I 118th CONGRESS 2d Session H. R. 9128 IN THE HOUSE OF REPRESENTATIVES July 24, 2024 Mr. Sablan (for himself and Mr. Moylan ) introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committees on Ways and Means , 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 committee concerned A BILL To amend title XVIII of the Social Security Act to establish a designation for territorial safety net hospitals, and for other purposes.

1. Short title This Act may be cited as the Supporting Territorial Safety Net Hospitals Act . 2. Designation for territorial safety net hospitals (a) Territorial safety net hospital defined Section 1861 of the Social Security Act ( 42 U.S.C. 1395x ) is amended by adding at the end the following new subsection: (nnn) Territorial safety net hospital (1) The term territorial safety net hospital means a hospital (as defined in subsection (e)) that is located in the Northern Mariana Islands, American Samoa, Guam, or the Virgin Islands. (2) The term inpatient territorial safety net hospital services means items and services, furnished to an inpatient of a territorial safety net hospital by such facility, that would be inpatient hospital services if furnished to an inpatient of a hospital by a hospital. (3) The term outpatient territorial safety net hospital services means medical and other health services furnished by a territorial safety net hospital on an outpatient basis. . (b) Payment for inpatient territorial safety net hospital services (1) In general Section 1814 of the Social Security Act ( 42 U.S.C. 1395f ) is amended— (A) in subsection (b), by inserting other than a territorial safety net hospital providing inpatient territorial safety net hospital services, after critical access hospital providing inpatient critical access hospital services, ; and (B) by adding at the end the following new subsection: (m) Payment for inpatient territorial safety net hospital services The amount of payment under this part for inpatient territorial safety net hospital services is equal to 101 percent of the reasonable costs of the territorial safety net hospital in providing such services. . (2) Scope of benefits Section 1812(a)(1) of the Social Security Act ( 42 U.S.C. 1395d(a)(1) ) is amended by striking or inpatient critical access hospital services and inserting , inpatient critical access hospital services, or inpatient territorial safety net hospital services . (3) Deductibles and coinsurance Section 1813 of the Social Security Act ( 42 U.S.C. 1395e ) is amended— (A) in subsection (a)(1), by striking or inpatient critical access hospital services each place it appears and inserting , inpatient critical access hospital services, or inpatient territorial safety net hospital services ; and (B) in subsection (b)(3)— (i) in subparagraph (A), by striking or inpatient critical access hospital services and inserting , inpatient critical access hospital services, or inpatient territorial safety net hospital services ; and (ii) in subparagraph (B), by inserting , inpatient territorial safety net hospital services, after inpatient critical access hospital services . (4) Payment to providers of services Section 1815(e)(2) of the Social Security Act ( 42 U.S.C. 1395g(e)(2) ) is amended— (A) in subparagraph (D), by striking and at the end; (B) in subparagraph (E), by inserting and after the semicolon at the end; and (C) by adding at the end the following new subparagraph: (F) inpatient territorial safety net hospital services; . (5) Administration of part A Section 1816(c)(2)(C) of the Social Security Act ( 42 U.S.C. 1395h(c)(2)(C) ) is amended by inserting territorial safety net hospital, after critical access hospital, . (c) Payment for outpatient territorial safety net hospital services (1) In general Section 1834 of the Social Security Act ( 42 U.S.C. 1395m ) is amended by adding at the end the following new subsection: (aa) Payment for outpatient territorial safety net hospital services (1) In general The amount of payment for outpatient territorial safety net hospital services of a territorial safety net hospital is equal to 101 percent of the reasonable costs of the hospital in providing such services, unless the hospital makes the election under paragraph (2). (2) Election of cost-based hospital outpatient service payment plus fee schedule for professional services A territorial safety net hospital may elect to be paid for outpatient territorial safety net hospital services amounts equal to the sum of the following, less the amount that such hospital may charge as described in section 1866(a)(2)(A): (A) Facility fee With respect to facility services, not including any services for which payment may be made under subparagraph (B), 101 percent of the reasonable costs of the territorial safety net hospital in providing such services. (B) Fee schedule for professional services With respect to professional services otherwise included within outpatient territorial safety net hospital services, 115 percent of such amounts as would otherwise be paid under this part if such services were not included in outpatient territorial safety net hospital services. Subsections (x) and (y) of section 1833 shall not be taken into account in determining the amounts that would otherwise be paid pursuant to the preceding sentence. The Secretary may not require, as a condition for applying subparagraph (B) with respect to a territorial safety net hospital, that each physician or other practitioner providing professional services in the hospital must assign billing rights with respect to such services, except that such subparagraph shall not apply to those physicians and practitioners who have not assigned such billing rights. (3) Disregarding charges The payment amounts under this subsection shall be determined without regard to the amount of the customary or other charge. (4) Treatment of clinical diagnostic laboratory services No coinsurance, deductible, copayment, or other cost-sharing otherwise applicable under this part shall apply with respect to clinical diagnostic laboratory services furnished as an outpatient territorial safety net hospital service. Nothing in this title shall be construed as providing for payment for clinical diagnostic laboratory services furnished as part of outpatient territorial safety net hospital services, other than on the basis described in this subsection. For purposes of the preceding sentence and section 1861(nnn)(3), clinical diagnostic laboratory services furnished by a territorial safety net hospital shall be treated as being furnished as part of outpatient critical access services without regard to whether the individual with respect to whom such services are furnished is physically present in the territorial safety net hospital, or in a skilled nursing facility or a clinic (including a rural health clinic) that is operated by a territorial safety net hospital, at the time the specimen is collected. (5) Coverage of costs for certain on-call emergency room providers In determining the reasonable costs of outpatient territorial safety net hospital services under paragraphs (1) and (2)(A), the Secretary shall recognize as allowable costs, amounts (as defined by the Secretary) for reasonable compensation and related costs for physicians, physician assistants, nurse practitioners, and clinical nurse specialists who are on-call (as defined by the Secretary) to provide emergency services but who are not present on the premises of the territorial safety net hospital involved, and are not otherwise furnishing services covered under this title and are not on-call at any other provider or facility. . (2) Scope of benefits Section 1832(a)(2) of the Social Security Act ( 42 U.S.C. 1395k(a)(2) ) is amended— (A) in subparagraph (I), by striking ; and and inserting a semicolon; (B) in subparagraph (J), by striking the period at the end and inserting ; and ; and (C) by adding at the end the following new subparagraph: (K) outpatient territorial safety net hospital services (as defined in section 1861(nnn)(3)). . (3) Payment of benefits Section 1833 of the Social Security Act ( 42 U.S.C. 1395l ) is amended— (A) in subsection (a)— (i) in paragraph (9), by striking ; and and inserting a semicolon; (ii) in paragraph (10), by striking the period at the end and inserting ; and ; and (iii) by inserting after paragraph (10) the following new paragraph: (11) in the case of outpatient territorial safety net hospital services, the amounts described in section 1834(aa). ; (B) in subsection (h)(5)(A)(iii), by inserting territorial safety net hospital, after critical access hospital, ; (C) in subsection (i)(1)(A), by inserting territorial safety net hospital, after critical access hospital, ; (D) in subsection (l)(5)— (i) in subparagraph (A), by inserting territorial safety net hospital, after critical access hospital, in each place it appears; and (ii) in subparagraph (B), by striking or critical access hospital in each place it appears and inserting , critical access hospital, or territorial safety net hospital in each such place; (E) in subsection (r)— (i) in paragraph (1), by inserting territorial safety net hospital, after critical access hospital ; and (ii) in paragraph (2), by striking or critical access hospital and inserting , critical access hospital, or territorial safety net hospital ; and (F) in subsection (cc)(2), by adding at the end the following new subparagraph: (F) Section 1834(aa), with respect to an outpatient territorial safety net hospital service. . (4) Payment for ambulance services furnished by a territorial safety net hospital Section 1834(l)(8) of the Social Security Act ( 42 U.S.C. 1395m(l)(8) ) is amended— (A) in the heading, by inserting and territorial safety net hospitals after critical access hospitals ; (B) in subparagraph (A), by inserting or a territorial safety net hospital (as defined in section 1861(nnn)) after (as defined in section 1861(mm)(1)) ; (C) in subparagraph (B), by inserting or a territorial safety net hospital after critical access hospital ; and (D) by amending the flush left text following subparagraph (B) to read as follows: but only if the critical access hospital, territorial safety net hospital, or entity is the only provider or supplier of ambulance services that is located within a 35-mile drive of such critical access hospital or territorial safety net hospital. . (d) Conforming amendments (1) Title XI (A) Civil monetary penalties Section 1128A(b)(1) of the Social Security Act (42 U.S.C. 1320a–7a(b)(1)) is amended by striking or a critical access hospital in each place it appears and inserting , critical access hospital, or territorial safety net hospital in each such place. (B) Criminal penalties for acts involving Federal health care programs Section 1128B(c) of the Social Security Act (42 U.S.C. 1320a–7b(c)) is amended by inserting territorial safety net hospital, after critical access hospital, . (C) Nonprofit hospital philanthropy Section 1134 of the Social Security Act ( 42 U.S.C. 1320b–4 ) is amended in the matter preceding paragraph (1) by striking or critical access hospitals in each place it appears and inserting , critical access hospitals, or territorial safety net hospitals in each such place. (D) Hospital protocols for organ procurement and standards for organ procurement agencies Section 1138 of the Social Security Act ( 42 U.S.C. 1320b–8 ) is amended by striking or critical access hospital in each place it appears and inserting , critical access hospital, or territorial safety net hospital in each such place. (2) Title XVIII (A) Definition of a hospital Section 1861(e) of the Social Security Act ( 42 U.S.C. 1395x(e) ) is amended in the flush left matter at the end by striking or a rural emergency hospital (as defined in subsection (kkk)(2)) and inserting , a rural emergency hospital (as defined in subsection (kkk)(2)), or a territorial safety net hospital (as defined in subsection (nnn)(1)) . (B) Definition of provider of services Section 1861(u) of the Social Security Act ( 42 U.S.C. 1395x(u) ) is amended by inserting territorial safety net hospital, after critical access hospital, . (C) Definition of reasonable costs Section 1861(v)(1)(S)(ii)(III) of the Social Security Act ( 42 U.S.C. 1395x(v)(1)(S)(ii)(III) ) is amended by striking or a critical access hospital (as defined in section 1861(mm)(1)) and inserting , a critical access hospital (as defined in section 1861(mm)(1)), or a territorial safety net hospital (as defined in subsection (nnn) of such section) . (D) Definition of arrangements Section 1861(w) of the Social Security Act ( 42 U.S.C. 1395x(w) ) is amended— (i) in paragraph (1), by inserting territorial safety net hospital, after critical access hospital, ; and (ii) in paragraph (2), by striking or critical access hospital in each place it appears and inserting , critical access hospital, or territorial safety net hospital in each such place. (E) Definition of post-institutional home health services; home health spell of illness Section 1861(tt) of the Social Security Act ( 42 U.S.C. 1395x(tt) ) is amended— (i) in paragraph (1)(A), by striking or critical access hospital and inserting , critical access hospital, or territorial safety net hospital ; and (ii) in paragraph (2)(B), by striking or critical access hospital and inserting , critical access hospital, or territorial safety net hospital . (F) Exclusion from coverage Section 1862(a)(14) of the Social Security Act ( 42 U.S.C. 1395y(a)(14) ) is amended by striking or critical access hospital in each place it appears and inserting , critical access hospital, or territorial safety net hospital in each such place. (G) Use of State agencies to determine compliance by providers of services with conditions of participation Section 1864 of the Social Security Act ( 42 U.S.C. 1395aa ) is amended— (i) in subsection (a), by inserting territorial safety net hospital, as defined in section 1861(nnn)(1), after a critical access hospital, as defined in section 1861(mm)(1), ; and (ii) by adding at the end the following new subparagraph: (f) For purposes of this section, the term State means the 50 States and includes the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. . (H) Agreements with providers of services Section 1866(a) of the Social Security Act ( 42 U.S.C. 1395cc(a) ) is amended— (i) in paragraph (1)— (I) in subparagraph (F)(ii), by inserting territorial safety net hospitals, after critical access hospitals, ; (II) in subparagraph (H), by striking and in the case of critical access hospitals which provide critical access hospital services and inserting , in the case of critical access hospitals which provide critical access hospital services, and in the case of territorial safety net hospitals which provide territorial safety net hospital services ; (III) in subparagraph (I), by inserting territorial safety net hospital, after critical access hospital, in each place it appears; (IV) in subparagraph (N), by inserting territorial safety net hospital, after critical access hospital, in each place it appears; (V) in subparagraph (T), by striking and critical access hospitals and inserting , critical access hospitals, and territorial safety net hospitals ; and (VI) in subparagraph (Y), by striking or critical access hospital each place it appears and inserting , critical access hospital, or territorial safety net hospital in each such place; and (ii) in paragraph (3)— (I) in subparagraph (A), by inserting territorial safety net hospital, after critical access hospital, ; (II) in subparagraph (B), by inserting territorial safety net hospital, after critical access hospital, in each place it appears; and (III) in subparagraph (C)(ii)(II), by inserting territorial safety net hospitals, after critical access hospitals, in each place it appears. (I) Examination and treatment for emergency medical conditions and women in labor Section 1867(e)(5) of the Social Security Act ( 42 U.S.C. 1395dd(e)(5) ) is amended by inserting , territorial safety net hospital (as defined in section 1861(nnn)(1)), after (as defined in section 1861(mm)(1)) . (J) Hospital providers of extended care services Section 1883(a)(3) of the Social Security Act ( 42 U.S.C. 1395tt(a)(3) ) is amended by inserting or a territorial safety net hospital after critical access hospital . (K) Payment to skilled nursing facilities for routine care Section 1888(e)(6)(B) of the Social Security Act ( 42 U.S.C. 1395yy(e)(6)(B) ) is amended— (i) in clause (i), by inserting or a territorial safety net hospital after critical access hospital ; and (ii) in clause (ii), by inserting or a territorial safety net hospital after critical access hospital . (L) Standardized post-acute care (PAC) assessment data for quality, payment, and discharge planning Section 1899B of the Social Security Act ( 42 U.S.C. 1395lll ) is amended— (i) in subsection (c)(1)(E)— (I) in clause (i), by striking or critical access hospital and inserting , critical access hospital, or territorial safety net hospital ; and (II) in clause (ii), by inserting territorial safety net hospital, after critical access hospital, ; and (ii) in subsection (i)(1)— (I) in the first sentence, by striking and critical access hospitals and inserting , critical access hospitals, and territorial safety net hospitals ; and (II) in the third sentence, by inserting territorial safety net hospitals, after critical access hospitals, . 3. Inclusion of territorial safety net hospitals as 340B covered entities Section 340B(a)(4) of the Public Health Service Act ( 42 U.S.C. 256b(a)(4) ) is amended by adding at the end the following new subparagraph: (P) An entity that is a territorial safety net hospital (as defined in section 1861(nnn) of the Social Security Act), and that meets the requirements of subparagraph (L)(i). . 4. Eliminating medicare sequestration for territorial safety net hospitals (a) Eliminating Medicare sequestration for territorial safety net hospitals (1) 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) Territorial safety net hospitals Payments under part A or part B of title XVIII of the Social Security Act with respect to items and services furnished by a territorial safety net hospital (as defined in section 1861(nnn)(1) of such Act). . (2) Applicability The amendment made by this section applies with respect to orders of sequestration effective on or after the date that is 60 days after the date of the enactment of this Act. (b) Reversing cuts to reimbursement of bad debt for territorial safety net hospitals (1) Territorial safety net hospitals Section 1861(v)(1)(W)(ii) of the Social Security Act ( 42 U.S.C. 1395x(v)(1)(W)(ii) ) is amended by inserting after or (V) the following: , a territorial safety net hospital . (2) Applicability The amendments made by this section apply with respect to cost reporting periods beginning more than 60 days after the date of the enactment of this Act.