I
103D CONGRESS
1ST SESSION
H. R. 536
To amend title XVIII of the Social Security Act to extend and revise programs
to assist rural hospitals under part A of the medicare program.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 21, 1993
Mr. ROBERTS introduced the following bill; which was referred jointly to the
Committees on Ways and Means and Energy and Commerce
A BILL
To amend title XVIII of the Social Security Act to extend
and revise programs to assist rural hospitals under part
A of the medicare program.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; REFERENCES IN ACT.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Medicare Rural Hospital Amendments of 1993’’.
(b) REFERENCES IN ACT.—Except as otherwise spe-
cifically provided, whenever in this Act, an amendment is
expressed in terms of an amendment to or repeal of a sec-
tion or other provision, the reference shall be considered
to be made to that section or other provision of the Social
Security Act.
SEC. 2. ESSENTIAL ACCESS COMMUNITY HOSPITAL (EACH)
AMENDMENTS.
(a) 
INCREASING
NUMBER
OF
PARTICIPATING
STATES.—Section 1820(a)(1) (42 U.S.C. 1395i–4(a)(1))
is amended by striking ‘‘7’’ and inserting ‘‘9’’.
(b) TREATMENT OF INPATIENT HOSPITAL SERVICES
PROVIDED IN RURAL PRIMARY CARE HOSPITALS.—
(1) IN
GENERAL.—Section 1820(f)(1)(F) (42
U.S.C. 1395i–4(f)(1)(F)) is amended to read as fol-
lows:
‘‘(F) subject to paragraph (4), provides not
more than 6 inpatient beds (meeting such con-
ditions as the Secretary may establish) for pro-
viding inpatient care to patients requiring sta-
bilization before discharge or transfer to a hos-
pital, except that the facility may not provide
any inpatient hospital services—
‘‘(i) to any patient whose attending
physician does not certify that the patient
may reasonably be expected to be dis-
charged or transferred to a hospital within
72 hours of admission to the facility; or
‘‘(ii) consisting of surgery or any
other service requiring the use of general
anesthesia (other than surgical procedures
specified by the Secretary under section
1833(i)(1)(A)), unless the attending physi-
cian certifies that the risk associated with
transferring the patient to a hospital for
such services outweighs the benefits of
transferring the patient to a hospital for
such services.’’.
(2) LIMITATION
ON
AVERAGE
LENGTH
OF
STAY.—Section 1820(f) (42 U.S.C. 1395i–4(f)) is
amended by adding at the end the following new
paragraph:
‘‘(4) LIMITATION ON AVERAGE LENGTH OF IN-
PATIENT STAYS.—The Secretary may terminate a
designation of a rural primary care hospital under
paragraph (1) if the Secretary finds that the average
length of stay for inpatients at the facility during
the previous year in which the designation was in ef-
fect exceeded 72 hours. In determining the compli-
ance of a facility with the requirement of the pre-
vious sentence, there shall not be taken into account
periods of stay of inpatients in excess of 72 hours
to the extent such periods exceed 72 hours because
transfer to a hospital is precluded because of inclem-
ent weather or other emergency conditions.’’.
(3) 
CONFORMING
AMENDMENT.—Section
1814(a)(8) (42 U.S.C. 1395f(a)(8)) is amended by
striking ‘‘such services’’ and all that follows and in-
serting ‘‘the individual may reasonably be expected
to be discharged or transferred to a hospital within
72 hours after admission to the rural primary care
hospital.’’.
(4) GAO REPORTS.—Not later than 2 years
after the date of the enactment of this Act, the
Comptroller General shall submit reports to Con-
gress on—
(A) the application of the requirements
under section 1820(f) of the Social Security Act
(as amended by this subsection) that rural pri-
mary care hospitals provide inpatient care only
to those individuals whose attending physicians
certify may reasonably be expected to be dis-
charged within 72 hours after admission and
maintain an average length of inpatient stay
during a year that does not exceed 72 hours;
and
(B) the extent to which such requirements
have resulted in such hospitals providing inpa-
tient care beyond their capabilities or have lim-
ited the ability of such hospitals to provide
needed services.
(c) DESIGNATION OF HOSPITALS.—
(1) PERMITTING DESIGNATION OF HOSPITALS
LOCATED IN URBAN AREAS.—
(A) IN
GENERAL.—Section 1820 (42
U.S.C. 1395i–4) is amended—
(i) by striking paragraph (1) of sub-
section (e) and redesignating paragraphs
(2) through (6) as paragraphs (1) through
(5); and
(ii) in subsection (e)(1)(A) (as redes-
ignated by subparagraph (A))—
(I) by striking ‘‘is located’’ and
inserting ‘‘except in the case of a hos-
pital located in an urban area, is lo-
cated’’,
(II) by striking ‘‘, (ii)’’ and in-
serting ‘‘or (ii)’’,
(III) by striking ‘‘or (iii)’’ and all
that follows through ‘‘section,’’, and
(IV) in subsection (i)(1)(B), by
striking ‘‘paragraph (3)’’ and insert-
ing ‘‘paragraph (2)’’.
(B) NO CHANGE IN MEDICARE PROSPEC-
TIVE
PAYMENT.—Section 1886(d)(5)(D) (42
U.S.C. 1395ww(d)(5)(D)) is amended—
(i) in clause (iii)(III), by inserting ‘‘lo-
cated in a rural area and’’ after ‘‘that is’’,
and
(ii) in clause (v), by inserting ‘‘located
in a rural area and’’ after ‘‘in the case of
a hospital’’.
(2) PERMITTING HOSPITALS LOCATED IN AD-
JOINING STATES TO PARTICIPATE IN STATE PRO-
GRAM.—
(A) IN
GENERAL.—Section 1820 (42
U.S.C. 1395i–4) is amended—
(i) by redesignating subsection (k) as
subsection (l); and
(ii) by inserting after subsection (j)
the following new subsection:
‘‘(k) ELIGIBILITY OF HOSPITALS NOT LOCATED IN
PARTICIPATING
STATES.—Notwithstanding any other
provision of this section—
‘‘(1) for purposes of including a hospital or fa-
cility as a member institution of a rural health net-
work, a State may designate a hospital or facility
that is not located in the State as an essential access
community hospital or a rural primary care hospital
if the hospital or facility is located in an adjoining
State and is otherwise eligible for designation as
such a hospital;
‘‘(2) the Secretary may designate a hospital or
facility that is not located in a State receiving a
grant under subsection (a)(1) as an essential access
community hospital or a rural primary care hospital
if the hospital or facility is a member institution of
a rural health network of a State receiving a grant
under such subsection; and
‘‘(3) a hospital or facility designated pursuant
to this subsection shall be eligible to receive a grant
under subsection (a)(2).’’.
(B) CONFORMING AMENDMENTS.—(i) Sec-
tion 1820(c)(1) (42 U.S.C. 1395i–4(c)(1)) is
amended by striking ‘‘paragraph (3)’’ and in-
serting ‘‘paragraph (3) or subsection (k)’’.
(ii) Paragraphs (1)(A) and (2)(A) of sec-
tion 1820(i) (42 U.S.C. 1395i–4(i)) are each
amended—
(I) in clause (i), by striking ‘‘(a)(1)’’
and inserting ‘‘(a)(1) (except as provided
in subsection (k))’’, and
(II) in clause (ii), by striking ‘‘sub-
paragraph (B)’’ and inserting ‘‘subpara-
graph (B) or subsection (k)’’.
(d) SKILLED NURSING SERVICES IN RURAL PRIMARY
CARE HOSPITALS.—Section 1820(f)(3) (42 U.S.C. 1395i–
4(f)(3)) is amended by striking ‘‘because the facility’’ and
all that follows and inserting the following: ‘‘because, at
the time the facility applies to the State for designation
as a rural primary care hospital, there is in effect an
agreement between the facility and the Secretary under
section 1883 under which the facility’s inpatient hospital
facilities are used for the furnishing of extended care serv-
ices, except that the number of beds used for the furnish-
ing of such services may not exceed the total number of
licensed inpatient beds at the time the facility applies to
the State for such designation (minus the number of inpa-
tient beds used for providing inpatient care pursuant to
paragraph (1)(F)). For purposes of the previous sentence,
the number of beds of the facility used for the furnishing
of extended care services shall not include any beds of a
unit of the facility that is licensed as a distinct-part skilled
nursing facility at the time the facility applies to the State
for designation as a rural primary care hospital.’’.
(e) PAYMENT
FOR OUTPATIENT RURAL PRIMARY
CARE
HOSPITAL
SERVICES.—Section 1834(g)(1) (42
U.S.C. 1395m(g)(1)) is amended by adding at the end the
following:
‘‘The amount of payment shall be determined under
either method without regard to the amount of the
customary or other charge.’’.
(f) CLARIFICATION
OF PHYSICIAN STAFFING RE-
QUIREMENT FOR RURAL PRIMARY CARE HOSPITALS.—
Section 1820(f)(1)(H) (42 U.S.C. 1395i–4(f)(1)(H)) is
amended by striking the period and inserting the follow-
ing: ‘‘, except that in determining whether a facility meets
the requirements of this subparagraph, subparagraphs (E)
and (F) of that paragraph shall be applied as if any ref-
erence to a ‘physician’ is a reference to a physician as de-
fined in section 1861(r)(1).’’.
(g) TECHNICAL AMENDMENTS RELATING TO PART
A DEDUCTIBLE, COINSURANCE, AND SPELL
OF ILL-
NESS.—(1) Section 1812(a)(1) (42 U.S.C. 1395d(a)(1))
is amended—
(A) by striking ‘‘inpatient hospital services’’ the
first place it appears and inserting ‘‘inpatient hos-
pital services or inpatient rural primary care hos-
pital services’’;
(B) by striking ‘‘inpatient hospital services’’ the
second place it appears and inserting ‘‘such serv-
ices’’; and
(C) by striking ‘‘and inpatient rural primary
care hospital services’’.
(2) Sections 1813(a) and 1813(b)(3)(A) (42 U.S.C.
1395e(a), 1395e(b)(3)(A)) are each amended by striking
‘‘inpatient hospital services’’ each place it appears and in-
serting ‘‘inpatient hospital services or inpatient rural pri-
mary care hospital services’’.
(3) 
Section 
1813(b)(3)(B) 
(42 
U.S.C.
1395e(b)(3)(B)) is amended by striking ‘‘inpatient hos-
pital services’’ and inserting ‘‘inpatient hospital services,
inpatient rural primary care hospital services’’.
(4) Section 1861(a) (42 U.S.C. 1395x(a)) is amend-
ed—
(A) in paragraphs (1), by striking ‘‘inpatient
hospital services’’ and inserting ‘‘inpatient hospital
services, inpatient rural primary care hospital serv-
ices’’; and
(B) in paragraph (2), by striking ‘‘hospital’’
and inserting ‘‘hospital or rural primary care hos-
pital’’.
(h) AUTHORIZATION OF APPROPRIATIONS.—Section
1820(k) (42 U.S.C. 1395i–4(k)) is amended by striking
‘‘1990, 1991, and 1992’’ and inserting ‘‘1990 through
1995’’.
(i) EFFECTIVE DATE.—The amendments made by
this section shall take effect on the date of the enactment
of this Act.
SEC. 3. REAUTHORIZATION OF RURAL TRANSITION GRANT
PROGRAM.
Section 4005(e)(9) of the Omnibus Budget Reconcili-
ation Act of 1987 is amended—
(1) by striking ‘‘1989 and’’ and inserting
‘‘1989,’’; and
(2) by striking ‘‘1992’’ and inserting ‘‘1992
and $30,000,000 for each of fiscal years 1993
through 1997’’.
SEC. 4. REGIONAL REFERRAL CENTERS.
(a) EXTENSION THROUGH FISCAL YEAR 1994.—Sec-
tion 6003(d) of the Omnibus Budget Reconciliation Act
of 1989 (42 U.S.C. 1395ww note) is amended by striking
‘‘October 1, 1992’’ and inserting ‘‘October 1, 1994’’.
(b) PERMITTING HOSPITALS TO DECLINE RECLASSI-
FICATION.—If any hospital fails to qualify as a rural refer-
ral center under section 1886(d)(5)(C) of the Social Secu-
rity Act as a result of a decision by the Medicare Geo-
graphic Classification Review Board under section
1886(d)(10) of such Act to reclassify the hospital as being
located in an urban area for fiscal year 1994, the Sec-
retary of Health and Human Services shall—
(1) notify such hospital of such failure to qual-
ify,
(2) provide an opportunity for such hospital to
decline such reclassification, and
(3) if the hospital declines such reclassification,
administer the Social Security Act (other than sec-
tion 1886(d)(8)(D)) for fiscal year 1994 as if the
decision by the Review Board had not occurred.
SEC. 5. MEDICARE-DEPENDENT, SMALL RURAL HOSPITALS.
(a) IN GENERAL.—Section 1886(d)(5)(G) (42 U.S.C.
1395ww(d)(5)(G)) is amended—
(1) by amending clause (i) to read as follows:
‘‘(i) In the case of a subsection (d) hospital which
is a medicare-dependent, small rural hospital, payment
under paragraph (1)(A) for discharges occurring before
October 1, 1994, shall be equal to the sum of the amount
determined under clause (ii) and the amount determined
under paragraph (1)(A)(iii).’’;
(2) by redesignating clauses (ii) and (iii) as
clauses (iii) and (iv); and
(3) by inserting after clause (i) the following
new clause:
‘‘(ii) The amount determined under this clause is—
‘‘(I) for discharges occurring during the first 3
12-month cost reporting periods that begin on or
after April 1, 1990, the amount by which the hos-
pital’s target amount for the cost reporting period
(as defined in subsection (b)(3)(D)) exceeds the
amount determined under paragraph (1)(A)(iii); and
‘‘(II) for discharges occurring during any subse-
quent cost reporting period (or portion thereof), 50
percent of the amount by which the hospital’s target
amount for the cost reporting period (as defined in
subsection (b)(3)(D)) exceeds the amount deter-
mined under paragraph (1)(A)(iii).’’.
(b) PERMITTING HOSPITALS TO DECLINE RECLASSI-
FICATION.—If any hospital fails to qualify as a medicare-
dependent, 
small 
rural 
hospital 
under 
section
1886(d)(5)(G)(i) of the Social Security Act as a result of
a decision by the Medicare Geographic Classification Re-
view Board under section 1886(d)(10) of such Act to re-
classify the hospital as being located in an urban area for
fiscal year 1994, the Secretary of Health and Human
Services shall—
(1) notify such hospital of such failure to qual-
ify,
(2) provide an opportunity for such hospital to
decline such reclassification, and
(3) if the hospital declines such reclassification,
administer the Social Security Act (other than sec-
tion 1886(d)(8)(D)) for fiscal year 1994 as if the
decision by the Review Board had not occurred.
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