Rural Hospital Assistance Act of 2009 - Amends title XVIII (Medicare) of the Social Security Act with respect to the additional inpatient hospital service payment (payment adjustment) for low-volume hospitals (usually meaning a "subsection (d) hospital" located more than 25 road miles from another subsection (d) hospital and having less than 800 discharges during the fiscal year.)
(Generally, a subsection (d) hospital is an acute care hospital, particularly one that receives payments under Medicare's inpatient prospective payment system (IPPS) when providing covered inpatient services to eligible beneficiaries.)
Redefines low-volume hospital, for discharges occurring during FY2009 only, as a subsection (d) hospital located more than 15 (instead of 25) road miles from another subsection (d) hospital and having less than 1,500 (instead of 800) discharges of individuals entitled to, or enrolled for, Medicare part A (Hospital Insurance) benefits ("tweeners,'' or hospitals too large to be critical access hospitals, but too small to be financially viable under the Medicare hospital prospective payment system (PPS)).
Revises, for FY2010 only, the temporary applicable percentage in the formula for determining the payment adjustment for such hospitals.
Requires the use of the non-wage adjusted prospective payment rate (PPS) rate during FY2010 under the Medicare-dependent hospital (MDH) program.
Prescribes requirements for hospitals to qualify for a Medicare hospital exception to the prohibition on certain physician referrals to hospitals in which such physicians have an ownership or investment interest in the entity. (Eliminates the Medicare hospital exception for physician-owned hospitals, but provides a limited exception for existing facilities.)
[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 362 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 362
To amend title XVIII of the Social Security Act to provide for
temporary improvements to the Medicare inpatient hospital payment
adjustment for low-volume hospitals and to provide for the use of the
non-wage adjusted PPS rate under the Medicare-dependent hospital (MDH)
program, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
January 9, 2009
Mr. Boswell (for himself, Mr. Loebsack, Mr. Berry, Mr. Braley of Iowa,
and Mrs. Emerson) 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 provide for
temporary improvements to the Medicare inpatient hospital payment
adjustment for low-volume hospitals and to provide for the use of the
non-wage adjusted PPS rate under the Medicare-dependent hospital (MDH)
program, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Rural Hospital Assistance Act of
2009''.
SEC. 2. TEMPORARY IMPROVEMENTS TO THE MEDICARE INPATIENT HOSPITAL
PAYMENT ADJUSTMENT FOR LOW-VOLUME HOSPITALS.
(a) In General.--Section 1886(d)(12) of the Social Security Act (42
U.S.C. 1395ww(d)(12)) is amended--
(1) in subparagraph (A), by inserting ``or (D) (for
discharges occurring in fiscal year 2010)'' after
``subparagraph (B)'';
(2) in subparagraph (B), by striking ``The Secretary'' and
inserting ``Except as provided in subparagraph (D), the
Secretary'';
(3) in subparagraph (C)(i)--
(A) by inserting ``(or, with respect to fiscal year
2010, 15 road miles)'' after ``25 road miles''; and
(B) by inserting ``(or, with respect to fiscal year
2010, 1,500 discharges of individuals entitled to, or
enrolled for, benefits under part A)'' after ``800
discharges''; and
(4) by adding at the end the following new subparagraph:
``(D) Temporary applicable percentage increase.--
For discharges occurring in fiscal year 2010, the
Secretary shall determine an applicable percentage
increase for purposes of subparagraph (A) using a
continuous linear sliding scale ranging from 25 percent
for low-volume hospitals with 200 or fewer discharges
of individuals entitled to, or enrolled for, benefits
under part A in the fiscal year to 0 percent for low-
volume hospitals with greater than 1,500 discharges of
such individuals in the fiscal year.''.
(b) Implementation.--Notwithstanding any other provision of law,
the Secretary of Health and Human Services may implement the amendments
made by subsection (a) by program instruction or otherwise.
SEC. 3. USE OF NON-WAGE ADJUSTED PPS RATE UNDER THE MEDICARE-DEPENDENT
HOSPITAL (MDH) PROGRAM.
(a) In General.--Section 1886(d)(5)(G) of the Social Security Act
(42 U.S.C. 1395ww(d)(5)(G)) is amended by adding at the end the
following new clause:
``(v) In the case of discharges occurring on or after October 1,
2009, and before October 1, 2010, in determining the amount under
paragraph (1)(A)(iii) for purposes of clauses (i) and (ii)(II), such
amount shall, if it results in greater payments to the hospital, be
determined without regard to any adjustment for different area wage
levels under paragraph (3)(E).''.
(b) Implementation.--Notwithstanding any other provision of law,
the Secretary of Health and Human Services may implement the amendment
made by subsection (a) by program instruction or otherwise.
SEC. 4. LIMITATION ON MEDICARE EXCEPTION TO THE PROHIBITION ON CERTAIN
PHYSICIAN REFERRALS FOR HOSPITALS.
(a) In General.--Section 1877 of the Social Security Act (42 U.S.C.
1395nn) is amended--
(1) in subsection (d)(2)--
(A) in subparagraph (A), by striking ``and'' at the
end;
(B) in subparagraph (B), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(C) in the case where the entity is a hospital,
the hospital meets the requirements of paragraph
(3)(D).'';
(2) in subsection (d)(3)--
(A) in subparagraph (B), by striking ``and'' at the
end;
(B) in subparagraph (C), by striking the period at
the end and inserting ``; and''; and
(C) by adding at the end the following new
subparagraph:
``(D) the hospital meets the requirements described
in subsection (i)(1) not later than 18 months after the
date of the enactment of this subparagraph.''; and
(3) by adding at the end the following new subsection:
``(i) Requirements for Hospitals To Qualify for Hospital Exception
to Ownership or Investment Prohibition.--
``(1) Requirements described.--For purposes of subsection
(d)(3)(D), the requirements described in this paragraph for a
hospital are as follows:
``(A) Provider agreement.--The hospital had--
``(i) physician ownership on September 1,
2008; and
``(ii) a provider agreement under section
1866 in effect on such date.
``(B) Limitation on expansion of facility
capacity.--Except as provided in paragraph (3), the
number of operating rooms, procedure rooms, and beds of
the hospital at any time on or after the date of the
enactment of this subsection are no greater than the
number of operating rooms, procedure rooms, and beds as
of such date.
``(C) Preventing conflicts of interest.--
``(i) The hospital submits to the Secretary
an annual report containing a detailed
description of--
``(I) the identity of each
physician owner and any other owners of
the hospital; and
``(II) the nature and extent of all
ownership interests in the hospital.
``(ii) The hospital has procedures in place
to require that any referring physician owner
discloses to the patient being referred, by a
time that permits the patient to make a
meaningful decision regarding the receipt of
care, as determined by the Secretary--
``(I) the ownership interest of
such referring physician in the
hospital; and
``(II) if applicable, any such
ownership interest of the treating
physician.
``(iii) The hospital does not condition any
physician ownership interests either directly
or indirectly on the physician owner making or
influencing referrals to the hospital or
otherwise generating business for the hospital.
``(iv) The hospital discloses the fact that
the hospital is partially owned by physicians--
``(I) on any public website for the
hospital; and
``(II) in any public advertising
for the hospital.
``(D) Ensuring bona fide investment.--
``(i) Physician owners in the aggregate do
not own more than the greater of--
``(I) 40 percent of the total value
of the investment interests held in the
hospital or in an entity whose assets
include the hospital; or
``(II) the percentage of such total
value determined on the date of
enactment of this subsection.
``(ii) Any ownership or investment
interests that the hospital offers to a
physician owner are not offered on more
favorable terms than the terms offered to a
person who is not a physician owner.
``(iii) The hospital (or any investors in
the hospital) does not directly or indirectly
provide loans or financing for any physician
owner investments in the hospital.
``(iv) The hospital (or any investors in
the hospital) does not directly or indirectly
guarantee a loan, make a payment toward a loan,
or otherwise subsidize a loan, for any
individual physician owner or group of
physician owners that is related to acquiring
any ownership interest in the hospital.
``(v) Investment returns are distributed to
each investor in the hospital in an amount that
is directly proportional to the ownership
interest of such investor in the hospital.
``(vi) Physician owners do not receive,
directly or indirectly, any guaranteed receipt
of or right to purchase other business
interests related to the hospital, including
the purchase or lease of any property under the
control of other investors in the hospital or
located near the premises of the hospital.
``(vii) The hospital does not offer a
physician owner the opportunity to purchase or
lease any property under the control of the
hospital or any other investor in the hospital
on more favorable terms than the terms offered
to an individual who is not a physician owner.
``(E) Patient safety.--
``(i) Insofar as the hospital admits a
patient and does not have any physician
available on the premises to provide services
during all hours in which the hospital is
providing services to such patient, before
admitting the patient--
``(I) the hospital discloses such
fact to a patient; and
``(II) following such disclosure,
the hospital receives from the patient
a signed acknowledgment that the
patient understands such fact.
``(ii) The hospital has the capacity to--
``(I) provide assessment and
initial treatment for patients; and
``(II) refer and transfer patients
to hospitals with the capability to
treat the needs of the patient
involved.
``(F) Limitation on application to certain
converted facilities.--The hospital was not converted
from an ambulatory surgical center to a hospital on or
after the date of enactment of this subsection.
``(2) Publication of information reported.--The Secretary
shall publish, and update on an annual basis, the information
submitted by hospitals under paragraph (1)(C)(i) on the public
Internet website of the Centers for Medicare & Medicaid
Services.
``(3) Exception to prohibition on expansion of facility
capacity.--
``(A) Process.--
``(i) Establishment.--The Secretary shall
establish and implement a process under which
an applicable hospital (as defined in
subparagraph (E)) may apply for an exception
from the requirement under paragraph (1)(B).
``(ii) Opportunity for community input.--
The process under clause (i) shall provide
individuals and entities in the community that
the applicable hospital applying for an
exception is located with the opportunity to
provide input with respect to the application.
``(iii) Timing for implementation.--The
Secretary shall implement the process under
clause (i) on November 1, 2009.
``(iv) Regulations.--Not later than
November 1, 2009, the Secretary shall
promulgate regulations to carry out the process
under clause (i).
``(B) Frequency.--The process described in
subparagraph (A) shall permit an applicable hospital to
apply for an exception up to once every 2 years.
``(C) Permitted increase.--
``(i) In general.--Subject to clause (ii)
and subparagraph (D), an applicable hospital
granted an exception under the process
described in subparagraph (A) may increase the
number of operating rooms, procedure rooms, and
beds of the applicable hospital above the
baseline number of operating rooms, procedure
rooms, and beds of the applicable hospital (or,
if the applicable hospital has been granted a
previous exception under this paragraph, above
the number of operating rooms, procedure rooms,
and beds of the hospital after the application
of the most recent increase under such an
exception).
``(ii) Lifetime 100 percent increase
limitation.--The Secretary shall not permit an
increase in the number of operating rooms,
procedure rooms, and beds of an applicable
hospital under clause (i) to the extent such
increase would result in the number of
operating rooms, procedure rooms, and beds of
the applicable hospital exceeding 200 percent
of the baseline number of operating rooms,
procedure rooms, and beds of the applicable
hospital.
``(iii) Baseline number of operating rooms,
procedure rooms, and beds.--In this paragraph,
the term `baseline number of operating rooms,
procedure rooms, and beds' means the number of
operating rooms, procedure rooms, and beds of
the applicable hospital as of the date of
enactment of this subsection.
``(D) Increase limited to facilities on the main
campus of the hospital.--Any increase in the number of
operating rooms, procedure rooms, and beds of an
applicable hospital pursuant to this paragraph may only
occur in facilities on the main campus of the
applicable hospital.
``(E) Applicable hospital.--In this paragraph, the
term `applicable hospital' means a hospital--
``(i) that is located in a county in which
the percentage increase in the population
during the most recent 5-year period (as of the
date of the application under subparagraph (A))
is at least 150 percent of the percentage
increase in the population growth of the State
in which the hospital is located during that
period, as estimated by Bureau of the Census;
``(ii) whose annual percent of total
inpatient admissions that represent inpatient
admissions under the program under title XIX is
equal to or greater than the average percent
with respect to such admissions for all
hospitals located in the county in which the
hospital is located;
``(iii) that does not discriminate against
beneficiaries of Federal health care programs
and does not permit physicians practicing at
the hospital to discriminate against such
beneficiaries;
``(iv) that is located in a State in which
the average bed capacity in the State is less
than the national average bed capacity; and
``(v) that has an average bed occupancy
rate that is greater than the average bed
occupancy rate in the State in which the
hospital is located.
``(F) Procedure rooms.--In this subsection, the
term `procedure rooms' includes rooms in which
catheterizations, angiographies, angiograms, and
endoscopies are performed, except such term shall not
include emergency rooms or departments (exclusive of
rooms in which catheterizations, angiographies,
angiograms, and endoscopies are performed).
``(G) Publication of final decisions.--Not later
than 60 days after receiving a complete application
under this paragraph, the Secretary shall publish in
the Federal Register the final decision with respect to
such application.
``(H) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise of the process under this
paragraph (including the establishment of such
process).
``(4) Collection of ownership and investment information.--
For purposes of subparagraphs (A)(i) and (D)(i) of paragraph
(1), the Secretary shall collect physician ownership and
investment information for each hospital.
``(5) Physician owner defined.--For purposes of this
subsection, the term `physician owner' means a physician (or an
immediate family member of such physician) with a direct or an
indirect ownership interest in the hospital.''.
(b) Enforcement.--
(1) Ensuring compliance.--The Secretary of Health and Human
Services shall establish policies and procedures to ensure
compliance with the requirements described in subsection (i)(1)
of section 1877 of the Social Security Act, as added by
subsection (a)(3), beginning on the date such requirements
first apply. Such policies and procedures may include
unannounced site reviews of hospitals.
(2) Audits.--Beginning not later than January 1, 2010, the
Secretary of Health and Human Services shall conduct audits to
determine if hospitals violate the requirements referred to in
paragraph (1).
<all>
Introduced in House
Introduced in House
Referred to House Ways and Means
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.
Referred to House Energy and Commerce
Referred to the Subcommittee on Health.
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