I 
115TH CONGRESS 
1ST SESSION H. R. 4178 
To amend title XVIII of the Social Security Act to provide for reform 
to and a permanent extension of the Medicare-dependent hospital pro-
gram, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
OCTOBER 31, 2017 
Mr. ARRINGTON (for himself, Mr. GOHMERT, and Mr. CONAWAY) introduced 
the following bill; which was referred to the Committee on Ways and Means 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for reform to and a permanent extension of the Medi-
care-dependent hospital 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 ‘‘Healthcare Enhance-
ment for Americas Rural Towns Act’’ or the ‘‘HEART 
Act’’. 
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SEC. 2. REFORM AND PERMANENT EXTENSION OF THE 
MEDICARE-DEPENDENT 
HOSPITAL 
(MDH) 
PROGRAM. 
(a) EXTENSION OF PAYMENT METHODOLOGY.—Sec-
tion 1886(d)(5)(G) of the Social Security Act (42 U.S.C. 
1395ww(d)(5)(G)) is amended— 
(1) in clause (i), by striking ‘‘, and before Octo-
ber 1, 2017’’ and inserting ‘‘before October 1, 
2018’’; 
(2) in clause (i), by adding at the end the fol-
lowing; ‘‘For fiscal year 2018 and each subsequent 
fiscal year, in the case of such a subsection (d) hos-
pital, payment under paragraph (1)(A) shall be 
equal to the sum of the amount determined under 
paragraph (1)(A)(iii) and the amount determined by 
the increase factor determined under clause (v) for 
such hospital and cost reporting period.’’; 
(3) in clause (ii)(II), by striking ‘‘, and before 
October 1, 2017’’ and inserting ‘‘before October 1, 
2018’’; and 
(4) by adding at the end the following new 
clauses: 
‘‘(v) Subject to subclause (II), for 
purposes of clause (i), for fiscal year 2019 
and each subsequent fiscal year with re-
spect to a subsection (d) hospital which is 
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a medicare-dependent, small rural hospital, 
the Secretary shall determine an increase 
factor to apply to such hospital with re-
spect to discharges occurring during such 
fiscal year. When determining such in-
crease factor, the Secretary may take into 
account a methodology that results in a 
similar amount of reimbursement to such 
hospital for such fiscal year as such 
amount that would have been determined if 
the first sentence of clause (i) applied with 
respect to such fiscal year. 
‘‘(vi) The aggregate amounts deter-
mined for all subsection (d) hospitals 
which are medicare-dependent, small rural 
hospitals by application of the increase fac-
tors determined under clause (v) for such 
hospitals shall not exceed a total of— 
‘‘(I) 
for 
fiscal 
year 
2019, 
$100,000,000; and 
‘‘(II) for each subsequent fiscal 
year, the amount specified in this 
clause for the previous fiscal year in-
creased by the market basket percent-
age increase (as defined in subsection 
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(b)(3)(B)(iii)) as determined prospec-
tively by the Secretary for such subse-
quent fiscal year.’’. 
(b) CONFORMING AMENDMENTS.— 
(1) EXTENSION OF TARGET AMOUNT.—Section 
1886(b)(3)(D) of the Social Security Act (42 U.S.C. 
1395ww(b)(3)(D)) is amended— 
(A) in the matter preceding clause (i), by 
striking ‘‘, and before October 1, 2017’’; 
(B) in clause (iii), by striking at the end 
‘‘and’’; 
(C) in clause (iv)— 
(i) by striking ‘‘through fiscal year 
2017’’ and inserting ‘‘through fiscal year 
2018’’; and 
(ii) by striking the period at the end 
and inserting ‘‘, and’’; and 
(D) by adding at the end the following new 
clause: 
‘‘(v) with respect to discharges occur-
ring during fiscal year 2019 or a subse-
quent fiscal year, the target amount for 
the preceding year increased by the appli-
cable percentage increase under subpara-
graph (B)(iv) and adjusted as determined 
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necessary by the Secretary to take into ac-
count 
the 
application 
of 
subsection 
(d)(5)(G)(vi) for such fiscal year.’’. 
(2) PERMITTING HOSPITALS TO DECLINE RE-
CLASSIFICATION.—Section 13501(e)(2) of the Omni-
bus Budget Reconciliation Act of 1993 (42 U.S.C. 
1395ww note) is amended by striking ‘‘fiscal year 
2000 through fiscal year 2017’’ and inserting ‘‘a 
subsequent fiscal year’’. 
SEC. 3. TEMPORARY EXTENSION OF THE MEDICARE LOW- 
VOLUME ADJUSTMENT PROGRAM. 
Section 1886(d)(12) of the Social Security Act (42 
U.S.C. 1395ww(d)(12)) is amended— 
(1) in subparagraph (B), in the matter pre-
ceding clause (i), by striking ‘‘and for discharges oc-
curring in fiscal year 2020 and subsequent fiscal 
years’’; 
(2) in subparagraph (C)(i)— 
(A) by striking ‘‘fiscal years 2011 through 
2017’’ each place it appears and inserting ‘‘fis-
cal years 2011 through 2019’’; and 
(B) by striking ‘‘or portion of fiscal year’’; 
and 
(3) in subparagraph (D)— 
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