I 115th CONGRESS 1st Session H. R. 3224 IN THE HOUSE OF REPRESENTATIVES July 13, 2017 Mr. Harper (for himself, Mr. Loebsack , Mr. Kind , Mr. Kelly of Mississippi , Mr. Thompson of Mississippi , Mr. Palazzo , and Mr. Peterson ) introduced the following 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 consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to clarify reasonable costs for critical access hospital payments under the Medicare program, and for other purposes.

1. Short title This Act may be cited as the Critical Access and Rural Equity Act of 2017 or the CARE Act of 2017 . 2. Clarifying reasonable costs for critical access hospital Medicare payments (a) Inclusion of certain costs as reasonable costs (1) Inpatient critical access hospital services Section 1814(l) of the Social Security Act ( 42 U.S.C. 1395f(l) ) is amended by adding at the end the following new paragraph: (6) In determining payment and reasonable costs under paragraph (1) for inpatient critical access services, the Secretary shall recognize as allowable costs of the critical access hospital at least the following: (A) Costs of services that would be considered bona fide emergency services (as defined in section 1861(v)(1)(K)(ii)) if provided in a hospital emergency room, including professional services and any associated surgical on-call and standby costs. (B) Costs of a test or procedure performed at a critical access hospital or an entity owned by the critical access hospital, including a clinical diagnostic laboratory test, mammogram (as defined in section 354(a)(5) of the Public Health Service Act), colonoscopy, cardiac stress test, pulmonary function test, echocardiogram, and bone density study. (C) Standby and on-call costs for certified registered nurse anesthetist services, regardless of the number of surgical procedures requiring anesthesia services and regardless of the number of full-time equivalent physicians. (D) Costs of services provided by the critical access hospital or satellite facility of the critical access hospital that improve the total health of communities, including immunization programs, health clinics, and medical homes. (E) Costs of services provided by an off-campus provider-based clinic described in section 1820(c)(2)(F) of the critical access hospital, regardless of distance of such clinic from a hospital or another critical access hospital. . (2) Outpatient critical access hospital services Section 1834(g) of the Social Security Act ( 42 U.S.C. 1395m(g) ) is amended by adding at the end the following new paragraph: (6) Coverage of certain additional costs as reasonable costs In determining the reasonable costs of outpatient critical access hospital services under paragraphs (1) and (2)(A), the Secretary shall recognize as allowable the costs described in paragraph (6) of section 1814(l). . (3) Conforming amendment Section 1861(v)(7) of the Social Security Act ( 42 U.S.C. 1395x(v)(7) ) is amended by adding at the end the following new subparagraph: (E) For provisions further describing costs recognized as reasonable costs for inpatient and outpatient critical access hospital services, see sections 1814(l)(6) and 1834(g)(6). . (b) Treatment of provider-Based clinics of critical access hospitals Section 1820(c)(2) of the Social Security Act ( 42 U.S.C. 1395i–4(c)(2) ) is amended— (1) in subparagraph (B)(i)(I), by striking is located and inserting subject to subparagraph (E), is located ; and (2) by adding at the end the following new subparagraph: (F) Treatment of off-campus pro­vider-based clinics Subparagraph (B)(i)(I) shall not apply to an off-campus provider-based clinic (as described in section 485.610 of title 45 of the Code of Federal Regulations) of a facility designated as a critical access hospital. . (c) Allowing coordination for provision of emergency services Section 1820(c)(2) of the Social Security Act ( 42 U.S.C. 1395i–4(c)(2) ), as amended by subsection (b), is further amended— (1) in subparagraph (B)(ii), by striking makes and inserting subject to subparagraph (G), makes ; and (2) by adding at the end the following new subparagraph: (G) Allowing coordination for provision of emergency services The Secretary may waive the requirements under subparagraph (B)(ii), with respect to a facility, if such facility— (i) is located not more than 15 miles of another facility or hospital that has an emergency department that satisfies the requirement of subparagraph (B)(ii); and (ii) coordinates with such other facility or hospital with respect to furnishing 24-hour emergency care services described in such subparagraph to the area served by such facility. . (d) Treatment of Medicaid provider taxes for critical access hospital reasonable costs (1) Inpatient critical access hospital services Section 1814(l) of the Social Security Act ( 42 U.S.C. 1395f(l) ), as amended by subsection (a)(1), is further amended by adding at the end the following new paragraph: (7) (A) In determining payment and reasonable costs under paragraph (1) for inpatient critical access services— (i) with respect to a current permissible health care related tax imposed and paid by the critical access hospital for a cost reporting period beginning before the date of enactment of this paragraph, the Secretary shall not, through recoupment or otherwise, disallow payment to the critical access hospital under this subsection on the basis that payments to the critical access hospital under this subsection offset some or all of the costs of such tax; and (ii) with respect to a current permissible health care related tax imposed and paid by the critical access hospital for a cost reporting period beginning on or after the date of enactment of this paragraph, the Secretary shall— (I) assess the percentage of individuals entitled to benefits under this part who are furnished inpatient critical access hospital services at such critical access hospital during such cost reporting period and who are also receiving medical assistance under the Medicaid program under title XIX during such period; and (II) adjust payments under this subsection with respect to such services furnished during such period in a manner specified by the Secretary based on such percentage to take into account such tax. (B) For purposes of this paragraph and section 1834(g)(7), the term current permissible health care related tax means a broad-based health care related tax (as defined in paragraph (3)(B) of such section) that is in effect prior to enactment of this paragraph and for which there is not in effect a hold harmless provision described in paragraph (4) of such section. . (2) Outpatient critical access hospital services Section 1834(g) of the Social Security Act ( 42 U.S.C. 1395m(g) ), as amended by subsection (a)(2), is further amended by adding at the end the following new paragraph: (7) Treatment of Medicaid provider taxes In determining payment for outpatient critical access hospital services under paragraphs (1) and (2), the provisions of paragraph (7) of section 1814(l) shall apply to payment for such services under this subsection in the same manner as such provisions apply to payment for inpatient critical access hospital services under section 1814(l), except that in applying subparagraph (B) of such paragraph (7), the reference to individuals entitled to benefits under this part shall be deemed a reference to individuals enrolled under part B . .