[Congressional Bills 117th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6400 Introduced in House (IH)]
<DOC>
117th CONGRESS
2d Session
H. R. 6400
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
January 13, 2022
Mr. Graves of Missouri (for himself and Mr. Huffman) 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 America's
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) Between January 2010 and January 1, 2021, 137 rural
hospitals 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) Four hundred and fifty-three hospitals are operating at
margins similar to those that have closed over the past decade.
Of those, 216 are considered most vulnerable to closure.
(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) Approximately sixty percent of all primary care health
professional shortage areas are located in rural areas.
(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 453 hospitals on the brink of closure,
millions of 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.
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.
Sec. 113. Making permanent Medicare telehealth service enhancements for
federally qualified health centers and
rural health clinics.
Sec. 114. Creation of reporting requirements for provider-based rural
health clinics.
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. Medicare rural hospital flexibility program grants.
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 15 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)) is amended--
(A) in clause (i), by striking ``, and before
October 1, 2022''; and
(B) in clause (ii)(II), by striking ``, and before
October 1, 2022''.
(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)) is amended--
(i) in the matter preceding clause (i), by
striking ``, and before October 1, 2022''; and
(ii) in clause (iv), by striking ``through
fiscal year 2022'' and inserting ``or a
subsequent fiscal year''.
(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) is amended by striking ``fiscal
year 2000 through fiscal year 2022'' and inserting ``a
subsequent fiscal year''.
(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)) is amended--
(1) in subparagraph (B)--
(A) in the header, by inserting ``for fiscal years
2005 through 2010'' after ``increase''; and
(B) in the matter preceding clause (i), by striking
``and for discharges occurring in fiscal year 2023 and
subsequent fiscal years'';
(2) in subparagraph (C)(i)--
(A) in the matter preceding subclause (I), by
striking ``through 2022'' and inserting ``and each
subsequent fiscal year'';
(B) in subclause (II), by adding at the end
``and'';
(C) in subclause (III)--
(i) by striking ``fiscal years 2019 through
2022'' and inserting ``fiscal year 2019 and
each subsequent fiscal year''; and
(ii) by striking ``; and'' and inserting a
period; and
(D) by striking subclause (IV); and
(3) in subparagraph (D)--
(A) by amending the heading to read as follows:
``Applicable percentage increase after fiscal year
2010'';
(B) in the matter preceding clause (i), by striking
``in fiscal years 2011 through 2022'' and inserting
``in fiscal year 2011 or a subsequent fiscal year'';
and
(C) in clause (ii), by striking ``each of fiscal
years 2019 through 2022'' and inserting ``fiscal year
2019 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 ``and after
fiscal year 2021'' 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 ``and after
fiscal year 2021'' 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 ``and on or
after January 1, 2022,'' after ``January 1, 2013,'';
and
(B) in the second sentence, by inserting ``, and
during or after 2022'' after ``or 2012''; and
(3) in subclause (III), in the first sentence, by inserting
``and on or after January 1, 2022,'' after ``January 1,
2013,''.
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) in the paragraph heading, 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, 2023''; and
(B) in clause (i), by striking ``, and before
January 1, 2023''.
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 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.
SEC. 113. MAKING PERMANENT MEDICARE TELEHEALTH SERVICE ENHANCEMENTS FOR
FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH
CLINICS.
Paragraph (8) of section 1834(m) of the Social Security Act (42
U.S.C. 1395m(m)) is amended--
(1) in the paragraph heading, be striking ``during
emergency period'';
(2) in the matter preceding subparagraph (A), by striking
``During the emergency period described in section
1135(g)(1)(B)'' and inserting ``Beginning on the first day of
the emergency period described in section 1135(g)(1)(B)'';
(3) in subparagraph (A)(ii), by striking ``determined under
subparagraph (B)'' and inserting ``determined, for services
furnished during the emergency period described in section
1135(g)(1)(B), under subparagraph (B) and, for services
furnished after such period, as an amount equal to the amount
that such center or clinic would have been paid under this
title had such service been furnished without the use of a
telecommunications system''; and
(4) in subparagraph (B)--
(A) by striking ``payment rule'' and all that
follows through ``The Secretary shall'' and inserting
``payment rule.--The Secretary shall''; and
(B) by redesignating clause (ii) as subparagraph
(C) and moving such subparagraph as so redesignated 2
ems to the left.
SEC. 114. CREATION OF REPORTING REQUIREMENTS FOR PROVIDER-BASED RURAL
HEALTH CLINICS.
(a) In General.--Not later than two years after the date of the
enactment of this Act, the Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall, taking into
account the recommendations made pursuant to subsection (b), implement
a voluntary Medicare provider-based rural health clinic quality
reporting program, in accordance with this section, under which--
(1) provider-based rural health clinics established on or
after January 1, 2021, may voluntarily comply with reporting
requirements described in subsection (b)(2); and
(2) payments under title XVIII to such clinics complying
with such requirements are provided in accordance with
subsection (d).
(b) Consultation.--Not later than one year after the date of the
enactment of this Act, the Secretary, acting through the Administrator
for Centers for Medicare & Medicaid Services, the Federal Office of
Rural Health Policy, and the Agency for Healthcare Research and
Quality, shall consult with relevant stakeholders--
(1) to review rural health clinic data collection processes
and quality measurers identified for rural health clinics by
the National Quality Forum and other national quality-
monitoring systems; and
(2) to make recommendations to the Secretary for voluntary
reporting requirements for the Secretary to implement under the
eligible professional Merit-based Incentive Payment System
under section 1848(q) of the Social Security Act (42 U.S.C.
1395w-4) for provider-based rural health clinics established on
or after January 1, 2021.
(c) Collaboration.--In implementing the voluntary Medicare
provider-based rural health clinic quality reporting program, the
Secretary shall consult with a diverse group of rural health clinic
stakeholders, which shall include--
(1) the National Quality Forum, or such other standard-
setting organizations specified by the Secretary;
(2) relevant State and local public agencies, including
State offices of rural health;
(3) established provider-based rural health clinics,
including those in the application process;
(4) small rural hospitals with 50 beds or less;
(5) organizations representing provider-based rural health
clinics; and
(6) organizations representing rural health care.
(d) Conditions.--Under the voluntary Medicare provider-based rural
health clinic quality reporting program the Secretary shall provide
that in the case of a provider-based rural health clinic described in
subsection (a)(1) that voluntarily complies with the reporting
requirements described in subsection (b)(2), with respect to a year--
(1) reimbursement rates under title XVIII of the Social
Security Act for rural health services furnished by such clinic
during such year shall be consistent with reimbursement rates
under such title for such services furnished by a provider-
based rural health clinic established before December 31, 2020;
and
(2) the provisions of section 1833(f)(3) of such Act (42
U.S.C. 1395l(f)(3)) shall not apply with respect to such clinic
and such year.
(e) Grants for Technical Assistance.--
(1) In general.--Section 1820(g)(3) of the Social Security
Act (42 U.S.C. 1395i-4(g)(3)) is amended--
(A) in subparagraph (A)--
(i) by striking ``Balanced Budget Act of
1997 and'' and inserting ``Balanced Budget Act
of 1997,''; and
(ii) by inserting before the period at the
end the following: ``, and to provide to such
small rural hospitals that participate in the
voluntary Medicare provider-based rural health
clinic quality reporting program established
pursuant to section 114 of the Save America's
Rural Hospitals Act technical assistance
necessary to so participate in such program'';
and
(B) in subparagraph (E)--
(i) by striking ``and to participate in
delivery system reforms'' and inserting ``, to
participate in delivery system reforms''; and
(ii) by inserting before the period at the
end the following: ``, and in the case of small
rural hospitals that participate in the
voluntary Medicare provider-based rural health
clinic quality reporting program established
pursuant to section 114 of the Save America's
Rural Hospitals Act, for technical assistance
necessary to so participate in such program''.
(2) Funding.--In addition to amounts otherwise made
available for grants under section 1820(g)(3) of the Social
Security Act, there is appropriated to the Secretary of Health
and Human Services, out of any monies in the Treasury not
otherwise appropriated, $15,000,000 for the period of fiscal
years 2022 through 2026 to provide grants under such section to
small rural hospitals that participate in the voluntary
Medicare provider-based rural health clinic quality reporting
program established pursuant to this section for technical
assistance necessary to so participate in such program.
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 charges 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 new subsection:
``(ee) 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 2022 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(cc)(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, 2021, 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)) is amended--
(1) in paragraph (1), by inserting ``, for recovery
activities conducted during a fiscal year before fiscal year
2022'' after ``Under the contracts''; and
(2) by adding at the end the following new paragraph:
``(11) Payment for recovery activities performed after
fiscal year 2021.--
``(A) In general.--Under the contracts, subject to
paragraphs (B) and (C), payment shall be made to
recovery audit contractors for recovery activities
conducted during fiscal year 2022 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 2021 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
2022 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 2022 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
0.1 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. MEDICARE RURAL HOSPITAL FLEXIBILITY PROGRAM GRANTS.
Section 1820(g) of the Social Security Act (42 U.S.C. 1395i-4(g))
is amended--
(1) in paragraph (1)--
(A) in subparagraph (C), by striking ``and'' at the
end;
(B) in subparagraph (D), by striking the period at
the end and inserting a semicolon; and
(C) by adding at the end the following new
subparagraphs:
``(E) rural emergency hospitals providing support
for critical access hospitals to convert to rural
emergency hospitals to stabilize hospital emergency
services in their communities; and
``(F) supporting certified rural health clinics for
maintaining and building business operations,
increasing financial indicators, addressing population
health, transforming services, and providing linkages
and services for behavioral health and substance use
disorders responding to public health emergencies.'';
(2) by redesignating paragraphs (3) through (7) as
paragraphs (4) through (8), respectively;
(3) after paragraph (2), by inserting the following new
paragraph:
``(3) Activities to support carrying out flex grants.--The
Secretary may award grants or cooperative agreements to
entities that submit to the Secretary applications, at such
time and in such form and manner and containing such
information as the Secretary specifies, for purposes of
supporting States and hospitals in carrying out the activities
under this subsection by providing technical assistance, data
analysis, and evaluation efforts.'';
(4) in paragraph (4), as redesignated--
(A) in subparagraph (A), by inserting ``State
Offices of Rural Health on behalf of eligible
hospitals'' after ``award grants to'';
(B) by amending subparagraph (C) to read as
follows:
``(C) Application.--The State Office of Rural
Health shall submit an application, on behalf of
eligible rural hospitals, to the Secretary on or before
such date and in such form and manner as the Secretary
specifies.'';
(C) by amending subparagraph (D), to read as
follows:
``(D) Amount of grant.--A grant to a hospital under
this paragraph shall be determined on an equal national
distribution so that each hospital receives the same
amount of support related to the funds appropriated.'';
(D) by amending subparagraph (E), to read as
follows:
``(E) Use of funds.--State Offices of Rural Health
and eligible hospitals may use the funds received
through a grant under this paragraph for the purchase
of computer software and hardware; the education and
training of hospital staff on billing, operational,
quality improvement and related value-focused efforts;
and other delivery system reform programs determined
appropriate by the Secretary.''; and
(5) by adding at the end the following new paragraph:
``(9) Rural health transformation grants.--
``(A) Grants.--The Secretary may award 5-year
grants to State Offices of Rural Health and to eligible
rural health care providers (as defined in subparagraph
(E)) on the transition to new models, including rural
emergency hospitals, extended stay clinics,
freestanding emergency departments, rural health
clinics, and integration of behavioral, oral health
services, telehealth and other transformational models
relevant to rural providers as such providers evolve to
better meet community needs and the changing health
care environment.
``(B) Application.--An applicable rural health care
provider, in partnership with the State Office of Rural
Health in the State in which the rural health care
provider seeking a grant under this paragraph is
located, shall submit an application to the Secretary
on or before such date and in such form and manner as
the Secretary specifies.
``(C) Additional requirements.--The Secretary may
not award a grant under this paragraph to an eligible
rural health care provider unless--
``(i) local organizations or the State in
which the hospital is located provides support
(either direct or in kind); and there are
letters of support from key State payers such
as Medicaid and private insurance; and
``(ii) the applicant describes in detail
how the transition of the health care provider
or providers will better meet local needs and
be sustainable.
``(D) Eligible rural health care provider
defined.--For purposes of this paragraph, the term
`eligible rural health care provider' includes a
critical access hospital, a certified rural health
clinic, a rural nursing home, skilled nursing facility,
emergency care provider, or other entity identified by
the Secretary. An eligible rural health care provider
may include other entities applying on behalf of a
group of providers such as a State Office of Rural
Health, a State or local health care authority, a rural
health network, or other entity identified by the
Secretary.''.
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