 
after the close of the first regular session of the 
State legislature that begins after the date of the en-
actment of this Act. For purposes of the previous 
sentence, in the case of a State that has a 2-year 
legislative session, each year of such session shall be 
deemed to be a separate regular session of the State 
legislature. 
SEC. 113. MAKING PERMANENT MEDICARE TELEHEALTH 
SERVICE ENHANCEMENTS FOR FEDERALLY 
QUALIFIED HEALTH CENTERS AND RURAL 
HEALTH CLINICS. 
Paragraph (8) of section 1834(m) of the Social Secu-
rity Act (42 U.S.C. 1395m(m)) is amended— 
(1) in the paragraph heading, be striking ‘‘DUR-
ING EMERGENCY PERIOD’’; 
(2) in the matter preceding subparagraph (A), 
by striking ‘‘During the emergency period described 
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in section 1135(g)(1)(B)’’ and inserting ‘‘Beginning 
on the first day of the emergency period described 
in section 1135(g)(1)(B)’’; 
(3) in subparagraph (A)(ii), by striking ‘‘deter-
mined under subparagraph (B)’’ and inserting ‘‘de-
termined, for services furnished during the emer-
gency period described in section 1135(g)(1)(B), 
under subparagraph (B) and, for services furnished 
after such period, as an amount equal to the amount 
that such center or clinic would have been paid 
under this title had such service been furnished 
without the use of a telecommunications system’’; 
and 
(4) in subparagraph (B)— 
(A) by striking ‘‘PAYMENT RULE’’ and all 
that follows through ‘‘The Secretary shall’’ and 
inserting ‘‘PAYMENT
RULE.—The Secretary 
shall’’; and 
(B) by redesignating clause (ii) as sub-
paragraph (C) and moving such subparagraph 
as so redesignated 2 ems to the left. 
SEC. 114. CREATION OF REPORTING REQUIREMENTS FOR 
PROVIDER-BASED RURAL HEALTH CLINICS. 
(a) IN GENERAL.—Not later than two years after the 
date of the enactment of this Act, the Secretary of Health 
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and Human Services (in this section referred to as the 
‘‘Secretary’’) shall, taking into account the recommenda-
tions made pursuant to subsection (b), implement a vol-
untary Medicare provider-based rural health clinic quality 
reporting program, in accordance with this section, under 
which— 
(1) provider-based rural health clinics estab-
lished on or after January 1, 2021, may voluntarily 
comply with reporting requirements described in 
subsection (b)(2); and 
(2) payments under title XVIII to such clinics 
complying with such requirements are provided in 
accordance with subsection (d). 
(b) CONSULTATION.—Not later than one year after 
the date of the enactment of this Act, the Secretary, acting 
through the Administrator for Centers for Medicare & 
Medicaid Services, the Federal Office of Rural Health Pol-
icy, and the Agency for Healthcare Research and Quality, 
shall consult with relevant stakeholders— 
(1) to review rural health clinic data collection 
processes and quality measurers identified for rural 
health clinics by the National Quality Forum and 
other national quality-monitoring systems; and 
(2) to make recommendations to the Secretary 
for voluntary reporting requirements for the Sec-
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retary to implement under the eligible professional 
Merit-based Incentive Payment System under sec-
tion 1848(q) of the Social Security Act (42 U.S.C. 
1395w–4) for provider-based rural health clinics es-
tablished on or after January 1, 2021. 
(c) COLLABORATION.—In implementing the vol-
untary Medicare provider-based rural health clinic quality 
reporting program, the Secretary shall consult with a di-
verse group of rural health clinic stakeholders, which shall 
include— 
(1) the National Quality Forum, or such other 
standard-setting organizations specified by the Sec-
retary; 
(2) relevant State and local public agencies, in-
cluding State offices of rural health; 
(3) established provider-based rural health clin-
ics, including those in the application process; 
(4) small rural hospitals with 50 beds or less; 
(5) organizations representing provider-based 
rural health clinics; and 
(6) organizations representing rural health care. 
(d) CONDITIONS.—Under the voluntary Medicare 
provider-based rural health clinic quality reporting pro-
gram the Secretary shall provide that in the case of a pro-
vider-based rural health clinic described in subsection 
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(a)(1) that voluntarily complies with the reporting require-
ments described in subsection (b)(2), with respect to a 
year— 
(1) reimbursement rates under title XVIII of 
the Social Security Act for rural health services fur-
nished by such clinic during such year shall be con-
sistent with reimbursement rates under such title for 
such services furnished by a provider-based rural 
health clinic established before December 31, 2020; 
and 
(2) the provisions of section 1833(f)(3) of such 
Act (42 U.S.C. 1395l(f)(3)) shall not apply with re-
spect to such clinic and such year. 
(e) GRANTS FOR TECHNICAL ASSISTANCE.— 
(1) IN GENERAL.—Section 1820(g)(3) of the 
Social Security Act (42 U.S.C. 1395i–4(g)(3)) is 
amended— 
(A) in subparagraph (A)— 
(i) by striking ‘‘Balanced Budget Act 
of 1997 and’’ and inserting ‘‘Balanced 
Budget Act of 1997,’’; and 
(ii) by inserting before the period at 
the end the following: ‘‘, and to provide to 
such small rural hospitals that participate 
in the voluntary Medicare provider-based 
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rural health clinic quality reporting pro-
gram established pursuant to section 114 
of the Save America’s Rural Hospitals Act 
technical assistance necessary to so partici-
pate in such program’’; and 
(B) in subparagraph (E)— 
(i) by striking ‘‘and to participate in 
delivery system reforms’’ and inserting ‘‘, 
to participate in delivery system reforms’’; 
and 
(ii) by inserting before the period at 
the end the following: ‘‘, and in the case of 
small rural hospitals that participate in the 
voluntary Medicare provider-based rural 
health clinic quality reporting program es-
tablished pursuant to section 114 of the 
Save America’s Rural Hospitals Act, for 
technical assistance necessary to so partici-
pate in such program’’. 
(2) FUNDING.—In addition to amounts other-
wise made available for grants under section 
1820(g)(3) of the Social Security Act, there is ap-
propriated to the Secretary of Health and Human 
Services, out of any monies in the Treasury not oth-
erwise appropriated, $15,000,000 for the period of 
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fiscal years 2022 through 2026 to provide grants 
under such section to small rural hospitals that par-
ticipate in the voluntary Medicare provider-based 
rural health clinic quality reporting program estab-
lished pursuant to this section for technical assist-
ance necessary to so participate in such program. 
TITLE II—RURAL MEDICARE 
BENEFICIARY EQUITY 
SEC. 201. EQUALIZING BENEFICIARY COPAYMENTS FOR 
SERVICES FURNISHED BY CAHS. 
(a) IN GENERAL.—Section 1866(a)(2)(A) of the So-
cial Security Act (42 U.S.C. 1395cc(a)(2)(A)) is amended 
by adding at the end the following: ‘‘In the case of out-
patient critical access hospital services for which payment 
is made under section 1834(g), clause (ii) of the first sen-
tence shall be applied by substituting ‘20 percent of the 
lesser of the actual charge or the payment basis under 
this part for such services if the critical access hospital 
were treated as a hospital’ for ‘20 per centum of the rea-
sonable charges for such items and services’.’’. 
(b) APPLICABILITY.—The amendment made by this 
section applies with respect to services furnished during 
a year that begins more than 60 days after the date of 
the enactment of this Act. 
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TITLE III—REGULATORY RELIEF 
SEC. 301. ELIMINATING 96-HOUR PHYSICIAN CERTIFI-
CATION REQUIREMENT WITH RESPECT TO 
INPATIENT CAH SERVICES. 
(a) IN GENERAL.—Section 1814(a) of the Social Se-
curity Act (42 U.S.C. 1395f(a)) is amended— 
(1) in paragraph (6), by adding ‘‘and’’ at the 
end; 
(2) in paragraph (7)(E), by striking ‘‘; and’’ 
and inserting a period; and 
(3) by striking paragraph (8). 
(b) APPLICABILITY.—The amendments made by this 
section apply with respect to services furnished during a 
year that begins more than 60 days after the date of the 
enactment of this Act. 
SEC. 302. REBASING SUPERVISION REQUIREMENTS. 
(a) THERAPEUTIC HOSPITAL OUTPATIENT SERV-
ICES.— 
(1) 
SUPERVISION
REQUIREMENTS.—Section 
1833 of the Social Security Act (42 U.S.C. 1395l) 
is amended by adding at the end the following new 
subsection: 
‘‘(ee) PHYSICIAN SUPERVISION REQUIREMENTS FOR 
THERAPEUTIC HOSPITAL OUTPATIENT SERVICES.— 
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‘‘(1) GENERAL SUPERVISION FOR THERAPEUTIC 
SERVICES.—Except as may be provided under para-
graph (2), insofar as the Secretary requires the su-
pervision by a physician or a non-physician practi-
tioner for payment for therapeutic hospital out-
patient services (as defined in paragraph (5)(A)) 
furnished under this part, such requirement shall be 
met if such services are furnished under the general 
supervision (as defined in paragraph (5)(B)) of the 
physician or non-physician practitioner, as the case 
may be. 
‘‘(2) EXCEPTIONS PROCESS FOR HIGH-RISK OR 
COMPLEX MEDICAL SERVICES REQUIRING A DIRECT 
LEVEL OF SUPERVISION.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this paragraph, the Sec-
retary shall establish a process for the designa-
tion of therapeutic hospital outpatient services 
furnished under this part that, by reason of 
complexity or high risk, require— 
‘‘(i) direct supervision (as defined in 
paragraph (5)(C)) for the entire service; or 
‘‘(ii) direct supervision during the ini-
tiation of the service followed by general 
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supervision for the remainder of the serv-
ice. 
‘‘(B) CONSULTATION WITH CLINICAL EX-
PERTS.— 
‘‘(i) IN GENERAL.—Under the process 
established under subparagraph (A), before 
the designation of any therapeutic hospital 
outpatient service for which direct super-
vision may be required under this part, the 
Secretary shall consult with a panel of out-
side experts described in clause (ii) to ad-
vise the Secretary with respect to each 
such designation. 
‘‘(ii) ADVISORY
PANEL
ON
SUPER-
VISION OF THERAPEUTIC HOSPITAL OUT-
PATIENT
SERVICES.—For 
purposes 
of 
clause (i), a panel of outside experts de-
scribed in this clause is a panel appointed 
by the Secretary, based on nominations 
submitted by hospital, rural health, and 
medical organizations representing physi-
cians, non-physician practitioners, and hos-
pital administrators, as the case may be, 
that meets the following requirements: 
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‘‘(I) COMPOSITION.—The panel 
shall be composed of at least 15 phy-
sicians 
and 
non-physician 
practi-
tioners who furnish therapeutic hos-
pital outpatient services for which 
payment is made under this part and 
who collectively represent the medical 
specialties that furnish such services, 
and of 4 hospital administrators of 
hospitals located in rural areas (as de-
fined in section 1886(d)(2)(D)) or 
critical access hospitals. 
‘‘(II) PRACTICAL
EXPERIENCE 
REQUIRED FOR PHYSICIANS AND NON- 
PHYSICIAN
PRACTITIONERS.—During 
the 12-month period preceding ap-
pointment to the panel by the Sec-
retary, each physician or non-physi-
cian practitioner described in sub-
clause (I) shall have furnished thera-
peutic hospital outpatient services for 
which payment was made under this 
part. 
‘‘(III) MINIMUM
RURAL
REP-
RESENTATION
REQUIREMENT
FOR 
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PHYSICIANS
AND
NON-PHYSICIAN 
PRACTITIONERS.—Not less than 50 
percent of the membership of the 
panel that is comprised of physicians 
and non-physician practitioners shall 
be physicians or non-physician practi-
tioners described in subclause (I) who 
practice in rural areas (as defined in 
section 1886(d)(2)(D)) or who furnish 
such services in critical access hos-
pitals. 
‘‘(iii) APPLICATION
OF
FACA.—The 
Federal Advisory Committee Act (5 U.S.C. 
2 App.), other than section 14 of such Act, 
shall apply to the panel of outside experts 
appointed by the Secretary under clause 
(ii). 
‘‘(C) SPECIAL
RULE
FOR
OUTPATIENT 
CRITICAL
ACCESS
HOSPITAL
SERVICES.—Inso-
far as a therapeutic outpatient hospital service 
that is an outpatient critical access hospital 
service is designated as requiring direct super-
vision under the process established under sub-
paragraph (A), the Secretary shall deem the 
critical access hospital furnishing that service 
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as having met the requirement for direct super-
vision for that service if, when furnishing such 
service, the critical access hospital meets the 
standard for personnel required as a condition 
of participation under section 485.618(d) of 
title 42, Code of Federal Regulations (as in ef-
fect on the date of the enactment of this sub-
section). 
‘‘(D) CONSIDERATION
OF
COMPLIANCE 
BURDENS.—Under 
the 
process 
established 
under subparagraph (A), the Secretary shall 
take into account the impact on hospitals and 
critical access hospitals in complying with re-
quirements for direct supervision in the fur-
nishing of therapeutic hospital outpatient serv-
ices, including hospital resources, availability of 
hospital-privileged physicians, specialty physi-
cians, and non-physician practitioners, and ad-
ministrative burdens. 
‘‘(E) REQUIREMENT
FOR
NOTICE
AND 
COMMENT
RULEMAKING.—Under the process 
established under subparagraph (A), the Sec-
retary shall only designate therapeutic hospital 
outpatient services requiring direct supervision 
under this part through proposed and final 
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rulemaking that provides for public notice and 
opportunity for comment. 
‘‘(F) RULE OF CONSTRUCTION.—Nothing 
in this subsection shall be construed as author-
izing the Secretary to apply or require any level 
of supervision other than general or direct su-
pervision with respect to the furnishing of 
therapeutic hospital outpatient services. 
‘‘(3) INITIAL LIST OF DESIGNATED SERVICES.— 
The Secretary shall include in the proposed and final 
regulation for payment for hospital outpatient serv-
ices for 2022 under this part a list of initial thera-
peutic hospital outpatient services, if any, designated 
under the process established under paragraph 
(2)(A) as requiring direct supervision under this 
part. 
‘‘(4) DIRECT SUPERVISION BY NON-PHYSICIAN 
PRACTITIONERS
FOR
CERTAIN
HOSPITAL
OUT-
PATIENT SERVICES PERMITTED.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this subsection, a non-phy-
sician practitioner may directly supervise the 
furnishing of— 
‘‘(i) therapeutic hospital outpatient 
services under this part, including cardiac 
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rehabilitation 
services 
(under 
section 
1861(eee)(1)), intensive cardiac rehabilita-
tion services (under section 1861(eee)(4)), 
and 
pulmonary 
rehabilitation 
services 
(under section 1861(fff)(1)); and 
‘‘(ii) those hospital outpatient diag-
nostic 
services 
(described 
in 
section 
1861(s)(2)(C)) that require direct super-
vision under the fee schedule established 
under section 1848. 
‘‘(B) REQUIREMENTS.—Subparagraph (A) 
shall apply insofar as the non-physician practi-
tioner involved meets the following require-
ments: 
‘‘(i) SCOPE OF PRACTICE.—The non- 
physician practitioner is acting within the 
scope of practice under State law applica-
ble to the practitioner. 
‘‘(ii) ADDITIONAL
REQUIREMENTS.— 
The non-physician practitioner meets such 
requirements as the Secretary may specify. 
‘‘(5) DEFINITIONS.—In this subsection: 
‘‘(A) 
THERAPEUTIC
HOSPITAL
OUT-
PATIENT
SERVICES.—The term ‘therapeutic 
hospital outpatient services’ means hospital 
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services described in section 1861(s)(2)(B) fur-
nished by a hospital or critical access hospital 
and includes— 
‘‘(i) cardiac rehabilitation services and 
intensive cardiac rehabilitation services (as 
defined in paragraphs (1) and (4), respec-
tively, of section 1861(eee)); and 
‘‘(ii) pulmonary rehabilitation services 
(as defined in section 1861(fff)(1)). 
‘‘(B) GENERAL SUPERVISION.— 
‘‘(i) OVERALL DIRECTION AND CON-
TROL
OF
PHYSICIAN.—Subject to clause 
(ii), with respect to the furnishing of 
therapeutic hospital outpatient services for 
which payment may be made under this 
part, the term ‘general supervision’ means 
such services that are furnished under the 
overall direction and control of a physician 
or non-physician practitioner, as the case 
may be. 
‘‘(ii) PRESENCE NOT REQUIRED.—For 
purposes of clause (i), the presence of a 
physician or non-physician practitioner is 
not required during the performance of the 
procedure involved. 
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‘‘(C) DIRECT SUPERVISION.— 
‘‘(i) PROVISION OF ASSISTANCE AND 
DIRECTION.—Subject to clause (ii), with 
respect to the furnishing of therapeutic 
hospital outpatient services for which pay-
ment may be made under this part, the 
term ‘direct supervision’ means that a phy-
sician or non-physician practitioner, as the 
case may be, is immediately available (in-
cluding by telephone or other means) to 
furnish assistance and direction through-
out the furnishing of such services. Such 
term includes, with respect to the fur-
nishing of a therapeutic hospital outpatient 
service for which payment may be made 
under this part, direct supervision during 
the initiation of the service followed by 
general supervision for the remainder of 
the service (as described in paragraph 
(2)(A)(ii)). 
‘‘(ii) PRESENCE
IN
ROOM
NOT
RE-
QUIRED.—For purposes of clause (i), a 
physician or non-physician practitioner, as 
the case may be, is not required to be 
present in the room during the perform-
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ance of the procedure involved or within 
any other physical boundary as long as the 
physician or non-physician practitioner, as 
the case may be, is immediately available. 
‘‘(D) NON-PHYSICIAN
PRACTITIONER
DE-
FINED.—The term ‘non-physician practitioner’ 
means an individual who— 
‘‘(i) is a physician assistant, a nurse 
practitioner, a clinical nurse specialist, a 
clinical social worker, a clinical psycholo-
gist, a certified nurse midwife, or a cer-
tified registered nurse anesthetist, and in-
cludes such other practitioners as the Sec-
retary may specify; and 
‘‘(ii) with respect to the furnishing of 
therapeutic outpatient hospital services, 
meets the requirements of paragraph 
(4)(B).’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1861(eee)(2)(B) of the Social Security Act (42 
U.S.C. 1395x(eee)(2)(B)) is amended by inserting ‘‘, 
and a non-physician practitioner (as defined in sec-
tion 1833(cc)(5)(D)) may supervise the furnishing of 
such items and services in the hospital’’ after ‘‘in 
the case of items and services furnished under such 
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a program in a hospital, such availability shall be 
presumed’’. 
(b) PROHIBITION ON RETROACTIVE ENFORCEMENT 
OF REVISED INTERPRETATION.— 
(1) REPEAL
OF
REGULATORY
CLARIFICA-
TION.—The restatement and clarification under the 
final rulemaking changes to the Medicare hospital 
outpatient prospective payment system and calendar 
year 2009 payment rates (published in the Federal 
Register on November 18, 2008, 73 Fed. Reg. 
68702 through 68704) with respect to requirements 
for direct supervision by physicians for therapeutic 
hospital outpatient services (as defined in paragraph 
(3)) for purposes of payment for such services under 
the Medicare program shall have no force or effect 
in law. 
(2) HOLD
HARMLESS.—A hospital or critical 
access hospital that furnishes therapeutic hospital 
outpatient services during the period beginning on 
January 1, 2001, and ending on the later of Decem-
ber 31, 2021, or the date on which the final regula-
tion promulgated by the Secretary of Health and 
Human Services to carry out this section takes ef-
fect, for which a claim for payment is made under 
part B of title XVIII of the Social Security Act shall 
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not be subject to any civil or criminal action or pen-
alty under Federal law for failure to meet super-
vision requirements under the regulation described 
in paragraph (1), under program manuals, or other-
wise. 
(3) 
THERAPEUTIC
HOSPITAL
OUTPATIENT 
SERVICES DEFINED.—In this subsection, the term 
‘‘therapeutic hospital outpatient services’’ means 
medical and other health services furnished by a 
hospital or critical access hospital that are— 
(A) hospital services described in sub-
section (s)(2)(B) of section 1861 of the Social 
Security Act (42 U.S.C. 1395x); 
(B) cardiac rehabilitation services or inten-
sive cardiac rehabilitation services (as defined 
in paragraphs (1) and (4), respectively, of sub-
section (eee) of such section); or 
(C) pulmonary rehabilitation services (as 
defined in subsection (fff)(1) of such section). 
SEC. 303. REFORMING PRACTICES OF RECOVERY AUDIT 
CONTRACTORS UNDER MEDICARE. 
(a) ELIMINATION OF CONTINGENCY FEE PAYMENT 
SYSTEM.—Section 1893(h) of the Social Security Act (42 
U.S.C. 1395ddd(h)) is amended— 
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(1) in paragraph (1), by inserting ‘‘, for recov-
ery activities conducted during a fiscal year before 
fiscal year 2022’’ after ‘‘Under the contracts’’; and 
(2) by adding at the end the following new 
paragraph: 
‘‘(11) PAYMENT
FOR
RECOVERY
ACTIVITIES 
PERFORMED AFTER FISCAL YEAR 2021.— 
‘‘(A) IN GENERAL.—Under the contracts, 
subject to paragraphs (B) and (C), payment 
shall be made to recovery audit contractors for 
recovery activities conducted during fiscal year 
2022 and each fiscal year thereafter in the 
same manner, and from the same amounts, as 
payment is made to eligible entities under con-
tracts entered into for recovery activities con-
ducted during fiscal year 2021 under subsection 
(a). 
‘‘(B) PROHIBITION
ON
INCENTIVE
PAY-
MENTS.—Under the contracts, payment made 
to a recovery audit contractor for recovery ac-
tivities conducted during fiscal year 2022 or 
any fiscal year thereafter may not include any 
incentive payments. 
‘‘(C) PERFORMANCE ACCOUNTABILITY.— 
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issued by the contractor that is over-
turned on appeal). 
‘‘(iii) TIMING OF DETERMINATIONS OF 
PAYMENT
REDUCTIONS.—The Secretary 
shall, with respect to a recovery audit con-
tractor, determine not later than six 
months after the end of a fiscal year— 
‘‘(I) whether to reduce payment 
to the recovery audit contractor under 
clause (i) for recovery activities con-
ducted during such fiscal year; and 
‘‘(II) in the case that the Sec-
retary determines to so reduce pay-
ment to the contractor, the amount of 
such payment reduction. 
‘‘(iv) METHODOLOGY
FOR
CALCULA-
TION
OF
OVERTURNED
COMPLEX
AUDIT 
DENIAL OVERTURN RATE.— 
‘‘(I) CALCULATION OF OVERTURN 
RATE.—The Secretary shall calculate 
a complex audit denial overturn rate 
for a recovery audit contractor for a 
fiscal year by— 
‘‘(aa) determining, with re-
spect to the contract entered into 
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under paragraph (1) by the con-
tractor, the number of complex 
audit denials issued by the con-
tractor under the contract (in-
cluding denials issued before such 
fiscal year and during such fiscal 
year) that are overturned on ap-
peal; and 
‘‘(bb) dividing the number 
determined under item (aa) by 
the number of complex audit de-
nials issued by the contractor 
under such contract (including 
denials issued before such fiscal 
year and during such fiscal year). 
‘‘(II) FAIRNESS
AND
TRANS-
PARENCY.—The Secretary shall cal-
culate the percentage described in 
subclause (I) in a fair and trans-
parent manner. 
‘‘(III) ACCOUNTING FOR SUBSE-
QUENTLY
OVERTURNED
APPEALS.— 
The Secretary shall calculate the per-
centage described in subclause (I) in a 
manner that accounts for the likeli-
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hood that complex audit denials 
issued by the contractor for such fis-
cal year will be overturned on appeal 
in a subsequent fiscal year. 
‘‘(IV) COMPLEX
AUDIT
DENIAL 
DEFINED.—In this subparagraph, the 
term ‘complex audit denial’ means a 
denial by a recovery audit contractor 
of a claim for payment under this title 
submitted by a hospital, psychiatric 
hospital, or critical access hospital 
that is so denied by the contractor 
after the contractor has— 
‘‘(aa) requested that the 
hospital, psychiatric hospital, or 
critical access hospital, in order 
to support such claim for pay-
ment, provide supporting medical 
records to the contractor; and 
‘‘(bb) reviewed such medical 
records in order to determine 
whether an improper payment 
has been made to the hospital, 
psychiatric hospital, or critical 
access hospital for such claim. 
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‘‘(V) OVERTURNED
ON
APPEAL 
DEFINED.—In this subparagraph, the 
term ‘overturned on appeal’ means, 
with respect to a complex audit de-
nial, a denial that is overturned on 
appeal at the reconsideration level, the 
redetermination level, or the adminis-
trative law judge hearing level. 
‘‘(D) APPLICATION
TO
EXISTING
CON-
TRACTS.—Not later than 60 days after the date 
of the enactment of this paragraph, the Sec-
retary shall modify, as necessary, each contract 
under paragraph (1) that the Secretary entered 
into prior to such date of enactment in order to 
ensure that payment with respect to recovery 
activities conducted under such contract is 
made in accordance with the requirements de-
scribed in this paragraph.’’. 
(b) ELIMINATION
OF ONE-YEAR TIMELY FILING 
LIMIT TO REBILL PART B CLAIMS.— 
(1) IN GENERAL.—Section 1842(b) of the So-
cial Security Act (42 U.S.C. 1395u(b)) is amended 
by adding at the end the following new paragraph: 
‘‘(20) EXCEPTION TO THE ONE-YEAR TIMELY 
FILING LIMIT FOR CERTAIN REBILLED CLAIMS.— 
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‘‘(A) IN GENERAL.—In the case of a claim 
submitted under this part by a hospital (as de-
fined in subparagraph (B)(i)) for hospital serv-
ices with respect to which there was a previous 
claim submitted under part A as inpatient hos-
pital services or inpatient critical access hos-
pital services that was denied by a medicare 
contractor (as defined in subparagraph (B)(ii)) 
because of a determination that the inpatient 
admission was not medically reasonable and 
necessary under section 1862(a)(1)(A), the 
deadline described in this paragraph is 180 
days after the date of the final denial of such 
claim under part A. 
‘‘(B) DEFINITIONS.—In this paragraph: 
‘‘(i) HOSPITAL.—The term ‘hospital’ 
has the meaning given such term in section 
1861(e) and includes a psychiatric hospital 
(as defined in section 1861(f)) and a crit-
ical access hospital (as defined in section 
1861(mm)(1)). 
‘‘(ii) MEDICARE
CONTRACTOR.—The 
term ‘medicare contractor’ has the mean-
ing given such term under section 1889(g), 
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and includes a recovery audit contractor 
with a contract under section 1893(h). 
‘‘(iii) FINAL DENIAL.—The term ‘final 
denial’ means— 
‘‘(I) in the case that a hospital 
elects not to appeal a denial described 
in subparagraph (A) by a medicare 
contractor, the date of such denial; or 
‘‘(II) in the case that a hospital 
elects to appeal a such a denial, the 
date on which such appeal is ex-
hausted.’’. 
(2) CONFORMING AMENDMENTS.— 
(A) Section 1835(a)(1) of the Social Secu-
rity Act (42 U.S.C. 1395n(a)(1)) is amended by 
inserting ‘‘or, in the case of a claim described 
in section 1842(b)(20), not later than the dead-
line described in such paragraph’’ after ‘‘the 
date of service’’. 
(B) Section 1842(b)(3)(B) of the Social 
Security Act (42 U.S.C. 1395u(b)(3)(B)) is 
amended in the flush language following clause 
(ii) by inserting ‘‘or, in the case of a claim de-
scribed in section 1842(b)(20), not later than 
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the deadline described in such paragraph’’ after 
‘‘the date of service’’. 
(3) APPLICABILITY.—The amendments made 
by this subsection apply to claims submitted under 
part B of title XVIII of the Social Security Act for 
hospital services for which there was a previous 
claim submitted under part A as inpatient hospital 
services or inpatient critical access hospital services 
that was subject to a final denial (as defined in 
paragraph (20)(B)(iii) of section 1842(b) of such 
Act (42 U.S.C. 1395u(b))) on or after the date of 
the enactment of this Act. 
(c) MEDICAL DOCUMENTATION CONSIDERED
FOR 
MEDICAL NECESSITY REVIEWS OF CLAIMS FOR INPA-
TIENT HOSPITAL SERVICES.—Section 1862(a) of the So-
cial Security Act (42 U.S.C. 1395y(a)) is amended by add-
ing at the end the following new sentence: ‘‘A determina-
tion under paragraph (1) of whether inpatient hospital 
services or inpatient critical access hospital services fur-
nished to an individual on or after the date of the enact-
ment of this sentence are reasonable and necessary shall 
be based solely upon information available to the admit-
ting physician at the time of the inpatient admission of 
the individual for such inpatient services, as documented 
in the medical record.’’. 
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TITLE IV—FUTURE OF RURAL 
HEALTH CARE 
SEC. 401. MEDICARE RURAL HOSPITAL FLEXIBILITY PRO-
GRAM GRANTS. 
Section 1820(g) of the Social Security Act (42 U.S.C. 
1395i–4(g)) is amended— 
(1) in paragraph (1)— 
(A) in subparagraph (C), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (D), by striking the 
period at the end and inserting a semicolon; 
and 
(C) by adding at the end the following new 
subparagraphs: 
‘‘(E) rural emergency hospitals providing 
support for critical access hospitals to convert 
to rural emergency hospitals to stabilize hos-
pital emergency services in their communities; 
and 
‘‘(F) supporting certified rural health clin-
ics for maintaining and building business oper-
ations, increasing financial indicators, address-
ing population health, transforming services, 
and providing linkages and services for behav-
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ioral health and substance use disorders re-
sponding to public health emergencies.’’; 
(2) by redesignating paragraphs (3) through 
(7) as paragraphs (4) through (8), respectively; 
(3) after paragraph (2), by inserting the fol-
lowing new paragraph: 
‘‘(3) ACTIVITIES TO SUPPORT CARRYING OUT 
FLEX GRANTS.—The Secretary may award grants or 
cooperative agreements to entities that submit to the 
Secretary applications, at such time and in such 
form and manner and containing such information 
as the Secretary specifies, for purposes of supporting 
States and hospitals in carrying out the activities 
under this subsection by providing technical assist-
ance, data analysis, and evaluation efforts.’’; 
(4) in paragraph (4), as redesignated— 
(A) in subparagraph (A), by inserting 
‘‘State Offices of Rural Health on behalf of eli-
gible hospitals’’ after ‘‘award grants to’’; 
(B) by amending subparagraph (C) to read 
as follows: 
‘‘(C) APPLICATION.—The State Office of 
Rural Health shall submit an application, on 
behalf of eligible rural hospitals, to the Sec-
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retary on or before such date and in such form 
and manner as the Secretary specifies.’’; 
(C) by amending subparagraph (D), to 
read as follows: 
‘‘(D) AMOUNT OF GRANT.—A grant to a 
hospital under this paragraph shall be deter-
mined on an equal national distribution so that 
each hospital receives the same amount of sup-
port related to the funds appropriated.’’; 
(D) by amending subparagraph (E), to 
read as follows: 
‘‘(E) USE
OF
FUNDS.—State Offices of 
Rural Health and eligible hospitals may use the 
funds received through a grant under this para-
graph for the purchase of computer software 
and hardware; the education and training of 
hospital staff on billing, operational, quality im-
provement and related value-focused efforts; 
and other delivery system reform programs de-
termined appropriate by the Secretary.’’; and 
(5) by adding at the end the following new 
paragraph: 
‘‘(9) 
RURAL
HEALTH
TRANSFORMATION 
GRANTS.— 
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‘‘(A) GRANTS.—The Secretary may award 
5-year grants to State Offices of Rural Health 
and to eligible rural health care providers (as 
defined in subparagraph (E)) on the transition 
to new models, including rural emergency hos-
pitals, extended stay clinics, freestanding emer-
gency departments, rural health clinics, and in-
tegration of behavioral, oral health services, 
telehealth and other transformational models 
relevant to rural providers as such providers 
evolve to better meet community needs and the 
changing health care environment. 
‘‘(B) APPLICATION.—An applicable rural 
health care provider, in partnership with the 
State Office of Rural Health in the State in 
which the rural health care provider seeking a 
grant under this paragraph is located, shall 
submit an application to the Secretary on or be-
fore such date and in such form and manner as 
the Secretary specifies. 
‘‘(C) ADDITIONAL
REQUIREMENTS.—The 
Secretary may not award a grant under this 
paragraph to an eligible rural health care pro-
vider unless— 
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‘‘(i) local organizations or the State in 
which the hospital is located provides sup-
port (either direct or in kind); and there 
are letters of support from key State pay-
ers such as Medicaid and private insur-
ance; and 
‘‘(ii) the applicant describes in detail 
how the transition of the health care pro-
vider or providers will better meet local 
needs and be sustainable. 
‘‘(D) ELIGIBLE RURAL HEALTH CARE PRO-
VIDER DEFINED.—For purposes of this para-
graph, the term ‘eligible rural health care pro-
vider’ includes a critical access hospital, a cer-
tified rural health clinic, a rural nursing home, 
skilled nursing facility, emergency care pro-
vider, or other entity identified by the Sec-
retary. An eligible rural health care provider 
may include other entities applying on behalf of 
a group of providers such as a State Office of 
Rural Health, a State or local health care au-
thority, a rural health network, or other entity 
identified by the Secretary.’’. 
Æ 
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