CAH Legislative Priorities History


Medicare Program Extensions
On May 20, the AHA was joined by 13 related organizations including the National Rural Health Association in a letter to Congressional leaders of the House and Senate requesting immediate action to address harmful Medicare policies that will go into effect on January 1, 2011 without legislative action in Congress. Many of these Medicare policies have been temporarily addressed by Congress in multiple bills over the past decade including a temporary extension of these provisions for 2010 as part of the recently passed health care reform laws. Without Congressional action by December 31, 2010 these policies will expire and revert back to the detrimental provisions that limit access, beneficiary choice, and provider reimbursement. Therefore, these Medicare extenders must be addressed immediately.
Following is a list of provisions that have been addressed by Congress in the past for which we request action to pass legislation that, at a minimum, will extend policies beyond their current expiration on December 31, 2010.

  • Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule. Extends a floor on geographic adjustments to the work portion of the fee schedule through the end of 2010, with the effect of increasing practitioner fees in rural areas. Also provides immediate relief to areas negatively impacted by the geographic adjustment for practice expenses, and requires the Secretary of HHS to improve the methodology for calculating practice expense adjustments.
  • Extension of exceptions process for Medicare therapy caps. Extends the process allowing exceptions to limitations on medically necessary therapy.
  • Extension of payment for the technical component of certain physician pathology services. Extends a provision that allows independent laboratories to bill Medicare directly for certain clinical laboratory services.
  • Extension of ambulance add-ons. Extends bonus payments made by Medicare for ground and air ambulance services in rural and other areas.
  • Extension of certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities. Extends Sections 114 (c) and (d) of the Medicare, Medicaid and SCHIP Extension Act of 2007.
  • Extension of physician fee schedule mental health add-on. Increases the payment rate for psychiatric services delivered by physicians, clinical psychologists and clinical social workers by 5 percent.
  • Extension of outpatient hold harmless provision. Extends the existing outpatient hold harmless provision and would allow Sole Community Hospitals with more than 100 beds to also be eligible to receive this adjustment.
  • Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas. Reinstates the policy included in the Medicare Modernization Act of 2003 (P.L. 108-173) that provides reasonable cost reimbursement for laboratory services provided by certain small rural hospitals (expires June 30, 2011).

Hospital wage index improvement. Extends reclassifications under section 508 of the Medicare Modernization Act (P.L 108-173).

CRNA Pass-Through Through and Standby Services - H.R. 3151 and S.1585 were introduced to permit pass-through payment for reasonable costs of certified registered nurse anesthetist services in critical access hospitals despite the reclassification of such hospitals as urban hospitals, including hospitals located in "Lugar counties", and for on-call and standby costs for such services


Craig Thomas Rural Hospital and Provider Equity Act (S.1157) or R-HoPE
Sens. Kent Conrad (D-ND), Pat Roberts (R-KA), Tom Harkin (D-IA) and John Barasso (R-WY) have introduced AHA-supported legislation that would improve Medicare reimbursements to rural hospitals. The Craig Thomas Rural Hospital and Provider Equity Act (S.1157) or R-HoPE would provide a temporary payment increase for hospitals with low-volume inpatient discharges. The bill also would continue allowing direct payments to independent laboratories for the technical component of pathology services, and the 5% rural add-on payment for home health services. In addition, the bill would extend the outpatient hold-harmless provision for sole community hospitals and rural hospitals with fewer than 100 beds, remove the cap on disproportionate share adjustment percentages for all hospitals and improve payments for ambulance services in rural areas.

Critical Access Hospital Flexibility Act of 2009 (S. 307/HR. 668) - Would provide flexibility in the manner in which beds are counted for purposes of determining whether a hospital may be designated as a critical access hospital under the Medicare Program and to exempt from the critical access hospital inpatient bed limitation the number of beds provided for certain veterans.  Legislation was introduced by Senators Ron Wyden (D-Ore.), Mike Crapo (R-Idaho) and Representative Greg Walden (R-Ore.)

Rural Hospital Assistance Act (H.R. 362) Rural Hospital Assistance Act of 2009 and (S. 318) the Medicare Rural Health Access Improvement Act of 2009 - Introduced by Rep. Leonard Boswell (D-IA) and Sen. Charles Grassley (R-IA), legislation would improve Medicare payments to rural hospitals that are too large to be critical access hospitals, but too small to be financially viable under the Medicare prospective payment system; would allow such Medicare-dependent hospitals to receive the non-wage-adjusted payment rate and a low-volume adjustment for Medicare inpatient services. It also includes a prospective ban on physician self-referral to hospitals in which a physician has an ownership interest.


The Health Care Access and Rural Equity Act (H-CARE) (H.R. 2860) would extend through 2011 existing critical rural health provisions of the Medicare Modernization (MMA) and Deficit Reduction Acts (DRA). Introduced by Reps. Earl Pomeroy (D-ND) and Greg Walden (R-OR), H.R. 2860 would extend the outpatient hold-harmless provision for rural hospitals with fewer than 100 beds and reauthorizes for sole community hospitals, the 2% add-on for ambulance trips in rural areas and the 5% add-on for rural home health services. It also would extend Section 508 of the MMA to allow certain Medicare wage index reclassifications to proceed in a non-budget neutral way, and hospitals near a Section 508 hospital to participate in a group reclassification. CAHs would gain flexibility to respond to daily and seasonal fluctuations in patient load and cost-based reimbursement for outpatient lab services. The bill also would remove the cap on disproportionate-share adjustment percentages for all hospitals, rebase sole community hospital payments, provide grants for health information technology, and expand the 340B drug discount program.

The Craig Thomas Rural Hospital and Provider Equity Act (R-HoPE) (S.1605) would extend the outpatient hold-harmless provision for rural hospitals under 100 beds and sole community hospitals, continue the grandfather clause allowing direct payments to independent laboratories for the technical component of pathology services, and extend the 5% rural add-on payment for home health services.  In addition, the bill would provide cost-based reimbursement for CAHs' outpatient lab services regardless of where the patient is physically located, remove the cap on disproportionate share adjustment percentages for all hospitals and improve payments for ambulance services in rural areas.  The bill was introduced by Sens. Kent Conrad (D-ND) and Pat Roberts (R-KS).

Critical Access to Clinical Lab Services Act (S. 1277) would work to restore cost-based reimbursement of referral lab services.  In 2003 CMS revised its lab payment policy specifying that CAHs could no longer be reimbursed at-cost for lab services, unless patients are physically present in the hospital lab when specimens are collected. Many CAHs continue to provide lab services at community health centers, skilled nursing facilities and in patients' homes. They are increasingly concerned about the costs of offering off-site lab testing.  The bill was introduced by Sen. Ben Nelson (D-NE).

The 340B Program Improvement and Integrity Act (H.R. 2606) would allow CAHs, sole community hospitals, rural referral centers and Medicare-dependent hospitals to access 340B discounts for inpatient and outpatient drugs.  The bill also would extend the discount to inpatient drugs for current eligible 340B hospitals.  H.R. 2606's sponsors include Reps. Bobby Rush (D-IL), Bart Stupak (D-MI) and Jo Ann Emerson (R-MO).

Rural Health Services Preservation Act (S.630/H.R. 2159) would ensure CAHs receive at least 101% of costs for inpatient, swing-bed and outpatient hospital services and rural health clinics receive the applicable all-inclusive rate for services provided to Medicare Advantage patients.  The bill's sponsors are Sens. Norm Coleman (R-MN), Tom Harkin (D-IA) and Richard Durbin (D-IL) and Reps. Ron Kind (D-WI) and Cathy McMorris-Rodgers (R-WA).


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