A bipartisan group of lawmakers have recently introduced a spate of AHA-backed legislation that supports small and rural prospective payment system (PPS) hospitals and critical access hospitals (CAH).  Securing passage of the legislation is part of the AHA’s advocacy agenda. The rural hospital relief bills include the following.

 Making MDH program, low-volume adjustment permanent.Sens. Charles Grassley, R-Iowa, and Chuck Schumer, D-N.Y., joined Reps. Tom Reed, R-N.Y., and Peter Welch, D-Vt., on Feb. 3 to introduce the Rural Hospital Access Act, S. 332/H.R. 663, legislation that would make permanent both the Medicare-dependent Hospital (MDH) program and the enhanced low-volume Medicare adjustment for small rural PPS hospitals.

Without congressional action, the current short-term extension of the programs will expire on March 31. In letters of support for the legislation, AHA Executive Vice President Rick Pollack called these “vital programs for America’s rural hospitals and the patients and communities they serve.”

Under the MDH program, about 200 hospitals that are more dependent on Medicare revenue because of the high percentage of Medicare beneficiaries in rural areas receive the sum of their PPS payment rate, plus three-quarters of the amount by which their cost per discharge exceeds the PPS rate. The enhanced low-volume adjustment helps level the playing field for hospitals in small and isolated communities, which frequently cannot achieve the economies of scale possible for their larger counterparts.


Extending the Rural Community Hospital Demonstration. Rep. Don Young, R-Alaska, introduced on Feb. 3 the Rural Community Hospital Demonstration (RCH) Extension Act, H.R. 672, which would extend the demonstration for five years.

The program enables rural hospitals with fewer than 51 acute-care beds to test the feasibility of cost-based reimbursement. Currently, 23 small rural hospitals participate.

“By extending the demonstration for five more years, your legislation will ensure that RCH continues to help America’s communities in many ways, especially by allowing hospitals to expand and improve the services rural communities need,” the AHA’s Pollack wrote the bill’s sponsor in a letter of support. The program was created by the 2003 Medicare Modernization Act of 2003 and extended by the Affordable Care Act.


Removing 96-hour certification requirement for CAHs. Sens. Pat Roberts, R-Kan., and Jon Tester, D-Mont., Jan. 27 introduced a Senate companion to the Critical Access Hospital Relief Act, S. 258/H.R. 169. The legislation would remove the 96-hour physician certification requirement as a condition of payment for CAHs.

Medicare currently requires physicians to certify that patients admitted to a CAH will be discharged or transferred to another hospital within 96 hours in order for the CAH to receive payment under Medicare Part A.

The Centers for Medicare & Medicaid Services (CMS) has not historically enforced the requirement, but in recent guidance related to its two-midnight admissions policy implied that it will, a situation that would threaten patients’ access to longer care when needed. The legislation would not remove the requirement that CAHs maintain an average annual length of stay of 96 hours, nor affect other certification requirements for hospitals.

“This absurd rule puts arbitrary limits on how many hours patients can stay in critical access hospitals, and asks doctors to be clairvoyant and predict the unknown when admitting a patient,” said Roberts, who is co-chairman of the Senate Rural Health Caucus.

Original co-sponsors include Sens. John Thune, R-S.D., Jerry Moran, R-Kan., John Barrasso, R-Wyo., Daniel Coats, R-Ind., Grassley, Thad Cochran, R-Miss., Deb Fischer R-Neb., Steve Daines, R-Mont., James Inhofe, R-Okla., Roger Wicker, R-Miss., John Hoeven, R-N.D., Heidi Heitkamp, D-N.D., and Tammy Baldwin, D-Wis.

The AHA’s Pollack wrote the bill’s sponsors that the measure would “provide important relief for (critical access hospitals) and help ensure all Americans – no matter where they live – have access to essential health care services.”


Protecting rural access to outpatient services.  Moran, Tester and Thune Jan. 27 introduced the Protecting Access to Rural Therapy Services (PARTS) Act, S. 257. The legislation would allow general supervision by a physician or non-physician practitioner for many outpatient therapeutic services.

The bill would require CMS to adopt a default setting of general supervision (rather than direct supervision) for outpatient therapeutic services, and create an advisory panel to establish an exceptions process for risky and complex outpatient services that require a higher, direct level of supervision. The legislation also would create a special rule for critical access hospitals that recognizes their unique size and Medicare conditions of participation, and hold hospitals and CAHs harmless from civil or criminal action regarding CMS’s retroactive reinterpretation of “direct supervision” requirements for the period 2001 through 2015.


Extending add-on payments for rural ambulance providers. AHA-supported legislation introduced Feb. 5 in the House and Senate would permanently extend add-on payments for ambulance services in rural areas, which are set to expire March 31. The Medicare Ambulance Access, Fraud Prevention, and Reform Act, S. 377/H.R. 745, was introduced by Roberts, Schumer, Welch and Rep. Greg Walden, R-Ore. The legislation directs the Department of Health and Human Services (HHS) to study if additional payments should be modified to account for the costs of providing ambulance services in urban, rural and so-called “super-rural” areas. “This ensures federal payments are aligned with appropriate data and utilization patterns,” the AHA’s Pollack wrote in a letter of support for the bill. The legislation also directs HHS to establish a process for preauthorizing ambulance services for patients with end-stage renal disease.

For more on the AHA’s letters of support for these bills, click here