I 
119TH CONGRESS 
1ST SESSION H. R. 3684 
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 
JUNE 3, 2025 
Mr. GRAVES (for himself and Ms. BUDZINSKI) introduced the following bill; 
which was referred to the Committee on Ways and Means, and in addi-
tion to the Committees on Energy and Commerce, 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 jurisdiction of the com-
mittee 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: 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
(1) More than 60,000,000 individuals in rural 
areas of the United States rely on rural hospitals 
and other providers as critical access points to 
health care. 
(2) Access to health care is essential to commu-
nities that Americans living in rural areas call home. 
(3) Americans living in rural areas are older, 
poorer, and sicker than Americans living in urban 
areas. 
(4) As of May 1, 2025, 151 rural hospitals have 
closed in the United States, according to the Univer-
sity of North Carolina’s Cecil G. Sheps Center for 
Health Services Research, and the rate of these clo-
sures is increasing. 
(5) Four hundred and thirty-two hospitals are 
operating at margins similar to those that have 
closed over the past decade. Of those, 216 are con-
sidered most vulnerable to closure. 
(6) Rural Medicare beneficiaries already face a 
number of challenges when trying to access health 
care services close to home, including the weather, 
geography, and cultural, social, and language bar-
riers. 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
(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 432 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. Permanently extending payment levels for low-volume hospitals and 
Medicare-dependent hospitals (MDHs). 
Sec. 104. Extending disproportionate share payments for sole community hos-
pitals and medicare-dependent hospitals. 
Sec. 105. Rebasing target amounts for Medicare-dependent hospitals and sole 
community hospitals. 
Sec. 106. Implementing area wage index adjustments. 
Subtitle B—Other Rural Providers 
Sec. 111. Making permanent increased Medicare payments for ground ambu-
lance services in rural areas. 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6211
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
Sec. 112. Permanently extending Medicare telehealth service enhancements for 
federally qualified health centers and rural health clinics. 
Sec. 113. Restoring State authority to waive the 35-mile rule for certain Medi-
care critical access hospital designations. 
TITLE II—RURAL MEDICARE BENEFICIARY EQUITY 
Sec. 201. Equalizing beneficiary copayments for services furnished by CAHs. 
TITLE III—REGULATORY RELIEF 
Sec. 301. Eliminating 96-hour requirements with respect to inpatient CAH 
services. 
Sec. 302. Eliminating hospitalization requirement for extended care services 
furnished by certain hospitals. 
TITLE IV—FUTURE OF RURAL HEALTH CARE 
Sec. 401. Medicare rural hospital flexibility program grants. 
TITLE I—RURAL PROVIDER 
PAYMENT STABILIZATION 
Subtitle A—Rural Hospitals 
SEC. 101. ELIMINATING MEDICARE SEQUESTRATION FOR 
RURAL HOSPITALS. 
(a) IN GENERAL.—Section 256(d)(7) of the Balanced 
Budget and Emergency Deficit Control Act of 1985 (2 
U.S.C. 906(d)(7)) is amended by adding at the end the 
following: 
‘‘(D) 
RURAL
HOSPITALS.—Payments 
under part A or part B of title XVIII of the So-
cial Security Act with respect to items and serv-
ices furnished by a critical access hospital (as 
defined in section 1861(mm)(1) of such Act), a 
sole community hospital (as defined in section 
1886(d)(5)(D)(iii) of such Act), a medicare-de-
pendent, small rural hospital (as defined in sec-
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
tion 1886(d)(5)(G)(iv) of such Act), or a sub-
section (d) hospital (as defined in section 
1886(d)(1)(B) of such Act) 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 at the end the fol-
lowing: ‘‘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 ‘‘, a critical access hospital’’ after ‘‘or (V)’’. 
(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. 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
SEC. 103. PERMANENTLY EXTENDING PAYMENT LEVELS 
FOR LOW-VOLUME HOSPITALS AND MEDI-
CARE-DEPENDENT HOSPITALS (MDHS). 
(a) EXTENSION
OF INCREASED PAYMENTS
FOR 
MDHS.— 
(1) EXTENSION OF PAYMENT METHODOLOGY.— 
Section 1886(d)(5)(G) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(G)) is amended— 
(A) in clause (i), by striking ‘‘, and before 
October 1, 2025’’; and 
(B) in clause (ii)(II), by striking ‘‘, and be-
fore October 1, 2025’’. 
(2) CONFORMING AMENDMENTS.— 
(A) EXTENSION
OF
TARGET
AMOUNT.— 
Section 1886(b)(3)(D) of the Social Security 
Act (42 U.S.C. 1395ww(b)(3)(D)) is amend-
ed— 
(i) in the matter preceding clause (i), 
by striking ‘‘, and before October 1, 
2025’’; and 
(ii) 
in 
clause 
(iv), 
by 
striking 
‘‘through fiscal year 2025’’ and inserting 
‘‘or a subsequent fiscal year’’. 
(B) EXTENDING
THE
PERIOD
DURING 
WHICH
HOSPITALS
CAN
DECLINE
RECLASSI-
FICATION AS URBAN.—Section 13501(e)(2) of 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
(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 2025’’ 
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 2025’’ and inserting 
‘‘fiscal year 2019 and each subsequent fiscal 
year’’. 
SEC. 104. EXTENDING DISPROPORTIONATE SHARE PAY-
MENTS FOR SOLE COMMUNITY HOSPITALS 
AND MEDICARE-DEPENDENT HOSPITALS. 
Section 1886 of the Social Security Act (42 U.S.C. 
1395ww) is amended— 
(1) in subsection (d)(5)(F)(i), by inserting ‘‘, 
including, with respect to discharges occurring in fis-
cal year 2026 and each subsequent fiscal year, a 
subsection (d) hospitals that is a sole community 
hospitals paid the amount described in subparagraph 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
(D)(i)(I) or a medicare-dependent, small rural hos-
pital paid the amount described in subparagraph 
(G),’’ after ‘‘subsection (d) hospital’’; and 
(2) in subsection (r)(2), by inserting ‘‘(includ-
ing, with respect to fiscal year 2026 and each subse-
quent fiscal year, subsection (d) hospitals that are 
sole community hospitals or medicare-dependent, 
small 
rural 
hospitals 
described 
in 
subsection 
(d)(5)(F)(i))’’ after ‘‘such subsection (d) hospitals’’. 
SEC. 105. REBASING TARGET AMOUNTS FOR MEDICARE-DE-
PENDENT HOSPITALS AND SOLE COMMUNITY 
HOSPITALS. 
Section 1886(b)(3) of the Social Security Act (42 
U.S.C. 1395ww(b)(3)) is amended— 
(1) in subparagraph (K)(i)— 
(A) in subclause (I), by inserting ‘‘(or, 
with respect to discharges occurring on or after 
October 1, 2025, the 12-month cost reporting 
period beginning during fiscal year 2024)’’ after 
‘‘fiscal year 2002’’; and 
(B) in subclause (II), by inserting ‘‘(or, 
with respect to discharges occurring on or after 
October 1, 2025, the first cost reporting period 
beginning on or after such date)’’ after ‘‘Octo-
ber 1, 2006’’; and 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
(2) in subparagraph (L)(ii)— 
(A) in subclause (I), by inserting ‘‘(or, 
with respect to discharges occurring on or after 
October 1, 2025, the 12-month cost reporting 
period beginning during fiscal year 2024)’’ after 
‘‘fiscal year 2006’’; and 
(B) in subclause (II), by inserting ‘‘(or, 
with respect to discharges occurring on or after 
October 1, 2025, the first cost reporting period 
beginning on or after such date)’’ after ‘‘Janu-
ary 1, 2009’’. 
SEC. 106. IMPLEMENTING AREA WAGE INDEX ADJUST-
MENTS. 
(a) CODIFICATION OF LOW-WAGE INDEX HOSPITAL 
POLICY.—Section 1886(d)(3)(E) of the Social Security 
Act (42 U.S.C. 1395ww(d)(3)(E)) is amended by adding 
at the end the following new clause: 
‘‘(v) LOW-WAGE
HOSPITALS.—For dis-
charges occurring on or after October 1, 2025, 
the area wage index applicable under this sub-
paragraph for a fiscal year to a hospital with an 
area wage index below the 25th percentile area 
wage index shall be increased by 1⁄2 of the dif-
ference between the otherwise applicable final 
area wage index for such fiscal year for such 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
hospital and the 25th percentile area wage 
index for such fiscal year across all hospitals. 
Pursuant to the fourth sentence of clause (i), 
the preceding sentence shall be applied in a 
budget neutral manner.’’. 
(b) AREA WAGE ADJUSTMENT FOR HOSPITALS NOT 
LOCATED IN FRONTIER STATES.— 
(1) HOSPITAL
INPATIENT
SERVICES.—Section 
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 
1395ww(d)(3)(E)), as amended by subsection (a), is 
further amended by adding at the end the following 
new clause: 
‘‘(vi) FLOOR ON AREA WAGE INDEX FOR 
HOSPITALS IN CERTAIN OTHER AREAS.— 
‘‘(I) IN
GENERAL.—For discharges 
occurring on or after October 1, 2025, the 
area wage index applicable under this sub-
paragraph to any hospital which is not lo-
cated in a frontier State (as defined in 
clause (iii)(II)) may not be less than 0.85. 
‘‘(II) 
ENSURING
BUDGET
NEU-
TRALITY.—In order to ensure that the ag-
gregate payments made under this sub-
section for a fiscal year (beginning with 
fiscal year 2026) are not greater than the 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
aggregate payments that would have been 
made under this subsection for such fiscal 
year without the application of subclause 
(I), as estimated by the Secretary, the Sec-
retary shall establish pursuant to rule-
making a maximum area wage index to 
apply under this subparagraph to any hos-
pital which is not located in a frontier 
State (as defined in clause (iii)(II)). 
‘‘(III) NO
IMPACT
FOR
HOSPITALS 
WITH
AN
AREA
WAGE
INDEX
BETWEEN 
THE FLOOR AND THE MAXIMUM INDEX.— 
Subclauses (I) and (II) shall have no effect 
on the area wage index applicable in a fis-
cal year to a hospital with an area wage 
index that is greater than the floor under 
subclause (I) but less than the maximum 
area wage index established under sub-
clause (II) for the fiscal year.’’. 
(2) 
HOSPITAL
OUTPATIENT
DEPARTMENT 
SERVICES.—Section 1833(t) of the Social Security 
Act (42 U.S.C. 1395l(t)), is amended— 
(A) in paragraph (2)(D), by striking 
‘‘paragraph (19)’’ and inserting ‘‘paragraphs 
(19) and (23)’’; and 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
(B) by adding at the end the following new 
paragraph: 
‘‘(23) FLOOR
ON
AREA
WAGE
ADJUSTMENT 
FACTOR FOR HOSPITAL OUTPATIENT DEPARTMENT 
SERVICES
IN
AREAS
OTHER
THAN
IN
FRONTIER 
STATES.— 
‘‘(A) IN GENERAL.—With respect to cov-
ered OPD services furnished on or after Janu-
ary 1, 2026, the area wage adjustment factor 
applicable under the payment system estab-
lished under this subsection to any hospital out-
patient department which is not located in a 
frontier 
State 
(as 
defined 
in 
section 
1886(d)(3)(E)(iii)(II)) may not be less than 
0.85. 
‘‘(B) ENSURING BUDGET NEUTRALITY.— 
In order to ensure that the aggregate payments 
made under this subsection for a year (begin-
ning with 2026) are not greater than the aggre-
gate payments that would have been made 
under this subsection for such year without the 
application of subparagraph (A), as estimated 
by the Secretary, the Secretary shall establish 
pursuant to rulemaking a maximum area wage 
adjustment factor to apply under the payment 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
system established under this subsection to any 
hospital outpatient department which is not lo-
cated in a frontier State (as defined in clause 
(iii)(II)). 
‘‘(C) NO IMPACT FOR HOSPITALS WITH AN 
AREA
WAGE
ADJUSTMENT
FACTOR
BETWEEN 
THE FLOOR AND THE MAXIMUM FACTOR.—Sub-
paragraphs (A) and (B) shall have no effect on 
the area wage adjustment factor applicable in a 
year to a hospital with an area wage adjust-
ment factor that is greater than the floor under 
subparagraph (A) but less than the maximum 
area wage adjustment factor established under 
subparagraph (B) for the year.’’. 
(c) 
CONFORMING
AMENDMENTS.—Section 
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 
1395ww(d)(3)(E)), as amended by subsections (a) and 
(b), is further amended— 
(1) in clause (i), by striking ‘‘or (iv)’’ and in-
serting ‘‘(iv), (v), or (vi)’’; 
(2) in clause (iii), by adjusting the margins of 
such clause 2 ems to the left; and 
(3) in clause (iv), by adjusting the margins of 
such clause 2 ems to the left. 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
Subtitle B—Other Rural Providers 
SEC. 111. MAKING PERMANENT INCREASED MEDICARE 
PAYMENTS FOR GROUND AMBULANCE SERV-
ICES IN RURAL AREAS. 
Section 1834(l)(13) of the Social Security Act (42 
U.S.C. 1395m(l)(13)) is amended— 
(1) in the paragraph heading, by striking 
‘‘TEMPORARY
INCREASE’’ and inserting ‘‘IN-
CREASE’’; and 
(2) in subparagraph (A)— 
(A) in the matter preceding clause (i), by 
striking ‘‘, and before October 1, 2025’’; and 
(B) in clause (i), by striking ‘‘, and before 
October 1, 2025’’. 
SEC. 112. PERMANENTLY EXTENDING MEDICARE TELE-
HEALTH SERVICE ENHANCEMENTS FOR FED-
ERALLY QUALIFIED HEALTH CENTERS AND 
RURAL HEALTH CLINICS. 
Section 1834(m)(8) of the Social Security Act (42 
U.S.C. 1395m(m)(8)) is amended— 
(1) in subparagraph (A)— 
(A) in the matter preceding clause (i), by 
striking ‘‘During the emergency period de-
scribed in section 1135(g)(1)(B) and, in the 
case that such emergency period ends before 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
December 31, 2024, during the period begin-
ning on the first day after the end of such 
emergency period and ending on September 30, 
2025’’ and inserting ‘‘Beginning on the first 
day of the emergency period described in sec-
tion 1135(g)(1)(B)’’; and 
(B) in clause (ii), by striking ‘‘determined 
under subparagraph (B)’’ and inserting ‘‘, for 
services furnished during the period beginning 
on the first day of the emergency period de-
scribed in section 1135(g)(1)(B) and ending on 
the date that is 60 days after the date of the 
enactment of the Save America’s Rural Hos-
pitals Act, determined under subparagraph (B) 
and, for services furnished after such period, an 
amount equal to the amount that such center or 
clinic would have been paid under this title had 
such services been furnished without the use of 
a telecommunications system’’; and 
(2) in subparagraph (B)— 
(A) by striking ‘‘PAYMENT RULE’’ and all 
that follows through ‘‘The Secretary shall’’ and 
inserting ‘‘PAYMENT
RULE.—The Secretary 
shall’’; 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
(B) by striking ‘‘during the periods for 
which subparagraph (A) applies’’ and inserting 
‘‘during the period described in subparagraph 
(A)(ii)’’; and 
(C) by redesignating clause (ii) as subpara-
graph (C), and adjusting the margin accord-
ingly. 
SEC. 113. RESTORING STATE AUTHORITY TO WAIVE THE 35- 
MILE RULE FOR CERTAIN MEDICARE CRIT-
ICAL ACCESS HOSPITAL DESIGNATIONS. 
(a) IN GENERAL.—Section 1820 of the Social Secu-
rity Act (42 U.S.C. 1395i–4) is amended— 
(1) in subsection (c)(2)— 
(A) in subparagraph (B)(i)— 
(i) in subclause (I), by striking at the 
end ‘‘or’’; 
(ii) in subclause (II), by inserting at 
the end ‘‘or’’; and 
(iii) by adding at the end the fol-
lowing new subclause: 
‘‘(III) subject to subparagraph 
(G), is a hospital described in sub-
paragraph (F) and is certified on or 
after the date of the enactment of the 
Save America’s Rural Hospitals Act 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
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 
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), a subsection (d) hospital (as 
defined in section 1886(d)(1)(B)) that has 
fewer than 50 beds, or, subject to the limi-
tation under subparagraph (G)(i)(I), is a 
facility described in subparagraph (G)(ii); 
‘‘(ii) is located in a rural area, as de-
fined in section 1886(d)(2)(D); 
‘‘(iii)(I) is located— 
‘‘(aa) in a county that has a per-
centage of individuals with income 
VerDate Sep 11 2014 
00:14 Jun 08, 2025
Jkt 059200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB
that is below 150 percent of the pov-
erty line that is higher than the na-
tional or statewide average in 2020; 
or 
‘‘(bb) in a health professional 
shortage area (as defined in section 
332(a)(1)(A) of the Public Health 
Service Act); or 
‘‘(II) has a percentage of inpatient 
days of individuals entitled to benefits 
under part A of this title, enrolled under 
part B of this title, or enrolled under a 
State plan under title XIX that is higher 
than the national or statewide average in 
2019 or 2020; 
‘‘(iv) 
subject 
to 
subparagraph 
(G)(ii)(II), has attested to the Secretary 2 
consecutive years of negative operating 
margins preceding the date of certification 
described in subparagraph (B)(i)(III); and 
‘‘(v) submits to the Secretary— 
‘‘(I) at such time and in such 
manner as the Secretary may require, 
an attestation outlining the good gov-
ernance qualifications and strategic 
VerDate Sep 11 2014 
02:29 Jun 04, 2025
Jkt 059200
PO 00000
Frm 00019
Fmt 6652
Sfmt 6201
E:\BILLS\H3684.IH
H3684
kjohnson on DSK7ZCZBW3PROD with $$_JOB