Save Rural Hospitals Act
This bill amends titles XVIII (Medicare) of the Social Security Act (SSAct) to increase payments to, and modify various requirements regarding, rural health care providers under the Medicare program. Among other provisions, the bill: (1) reverses cuts to reimbursement of bad debt for critical access hospitals (CAHs) and rural hospitals, as well as alters certain requirements with regard to CAHs; (2) extends payment levels for low-volume hospitals and Medicare-dependent hospitals (MDHs); (3) reinstates revised diagnosis-related group payments to MDHs and sole community hospitals (SCHs), as well as reinstates hold harmless treatment for hospital outpatient services for SCHs; (4) delays the application of penalties for a rural hospital's failure to become a meaningful electronic health record user; (5) makes permanent increased Medicare payments for ground ambulance services in rural areas; (6) alters certain supervision requirements for therapeutic hospital outpatient services; (7) modifies requirements related to the use and payment of recovery audit contractors; and (8) establishes a program under which rural hospitals meeting specified requirements may be eligible for enhanced payment for qualified outpatient services.
In addition, the bill amends the Balanced Budget and Emergency Deficit Control Act of 1985 to eliminate Medicare sequestration for rural hospitals.
The bill also amends title XIX (Medicaid) of SSAct to extend Medicaid primary care payments.
With respect to both the Medicare and Medicaid programs, the bill eliminates disproportionate share hospital payment reductions for rural hospitals.
The bill also amends the Public Health Service Act to authorize several competitive grant programs to assist eligible rural hospitals.
[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2957 Introduced in House (IH)]
<DOC>
115th CONGRESS
1st Session
H. R. 2957
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
June 20, 2017
Mr. Graves of Missouri (for himself and Mr. Loebsack) 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 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 Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Save Rural
Hospitals Act''.
(b) Findings.--Congress finds the following:
(1) More than 60,000,000 individuals in rural areas of the
United States rely on rural hospitals and other providers as
critical access points to health care.
(2) Access to health care is essential to communities that
Americans living in rural areas call home.
(3) Americans living in rural areas are older, poorer, and
sicker than Americans living in urban areas.
(4) From January 2010 until January 1, 2017, 80 rural
hospitals have closed in the United States, according to the
University of North Carolina's Cecil G. Sheps Center for Health
Services Research, and the rate of these closures is
increasing.
(5) Six hundred and seventy-three hospitals are at risk of
closing, according to iVantage's Hospital Strength INDEX study,
and such closings would impact 11,700,000 patient encounters,
99,000 community jobs would be lost, 137,000 healthcare jobs
would be lost, and 277,000,000,000 would be lost from the gross
domestic product (over 10 years).
(6) Rural Medicare beneficiaries already face a number of
challenges when trying to access health care services close to
home, including the weather, geography, and cultural, social,
and language barriers.
(7) Seventy-seven percent of rural counties in the United
States are designated as primary care health professional
shortage areas while 9 percent have no physicians at all.
(8) Seniors living in rural areas are forced to travel
significant distances for care.
(9) On average, trauma victims in rural areas must travel
twice as far as victims in urban areas to the closest hospital,
and, as a result, 60 percent of trauma deaths occur in rural
areas, even though only 20 percent of Americans live in rural
areas.
(10) With the 673 hospitals on the brink of closure,
11,700,000 Americans living in rural areas are on the brink of
losing access to the closest emergency room.
(c) Table of Contents.--The table of contents of this Act is as
follows:
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 hospitals (CAHs) and rural
hospitals.
Sec. 103. Extending 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.
Sec. 106. Delaying application of penalties for failure to be a
meaningful electronic health record user.
Sec. 107. Eliminating rural Medicare and Medicaid disproportionate
share hospital payment reductions.
Subtitle B--Other Rural Providers
Sec. 111. Making permanent increased Medicare payments for ground
ambulance services in rural areas.
Sec. 112. Extending Medicaid primary care payments.
TITLE II--RURAL MEDICARE BENEFICIARY EQUITY
Sec. 201. Equalizing beneficiary copayments for services furnished by
CAHs.
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. Community outpatient hospital program.
Sec. 402. Grant funding to assist rural hospitals.
Sec. 403. CMMI demonstration of shared savings in rural hospitals.
TITLE I--RURAL PROVIDER PAYMENT STABILIZATION
Subtitle A--Rural Hospitals
SEC. 101. ELIMINATING MEDICARE SEQUESTRATION FOR RURAL HOSPITALS.
(a) 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) Rural 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 critical
access hospital (as defined in section 1861(mm)(1) of
such Act), a sole community hospital (as defined in
section 1886(d)(5)(D)(iii) of such Act), a medicare-
dependent small rural hospital (as defined in section
1886(d)(5)(G)(iv) of such Act), or a subsection (d)
hospital located in a rural area (as defined in section
1886(d)(2)(D) of such Act).''.
(b) 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.
SEC. 102. REVERSING CUTS TO REIMBURSEMENT OF BAD DEBT FOR CRITICAL
ACCESS HOSPITALS (CAHS) AND RURAL HOSPITALS.
(a) Rural Hospitals.--Section 1861(v)(1)(T)(v) of the Social
Security Act (42 U.S.C. 1395x(v)(1)(T)(v)) is amended by inserting
before the period the following: ``or, in the case of a hospital
located in a rural area, by 30 percent of such amount otherwise
allowable''.
(b) CAHs.--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 critical access hospital''.
(c) 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.
SEC. 103. EXTENDING PAYMENT LEVELS FOR LOW-VOLUME HOSPITALS AND
MEDICARE-DEPENDENT HOSPITALS (MDHS).
(a) Extension of Increased Payments for MDHs.--
(1) Extension of payment methodology.--Section
1886(d)(5)(G) of the Social Security Act (42 U.S.C.
1395ww(d)(5)(G)), as amended by section 205(a) of the Medicare
Access and CHIP Reauthorization Act of 2015, is amended--
(A) in clause (i), by striking ``, and before
October 1, 2017''; and
(B) in clause (ii)(II), by striking ``, and before
October 1, 2017''.
(2) Conforming amendments.--
(A) Extension of target amount.--Section
1886(b)(3)(D) of the Social Security Act (42 U.S.C.
1395ww(b)(3)(D)), as amended by section 205(b) of the
Medicare Access and CHIP Reauthorization Act of 2015,
is amended--
(i) in the matter preceding clause (i), by
striking ``, and before October 1, 2017''; and
(ii) in clause (iv), by striking ``during
fiscal year 1998 through fiscal year 2017'' and
inserting ``during or after fiscal year 1998''.
(B) Extending the period during which hospitals can
decline reclassification as urban.--Section 13501(e)(2)
of the Omnibus Budget Reconciliation Act of 1993 (42
U.S.C. 1395ww note), as amended by section 205(b) of
the Medicare Access and CHIP Reauthorization Act of
2015, is amended--
(i) by inserting after ``2017'' the
following: ``or a subsequent fiscal year''; and
(ii) in subparagraph (C), by inserting
after ``such reclassification'' the following:
``during the 1-year period that begins on the
date of the notification of the hospital under
subparagraph (A)''.
(b) Extension of Increased Payments for Low-Volume Hospitals.--
Section 1886(d)(12) of the Social Security Act (42 U.S.C.
1395ww(d)(12)), as amended by section 204 of the Medicare Access and
CHIP Reauthorization Act of 2015, is amended--
(1) in subparagraph (B)--
(A) in the heading, by inserting after ``increase''
the following: ``through fiscal year 2010''; and
(B) by striking ``and for discharges occurring in
fiscal year 2018 and subsequent fiscal years'';
(2) in subparagraph (C)(i)--
(A) by striking ``25 road miles (or, with respect
to fiscal years 2011 through 2017, 15 road miles)'' and
inserting ``15 road miles''; and
(B) by striking ``(or, with respect to fiscal years
2011 through 2017, 1,600 discharges of individuals
entitled to, or enrolled for, benefits under part A)''
and inserting ``or 1,600 discharges of individuals
entitled to, or enrolled for, benefits under part A'';
and
(3) in subparagraph (D)--
(A) by amending the heading to read as follows:
``Applicable percentage increase after fiscal year
2010''; and
(B) by striking ``in fiscal years 2011 through
2017'' and inserting ``in fiscal year 2011 and each
subsequent fiscal year''.
SEC. 104. REINSTATING REVISED DIAGNOSIS-RELATED GROUP PAYMENTS FOR MDHS
AND SOLE COMMUNITY HOSPITALS (SCHS).
(a) Payments for MDHs and SCHs for Value-Based Incentive
Programs.--Section 1886(o)(7)(D)(ii)(I) of the Social Security Act (42
U.S.C. 1395ww(o)(7)(D)(ii)(I)) is amended by inserting ``or after
fiscal year 2018'' after ``2013''.
(b) Payments for MDHs and SCHs Under Hospital Readmissions
Reduction Program.--Section 1886(q)(2)(B)(i) of the Social Security Act
(42 U.S.C. 1395ww(q)(2)(B)(i)) is amended by inserting ``or after
fiscal year 2018'' after ``2013''.
SEC. 105. REINSTATING HOLD HARMLESS TREATMENT FOR HOSPITAL OUTPATIENT
SERVICES FOR SCHS.
Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C.
1395l(t)(7)(D)(i)) is amended--
(1) in the heading, by striking ``temporary'' and inserting
``permanent'';
(2) in subclause (II)--
(A) in the first sentence, by inserting ``or on or
after January 1, 2018,'' after ``January 1, 2013,'';
and
(B) in the second sentence, by inserting ``, or
during or after 2018'' after ``or 2012''; and
(3) in subclause (III), in the first sentence, by inserting
``or on or after January 1, 2018,'' after ``January 1, 2013,''.
SEC. 106. DELAYING APPLICATION OF PENALTIES FOR FAILURE TO BE A
MEANINGFUL ELECTRONIC HEALTH RECORD USER.
(a) In General.--Section 1886(b)(3)(B)(ix)(I) of the Social
Security Act (42 U.S.C. 1395ww(b)(3)(B)(ix)(I)) is amended by adding at
the end the following: ``In the case of a hospital located in a rural
area, each fiscal year referred to in the first sentence of this
subclause shall be applied as if it were a reference to the year that
is 4 fiscal years later.''.
(b) Applicability.--The amendment made by this section applies with
respect fiscal years beginning after the date of the enactment of this
Act.
SEC. 107. ELIMINATING RURAL MEDICARE AND MEDICAID DISPROPORTIONATE
SHARE HOSPITAL PAYMENT REDUCTIONS.
(a) Medicare.--Section 1886(r)(1) of the Social Security Act (42
U.S.C. 1395ww(r)(1)) is amended by inserting before ``25 percent'' the
following: ``(unless such hospital is located in a rural area, as
defined in subsection (d)(2)(D))''.
(b) Medicaid.--Section 1923(f)(3) of the Social Security Act (42
U.S.C.1396r-4(f)(3)) is amended--
(1) in subparagraph (A) by striking ``subparagraph (E)''
and inserting ``subparagraphs (E) and (F)''; and
(2) by adding at the end the following:
``(F) Increase in allotments and payments for rural
hospitals.--
``(i) Allotments.--Subject to clause (iii)
and notwithstanding subparagraphs (B), (C), and
(E), the DSH allotment for a State with respect
to a fiscal year that would be determined under
this paragraph for the State for the fiscal
year if this subparagraph did not apply, shall
be increased by the product of--
``(I) the reduction of such State's
DSH allotment under paragraph
(7)(A)(i)(I) for such fiscal year; and
``(II) the percentage of
individuals in the State who receive
medical assistance under a State plan
under this title and who live in a
rural area (as defined in section
1886(d)(2)(D)) of the State.
``(ii) Payments.--Subject to clause (iii),
the payments made to a State under section
1903(a) for each calendar quarter shall be
increased by the product of--
``(I) the reduction such State's
DSH allotment under paragraph
(7)(A)(i)(II) for such fiscal year; and
``(II) the percentage of
individuals in the State who receive
medical assistance under a State plan
under this title and who live in a
rural area (as defined in section
1886(d)(2)(D)) of the State.
``(iii) Supplement, not supplant.--A State
may only receive an increased allotment under
clause (i) or an increased payment under clause
(ii) if such State provides such assurances as
the Secretary may require that any funds made
available to such State pursuant to such
clauses shall be used to supplement, and not
supplant, amounts paid under this section to
hospitals in the State that are located in
rural areas (as defined in section
1886(d)(2)(D)).''.
(c) Applicability.--The amendments made by this section apply with
respect to fiscal year 2018 and each subsequent fiscal year.
Subtitle B--Other Rural Providers
SEC. 111. MAKING PERMANENT INCREASED MEDICARE PAYMENTS FOR GROUND
AMBULANCE SERVICES IN RURAL AREAS.
Section 1834(l)(13) of the Social Security Act (42 U.S.C.
1395m(l)(13)) is amended--
(1) by striking ``temporary increase'' and inserting
``increase''; and
(2) in subparagraph (A)--
(A) in the matter preceding clause (i), by striking
``, and before January 1, 2018''; and
(B) in clause (i), by striking ``, and before
January 1, 2018''.
SEC. 112. EXTENDING MEDICAID PRIMARY CARE PAYMENTS.
(a) In General.--Section 1902(a)(13)(C) of the Social Security Act
(42 U.S.C. 1396a(a)(13)(C)) is amended by inserting after ``2014'' the
following: ``(or in the case of a primary care services furnished by a
physician located in a rural area, as defined in section 1886(d)(2)(D),
furnished in any year)''.
(b) Applicability.--
(1) In general.--Except as provided in paragraph (2), the
amendment made by this section applies to services furnished in
a year beginning on or after the date of the enactment of this
Act.
(2) Exception if state legislation required.--In the case
of a State plan for medical assistance under title XIX of the
Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than
legislation appropriating funds) in order for the plan to meet
the additional requirement imposed by the amendment made by
this section, the State plan shall not be regarded as failing
to comply with the requirements of such title solely on the
basis of its failure to meet this additional requirement before
the first day of the first calendar quarter beginning after the
close of the first regular session of the State legislature
that begins after the date of the enactment of this Act. For
purposes of the previous sentence, in the case of a State that
has a 2-year legislative session, each year of such session
shall be deemed to be a separate regular session of the State
legislature.
TITLE II--RURAL MEDICARE BENEFICIARY EQUITY
SEC. 201. EQUALIZING BENEFICIARY COPAYMENTS FOR SERVICES FURNISHED BY
CAHS.
(a) In General.--Section 1866(a)(2)(A) of the Social Security Act
(42 U.S.C. 1395cc(a)(2)(A)) is amended by adding at the end the
following: ``In the case of outpatient critical access hospital
services for which payment is made under section 1834(g), clause (ii)
of the first sentence shall be applied by substituting `20 percent of
the lesser of the actual charge or the payment basis under this part
for such services if the critical access hospital were treated as a
hospital' for `20 per centum of the reasonable charge for such items
and services'.''.
(b) Applicability.--The amendment made by this section applies with
respect to services furnished during a year that begins more than 60
days after the date of the enactment of this Act.
TITLE III--REGULATORY RELIEF
SEC. 301. ELIMINATING 96-HOUR PHYSICIAN CERTIFICATION REQUIREMENT WITH
RESPECT TO INPATIENT CAH SERVICES.
(a) In General.--Section 1814(a) of the Social Security Act (42
U.S.C. 1395f(a)) is amended--
(1) in paragraph (6), by adding ``and'' at the end;
(2) in paragraph (7)(E), by striking ``; and'' and
inserting a period; and
(3) by striking paragraph (8).
(b) Applicability.--The amendments made by this section apply with
respect to services furnished during a year that begins more than 60
days after the date of the enactment of this Act.
SEC. 302. REBASING SUPERVISION REQUIREMENTS.
(a) Therapeutic Hospital Outpatient Services.--
(1) Supervision requirements.--Section 1833 of the Social
Security Act (42 U.S.C. 1395l) is amended by adding at the end
the following:
``(aa) Physician Supervision Requirements for Therapeutic Hospital
Outpatient Services.--
``(1) General supervision for therapeutic services.--Except
as may be provided under paragraph (2), insofar as the
Secretary requires the supervision by a physician or a non-
physician practitioner for payment for therapeutic hospital
outpatient services (as defined in paragraph (5)(A)) furnished
under this part, such requirement shall be met if such services
are furnished under the general supervision (as defined in
paragraph (5)(B)) of the physician or non-physician
practitioner, as the case may be.
``(2) Exceptions process for high-risk or complex medical
services requiring a direct level of supervision.--
``(A) In general.--Subject to the succeeding
provisions of this paragraph, the Secretary shall
establish a process for the designation of therapeutic
hospital outpatient services furnished under this part
that, by reason of complexity or high risk, require--
``(i) direct supervision (as defined in
paragraph (5)(C)) for the entire service; or
``(ii) direct supervision during the
initiation of the service followed by general
supervision for the remainder of the service.
``(B) Consultation with clinical experts.--
``(i) In general.--Under the process
established under subparagraph (A), before the
designation of any therapeutic hospital
outpatient service for which direct supervision
may be required under this part, the Secretary
shall consult with a panel of outside experts
described in clause (ii) to advise the
Secretary with respect to each such
designation.
``(ii) Advisory panel on supervision of
therapeutic hospital outpatient services.--For
purposes of clause (i), a panel of outside
experts described in this clause is a panel
appointed by the Secretary, based on
nominations submitted by hospital, rural
health, and medical organizations representing
physicians, non-physician practitioners, and
hospital administrators, as the case may be,
that meets the following requirements:
``(I) Composition.--The panel shall
be composed of at least 15 physicians
and non-physician practitioners who
furnish therapeutic hospital outpatient
services for which payment is made
under this part and who collectively
represent the medical specialties that
furnish such services, and of 4
hospital administrators of hospitals
located in rural areas (as defined in
section 1886(d)(2)(D)) or critical
access hospitals.
``(II) Practical experience
required for physicians and non-
physician practitioners.--During the
12-month period preceding appointment
to the panel by the Secretary, each
physician or non-physician practitioner
described in subclause (I) shall have
furnished therapeutic hospital
outpatient services for which payment
was made under this part.
``(III) Minimum rural
representation requirement for
physicians and non-physician
practitioners.--Not less than 50
percent of the membership of the panel
that is comprised of physicians and
non-physician practitioners shall be
physicians or non-physician
practitioners described in subclause
(I) who practice in rural areas (as
defined in section 1886(d)(2)(D)) or
who furnish such services in critical
access hospitals.
``(iii) Application of faca.--The Federal
Advisory Committee Act (5 U.S.C. 2 App.), other
than section 14 of such Act, shall apply to the
panel of outside experts appointed by the
Secretary under clause (ii).
``(C) Special rule for outpatient critical access
hospital services.--Insofar as a therapeutic outpatient
hospital service that is an outpatient critical access
hospital service is designated as requiring direct
supervision under the process established under
subparagraph (A), the Secretary shall deem the critical
access hospital furnishing that service as having met
the requirement for direct supervision for that service
if, when furnishing such service, the critical access
hospital meets the standard for personnel required as a
condition of participation under section 485.618(d) of
title 42, Code of Federal Regulations (as in effect on
the date of the enactment of this subsection).
``(D) Consideration of compliance burdens.--Under
the process established under subparagraph (A), the
Secretary shall take into account the impact on
hospitals and critical access hospitals in complying
with requirements for direct supervision in the
furnishing of therapeutic hospital outpatient services,
including hospital resources, availability of hospital-
privileged physicians, specialty physicians, and non-
physician practitioners, and administrative burdens.
``(E) Requirement for notice and comment
rulemaking.--Under the process established under
subparagraph (A), the Secretary shall only designate
therapeutic hospital outpatient services requiring
direct supervision under this part through proposed and
final rulemaking that provides for public notice and
opportunity for comment.
``(F) Rule of construction.--Nothing in this
subsection shall be construed as authorizing the
Secretary to apply or require any level of supervision
other than general or direct supervision with respect
to the furnishing of therapeutic hospital outpatient
services.
``(3) Initial list of designated services.--The Secretary
shall include in the proposed and final regulation for payment
for hospital outpatient services for 2018 under this part a
list of initial therapeutic hospital outpatient services, if
any, designated under the process established under paragraph
(2)(A) as requiring direct supervision under this part.
``(4) Direct supervision by non-physician practitioners for
certain hospital outpatient services permitted.--
``(A) In general.--Subject to the succeeding
provisions of this subsection, a non-physician
practitioner may directly supervise the furnishing of--
``(i) therapeutic hospital outpatient
services under this part, including cardiac
rehabilitation services (under section
1861(eee)(1)), intensive cardiac rehabilitation
services (under section 1861(eee)(4)), and
pulmonary rehabilitation services (under
section 1861(fff)(1)); and
``(ii) those hospital outpatient diagnostic
services (described in section 1861(s)(2)(C))
that require direct supervision under the fee
schedule established under section 1848.
``(B) Requirements.--Subparagraph (A) shall apply
insofar as the non-physician practitioner involved
meets the following requirements:
``(i) Scope of practice.--The non-physician
practitioner is acting within the scope of
practice under State law applicable to the
practitioner.
``(ii) Additional requirements.--The non-
physician practitioner meets such requirements
as the Secretary may specify.
``(5) Definitions.--In this subsection:
``(A) Therapeutic hospital outpatient services.--
The term `therapeutic hospital outpatient services'
means hospital services described in section
1861(s)(2)(B) furnished by a hospital or critical
access hospital and includes--
``(i) cardiac rehabilitation services and
intensive cardiac rehabilitation services (as
defined in paragraphs (1) and (4),
respectively, of section 1861(eee)); and
``(ii) pulmonary rehabilitation services
(as defined in section 1861(fff)(1)).
``(B) General supervision.--
``(i) Overall direction and control of
physician.--Subject to clause (ii), with
respect to the furnishing of therapeutic
hospital outpatient services for which payment
may be made under this part, the term `general
supervision' means such services that are
furnished under the overall direction and
control of a physician or non-physician
practitioner, as the case may be.
``(ii) Presence not required.--For purposes
of clause (i), the presence of a physician or
non-physician practitioner is not required
during the performance of the procedure
involved.
``(C) Direct supervision.--
``(i) Provision of assistance and
direction.--Subject to clause (ii), with
respect to the furnishing of therapeutic
hospital outpatient services for which payment
may be made under this part, the term `direct
supervision' means that a physician or non-
physician practitioner, as the case may be, is
immediately available (including by telephone
or other means) to furnish assistance and
direction throughout the furnishing of such
services. Such term includes, with respect to
the furnishing of a therapeutic hospital
outpatient service for which payment may be
made under this part, direct supervision during
the initiation of the service followed by
general supervision for the remainder of the
service (as described in paragraph (2)(A)(ii)).
``(ii) Presence in room not required.--For
purposes of clause (i), a physician or non-
physician practitioner, as the case may be, is
not required to be present in the room during
the performance of the procedure involved or
within any other physical boundary as long as
the physician or non-physician practitioner, as
the case may be, is immediately available.
``(D) Non-physician practitioner defined.--The term
`non-physician practitioner' means an individual who--
``(i) is a physician assistant, a nurse
practitioner, a clinical nurse specialist, a
clinical social worker, a clinical
psychologist, a certified nurse midwife, or a
certified registered nurse anesthetist, and
includes such other practitioners as the
Secretary may specify; and
``(ii) with respect to the furnishing of
therapeutic outpatient hospital services, meets
the requirements of paragraph (4)(B).''.
(2) Conforming amendment.--Section 1861(eee)(2)(B) of the
Social Security Act (42 U.S.C. 1395x(eee)(2)(B)) is amended by
inserting ``, and a non-physician practitioner (as defined in
section 1833(aa)(5)(D)) may supervise the furnishing of such
items and services in the hospital'' after ``in the case of
items and services furnished under such a program in a
hospital, such availability shall be presumed''.
(b) Prohibition on Retroactive Enforcement of Revised
Interpretation.--
(1) Repeal of regulatory clarification.--The restatement
and clarification under the final rulemaking changes to the
Medicare hospital outpatient prospective payment system and
calendar year 2009 payment rates (published in the Federal
Register on November 18, 2008, 73 Fed. Reg. 68702 through
68704) with respect to requirements for direct supervision by
physicians for therapeutic hospital outpatient services (as
defined in paragraph (3)) for purposes of payment for such
services under the Medicare program shall have no force or
effect in law.
(2) Hold harmless.--A hospital or critical access hospital
that furnishes therapeutic hospital outpatient services during
the period beginning on January 1, 2001, and ending on the
later of December 31, 2017, or the date on which the final
regulation promulgated by the Secretary of Health and Human
Services to carry out this section takes effect, for which a
claim for payment is made under part B of title XVIII of the
Social Security Act shall not be subject to any civil or
criminal action or penalty under Federal law for failure to
meet supervision requirements under the regulation described in
paragraph (1), under program manuals, or otherwise.
(3) Therapeutic hospital outpatient services defined.--In
this subsection, the term ``therapeutic hospital outpatient
services'' means medical and other health services furnished by
a hospital or critical access hospital that are--
(A) hospital services described in subsection
(s)(2)(B) of section 1861 of the Social Security Act
(42 U.S.C. 1395x);
(B) cardiac rehabilitation services or intensive
cardiac rehabilitation services (as defined in
paragraphs (1) and (4), respectively, of subsection
(eee) of such section); or
(C) pulmonary rehabilitation services (as defined
in subsection (fff)(1) of such section).
SEC. 303. REFORMING PRACTICES OF RECOVERY AUDIT CONTRACTORS UNDER
MEDICARE.
(a) Elimination of Contingency Fee Payment System.--Section 1893(h)
of the Social Security Act (42 U.S.C. 1395ddd(h)), as amended by
section 505(b) of the Medicare Access and CHIP Reauthorization Act of
2015, is amended--
(1) in paragraph (1), by inserting ``, for recovery
activities conducted during a fiscal year before fiscal year
2016'' after ``Under the contracts''; and
(2) by adding at the end the following new paragraph:
``(11) Payment for recovery activities performed after
fiscal year 2017.--
``(A) In general.--Under the contracts, subject to
subparagraphs (B) and (C), payment shall be made to
recovery audit contractors for recovery activities
conducted during fiscal year 2018 and each fiscal year
thereafter in the same manner, and from the same
amounts, as payment is made to eligible entities under
contracts entered into for recovery activities
conducted during fiscal year 2015 under subsection (a).
``(B) Prohibition on incentive payments.--Under the
contracts, payment made to a recovery audit contractor
for recovery activities conducted during fiscal year
2018 or any fiscal year thereafter may not include any
incentive payments.
``(C) Performance accountability.--
``(i) In general.--Under the contracts,
payment made to a recovery audit contractor for
recovery activities conducted during fiscal
year 2018 or any fiscal year thereafter shall,
in the case that the contractor has a complex
audit denial overturn rate at the end of such
fiscal year (as calculated under the
methodology described in clause (iv)) that is
.1 or greater, be reduced in an amount
determined in accordance with clause (ii).
``(ii) Payment reductions.--
``(I) Sliding scale of amount of
reductions.--The Secretary shall
establish, for purposes of determining
the amount of a reduction in payment to
a recovery audit contractor under
clause (i) for recovery activities
conducted during fiscal year, a linear
sliding scale of payment reductions for
recovery audit contractors for such
fiscal year. Under such linear sliding
scale, the amount of such a reduction
in payment to a recovery audit
contractor for a fiscal year shall be
calculated in a manner that provides
for such reduction to be greater than
the reduction for such fiscal year for
recovery audit contractors that have
complex audit denial overturn rates at
the end of such fiscal year (as
calculated under the methodology
described in clause (iv)) that are
lower than the complex audit denial
overturn rate of the contractor at the
end of such fiscal year (as so
calculated).
``(II) Manner of collecting
reduction.--The Secretary may assess
and collect the reductions in payment
to recovery audit contractors under
clause (i) in such manner as the
Secretary may specify (such as by
reducing the amount paid to the
contractor for recovery activities
conducted during a fiscal year or by
assessing the reduction as a separate
penalty payment to be paid to the
Secretary by the contractor with
respect to each complex audit denial
issued by the contractor that is
overturned on appeal).
``(iii) Timing of determinations of payment
reductions.--The Secretary shall, with respect
to a recovery audit contractor, determine not
later than six months after the end of a fiscal
year--
``(I) whether to reduce payment to
the recovery audit contractor under
clause (i) for recovery activities
conducted during such fiscal year; and
``(II) in the case that the
Secretary determines to so reduce
payment to the contractor, the amount
of such payment reduction.
``(iv) Methodology for calculation of
overturned complex audit denial overturn
rate.--
``(I) Calculation of overturn
rate.--The Secretary shall calculate a
complex audit denial overturn rate for
a recovery audit contractor for a
fiscal year by--
``(aa) determining, with
respect to the contract entered
into under paragraph (1) by the
contractor, the number of
complex audit denials issued by
the contractor under the
contract (including denials
issued before such fiscal year
and during such fiscal year)
that are overturned on appeal;
and
``(bb) dividing the number
determined under item (aa) by
the number of complex audit
denials issued by the
contractor under such contract
(including denials issued
before such fiscal year and
during such fiscal year).
``(II) Fairness and transparency.--
The Secretary shall calculate the
percentage described in subclause (I)
in a fair and transparent manner.
``(III) Accounting for subsequently
overturned appeals.--The Secretary
shall calculate the percentage
described in subclause (I) in a manner
that accounts for the likelihood that
complex audit denials issued by the
contractor for such fiscal year will be
overturned on appeal in a subsequent
fiscal year.
``(IV) Complex audit denial
defined.--In this subparagraph, the
term `complex audit denial' means a
denial by a recovery audit contractor
of a claim for payment under this title
submitted by a hospital, psychiatric
hospital, or critical access hospital
that is so denied by the contractor
after the contractor has--
``(aa) requested that the
hospital, psychiatric hospital,
or critical access hospital, in
order to support such claim for
payment, provide supporting
medical records to the
contractor; and
``(bb) reviewed such
medical records in order to
determine whether an improper
payment has been made to the
hospital, psychiatric hospital,
or critical access hospital for
such claim.
``(V) Overturned on appeal
defined.--In this subparagraph, the
term `overturned on appeal' means, with
respect to a complex audit denial, a
denial that is overturned on appeal at
the reconsideration level, the
redetermination level, or the
administrative law judge hearing level.
``(D) Application to existing contracts.--Not later
than 60 days after the date of the enactment of this
paragraph, the Secretary shall modify, as necessary,
each contract under paragraph (1) that the Secretary
entered into prior to such date of enactment in order
to ensure that payment with respect to recovery
activities conducted under such contract is made in
accordance with the requirements described in this
paragraph.''.
(b) Elimination of One-Year Timely Filing Limit To Rebill Part B
Claims.--
(1) In general.--Section 1842(b) of the Social Security Act
(42 U.S.C. 1395u(b)) is amended by adding at the end the
following new paragraph:
``(20) Exception to the one-year timely filing limit for
certain rebilled claims.--
``(A) In general.--In the case of a claim submitted
under this part by a hospital (as defined in
subparagraph (B)(i)) for hospital services with respect
to which there was a previous claim submitted under
part A as inpatient hospital services or inpatient
critical access hospital services that was denied by a
medicare contractor (as defined in subparagraph
(B)(ii)) because of a determination that the inpatient
admission was not medically reasonable and necessary
under section 1862(a)(1)(A), the deadline described in
this paragraph is 180 days after the date of the final
denial of such claim under part A.
``(B) Definitions.--In this paragraph:
``(i) Hospital.--The term `hospital' has
the meaning given such term in section 1861(e)
and includes a psychiatric hospital (as defined
in section 1861(f)) and a critical access
hospital (as defined in section 1861(mm)(1)).
``(ii) Medicare contractor.--The term
`medicare contractor' has the meaning given
such term under section 1889(g), and includes a
recovery audit contractor with a contract under
section 1893(h).
``(iii) Final denial.--The term `final
denial' means--
``(I) in the case that a hospital
elects not to appeal a denial described
in subparagraph (A) by a medicare
contractor, the date of such denial; or
``(II) in the case that a hospital
elects to appeal a such a denial, the
date on which such appeal is
exhausted.''.
(2) Conforming amendments.--
(A) Section 1835(a)(1) of the Social Security Act
(42 U.S.C. 1395n(a)(1)) is amended by inserting ``or,
in the case of a claim described in section
1842(b)(20), not later than the deadline described in
such paragraph'' after ``the date of service''.
(B) Section 1842(b)(3)(B) of the Social Security
Act (42 U.S.C. 1395u(b)(3)(B)) is amended in the flush
language following clause (ii) by inserting ``or, in
the case of a claim described in section 1842(b)(20),
not later than the deadline described in such
paragraph'' after ``the date of service''.
(3) Applicability.--The amendments made by this subsection
apply to claims submitted under part B of title XVIII of the
Social Security Act for hospital services for which there was a
previous claim submitted under part A as inpatient hospital
services or inpatient critical access hospital services that
was subject to a final denial (as defined in paragraph
(20)(B)(iii) of section 1842(b) of such Act (42 U.S.C.
1395u(b))) on or after the date of the enactment of this Act.
(c) Medical Documentation Considered for Medical Necessity Reviews
of Claims for Inpatient Hospital Services.--Section 1862(a) of the
Social Security Act (42 U.S.C. 1395y(a)) is amended by adding at the
end the following new sentence: ``A determination under paragraph (1)
of whether inpatient hospital services or inpatient critical access
hospital services furnished to an individual on or after the date of
the enactment of this sentence are reasonable and necessary shall be
based solely upon information available to the admitting physician at
the time of the inpatient admission of the individual for such
inpatient services, as documented in the medical record.''.
TITLE IV--FUTURE OF RURAL HEALTH CARE
SEC. 401. COMMUNITY OUTPATIENT HOSPITAL PROGRAM.
(a) In General.--
(1) Community outpatient hospital and qualified outpatient
services defined.--Section 1861 of the Social Security Act (42
U.S.C. 1395x) is amended--
(A) in the last sentence of subsection (e), by
inserting before the period at the end ``or a community
outpatient hospital (as defined in subsection
(iii)(1))''; and
(B) by adding at the end the following:
``Community Outpatient Hospital
``(iii)(1) The term `community outpatient hospital' means a
facility that--
``(A) at any time during the period beginning on the date
that is 5 years before the date of the enactment of this
subsection and ending on December 31, 2016, was a critical
access hospital, or is a hospital with not more than 50 beds
that is--
``(i) located in a rural area (as defined in
section 1886(d)(2)(D)); or
``(ii) treated as being located in a rural area
under section 1886(d)(8)(E);
``(B) provides emergency medical care and observation care
available on a 24-hour basis;
``(C) with respect to continuous care for an individual,
does not provide care over two or more consecutive midnights;
``(D) does not provide any acute care inpatient beds and
has protocols in place for the timely transfer of patients who
require other inpatient services;
``(E) has the resources required of a level IV or higher
trauma center (as verified by the American College of Surgeons
or other means specified by the Secretary), or has available
for consultation on a 24-hour basis a health care professional
who successfully completed the Advanced Trauma Life Support
Course offered by the American College of Surgeons (or an
equivalent course as determined by the Secretary) within the
preceding 4 years;
``(F) has in effect a transfer agreement with a level I or
level II trauma center designated under section 1231(1) of the
Public Health Service Act;
``(G) meets the requirements of subsection (aa)(2)(I);
``(H) has been approved by the State in which the facility
is located for treatment as a community outpatient hospital;
``(I) notifies the Secretary at such time and in such
manner as the Secretary may require of the intent of such
facility to be designated as a community outpatient facility;
and
``(J) meets such staff training and certification
requirements as the Secretary may require.
``(2) Nothing in this subsection or section 1834(r) shall be
construed to prohibit a community outpatient hospital from having an
agreement under section 1883 for the provision of extended care
services.
``(3) Unless the context otherwise requires, a reference to a
community outpatient hospital in this title shall be deemed to also be
a reference to a critical access hospital.
``Qualified Outpatient Services
``(jjj) The term `qualified outpatient services' means medical and
other health services furnished on an outpatient basis by a community
outpatient hospital, rural health clinic (as defined in section
1861(aa)(2)), federally qualified health center (as defined in section
1861(aa)(4)), or an entity certified by the Health Resources and
Services Administration as a federally qualified health center look-
alike, including, for individuals who require services from a hospital
or critical access hospital, transportation services from such
community outpatient hospital to a hospital or critical access
hospital.''.
(2) Payment for qualified outpatient services.--Section
1834 of the Social Security Act (42 U.S.C. 1395m) is amended by
adding at the end the following:
``(r) Payment for Qualified Outpatient Services.--
``(1) In general.--The amount of payment for qualified
outpatient services is equal to 105 percent of the reasonable
costs of providing such services.
``(2) Telehealth services as reasonable costs.--For
purposes of this subsection, with respect to qualified
outpatient services, costs reasonably associated with having a
backup physician available via a telecommunications system
shall be considered reasonable costs.''.
(b) Waiver of Distance Requirement for Replacement CAHs; Subsequent
Redesignation of Community Outpatient Hospitals as CAHs.--Section
1820(c)(2) of the Social Security Act (42 U.S.C. 1395i-4(c)(2)) is
amended--
(1) in subparagraph (B)(i)(I), by inserting ``, subject to
subparagraph (F),'' before ``is located''; and
(2) by adding at the end the following:
``(F) Option to waive distance requirement.--The
State may waive the distance requirement described in
subparagraph (B)(i)(I) with respect to a facility
located in the State that is seeking designation as a
critical access hospital under this paragraph if the
total number of waivers for such facilities does not
exceed the number of facilities that are critical
access hospitals without such a waiver.
``(G) Redesignation of a critical access hospital
as a community outpatient hospital.--A community
outpatient hospital may elect to be redesignated as a
community outpatient hospital by notifying the
Secretary at the same time and in the same manner as
notifications under section 1861(iii)(1)(I) if such
community outpatient hospital--
``(i) meets the requirements in paragraphs
(1) and (3) of section 1820(e); and
``(ii) was designated as a critical access
hospital under this paragraph on the date that
the Secretary first considered such community
outpatient hospital to be a community
outpatient hospital.''.
(c) Conforming Amendments.--
(1) Reasonable cost for cohs.--Section 1861(v)(7) of the
Social Security Act (42 U.S.C. 1395x(v)(7)) is amended by
adding at the end the following:
``(E) For additional items included in reasonable cost for
community outpatient hospitals and for determination of payment
amounts for qualified outpatient services, see section
1834(r).''.
(2) COHs as covered services.--Section 1832(a)(2)(H) of the
Social Security Act (42 U.S.C. 1395k(a)(2)(H)) is amended by
inserting ``and qualified outpatient services (as defined in
section 1861(iii)(2))'' before the semicolon.
(3) COH payments.--Section 1833(a) of the Social Security
Act (42 U.S.C. 1395l(a)) is amended--
(A) in paragraph (8), by striking ``; and'';
(B) in paragraph (9), by striking the period at the
end and inserting ``; and''; and
(C) by inserting after paragraph (9) the following:
``(10) in the case of qualified outpatient services, the
amounts described in section 1834(r).''.
(4) Effective date.--The amendments made by this subsection
shall apply to items and services furnished on or after the
first day of the first calendar year beginning more than 1 year
after the date of the enactment of this Act.
(d) Reports.--The Secretary of Health and Human Services shall
submit to Congress three reports on the impact of community outpatient
hospitals on the availability of health care and health outcomes in
rural areas (as defined in section 1886(d)(2)(D) of the Social Security
Act (42 U.S.C. 1395ww(d)(2)(D))) as follows:
(1) Initial report.--An initial report approximately 2
years after the date of the enactment of this Act.
(2) Interim report.--An interim report approximately 5
years after the date of the enactment of this Act.
(3) Final report.--A final report approximately 10 years
after the date of the enactment of this Act.
SEC. 402. GRANT FUNDING TO ASSIST RURAL HOSPITALS.
Section 330A of the Public Health Service Act (42 U.S.C. 254c) is
amended--
(1) in subsection (b)--
(A) in paragraph (1), by striking ``Director
specified in subsection (d)'' and inserting ``Director
of the Office of Rural Health Policy of the Health
Resources and Services Administration''; and
(B) by adding at the end the following:
``(6) Eligible rural hospital.--The term `eligible rural
hospital' means--
``(A) a hospital (as defined in section 1861(e) of
the Social Security Act) that--
``(i) has fewer than 50 beds; and
``(ii) is located in a rural area (as
defined in section 1886(d)(2)(D) of such Act)
or treated as being located in a rural area
pursuant to section 1886(d)(8)(E) of such Act;
``(B) a community outpatient hospital (as defined
in section 1861(iii) of such Act); or
``(C) a critical access hospital (as defined in
section 1861(mm) of such Act).''; and
(2) by adding at the end the following:
``(i) Quality Improvement and Compliance Grants for Eligible Rural
Hospitals.--
``(1) Grants.--The Director may award grants to eligible
rural hospitals to assist such hospitals with reporting on
quality and to prepare such hospitals to transition to value-
based reimbursement.
``(2) Applications.--To be eligible to receive a grant
under this subsection, an eligible rural hospital shall prepare
and submit to the Secretary an application, at such time, in
such manner, and containing such information as the Secretary
may require, including a description of--
``(A) how the eligible rural hospital will use the
funds provided under the grant; and
``(B) how the project will be evaluated.
``(3) Authorization of appropriations.--There is authorized
to be appropriated for each fiscal year (beginning with fiscal
year 2019) $12,000,000 to carry out this subsection.
``(j) Outreach Grants for Rural Hospital Population Health.--
``(1) Grants.--To help eligible rural hospitals meet a
specific community need identified in a community needs
assessment, the Director may award grants to eligible rural
hospitals.
``(2) Limitation on size of grants to cohs.--The Secretary
may not award more than $650,000 each fiscal year to a
community outpatient hospital that is described in subsection
(b)(6)(B).
``(3) Applications.--To be eligible to receive a grant
under this subsection, an eligible rural hospital shall prepare
and submit to the Secretary an application, at such time, in
such manner, and containing such information as the Secretary
may require, including--
``(A) a description of how the eligible rural
hospital will use the funds provided under the grant;
``(B) the results of community needs assessment
that identified the specific community need described
in paragraph (1); and
``(C) a description of how the project will be
evaluated.
``(4) Authorization of appropriations.--There is authorized
to be appropriated for each fiscal year (beginning with fiscal
year 2019)--
``(A) $15,000,000 for grants to eligible rural
hospitals described in subparagraphs (A) and (C) of
subsection (b)(6); and
``(B) $50,000,000 for grants to eligible rural
hospitals described in subparagraph (B) of such
subsection.
``(k) EMS Grant Funding.--
``(1) Grants.--The Director may award grants to eligible
rural hospitals to develop and implement strategies to develop
successful emergency medical services programs that meet
community needs, provide quality care, and address workforce
and funding problems.
``(2) Applications.--To be eligible to receive a grant
under this subsection, an eligible rural hospital shall prepare
and submit to the Secretary an application, at such time, in
such manner, and containing such information as the Secretary
may require, including a description of--
``(A) how the eligible rural hospital will use the
funds provided under the grant;
``(B) any multistate collaborations involved in
using such funds; and
``(C) how the use of funds will be evaluated.
``(3) Authorization of appropriations.--There is authorized
to be appropriated for each fiscal year (beginning with fiscal
year 2019) $2,000,000 to carry out this subsection.''.
SEC. 403. CMMI DEMONSTRATION OF SHARED SAVINGS IN RURAL HOSPITALS.
Section 1115A(b)(2)(B) of the Social Security Act (42 U.S.C.
1315a(b)(2)(B)) is amended by adding at the end the following:
``(xxv) Promoting greater shared savings
with hospitals located in rural areas, with
critical access hospitals (as defined in
section 1861(mm)(1)), and with community
outpatient hospitals (as defined in section
1861(iii)(1)).''.
<all>
Introduced in House
Introduced in House
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.
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.
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.
Referred to the Subcommittee on Digital Commerce and Consumer Protection.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health.
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