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Q: 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 specifically provided,
whenever in this Act, an amendment is expressed in terms of an
amendment to or repeal of a section 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. 1395i4(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.
1395i4(f)(1)(F)) is amended to read as follows:
''(F) subject to paragraph (4), provides not more
than 6 inpatient beds (meeting such conditions as the
Secretary may establish) for providing inpatient care
to patients requiring stabilization before discharge or
transfer to a hospital, 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 discharged 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 physician 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. 1395i4(f)) is amended by adding at the end the
following new paragraph:
''(4) Limitation on average length of inpatient 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 effect
exceeded 72 hours. In determining the compliance of a facility
with the requirement of the previous 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 inclement
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 inserting ''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 Congress on--
(A) the application of the requirements under
section 1820(f) of the Social Security Act (as amended
by this subsection) that rural primary care hospitals
provide inpatient care only to those individuals whose
attending physicians certify may reasonably be expected
to be discharged 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 inpatient care
beyond their capabilities or have limited 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. 1395i4) is
amended--
(i) by striking paragraph (1) of subsection
(e) and redesignating paragraphs (2) through
(6) as paragraphs (1) through (5); and
(ii) in subsection (e)(1)(A) (as
redesignated by subparagraph (A))--
(I) by striking ''is located'' and
inserting ''except in the case of a
hospital located in an urban area, is
located'',
(II) by striking '', (ii)'' and
inserting ''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
inserting ''paragraph (2)''.
(B) No change in medicare prospective payment.--
Section 1886(d)(5)(D) (42 U.S.C. 1395ww(d)(5)(D)) is
amended--
(i) in clause (iii)(III), by inserting
''located 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 adjoining states to
participate in state program.--
(A) In general.--Section 1820 (42 U.S.C. 1395i4) 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 facility as a
member institution of a rural health network, 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) Section 1820(c)(1)
(42 U.S.C. 1395i4(c)(1)) is amended by striking
''paragraph (3)'' and inserting ''paragraph (3) or
subsection (k)''.
(ii) Paragraphs (1)(A) and (2)(A) of section
1820(i) (42 U.S.C. 1395i4(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
''subparagraph (B)'' and inserting
''subparagraph (B) or subsection (k)''.
(d) Skilled Nursing Services in Rural Primary Care Hospitals.--
Section 1820(f)(3) (42 U.S.C. 1395i4(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 services, except that the number of
beds used for the furnishing 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 inpatient 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 Requirement for Rural
Primary Care Hospitals.--Section 1820(f)(1)(H) (42 U.S.C.
1395i4(f)(1)(H)) is amended by striking the period and inserting the
following: '', 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 reference to a 'physician' is a
reference to a physician as defined in section 1861(r)(1).''.
(g) Technical Amendments Relating to Part A Deductible,
Coinsurance, and Spell of Illness.--(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 hospital services or
inpatient rural primary care hospital services'';
(B) by striking ''inpatient hospital services'' the second
place it appears and inserting ''such services''; 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 inserting ''inpatient hospital
services or inpatient rural primary care hospital services''.
(3) Section 1813(b)(3)(B) (42 U.S.C. 1395e(b)(3)(B)) is amended by
striking ''inpatient hospital services'' and inserting ''inpatient
hospital services, inpatient rural primary care hospital services''.
(4) Section 1861(a) (42 U.S.C. 1395x(a)) is amended--
(A) in paragraphs (1), by striking ''inpatient hospital
services'' and inserting ''inpatient hospital services,
inpatient rural primary care hospital services''; and
(B) in paragraph (2), by striking ''hospital'' and
inserting ''hospital or rural primary care hospital''.
(h) Authorization of Appropriations.--Section 1820(k) (42 U.S.C.
1395i4(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 Reconciliation 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.--Section 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 Reclassification.--If any
hospital fails to qualify as a rural referral center under section
1886(d)(5)(C) of the Social Security Act as a result of a decision by
the Medicare Geographic 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 Secretary of Health and Human
Services shall--
(1) notify such hospital of such failure to qualify,
(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 section
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 hospital'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 subsequent 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
determined under paragraph (1)(A)(iii).''.
(b) Permitting Hospitals to Decline Reclassification.--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 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 Secretary of
Health and Human Services shall--
(1) notify such hospital of such failure to qualify,
(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 section
1886(d)(8)(D)) for fiscal year 1994 as if the decision by the
Review Board had not occurred.
A:
Medicare Rural Hospital Amendments of 1993 - Amends title XVIII (Medicare) of the Social Security Act to extend and revise programs to assist rural hospitals under Medicare part A (Hospital Insurance). Authorizes appropriations.
Amends the Omnibus Budget Reconciliation Act of 1987 to reauthorize and extend the rural transition grant program.
Amends the Omnibus Budget Reconciliation Act of 1989 to extend regional referral centers.
Revises Medicare-dependent, small rural hospital provisions under Medicare.
Requires the Secretary of Health and Human Services to provide rural referral centers and Medicare-dependent, small rural hospitals which have been reclassified as urban the opportunity to decline such reclassification.