I 
119TH CONGRESS 
1ST SESSION H. R. 6240 
To amend title XVIII of the Social Security Act to restore State authority 
to waive for certain facilities the 35-mile rule for designating critical 
access hospitals under the Medicare program, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
NOVEMBER 20, 2025 
Mr. VINDMAN (for himself, Mr. MANN, and Mr. MOYLAN) introduced the fol-
lowing bill; which was referred to the Committee on Ways and Means, 
and in addition to the Committee on Energy and Commerce, for a period 
to be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee 
concerned 
A BILL 
To amend title XVIII of the Social Security Act to restore 
State authority to waive for certain facilities the 35- 
mile rule for designating critical access hospitals 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 Closure 
Relief Act of 2025’’. 
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SEC. 2. 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 ‘‘or’’ 
at the end; 
(ii) in subclause (II), by inserting 
‘‘or’’ at the end; 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 
Rural Hospital Closure Relief Act of 
2025, and before the date that is 9 
years after the date of enactment of 
this subclause, by the State as being 
a necessary provider of health care 
services to residents in the area;’’; and 
(B) by adding at the end the following new 
subparagraphs: 
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‘‘(F) HOSPITAL
DESCRIBED.—For pur-
poses of subparagraph (B)(i)(III), a hospital 
described in this subparagraph is a hospital 
that— 
‘‘(i) is a sole community hospital (as 
defined in section 1886(d)(5)(D)(iii)), a 
medicare dependent, small rural hospital 
(as defined in section 1886(d)(5)(G)(iv)), a 
low-volume hospital that in 2021 receives a 
payment 
adjustment 
under 
section 
1886(d)(12), or a subsection (d) hospital 
(as defined in section 1886(d)(1)(B)); 
‘‘(ii) is located in a rural area, as de-
fined in section 1886(d)(2)(D), or a rural 
census tract of a metropolitan statistical 
area (as determined under the most recent 
modification of the Goldsmith Modifica-
tion, originally published in the Federal 
Register on February 27, 1992 (57 Fed. 
Reg. 6725)); 
‘‘(iii)(I) is located— 
‘‘(aa) in a county that has a per-
centage of individuals with income at 
or below the Federal poverty level in 
2023 or 2024 that is higher than the 
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national or statewide average in that 
year; or 
‘‘(bb) in a health professional 
shortage area (as defined in section 
332(a)(1)(A) of the Public Health 
Service Act); or 
‘‘(II) has a percentage of inpatient 
days of individuals entitled to benefits 
under part A of this title in 2023 or 2024 
that is higher than the national or state-
wide average in that year; 
‘‘(iv) has attested to the Secretary 
that the hospital— 
‘‘(I) was operating as of the date 
of enactment of this subparagraph; 
and 
‘‘(II) had 2 consecutive years of 
negative operating margins preceding 
the date of certification described in 
subparagraph (B)(i)(III), as defined 
by the Secretary in the regulations or 
program instruction issued pursuant 
to section 2(b) of the Rural Hospital 
Closure Relief Act of 2025; and 
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‘‘(v) submits to the Secretary, at such 
time and in such manner as the Secretary 
may require, an application for certifi-
cation of the facility as a critical access 
hospital, including an attestation out-
lining— 
‘‘(I) the good governance quali-
fications and strategic plan for multi- 
year financial solvency of the hospital; 
and 
‘‘(II) the hospital’s commitment 
to open and maintain, for the dura-
tion of the hospital’s designation as a 
critical access hospital under this sec-
tion, a new service line or expanded 
service capacity for a service that is in 
high demand or limited supply in the 
hospital’s service area (determined 
based on the hospital’s most recent 
community health needs assessment 
under section 501(r)(3) of the Inter-
nal Revenue Code of 1986 (or other 
comparable assessment)), such as ob-
stetrics or behavioral health care serv-
ices. 
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‘‘(G) LIMITATION ON CERTAIN DESIGNA-
TIONS.— 
‘‘(i) IN GENERAL.—Subject to clauses 
(ii) and (iii), the Secretary may not under 
subsection (e) certify pursuant to a certifi-
cation by a State under subparagraph 
(B)(i)(III)— 
‘‘(I) more than a total of 120 fa-
cilities as critical access hospitals; and 
‘‘(II) within any one State, more 
than 5 facilities as critical access hos-
pitals. 
‘‘(ii) PROCESS.—The Secretary shall 
follow the following process in carrying out 
clause (i) with respect to each year in 
which the Secretary determines that the 
limitation under clause (i)(I) has not been 
reached: 
‘‘(I) INITIAL ASSESSMENT.—The 
Secretary shall conduct an initial as-
sessment of the total number of hos-
pitals described in paragraph (2)(F). 
‘‘(II) INITIAL
ALLOCATION.—Of 
the total number of designations avail-
able under clause (i), the Secretary 
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shall allocate 1 for a hospital in each 
State that the Secretary determines 
(based on the initial assessment under 
subclause (I)) has one or more hos-
pitals described in paragraph (2)(F). 
‘‘(III) 
REMAINING
ALLOCA-
TION.—Of the total number of des-
ignations available under clause (i), 
after application of subclause (II), the 
Secretary shall allocate the remaining 
number on a proportional basis based 
on the total number of hospitals de-
scribed in paragraph (2)(F) in each 
State that are eligible (as determined 
based on the initial assessment under 
subclause (I)). 
‘‘(iii) SUNSET.—Effective beginning 
on the date that is 9 years after the date 
of enactment of this subparagraph, the 
Secretary may not certify a hospital as a 
critical access hospital pursuant to a cer-
tification by a State under subparagraph 
(B)(i)(III). 
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‘‘(H) INFORMATION SUBMISSION REQUIRE-
MENTS FOR HOSPITALS CERTIFIED PURSUANT 
TO RURAL HOSPITAL CLOSURE RELIEF ACT.— 
‘‘(i) IN GENERAL.—A critical access 
hospital that is certified under subsection 
(e) pursuant to a certification by a State 
under subparagraph (B)(i)(III) shall sub-
mit to the Secretary the following at a 
time, and in a manner, specified by the 
Secretary: 
‘‘(I) 
REPORTS.—Reports 
con-
taining such information as the Sec-
retary may specify with respect to 
items and services furnished as part 
of the new service line or expanded 
service capacity for a service as de-
scribed in the attestation submitted 
by the critical access hospital under 
subparagraph (F)(v)(II). To the ex-
tent practicable, the Secretary shall 
align such reporting with other report-
ing requirements applicable to critical 
access hospitals under this subsection. 
‘‘(II) NOTICE.—If the critical ac-
cess hospital materially changes the 
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new service line or expanded capacity 
for a service as so described, notice of 
such changes along with a plan to sat-
isfactorily maintain access to care (as 
determined by the Secretary). 
‘‘(ii) REVOCATION OF CERTIFICATION 
FOR
NONCOMPLIANCE.—If the Secretary 
determines that a critical access hospital 
described in clause (i) has failed to submit 
an annual report required under subclause 
(I) of such clause or a notice required 
under subclause (II) of such clause, the 
Secretary may, as the Secretary deter-
mines appropriate, revoke the certification 
of the critical access hospital under sub-
section (e).’’; and 
(2) in subsection (e), by inserting ‘‘, subject to 
subsection (c)(2)(G),’’ after ‘‘The Secretary shall’’. 
(b) IMPLEMENTATION.—Not later than 1 year after 
the date of the enactment of this Act, the Secretary of 
Health and Human Services shall issue final regulations 
or program instruction to carry out subsection (a). 
I CLARIFICATION REGARDING FACILITIES THAT 
MEET DISTANCE OR OTHER CRITERIA AND APPLICATION 
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OF OTHER CRITERIA.—Nothing in this section shall af-
fect— 
(1) the application of criteria for designation as 
a critical access hospital described in subclause (I) 
or (II) of section 1820(c)(2)(B)(i) of the Social Se-
curity Act (42 U.S.C. 1395i–4(c)(2)(B)(i)); or 
(2) the application of criteria for designation as 
a critical access hospital described in clauses (ii) 
through (v) of section 1820(c)(2)(B) of the Social 
Security Act (42 U.S.C. 1395i–4(c)(2)(B)). 
(d) GAO STUDY AND REPORT.— 
(1) STUDY.—The Comptroller General of the 
United States (in this section referred to as the 
‘‘Comptroller General’’) shall conduct a study on the 
implementation of the amendments made by sub-
section (a). To the extent such data are available 
and reliable, such study shall include— 
(A) an analysis of— 
(i) the characteristics of facilities des-
ignated as critical access hospitals pursu-
ant to section 1820(c)(2)(B)(i)(III) of the 
Social Security Act, as added by subsection 
(a); 
(ii) an analysis of the financial status 
and outlook for such facilities based on 
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their designation as a critical access hos-
pital pursuant to such section; and 
(iii) an analysis of any increase in ex-
penditures under the Medicare program 
under title XVIII of the Social Security 
Act (42 U.S.C. 1395 et seq.) as a result of 
such designation, relative to the expected 
baseline expenditures under the Medicare 
program if such facilities had not received 
such designation; and 
(B) an assessment of whether the author-
ity to designate facilities as critical access hos-
pitals 
pursuant 
to 
such 
section 
1820(c)(2)(B)(i)(III) promotes access to care in 
rural areas. 
(2) REPORT.—Not later than 6 years after the 
date of the enactment of this Act, the Comptroller 
General shall submit to Congress a report containing 
the results of the study conducted under subsection 
(a), together with recommendations for such legisla-
tion and administrative action as the Comptroller 
General determines appropriate. 
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SEC. 3. MEDPAC STUDY AND REPORT ON PAYMENT SYS-
TEMS FOR RURAL HOSPITALS. 
(a) STUDY.—The Medicare Payment Advisory Com-
mission (in this section referred to as the ‘‘Commission’’) 
shall conduct a study, using data from 2018 through 
2028, on payment systems for rural hospitals under the 
Medicare program under title XVIII of the Social Security 
Act (42 U.S.C. 1395 et seq.). Such study shall include 
an analysis of— 
(1) facilities designated as critical access hos-
pitals pursuant to section 1820(c)(2)(B)(i)(III) of 
the Social Security Act, as added by section 2(a); 
(2) features of payment systems for rural hos-
pitals, including value-based payment systems, that 
would— 
(A) ensure financial sustainability for the 
Medicare program; and 
(B) preserve access to care for Medicare 
beneficiaries; and 
(3) if the Commission recommends any new 
payment system for rural hospitals under the Medi-
care program, to the extent feasible, the impacts of 
transition from existing payment systems to such 
new payment system. 
(b) REPORT.—Not later than 8 years after the date 
of enactment of this Act, the Commission shall submit to 
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Congress a report on the study conducted under sub-
section (a), together with recommendations for such legis-
lation and administrative action as the Commission deter-
mines appropriate. 
I DEFINITION OF RURAL HOSPITAL.—In this sec-
tion, the term ‘‘rural hospital’’ means— 
(1) a critical access hospital (as defined in sec-
tion 1861(mm)(1) of the Social Security Act (42 
U.S.C. 1395x(mm)(1))); 
(2) a subsection (d) hospital (as defined in sec-
tion 1886(d)(1)(B) of the Social Security Act (42 
U.S.C. 1395ww(d)(1)(B))) that is located in a rural 
census tract of a metropolitan statistical area (as de-
termined under the most recent modification of the 
Goldsmith Modification, originally published in the 
Federal Register on February 27, 1992 (57 Fed. 
Reg. 6725)); 
(3) a sole community hospital (as defined in 
section 1886(d)(5)(D)(iii)) of the Social Security Act 
(42 U.S.C. 1395ww(d)(5)(D)(iii))); 
(4) a medicare dependent, small rural hospital 
(as defined in section 1886(d)(5)(G)(iv) of the Social 
Security Act (42 U.S.C. 1395ww(d)(5)(G)(iv))); and 
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(5) a low-volume hospital (as defined in section 
1886(d)(12)(C)(i) of the Social Security Act (42 
U.S.C. 1395ww(d)(12)(C)(i))). 
SEC. 4. ADJUSTING MEDICARE CRITCAL ACCESS HOSPITAL 
REQUIREMENTS 
FOR 
GUAM, 
AMERICAN 
SAMOA, THE NORTHERN MARIANA ISLANDS, 
AND THE VIRGIN ISLANDS. 
(a) IN GENERAL.—Section 1820(c)(2)(B)(iii) of the 
Social Security Act (42 U.S.S. 1395i–4I(2)(B)(iii)) is 
amended to read as follows: 
‘‘(iii) provides— 
‘‘(I) in the case of a facility lo-
cated in 1 of the 50 States, the Dis-
trict of Columbia, or Puerto Rico, not 
more than 25 acute care inpatient 
beds (meeting such standards as the 
Secretary may establish) for providing 
inpatient care for a period that does 
not exceed, as determined on an an-
nual, average basis, 96 hours per pa-
tient; or 
‘‘(II) in the case of a facility lo-
cated in Guam, American Samoa, the 
Northern Mariana Islands, or the 
United States Virgin Islands, acute 
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care inpatient beds in a number deter-
mined appropriate by the Secretary 
(meeting, such standards as the Sec-
retary may establish) for providing in-
patient car for a period that does not 
exceed, as determined on an annual, 
average basis, 96 hours per patient.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
this section shall apply beginning October 1, 2025. 
SEC. 5. SUNSET. 
Not later than 9 years after the date of enactment 
of this Act, the Secretary shall establish a mechanism and 
provide guidance and technical assistance under which any 
facility that was designated as a critical access hospital 
pursuant to a certification by a State under section 
1820(c)(2)(B)(i)(III) of the Social Security Act, as added 
by section 2(a), may transition within 1 year to one of 
the following payment models: 
(1) Such new model or models recommended by 
the Medicare Payment Advisory Commission in the 
report submitted under section 3. 
(2) The prospective payment model (or models) 
under which the facility received payment under title 
XVIII of the Social Security Act (42 U.S.C. 1395 et 
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seq.) prior to being designated pursuant to such 
certifcation. 
(3) Payment as a rural emergency hospital 
under section 1834(x) of the Social Security Act (42 
U.S.C. 1395m(x)). 
Æ 
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