Rural Health Bills


Approximately 51 million Americans live in rural areas and depend upon the hospitals in their communities. Remote geographic location, small size, limited workforce, physician shortages and often constrained financial resources pose a unique set of challenges for rural hospitals. Rural hospitals’ patient mix also makes them more reliant on public programs and, thus, particularly vulnerable to Medicare and Medicaid payment cuts.

Medicare and other federal programs must account for the special circumstances of rural communities. The AHA focuses on protecting vital funding, securing the future of existing special rural payment programs – including the critical access hospital (CAH), sole community hospital (SCH), Medicare-dependent hospital (MDH) and rural referral center (RRC) programs – and relieving regulatory burden. With congressional budget crises a continued threat in Washington, the continued viability of small and rural health care providers remains in jeopardy.


The AHA supports policies and legislation that enable rural hospitals to care for their communities. Below are some of the key areas of focus for our 2016 advocacy agenda.


  • Direct supervision. Pass S. 3129/H.R. 5613 to extend for CY 2016 the enforcement moratorium on CMS’s “direct supervision” policy on outpatient therapeutic services provided in critical access hospitals (CAHs) and small, rural hospitals. In addition, pass the Regulatory Relief for Rural Hospitals Act (H.R. 5164) to permanently extend the enforcement moratorium for CAHs and small rural hospitals. The AHA continues to urge Congress to pass the Protecting Access to Rural Therapy Services (PARTS) Act (S. 257, H.R. 1611), which would protect access to outpatient therapeutic services, among other provisions.
  • 96-hour physician certification. Pass the Critical Access Hospital Relief Act (S. 258/H.R. 169), which would remove the 96-hour physician certification requirement as a condition of payment for CAHs. These hospitals would still be required to satisfy the condition of participation requiring a 96-hour annual average length of stay.
  • IT and meaningful use. Urge CMS to modify the meaningful use rules by allowing providers meeting 70 percent of the requirements be designated as having met meaningful use. CMS also should delay Stage 3 implementation to no sooner than 2019.
  • Recovery Audit Contractors (RAC). Pass the Medicare Audit Improvement Act of 2015 (H.R. 2156), which would make much-needed improvements to the RAC program.
  • Telehealth. Expand Medicare coverage and payment for telehealth and provide resources for additional study of the cost-benefit of telehealth.
  • Medicare physician payment (MACRA). Urge CMS to implement the new payment system in a way that measures providers fairly, minimizes unnecessary data collection and reporting burden, focuses on important quality issues and promotes collaboration across the health care delivery system.
  • Bed size. Provide bed size flexibility for CAHs.
  • Rulemaking. Ensure the unique circumstances of rural hospitals are accounted for in the rulemaking process.
  • MedPAC. Ensure representation for rural health care on the Medicare Payment Advisory Commission.


  • RCH Demo. Pass the Rural Community Hospital (RCH) Demonstration Extension Act as passed by the Senate (S. 607), to extend the program for five years. The RCH demonstration program allows rural hospitals with fewer than 51 beds to test the feasibility of cost-based reimbursement.
  • MDH and low-volume adjustment. Pass the Rural Hospital Access Act (S. 332/H.R. 663), which would permanently extend the Medicare-dependent hospitals (MDH) and enhanced low-volume adjustment programs.
  • Ambulance add-on payment. Pass the Medicare Ambulance Access, Fraud Prevention and Reform Act (S. 377/H.R. 745), which would permanently extend the ambulance add-on payment adjustment.
  • Therapy cap. Exempt CAHs from the cap on outpatient therapy services. Extend the outpatient therapy exception process (and oppose the expansion of the cap to services provided in the outpatient departments of hospitals and CAHs).


  • Maintain CAH designation, as currently defined.
  • Relieve hospitals from cuts to Medicare disproportionate share hospitals.
  • Preserve the 340B Drug Pricing Program and oppose attempts to scale back this vital program.
  • Ensure CAHs are paid at least 101 percent of costs by Medicare and are paid at least the same by Medicare Advantage plans.
  • Exempt CAHs from the Independent Payment Advisory Board.
  • Allow hospitals to claim the full cost of provider taxes as allowable costs.


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