I 
115TH CONGRESS 
2D SESSION 
H. R. 7391 
To amend title XVIII of the Social Security Act to provide for coverage 
of rural emergency medical access services under the Medicare program, 
and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
DECEMBER 21, 2018 
Mr. ARRINGTON introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for coverage of rural emergency medical access services 
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 ‘‘Rural Hospital Free-
dom and Flexibility Act of 2018’’. 
SEC. 2. MEDICARE RURAL EMERGENCY ACCESS CENTERS 
AND SERVICES. 
(a) IN GENERAL.— 
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(1) RURAL EMERGENCY ACCESS CENTER AND 
SERVICES DEFINED.—Section 1861 of the Social Se-
curity Act (42 U.S.C. 1395x) is amended— 
(A) in subsection (e), in the last sentence 
of the matter following paragraph (9), by in-
serting ‘‘or a rural emergency access center (as 
defined in subsection (kkk)(1))’’ before the pe-
riod at the end; and 
(B) by adding at the end the following sub-
section: 
‘‘Rural Emergency Access Center; Rural Access Medical 
Center Services 
‘‘(kkk)(1) The term ‘rural emergency access center’ 
means a facility that— 
‘‘(A) was a critical access hospital as of the 
date of the enactment of this subsection; 
‘‘(B) provides 24-hour emergency medical care 
and observation care that does not exceed an annual 
per patient average of 24 hours or more than 1 mid-
night; 
‘‘(C) does not provide any acute care inpatient 
beds and has protocols in place for the timely trans-
fer of patients who require acute care inpatient serv-
ices or other inpatient services; 
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‘‘(D) provides for the transport of patients who 
require acute care inpatient services or other inpa-
tient services from the rural emergency access center 
to a hospital or critical access hospital, either by the 
rural emergency access center’s ambulance service 
provider or through another ambulance service sup-
plier; 
‘‘(E) has elected to be designated as a rural 
emergency access center; 
‘‘(F) has been licensed by, or received approval 
to operate as a qualified emergency medical center 
from, the State under paragraph (3); and 
‘‘(G) is certified by the Secretary under para-
graph (4). 
‘‘(2) The term ‘rural emergency access center serv-
ices’ means medical and other health services furnished 
by a rural emergency access center on an outpatient basis. 
‘‘(3) A facility may not operate as a rural emergency 
access center unless the facility— 
‘‘(A) is located in a State that provides for the 
licensing of emergency medical centers under State 
or applicable local law; and 
‘‘(B)(i) is licensed pursuant to such law; or 
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‘‘(ii) is approved by the agency of such State or 
locality responsible for licensing hospitals, as meet-
ing the standards established for such licensing. 
‘‘(4) The Secretary shall certify a facility as a rural 
emergency access center if the facility— 
‘‘(A) meets the criteria for rural emergency ac-
cess center described in subparagraphs (A) through 
(F) of paragraph (1); 
‘‘(B) has in effect a transfer agreement with a 
level I or level II trauma center; and 
‘‘(C) meets such staff training and certification 
requirements as the Secretary may require. 
‘‘(5) A facility certified by the Secretary as a rural 
emergency access center shall be deemed to be a critical 
access hospital for purposes of section 340B of the Public 
Health Service Act.’’. 
(2) PAYMENT FOR RURAL EMERGENCY ACCESS 
CENTER SERVICES.— 
(A) IN GENERAL.—Section 1833(a) of the 
Social Security Act (42 U.S.C. 1395l(a)) is 
amended— 
(i) in paragraph (8), by striking 
‘‘and’’ at the end; 
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(ii) in paragraph (9), by striking the 
period at the end and inserting ‘‘; and’’; 
and 
(iii) by inserting after paragraph (9) 
the following new paragraph: 
‘‘(10) in the case of rural emergency access cen-
ter services and services provided by a rural emer-
gency access center ambulance service provider or 
another ambulance service supplier to transport pa-
tients who require acute care inpatient services or 
other inpatient services from such rural emergency 
access center to a hospital or critical access hospital, 
the amounts described in section 1834(x).’’. 
(B) PAYMENT AMOUNT.—Section 1834 of 
the Social Security Act (42 U.S.C. 1395m) is 
amended by adding at the end the following 
subsection: 
‘‘(x) PAYMENT RULES RELATING TO RURAL EMER-
GENCY ACCESS CENTERS.— 
‘‘(1) PAYMENT FOR RURAL EMERGENCY ACCESS 
CENTER
OUTPATIENT
SERVICES.—The amount of 
payment for rural emergency access center services 
of a rural emergency access center is determined as 
follows: 
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‘‘(A) FACILITY FEE.—With respect to fa-
cility services (other than services for which 
payment is made under subparagraph (B)), the 
sum of the following: 
‘‘(i) OPPS RATE.—The amount of 
payment that would otherwise apply under 
section 1833(t) for covered OPD services 
(as defined in section 1833(t)(1)(B) (other 
than clause (ii) of such section)). 
‘‘(ii) ADDITIONAL
FEE.—An addi-
tional facility payment in an amount deter-
mined appropriate by the Secretary that 
takes into account the low volume of serv-
ices provided by such center and the low 
number of individuals served by such cen-
ter. 
‘‘(B) PROFESSIONAL SERVICES.—With re-
spect to professional services, the amount of 
payment that would otherwise be made under 
this 
part 
(other 
than 
under 
section 
1833(t)(21)) for such services. 
‘‘(2) PAYMENT
FOR
TRANSPORTATION
SERV-
ICES.—The payment amount for ambulance services 
provided by a rural emergency access center ambu-
lance service provider or another ambulance service 
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supplier to transport patients who require acute care 
inpatient services or other inpatient services from 
such rural emergency access center to a hospital or 
critical access hospital is equal to the sum of— 
‘‘(A) the amount that would otherwise be 
paid for such ambulance services under section 
1834(l); and 
‘‘(B) an additional amount determined ap-
propriate by the Secretary.’’. 
(b) 
CONDITIONS
OF
PARTICIPATION.—Section 
1866(a)(1) of the Social Security Act (42 U.S.C. 
1395cc(a)(1)) is amended— 
(1) in subparagraph (X), by striking at the end 
‘‘and’’; 
(2) in the subparagraph (Y), by striking at the 
end the period and inserting a comma; and 
(3) by inserting after subparagraph (Y) the fol-
lowing new subparagraph: 
‘‘(Z) in the case of a rural emergency access 
center, to meet requirements applicable to critical 
access hospitals under this title, other than— 
‘‘(i) requirements relating to a Medicare 
rural hospital flexibility program under section 
1820(c), including state designation of a facility 
as a critical access hospital and criteria for 
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Act (42 U.S.C. 1395m(m)(4)(C)(ii)) is amended by adding 
at the end the following new subclause: 
‘‘(IX) A rural emergency access 
center 
(as 
defined 
in 
section 
1861(kkk)(1)).’’. 
(d) CONFORMING AMENDMENT.—Section 1861(u) of 
the Social Security Act (42 U.S.C. 1395x(u)) is amended 
by inserting ‘‘rural emergency access center,’’ after ‘‘crit-
ical access hospital,’’. 
Æ 
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