I 115th CONGRESS 1st Session H. R. 4178 IN THE HOUSE OF REPRESENTATIVES October 31, 2017 Mr. Arrington (for himself, Mr. Gohmert , and Mr. Conaway ) introduced the following bill; which was referred to the Committee on Ways and Means A BILL To amend title XVIII of the Social Security Act to provide for reform to and a permanent extension of the Medicare-dependent hospital program, and for other purposes.

1. Short title This Act may be cited as the Healthcare Enhancement for Americas Rural Towns Act or the HEART Act . 2. Reform and permanent extension of the Medicare-dependent hospital (MDH) program (a) Extension of Payment Methodology Section 1886(d)(5)(G) of the Social Security Act ( 42 U.S.C. 1395ww(d)(5)(G) ) is amended— (1) in clause (i), by striking , and before October 1, 2017 and inserting before October 1, 2018 ; (2) in clause (i), by adding at the end the following; For fiscal year 2018 and each subsequent fiscal year, in the case of such a subsection (d) hospital, payment under paragraph (1)(A) shall be equal to the sum of the amount determined under paragraph (1)(A)(iii) and the amount determined by the increase factor determined under clause (v) for such hospital and cost reporting period. ; (3) in clause (ii)(II), by striking , and before October 1, 2017 and inserting before October 1, 2018 ; and (4) by adding at the end the following new clauses: (v) Subject to subclause (II), for purposes of clause (i), for fiscal year 2019 and each subsequent fiscal year with respect to a subsection (d) hospital which is a medicare-dependent, small rural hospital, the Secretary shall determine an increase factor to apply to such hospital with respect to discharges occurring during such fiscal year. When determining such increase factor, the Secretary may take into account a methodology that results in a similar amount of reimbursement to such hospital for such fiscal year as such amount that would have been determined if the first sentence of clause (i) applied with respect to such fiscal year. (vi) The aggregate amounts determined for all subsection (d) hospitals which are medicare-dependent, small rural hospitals by application of the increase factors determined under clause (v) for such hospitals shall not exceed a total of— (I) for fiscal year 2019, $100,000,000; and (II) for each subsequent fiscal year, the amount specified in this clause for the previous fiscal year increased by the market basket percentage increase (as defined in subsection (b)(3)(B)(iii)) as determined prospectively by the Secretary for such subsequent fiscal year. . (b) Conforming Amendments (1) Extension of target amount Section 1886(b)(3)(D) of the Social Security Act ( 42 U.S.C. 1395ww(b)(3)(D) ) is amended— (A) in the matter preceding clause (i), by striking , and before October 1, 2017 ; (B) in clause (iii), by striking at the end and ; (C) in clause (iv)— (i) by striking through fiscal year 2017 and inserting through fiscal year 2018 ; and (ii) by striking the period at the end and inserting , and ; and (D) by adding at the end the following new clause: (v) with respect to discharges occurring during fiscal year 2019 or a subsequent fiscal year, the target amount for the preceding year increased by the applicable percentage increase under subparagraph (B)(iv) and adjusted as determined necessary by the Secretary to take into account the application of subsection (d)(5)(G)(vi) for such fiscal year. . (2) Permitting hospitals to decline reclassification Section 13501(e)(2) of the Omnibus Budget Reconciliation Act of 1993 ( 42 U.S.C. 1395ww note) is amended by striking fiscal year 2000 through fiscal year 2017 and inserting a subsequent fiscal year . 3. Temporary extension of the Medicare low-volume adjustment program Section 1886(d)(12) of the Social Security Act ( 42 U.S.C. 1395ww(d)(12) ) is amended— (1) in subparagraph (B), in the matter preceding clause (i), by striking and for discharges occurring in fiscal year 2020 and subsequent fiscal years ; (2) in subparagraph (C)(i)— (A) by striking fiscal years 2011 through 2017 each place it appears and inserting fiscal years 2011 through 2019 ; and (B) by striking or portion of fiscal year ; and (3) in subparagraph (D)— (A) in the heading, by striking Temporary applicable percentage increase and inserting Applicable percentage increase beginning with fiscal year 2011 ; (B) by striking fiscal years 2011 through 2017, and inserting fiscal years 2011 through 2019 ; and (C) by striking or the portion of fiscal year each place it appears. 4. Budget neutral pay-for For fiscal year 2018 and each subsequent fiscal year, the Secretary of Health and Human Services shall adjust payments under section 1886(d) of the Social Security Act ( 42 U.S.C. 1395ww(d) ) in a manner such that the estimated aggregate amount of expenditures under such section for such fiscal year with application of the amendments made by sections 2 and 3 of this Act is equal to the estimated aggregate amount of expenditures under such section for such fiscal year without application of such amendments.