I 
118TH CONGRESS 
1ST SESSION 
H. R. 833 
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 
FEBRUARY 6, 2023 
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 permanently payment levels for low-volume hospitals and 
Medicare-dependent 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. Restoring State authority to waive the 35-mile rule for certain Medi-
care critical access hospital designations. 
Sec. 115. CMI testing of new rural hospital delivery and payment model. 
TITLE II—RURAL MEDICARE BENEFICIARY EQUITY 
Sec. 201. Equalizing beneficiary copayments for services furnished by CAHs. 
Sec. 202. Removing supervision of certified registered nurse anesthetists. 
Sec. 203. CRNA services as a Medicaid-required benefit. 
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-
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pendent, small rural hospital (as defined in sec-
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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SEC. 103. EXTENDING PERMANENTLY PAYMENT LEVELS 
FOR LOW-VOLUME HOSPITALS AND MEDI-
CARE-DEPENDENT HOSPITALS (MDHS). 
(a) EXTENSION
OF INCREASED PAYMENTS
FOR 
MDHS.— 
(1) EXTENSION OF PAYMENT METHODOLOGY.— 
Section 1886(d)(5)(G) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(G)) is amended— 
(A) in clause (i), by striking ‘‘, and before 
October 1, 2024’’; and 
(B) in clause (ii)(II), by striking ‘‘, and be-
fore October 1, 2024’’. 
(2) CONFORMING AMENDMENTS.— 
(A) EXTENSION
OF
TARGET
AMOUNT.— 
Section 1886(b)(3)(D) of the Social Security 
Act (42 U.S.C. 1395ww(b)(3)(D)) is amend-
ed— 
(i) in the matter preceding clause (i), 
by striking ‘‘, and before October 1, 
2024’’; and 
(ii) 
in 
clause 
(iv), 
by 
striking 
‘‘through fiscal year 2024’’ and inserting 
‘‘or a subsequent fiscal year’’. 
(B) EXTENDING
THE
PERIOD
DURING 
WHICH
HOSPITALS
CAN
DECLINE
RECLASSI-
FICATION AS URBAN.—Section 13501(e)(2) of 
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the Omnibus Budget Reconciliation Act of 1993 
(42 U.S.C. 1395ww note) is amended by strik-
ing ‘‘fiscal year 2000 through fiscal year 2024’’ 
and inserting ‘‘a subsequent fiscal year’’. 
(b) EXTENSION OF INCREASED PAYMENTS FOR LOW- 
VOLUME HOSPITALS.—Section 1886(d)(12) of the Social 
Security Act (42 U.S.C. 1395ww(d)(12)) is amended— 
(1) in subparagraph (B)— 
(A) in the header, by inserting ‘‘for fiscal 
years 2005 through 2010’’ after ‘‘increase’’; 
and 
(B) in the matter preceding clause (i), by 
striking ‘‘and for discharges occurring in fiscal 
year 2025 and subsequent fiscal years’’; 
(2) in subparagraph (C)(i)— 
(A) in the matter preceding subclause (I), 
by striking ‘‘through 2024’’ and inserting ‘‘and 
each subsequent fiscal year’’; 
(B) in subclause (II), by adding at the end 
‘‘and’’; 
(C) in subclause (III)— 
(i) by striking ‘‘fiscal years 2019 
through 2024’’ and inserting ‘‘fiscal year 
2019 and each subsequent fiscal year’’; 
and 
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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: ‘‘PERMANENT
APPLICABLE
PERCENT-
AGE INCREASE’’; 
(B) in the matter preceding clause (i), by 
striking ‘‘in fiscal years 2011 through 2024’’ 
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 2024’’ 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 2022’’ 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 2022’’ 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, 2023,’’ after ‘‘January 
1, 2013,’’; and 
(B) in the second sentence, by inserting ‘‘, 
and during or after 2023’’ after ‘‘or 2012’’; and 
(3) in subclause (III), in the first sentence, by 
inserting ‘‘and on or after January 1, 2023,’’ 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, 2025’’; and 
(B) in clause (i), by striking ‘‘, and before 
January 1, 2025’’. 
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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SEC. 114. RESTORING STATE AUTHORITY TO WAIVE THE 35- 
MILE RULE FOR CERTAIN MEDICARE CRIT-
ICAL ACCESS HOSPITAL DESIGNATIONS. 
(a) IN GENERAL.—Section 1820 of the Social Secu-
rity Act (42 U.S.C. 1395i–4) is amended— 
(1) in subsection (c)(2)— 
(A) in subparagraph (B)(i)— 
(i) in subclause (I), by striking at the 
end ‘‘or’’; 
(ii) in subclause (II), by inserting at 
the end ‘‘or’’; and 
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(III) subject to subparagraph 
(G), is a hospital described in sub-
paragraph (F) and is certified on or 
after the date of the enactment of the 
Save America’s Rural Hospitals Act 
by the State as being a necessary pro-
vider of health care services to resi-
dents in the area;’’; and 
(B) by adding at the end the following new 
subparagraphs: 
‘‘(F) HOSPITAL
DESCRIBED.—For pur-
poses of subparagraph (B)(i)(III), a hospital 
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