At the recent AHA Health Forum Rural Healthcare Leadership Conference in Phoenix, AHA President Rich Umbdenstock and AHA staff  briefed attendees on the latest rural health care legislative developments.

A bipartisan group of lawmakers recently introduced a spate of AHA-backed legislation that supports small and rural prospective payment system (PPS) hospitals and critical access hospitals (CAH). The legislation would make the Medicare-dependent Hospital (MDH) program permanent; extend the Rural Community Demonstration program; remove the 96-hour certification requirement for CAHs; and protect rural access to outpatient services.

Rural hospital leaders will make their case for passing these measures at the AHA’s upcoming Advocacy Day briefings scheduled for Feb. 26 and March 19 in Washington, D.C. For more on Advocacy Day, visit


AHA-backed rural hospital legislation. 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 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. 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.

More than 500 hospitals receive the low-volume adjustment, which Congress established in 1988. Under the program, a hospital can receive a special Medicare payment if it is more than 15 miles from another comparable hospital and discharges fewer than 1,600 Medicare patients a year. 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.

Rep. Don Young, R-Alaska, introduced on Feb. 3 the Rural Community Hospital Demonstration 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.


Support for critical access hospitals. Sens. Pat Roberts, R-Kan., and Jon Tester, D-Mont., and Rep. Adrian Smith, R-Neb., last month introduced 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.

Sens. Jerry Moran, R-Kan., Tester and John Thune, R-S.D., last month introduced the Protecting Access to Rural Therapy Services (PARTS) Act, S. 257, which would allow general supervision by a physician or non-physician practitioner for many outpatient therapeutic services.

For more on the important role that CAHs play in rural communities, click on the CAH infographic.