What This Bill Does
This bill tries to help rural hospitals and health care providers stay open by changing how Medicare and Medicaid pay them. It removes certain payment cuts, extends payment protections, and reduces requirements that rural hospitals must follow. The bill also tests new ways for rural hospitals to provide and get paid for services.
##
Who It Affects
* Rural hospitals and critical access hospitals (smaller hospitals in rural areas)
* Medicare beneficiaries living in rural areas
* Ground ambulance services in rural areas
* Rural health clinics and federally qualified health centers
* Certified registered nurse anesthetists (medical professionals)
* States that run Medicaid programs
* Recovery audit contractors (companies that check for improper Medicare payments)
##
Key Provisions
* Rural hospitals will no longer have certain automatic payment cuts applied to their Medicare payments (Sec. 101)
* Payment protections for low-volume hospitals and Medicare-dependent hospitals will become permanent instead of expiring in 2024 (Sec. 103)
* Medicare will permanently pay higher rates for ground ambulance services in rural areas instead of letting this payment increase expire (Sec. 111)
* States can now certify additional hospitals as critical access hospitals even if they don't meet the normal 35-mile distance requirement, up to 175 total facilities nationwide with limits per state (Sec. 114)
* The federal government will test new payment and service delivery models for rural hospitals, including 24-hour-a-day, 7-day-a-week emergency outpatient services (Sec. 115)
* Certified registered nurse anesthetists no longer need physician supervision to provide anesthesia services under Medicare (Sec. 202)
* Recovery audit contractors can no longer be paid based on how much money they recover; instead they receive fixed payment with reductions if they overturn too many claims on appeal (Sec. 303)
##
What Changes
**Payment Changes:**
If this becomes law, rural hospitals will receive higher and more stable Medicare payments. The automatic payment cuts called "sequestration" will stop applying to them. Hospitals that treat uninsured patients will recover 15 percent more of those unpaid bills instead of losing them entirely.
**Service Delivery Changes:**
Rural areas will keep telehealth services (remote medical visits) that were temporary during emergencies. These services can now continue permanently. Nurse anesthetists can work independently without doctor supervision.
**Regulatory Changes:**
Rural hospitals no longer have to get physician certification within 96 hours for certain inpatient services. Supervision requirements for hospital services become less strict, allowing more flexibility in how services are provided.
**New Hospital Types:**
States can now designate certain struggling hospitals as critical access hospitals even if they are not exactly 35 miles from another hospital. This gives more hospitals access to special Medicare payment methods.
**Audit Reform:**
Companies that audit Medicare claims for incorrect payments can no longer keep a percentage of the money they recover. Instead they get a fixed fee, but face payment cuts if they deny too many claims that get overturned on appeal.
**Timeline Extensions:**
Rural hospitals receive extended or permanent special payment protections that were previously set to expire.
##
Important Definitions
**Critical access hospital:** A small hospital in a rural area with 25 or fewer beds that provides inpatient and outpatient services
**Medicare-dependent hospital:** A hospital where Medicare payments are unusually high compared to total revenues
**Sole community hospital:** A hospital that is the only hospital in a geographic area
**Low-volume hospital:** A hospital that treats fewer patients than average
**Rural area:** As defined in the Social Security Act based on population density and geography
**Certified registered nurse anesthetist:** A specialized nurse with additional training who administers anesthesia
**General supervision:** Services furnished under overall direction and control of a physician or other qualified practitioner, but the practitioner does not need to be physically present
**Direct supervision:** A physician or other qualified practitioner is immediately available (including by phone) to provide assistance throughout the service
**Recovery audit contractor:** A company hired by Medicare to review claims and identify improper payments
**Telehealth:** Health care services provided through electronic communications technology
##
Effective Date
Most changes take effect 60 days after the bill becomes law, except as specifically noted for individual sections. Some provisions apply to specific future fiscal years beginning after enactment. The Secretary of Health and Human Services must issue final regulations for the critical access hospital distance waiver within 120 days of enactment.
I
118TH CONGRESS
1ST SESSION
H. R. 833
To amend titles XVIII and XIX of the Social Security Act to provide for
enhanced payments to rural health care providers under the Medicare
and Medicaid programs, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY 6, 2023
Mr. GRAVES of Missouri (for himself and Mr. HUFFMAN) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, 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 jurisdic-
tion of the committee concerned
A BILL
To amend titles XVIII and XIX of the Social Security Act
to provide for enhanced payments to rural health care
providers under the Medicare and Medicaid programs,
and for other purposes.
Be it enacted by the Senate and House of Representa-
1
tives of the United States of America in Congress assembled,
2
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
3
(a) SHORT TITLE.—This Act may be cited as the
4
‘‘Save America’s Rural Hospitals Act’’.
5
(b) FINDINGS.—Congress finds the following:
6
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(1) More than 60,000,000 individuals in rural
1
areas of the United States rely on rural hospitals
2
and other providers as critical access points to
3
health care.
4
(2) Access to health care is essential to commu-
5
nities that Americans living in rural areas call home.
6
(3) Americans living in rural areas are older,
7
poorer, and sicker than Americans living in urban
8
areas.
9
(4) Between January 2010 and January 1,
10
2021, 137 rural hospitals closed in the United
11
States, according to the University of North Caro-
12
lina’s Cecil G. Sheps Center for Health Services Re-
13
search, and the rate of these closures is increasing.
14
(5) Four hundred and fifty-three hospitals are
15
operating at margins similar to those that have
16
closed over the past decade. Of those, 216 are con-
17
sidered most vulnerable to closure.
18
(6) Rural Medicare beneficiaries already face a
19
number of challenges when trying to access health
20
care services close to home, including the weather,
21
geography, and cultural, social, and language bar-
22
riers.
23
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(7) Approximately sixty percent of all primary
1
care health professional shortage areas are located
2
in rural areas.
3
(8) Seniors living in rural areas are forced to
4
travel significant distances for care.
5
(9) On average, trauma victims in rural areas
6
must travel twice as far as victims in urban areas
7
to the closest hospital, and, as a result, 60 percent
8
of trauma deaths occur in rural areas, even though
9
only 20 percent of Americans live in rural areas.
10
(10) With the 453 hospitals on the brink of clo-
11
sure, millions of Americans living in rural areas are
12
on the brink of losing access to the closest emer-
13
gency room.
14
(c) TABLE OF CONTENTS.—The table of contents of
15
this Act is as follows:
16
Sec. 1. Short title; table of contents.
TITLE I—RURAL PROVIDER PAYMENT STABILIZATION
Subtitle A—Rural Hospitals
Sec. 101. Eliminating Medicare sequestration for rural hospitals.
Sec. 102. Reversing cuts to reimbursement of bad debt for critical access hos-
pitals (CAHs) and rural hospitals.
Sec. 103. Extending permanently payment levels for low-volume hospitals and
Medicare-dependent hospitals (MDHs).
Sec. 104. Reinstating revised diagnosis-related group payments for MDHs and
sole community hospitals (SCHs).
Sec. 105. Reinstating hold harmless treatment for hospital outpatient services
for SCHs.
Subtitle B—Other Rural Providers
Sec. 111. Making permanent increased Medicare payments for ground ambu-
lance services in rural areas.
Sec. 112. Extending Medicaid primary care payments.
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Sec. 113. Making permanent Medicare telehealth service enhancements for fed-
erally qualified health centers and rural health clinics.
Sec. 114. Restoring State authority to waive the 35-mile rule for certain Medi-
care critical access hospital designations.
Sec. 115. CMI testing of new rural hospital delivery and payment model.
TITLE II—RURAL MEDICARE BENEFICIARY EQUITY
Sec. 201. Equalizing beneficiary copayments for services furnished by CAHs.
Sec. 202. Removing supervision of certified registered nurse anesthetists.
Sec. 203. CRNA services as a Medicaid-required benefit.
TITLE III—REGULATORY RELIEF
Sec. 301. Eliminating 96-hour physician certification requirement with respect
to inpatient CAH services.
Sec. 302. Rebasing supervision requirements.
Sec. 303. Reforming practices of recovery audit contractors under Medicare.
TITLE IV—FUTURE OF RURAL HEALTH CARE
Sec. 401. Medicare rural hospital flexibility program grants.
TITLE I—RURAL PROVIDER
1
PAYMENT STABILIZATION
2
Subtitle A—Rural Hospitals
3
SEC. 101. ELIMINATING MEDICARE SEQUESTRATION FOR
4
RURAL HOSPITALS.
5
(a) IN GENERAL.—Section 256(d)(7) of the Balanced
6
Budget and Emergency Deficit Control Act of 1985 (2
7
U.S.C. 906(d)(7)) is amended by adding at the end the
8
following:
9
‘‘(D)
RURAL
HOSPITALS.—Payments
10
under part A or part B of title XVIII of the So-
11
cial Security Act with respect to items and serv-
12
ices furnished by a critical access hospital (as
13
defined in section 1861(mm)(1) of such Act), a
14
sole community hospital (as defined in section
15
1886(d)(5)(D)(iii) of such Act), a medicare-de-
16
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pendent, small rural hospital (as defined in sec-
1
tion 1886(d)(5)(G)(iv) of such Act), or a sub-
2
section (d) hospital located in a rural area (as
3
defined in section 1886(d)(2)(D) of such Act).’’.
4
(b) APPLICABILITY.—The amendment made by this
5
section applies with respect to orders of sequestration ef-
6
fective on or after the date that is 60 days after the date
7
of the enactment of this Act.
8
SEC. 102. REVERSING CUTS TO REIMBURSEMENT OF BAD
9
DEBT FOR CRITICAL ACCESS HOSPITALS
10
(CAHS) AND RURAL HOSPITALS.
11
(a) RURAL HOSPITALS.—Section 1861(v)(1)(T)(v) of
12
the Social Security Act (42 U.S.C. 1395x(v)(1)(T)(v)) is
13
amended by inserting before the period the following: ‘‘or,
14
in the case of a hospital located in a rural area, by 15
15
percent of such amount otherwise allowable’’.
16
(b) CAHS.—Section 1861(v)(1)(W)(ii) of the Social
17
Security Act (42 U.S.C. 1395x(v)(1)(W)(ii)) is amended
18
by inserting after ‘‘or (V)’’ the following: ‘‘, a critical ac-
19
cess hospital’’.
20
(c) APPLICABILITY.—The amendments made by this
21
section apply with respect to cost reporting periods begin-
22
ning more than 60 days after the date of the enactment
23
of this Act.
24
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SEC. 103. EXTENDING PERMANENTLY PAYMENT LEVELS
1
FOR LOW-VOLUME HOSPITALS AND MEDI-
2
CARE-DEPENDENT HOSPITALS (MDHS).
3
(a) EXTENSION
OF INCREASED PAYMENTS
FOR
4
MDHS.—
5
(1) EXTENSION OF PAYMENT METHODOLOGY.—
6
Section 1886(d)(5)(G) of the Social Security Act (42
7
U.S.C. 1395ww(d)(5)(G)) is amended—
8
(A) in clause (i), by striking ‘‘, and before
9
October 1, 2024’’; and
10
(B) in clause (ii)(II), by striking ‘‘, and be-
11
fore October 1, 2024’’.
12
(2) CONFORMING AMENDMENTS.—
13
(A) EXTENSION
OF
TARGET
AMOUNT.—
14
Section 1886(b)(3)(D) of the Social Security
15
Act (42 U.S.C. 1395ww(b)(3)(D)) is amend-
16
ed—
17
(i) in the matter preceding clause (i),
18
by striking ‘‘, and before October 1,
19
2024’’; and
20
(ii)
in
clause
(iv),
by
striking
21
‘‘through fiscal year 2024’’ and inserting
22
‘‘or a subsequent fiscal year’’.
23
(B) EXTENDING
THE
PERIOD
DURING
24
WHICH
HOSPITALS
CAN
DECLINE
RECLASSI-
25
FICATION AS URBAN.—Section 13501(e)(2) of
26
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the Omnibus Budget Reconciliation Act of 1993
1
(42 U.S.C. 1395ww note) is amended by strik-
2
ing ‘‘fiscal year 2000 through fiscal year 2024’’
3
and inserting ‘‘a subsequent fiscal year’’.
4
(b) EXTENSION OF INCREASED PAYMENTS FOR LOW-
5
VOLUME HOSPITALS.—Section 1886(d)(12) of the Social
6
Security Act (42 U.S.C. 1395ww(d)(12)) is amended—
7
(1) in subparagraph (B)—
8
(A) in the header, by inserting ‘‘for fiscal
9
years 2005 through 2010’’ after ‘‘increase’’;
10
and
11
(B) in the matter preceding clause (i), by
12
striking ‘‘and for discharges occurring in fiscal
13
year 2025 and subsequent fiscal years’’;
14
(2) in subparagraph (C)(i)—
15
(A) in the matter preceding subclause (I),
16
by striking ‘‘through 2024’’ and inserting ‘‘and
17
each subsequent fiscal year’’;
18
(B) in subclause (II), by adding at the end
19
‘‘and’’;
20
(C) in subclause (III)—
21
(i) by striking ‘‘fiscal years 2019
22
through 2024’’ and inserting ‘‘fiscal year
23
2019 and each subsequent fiscal year’’;
24
and
25
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•HR 833 IH
(ii) by striking ‘‘; and’’ and inserting
1
a period; and
2
(D) by striking subclause (IV); and
3
(3) in subparagraph (D)—
4
(A) by amending the heading to read as
5
follows: ‘‘PERMANENT
APPLICABLE
PERCENT-
6
AGE INCREASE’’;
7
(B) in the matter preceding clause (i), by
8
striking ‘‘in fiscal years 2011 through 2024’’
9
and inserting ‘‘in fiscal year 2011 or a subse-
10
quent fiscal year’’; and
11
(C) in clause (ii), by striking ‘‘each of fis-
12
cal years 2019 through 2024’’ and inserting
13
‘‘fiscal year 2019 and each subsequent fiscal
14
year’’.
15
SEC. 104. REINSTATING REVISED DIAGNOSIS-RELATED
16
GROUP PAYMENTS FOR MDHS AND SOLE
17
COMMUNITY HOSPITALS (SCHS).
18
(a) PAYMENTS FOR MDHS AND SCHS FOR VALUE-
19
BASED
INCENTIVE
PROGRAMS.—Section
20
1886(o)(7)(D)(ii)(I) of the Social Security Act (42 U.S.C.
21
1395ww(o)(7)(D)(ii)(I)) is amended by inserting ‘‘and
22
after fiscal year 2022’’ after ‘‘2013’’.
23
(b) PAYMENTS FOR MDHS AND SCHS UNDER HOS-
24
PITAL READMISSIONS REDUCTION PROGRAM.—Section
25
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•HR 833 IH
1886(q)(2)(B)(i) of the Social Security Act (42 U.S.C.
1
1395ww(q)(2)(B)(i)) is amended by inserting ‘‘and after
2
fiscal year 2022’’ after ‘‘2013’’.
3
SEC. 105. REINSTATING HOLD HARMLESS TREATMENT FOR
4
HOSPITAL OUTPATIENT SERVICES FOR SCHS.
5
Section 1833(t)(7)(D)(i) of the Social Security Act
6
(42 U.S.C. 1395l(t)(7)(D)(i)) is amended—
7
(1) in the heading, by striking ‘‘TEMPORARY’’
8
and inserting ‘‘PERMANENT’’;
9
(2) in subclause (II)—
10
(A) in the first sentence, by inserting ‘‘and
11
on or after January 1, 2023,’’ after ‘‘January
12
1, 2013,’’; and
13
(B) in the second sentence, by inserting ‘‘,
14
and during or after 2023’’ after ‘‘or 2012’’; and
15
(3) in subclause (III), in the first sentence, by
16
inserting ‘‘and on or after January 1, 2023,’’ after
17
‘‘January 1, 2013,’’.
18
Subtitle B—Other Rural Providers
19
SEC. 111. MAKING PERMANENT INCREASED MEDICARE
20
PAYMENTS FOR GROUND AMBULANCE SERV-
21
ICES IN RURAL AREAS.
22
Section 1834(l)(13) of the Social Security Act (42
23
U.S.C. 1395m(l)(13)) is amended—
24
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(1) in the paragraph heading, by striking
1
‘‘TEMPORARY
INCREASE’’ and inserting ‘‘IN-
2
CREASE’’; and
3
(2) in subparagraph (A)—
4
(A) in the matter preceding clause (i), by
5
striking ‘‘, and before January 1, 2025’’; and
6
(B) in clause (i), by striking ‘‘, and before
7
January 1, 2025’’.
8
SEC. 112. EXTENDING MEDICAID PRIMARY CARE PAY-
9
MENTS.
10
(a) IN GENERAL.—Section 1902(a)(13)(C) of the So-
11
cial Security Act (42 U.S.C. 1396a(a)(13)(C)) is amended
12
by inserting after ‘‘2014’’ the following: ‘‘(or, in the case
13
of primary care services furnished by a physician located
14
in a rural area, as defined in section 1886(d)(2)(D), fur-
15
nished in any year)’’.
16
(b) APPLICABILITY.—
17
(1) IN GENERAL.—Except as provided in para-
18
graph (2), the amendment made by this section ap-
19
plies to services furnished in a year beginning on or
20
after the date of the enactment of this Act.
21
(2) EXCEPTION
IF
STATE
LEGISLATION
RE-
22
QUIRED.—In the case of a State plan for medical as-
23
sistance under title XIX of the Social Security Act
24
which the Secretary of Health and Human Services
25
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determines requires State legislation (other than leg-
1
islation appropriating funds) in order for the plan to
2
meet the additional requirement imposed by the
3
amendment made by this section, the State plan
4
shall not be regarded as failing to comply with the
5
requirements of such title solely on the basis of its
6
failure to meet this additional requirement before
7
the first day of the first calendar quarter beginning
8
after the close of the first regular session of the
9
State legislature that begins after the date of the en-
10
actment of this Act. For purposes of the previous
11
sentence, in the case of a State that has a 2-year
12
legislative session, each year of such session shall be
13
deemed to be a separate regular session of the State
14
legislature.
15
SEC. 113. MAKING PERMANENT MEDICARE TELEHEALTH
16
SERVICE ENHANCEMENTS FOR FEDERALLY
17
QUALIFIED HEALTH CENTERS AND RURAL
18
HEALTH CLINICS.
19
Paragraph (8) of section 1834(m) of the Social Secu-
20
rity Act (42 U.S.C. 1395m(m)) is amended—
21
(1) in the paragraph heading, be striking ‘‘DUR-
22
ING EMERGENCY PERIOD’’;
23
(2) in the matter preceding subparagraph (A),
24
by striking ‘‘During the emergency period described
25
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in section 1135(g)(1)(B) and, in the case that such
1
emergency period ends before De
[Text truncated for display. Full text available on Congress.gov.]