[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3684 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 3684
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
June 3, 2025
Mr. Graves (for himself and Ms. Budzinski) introduced the following
bill; which was referred to the Committee on Ways and Means, and in
addition to the Committees on Energy and Commerce, 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) As of May 1, 2025, 151 rural hospitals have 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 thirty-two 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 432 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. Permanently extending payment levels for low-volume hospitals
and Medicare-dependent hospitals (MDHs).
Sec. 104. Extending disproportionate share payments for sole community
hospitals and medicare-dependent hospitals.
Sec. 105. Rebasing target amounts for Medicare-dependent hospitals and
sole community hospitals.
Sec. 106. Implementing area wage index adjustments.
Subtitle B--Other Rural Providers
Sec. 111. Making permanent increased Medicare payments for ground
ambulance services in rural areas.
Sec. 112. Permanently extending Medicare telehealth service
enhancements for federally qualified health
centers and rural health clinics.
Sec. 113. Restoring State authority to waive the 35-mile rule for
certain Medicare critical access hospital
designations.
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 requirements with respect to inpatient
CAH services.
Sec. 302. Eliminating hospitalization requirement for extended care
services furnished by certain hospitals.
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 (as defined in section 1886(d)(1)(B) of such
Act) 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 at the end 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 ``, a critical
access hospital'' after ``or (V)''.
(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. PERMANENTLY 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, 2025''; and
(B) in clause (ii)(II), by striking ``, and before
October 1, 2025''.
(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, 2025''; and
(ii) in clause (iv), by striking ``through
fiscal year 2025'' 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 ``through
fiscal year 2025'' and inserting ``, or 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 subparagraph heading, 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 2026 and
subsequent fiscal years'';
(2) in subparagraph (C)(i)--
(A) in the matter preceding subclause (I), by
striking ``through 2025'' and inserting ``and each
subsequent fiscal year'';
(B) in subclause (II), by adding ``and'' at the
end;
(C) in subclause (III)--
(i) by striking ``fiscal years 2019 through
2025'' 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:
``Permanent applicable percentage increase'';
(B) in the matter preceding clause (i), by striking
``in fiscal years 2011 through 2025'' and inserting
``in fiscal year 2011 or a subsequent fiscal year'';
and
(C) in clause (ii), by striking ``each of fiscal
years 2019 through 2025'' and inserting ``fiscal year
2019 and each subsequent fiscal year''.
SEC. 104. EXTENDING DISPROPORTIONATE SHARE PAYMENTS FOR SOLE COMMUNITY
HOSPITALS AND MEDICARE-DEPENDENT HOSPITALS.
Section 1886 of the Social Security Act (42 U.S.C. 1395ww) is
amended--
(1) in subsection (d)(5)(F)(i), by inserting ``, including,
with respect to discharges occurring in fiscal year 2026 and
each subsequent fiscal year, a subsection (d) hospitals that is
a sole community hospitals paid the amount described in
subparagraph (D)(i)(I) or a medicare-dependent, small rural
hospital paid the amount described in subparagraph (G),'' after
``subsection (d) hospital''; and
(2) in subsection (r)(2), by inserting ``(including, with
respect to fiscal year 2026 and each subsequent fiscal year,
subsection (d) hospitals that are sole community hospitals or
medicare-dependent, small rural hospitals described in
subsection (d)(5)(F)(i))'' after ``such subsection (d)
hospitals''.
SEC. 105. REBASING TARGET AMOUNTS FOR MEDICARE-DEPENDENT HOSPITALS AND
SOLE COMMUNITY HOSPITALS.
Section 1886(b)(3) of the Social Security Act (42 U.S.C.
1395ww(b)(3)) is amended--
(1) in subparagraph (K)(i)--
(A) in subclause (I), by inserting ``(or, with
respect to discharges occurring on or after October 1,
2025, the 12-month cost reporting period beginning
during fiscal year 2024)'' after ``fiscal year 2002'';
and
(B) in subclause (II), by inserting ``(or, with
respect to discharges occurring on or after October 1,
2025, the first cost reporting period beginning on or
after such date)'' after ``October 1, 2006''; and
(2) in subparagraph (L)(ii)--
(A) in subclause (I), by inserting ``(or, with
respect to discharges occurring on or after October 1,
2025, the 12-month cost reporting period beginning
during fiscal year 2024)'' after ``fiscal year 2006'';
and
(B) in subclause (II), by inserting ``(or, with
respect to discharges occurring on or after October 1,
2025, the first cost reporting period beginning on or
after such date)'' after ``January 1, 2009''.
SEC. 106. IMPLEMENTING AREA WAGE INDEX ADJUSTMENTS.
(a) Codification of Low-Wage Index Hospital Policy.--Section
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)) is
amended by adding at the end the following new clause:
``(v) Low-wage hospitals.--For discharges occurring
on or after October 1, 2025, the area wage index
applicable under this subparagraph for a fiscal year to
a hospital with an area wage index below the 25th
percentile area wage index shall be increased by \1/2\
of the difference between the otherwise applicable
final area wage index for such fiscal year for such
hospital and the 25th percentile area wage index for
such fiscal year across all hospitals. Pursuant to the
fourth sentence of clause (i), the preceding sentence
shall be applied in a budget neutral manner.''.
(b) Area Wage Adjustment for Hospitals Not Located in Frontier
States.--
(1) Hospital inpatient services.--Section 1886(d)(3)(E) of
the Social Security Act (42 U.S.C. 1395ww(d)(3)(E)), as amended
by subsection (a), is further amended by adding at the end the
following new clause:
``(vi) Floor on area wage index for hospitals in
certain other areas.--
``(I) In general.--For discharges occurring
on or after October 1, 2025, the area wage
index applicable under this subparagraph to any
hospital which is not located in a frontier
State (as defined in clause (iii)(II)) may not
be less than 0.85.
``(II) Ensuring budget neutrality.--In
order to ensure that the aggregate payments
made under this subsection for a fiscal year
(beginning with fiscal year 2026) are not
greater than the aggregate payments that would
have been made under this subsection for such
fiscal year without the application of
subclause (I), as estimated by the Secretary,
the Secretary shall establish pursuant to
rulemaking a maximum area wage index to apply
under this subparagraph to any hospital which
is not located in a frontier State (as defined
in clause (iii)(II)).
``(III) No impact for hospitals with an
area wage index between the floor and the
maximum index.--Subclauses (I) and (II) shall
have no effect on the area wage index
applicable in a fiscal year to a hospital with
an area wage index that is greater than the
floor under subclause (I) but less than the
maximum area wage index established under
subclause (II) for the fiscal year.''.
(2) Hospital outpatient department services.--Section
1833(t) of the Social Security Act (42 U.S.C. 1395l(t)), is
amended--
(A) in paragraph (2)(D), by striking ``paragraph
(19)'' and inserting ``paragraphs (19) and (23)''; and
(B) by adding at the end the following new
paragraph:
``(23) Floor on area wage adjustment factor for hospital
outpatient department services in areas other than in frontier
states.--
``(A) In general.--With respect to covered OPD
services furnished on or after January 1, 2026, the
area wage adjustment factor applicable under the
payment system established under this subsection to any
hospital outpatient department which is not located in
a frontier State (as defined in section
1886(d)(3)(E)(iii)(II)) may not be less than 0.85.
``(B) Ensuring budget neutrality.--In order to
ensure that the aggregate payments made under this
subsection for a year (beginning with 2026) are not
greater than the aggregate payments that would have
been made under this subsection for such year without
the application of subparagraph (A), as estimated by
the Secretary, the Secretary shall establish pursuant
to rulemaking a maximum area wage adjustment factor to
apply under the payment system established under this
subsection to any hospital outpatient department which
is not located in a frontier State (as defined in
clause (iii)(II)).
``(C) No impact for hospitals with an area wage
adjustment factor between the floor and the maximum
factor.--Subparagraphs (A) and (B) shall have no effect
on the area wage adjustment factor applicable in a year
to a hospital with an area wage adjustment factor that
is greater than the floor under subparagraph (A) but
less than the maximum area wage adjustment factor
established under subparagraph (B) for the year.''.
(c) Conforming Amendments.--Section 1886(d)(3)(E) of the Social
Security Act (42 U.S.C. 1395ww(d)(3)(E)), as amended by subsections (a)
and (b), is further amended--
(1) in clause (i), by striking ``or (iv)'' and inserting
``(iv), (v), or (vi)'';
(2) in clause (iii), by adjusting the margins of such
clause 2 ems to the left; and
(3) in clause (iv), by adjusting the margins of such clause
2 ems to the left.
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 stri