Attachment A - U.S. Code

§ 1395i–4

TITLE 42—THE PUBLIC HEALTH AND WELFARE

(VI) Area Agencies on Aging; and
(VII) other appropriate entities.
(C) Authorization
There are authorized to be appropriated to
carry out this paragraph, for each of fiscal
years 2011 through 2014, $5,000,000.
(Pub. L. 111–148, title VI, § 6703(b)(1), (2), Mar. 23,
2010, 124 Stat. 798, 799.)
REFERENCES IN TEXT
The Social Security Act, referred to in par. (1)(A), is
act Aug. 14, 1935, ch. 531, 49 Stat. 620. Titles XVIII and
XIX of the Act are classified generally to this subchapter (§ 1395 et seq.) and subchapter XIX (§ 1396 et
seq.), respectively, of this chapter. For complete classification of this Act to the Code, see section 1305 of this
title and Tables.
CODIFICATION
Section was enacted as part of the Elder Justice Act
of 2009 and also as part of the Patient Protection and
Affordable Care Act, and not as part of the Social Security Act which comprises this chapter.
DEFINITIONS
Pub. L. 111–148, title VI, § 6702, Mar. 23, 2010, 124 Stat.
782, provided that: ‘‘Except as otherwise specifically
provided, any term that is defined in section 2011 of the
Social Security Act [42 U.S.C. 1397j] (as added by section 6703(a)) and is used in this subtitle [subtitle H
(§§ 6701–6703) of title VI of Pub. L. 111–148, enacting this
section and sections 1320b–25, 1397j, 1397j–1, 1397k to
1397k–3, 1397l, and 1397m to 1397m–5 of this title, amending sections 602, 604, 622, 671 to 673, 1320a–7, 1320a–7a,
1397, 1397a, 1397c to 1397e, and 1397g of this title, and enacting provisions set out as notes under sections 602
and 1305 of this title] has the meaning given such term
by such section.’’

§ 1395i–4. Medicare rural hospital flexibility program
(a) Establishment
Any State that submits an application in accordance with subsection (b) may establish a
medicare rural hospital flexibility program described in subsection (c).
(b) Application
A State may establish a medicare rural hospital flexibility program described in subsection
(c) if the State submits to the Secretary at such
time and in such form as the Secretary may require an application containing—
(1) assurances that the State—
(A) has developed, or is in the process of
developing, a State rural health care plan
that—
(i) provides for the creation of 1 or more
rural health networks (as defined in subsection (d)) in the State;
(ii) promotes regionalization of rural
health services in the State; and
(iii) improves access to hospital and
other health services for rural residents of
the State; and
(B) has developed the rural health care
plan described in subparagraph (A) in consultation with the hospital association of
the State, rural hospitals located in the
State, and the State Office of Rural Health
(or, in the case of a State in the process of
developing such plan, that assures the Sec-

Page 2584

retary that the State will consult with its
State hospital association, rural hospitals
located in the State, and the State Office of
Rural Health in developing such plan);
(2) assurances that the State has designated
(consistent with the rural health care plan described in paragraph (1)(A)), or is in the process of so designating, rural nonprofit or public
hospitals or facilities located in the State as
critical access hospitals; and
(3) such other information and assurances as
the Secretary may require.
(c) Medicare rural hospital flexibility program
described
(1) In general
A State that has submitted an application in
accordance with subsection (b), may establish
a medicare rural hospital flexibility program
that provides that—
(A) the State shall develop at least 1 rural
health network (as defined in subsection (d))
in the State; and
(B) at least 1 facility in the State shall be
designated as a critical access hospital in accordance with paragraph (2).
(2) State designation of facilities
(A) In general
A State may designate 1 or more facilities
as a critical access hospital in accordance
with subparagraphs (B), (C), and (D).
(B) Criteria for designation as critical access
hospital
A State may designate a facility as a critical access hospital if the facility—
(i) is a hospital that is located in a county (or equivalent unit of local government)
in a rural area (as defined in section
1395ww(d)(2)(D) of this title) or is treated
as being located in a rural area pursuant
to section 1395ww(d)(8)(E) of this title, and
that—
(I) is located more than a 35-mile drive
(or, in the case of mountainous terrain
or in areas with only secondary roads
available, a 15-mile drive) from a hospital, or another facility described in
this subsection; or
(II) is certified before January 1, 2006,
by the State as being a necessary provider of health care services to residents
in the area;
(ii) makes available 24-hour emergency
care services that a State determines are
necessary for ensuring access to emergency care services in each area served by
a critical access hospital;
(iii) provides not more than 25 acute care
inpatient beds (meeting such standards as
the Secretary may establish) for providing
inpatient care for a period that does not
exceed, as determined on an annual, average basis, 96 hours per patient;
(iv) meets such staffing requirements as
would apply under section 1395x(e) of this
title to a hospital located in a rural area,
except that—
(I) the facility need not meet hospital
standards relating to the number of

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

hours during a day, or days during a
week, in which the facility must be open
and fully staffed, except insofar as the
facility is required to make available
emergency care services as determined
under clause (ii) and must have nursing
services available on a 24-hour basis, but
need not otherwise staff the facility except when an inpatient is present;
(II) the facility may provide any services otherwise required to be provided by
a full-time, on site dietitian, pharmacist,
laboratory technician, medical technologist, and radiological technologist
on a part-time, off site basis under arrangements as defined in section
1395x(w)(1) of this title; and
(III) the inpatient care described in
clause (iii) may be provided by a physician assistant, nurse practitioner, or
clinical nurse specialist subject to the
oversight of a physician who need not be
present in the facility; and
(v) meets the requirements of section
1395x(aa)(2)(I) of this title.
(C) Recently closed facilities
A State may designate a facility as a critical access hospital if the facility—
(i) was a hospital that ceased operations
on or after the date that is 10 years before
November 29, 1999; and
(ii) as of the effective date of such designation, meets the criteria for designation under subparagraph (B).
(D) Downsized facilities
A State may designate a health clinic or a
health center (as defined by the State) as a
critical access hospital if such clinic or center—
(i) is licensed by the State as a health
clinic or a health center;
(ii) was a hospital that was downsized to
a health clinic or health center; and
(iii) as of the effective date of such designation, meets the criteria for designation under subparagraph (B).
(E) Authority to establish psychiatric and rehabilitation distinct part units
(i) In general
Subject to the succeeding provisions of
this subparagraph, a critical access hospital may establish—
(I) a psychiatric unit of the hospital
that is a distinct part of the hospital;
and
(II) a rehabilitation unit of the hospital that is a distinct part of the hospital,
if the distinct part meets the requirements
(including conditions of participation)
that would otherwise apply to the distinct
part if the distinct part were established
by a subsection (d) hospital in accordance
with the matter following clause (v) 1 of
section 1395ww(d)(1)(B) of this title, includ1 See

References in Text note below.

§ 1395i–4

ing any regulations adopted by the Secretary under such section.
(ii) Limitation on number of beds
The total number of beds that may be established under clause (i) for a distinct
part unit may not exceed 10.
(iii) Exclusion of beds from bed count
In determining the number of beds of a
critical access hospital for purposes of applying the bed limitations referred to in
subparagraph (B)(iii) and subsection (f),
the Secretary shall not take into account
any bed established under clause (i).
(iv) Effect of failure to meet requirements
If a psychiatric or rehabilitation unit established under clause (i) does not meet
the requirements described in such clause
with respect to a cost reporting period, no
payment may be made under this subchapter to the hospital for services furnished in such unit during such period.
Payment to the hospital for services furnished in the unit may resume only after
the hospital has demonstrated to the Secretary that the unit meets such requirements.
(d) ‘‘Rural health network’’ defined
(1) In general
In this section, the term ‘‘rural health network’’ means, with respect to a State, an organization consisting of—
(A) at least 1 facility that the State has
designated or plans to designate as a critical
access hospital; and
(B) at least 1 hospital that furnishes acute
care services.
(2) Agreements
(A) In general
Each critical access hospital that is a
member of a rural health network shall have
an agreement with respect to each item described in subparagraph (B) with at least 1
hospital that is a member of the network.
(B) Items described
The items described in this subparagraph
are the following:
(i) Patient referral and transfer.
(ii) The development and use of communications systems including (where feasible)—
(I) telemetry systems; and
(II) systems for electronic sharing of
patient data.
(iii) The provision of emergency and nonemergency transportation among the facility and the hospital.
(C) Credentialing and quality assurance
Each critical access hospital that is a
member of a rural health network shall have
an agreement with respect to credentialing
and quality assurance with at least—
(i) 1 hospital that is a member of the
network;
(ii) 1 peer review organization or equivalent entity; or

§ 1395i–4

TITLE 42—THE PUBLIC HEALTH AND WELFARE

(iii) 1 other appropriate and qualified entity identified in the State rural health
care plan.
(e) Certification by Secretary
The Secretary shall certify a facility as a critical access hospital if the facility—
(1) is located in a State that has established
a medicare rural hospital flexibility program
in accordance with subsection (c);
(2) is designated as a critical access hospital
by the State in which it is located; and
(3) meets such other criteria as the Secretary may require.
(f) Permitting maintenance of swing beds
Nothing in this section shall be construed to
prohibit a State from designating or the Secretary from certifying a facility as a critical access hospital solely because, at the time the facility applies to the State for designation as a
critical access hospital, there is in effect an
agreement between the facility and the Secretary under section 1395tt of this title under
which the facility’s inpatient hospital facilities
are used for the provision of extended care services, so long as the total number of beds that
may be used at any time for the furnishing of either such services or acute care inpatient services does not exceed 25 beds. For purposes of the
previous sentence, any bed of a unit of the facility that is licensed as a distinct-part skilled
nursing facility at the time the facility applies
to the State for designation as a critical access
hospital shall not be counted.
(g) Grants
(1) Medicare rural hospital flexibility program
The Secretary may award grants to States
that have submitted applications in accordance with subsection (b) for—
(A) engaging in activities relating to planning and implementing a rural health care
plan;
(B) engaging in activities relating to planning and implementing rural health networks;
(C) designating facilities as critical access
hospitals; and
(D) providing support for critical access
hospitals for quality improvement, quality
reporting, performance improvements, and
benchmarking.
(2) Rural emergency medical services
(A) In general
The Secretary may award grants to States
that have submitted applications in accordance with subparagraph (B) for the establishment or expansion of a program for the
provision of rural emergency medical services.
(B) Application
An application is in accordance with this
subparagraph if the State submits to the
Secretary at such time and in such form as
the Secretary may require an application
containing the assurances described in subparagraphs (A)(ii), (A)(iii), and (B) of subsection (b)(1) and paragraph (3) of that subsection.

Page 2586

(3) Upgrading data systems
(A) Grants to hospitals
The Secretary may award grants to hospitals that have submitted applications in
accordance with subparagraph (C) to assist
eligible small rural hospitals in meeting the
costs of implementing data systems required
to meet requirements established under the
medicare program pursuant to amendments
made by the Balanced Budget Act of 1997 and
to assist such hospitals in participating in
delivery system reforms under the provisions of and amendments made by the Patient Protection and Affordable Care Act,
such as value-based purchasing programs,
accountable care organizations under section 1395jjj of this title, the National pilot
program on payment bundling under section
1395cc–4 of this title, and other delivery system reform programs determined appropriate by the Secretary.
(B) Eligible small rural hospital defined
For purposes of this paragraph, the term
‘‘eligible small rural hospital’’ means a nonFederal, short-term general acute care hospital that—
(i) is located in a rural area (as defined
for purposes of section 1395ww(d) of this
title); and
(ii) has less than 50 beds.
(C) Application
A hospital seeking a grant under this paragraph shall submit an application to the
Secretary on or before such date and in such
form and manner as the Secretary specifies.
(D) Amount of grant
A grant to a hospital under this paragraph
may not exceed $50,000.
(E) Use of funds
A hospital receiving a grant under this
paragraph may use the funds for the purchase of computer software and hardware,
the education and training of hospital staff
on computer information systems, to offset
costs related to the implementation of prospective payment systems and to participate
in delivery system reforms under the provisions of and amendments made by the Patient Protection and Affordable Care Act,
such as value-based purchasing programs,
accountable care organizations under section 1395jjj of this title, the National pilot
program on payment bundling under section
1395cc–4 of this title, and other delivery system reform programs determined appropriate by the Secretary.
(F) Reports
(i) Information
A hospital receiving a grant under this
section shall furnish the Secretary with
such information as the Secretary may require to evaluate the project for which the
grant is made and to ensure that the grant
is expended for the purposes for which it is
made.

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

(ii) Timing of submission
(I) Interim reports
The Secretary shall report to the Committee on Ways and Means of the House
of Representatives and the Committee
on Finance of the Senate at least annually on the grant program established
under this section, including in such report information on the number of
grants made, the nature of the projects
involved, the geographic distribution of
grant recipients, and such other matters
as the Secretary deems appropriate.
(II) Final report
The Secretary shall submit a final report to such committees not later than
180 days after the completion of all of
the projects for which a grant is made
under this section.
(4) Additional requirements with respect to
FLEX grants
With respect to grants awarded under paragraph (1) or (2) from funds appropriated for fiscal year 2005 and subsequent fiscal years—
(A) Consultation with the state hospital association and rural hospitals on the most
appropriate ways to use grants
A State shall consult with the hospital association of such State and rural hospitals
located in such State on the most appropriate ways to use the funds under such
grant.
(B) Limitation on use of grant funds for administrative expenses
A State may not expend more than the
lesser of—
(i) 15 percent of the amount of the grant
for administrative expenses; or
(ii) the State’s federally negotiated indirect rate for administering the grant.
(5) Use of funds for Federal administrative expenses
Of the total amount appropriated for grants
under paragraphs (1) and (2) for a fiscal year
(for each of fiscal years 2005 through 2008) and,
of the total amount appropriated for grants
under paragraphs (1), (2), and (6) for a fiscal
year (beginning with fiscal year 2009), up to 5
percent of such amount shall be available to
the Health Resources and Services Administration for purposes of administering such
grants.
(6) Providing mental health services and other
health services to veterans and other residents of rural areas
(A) Grants to States
The Secretary may award grants to States
that have submitted applications in accordance with subparagraph (B) for increasing
the delivery of mental health services or
other health care services deemed necessary
to meet the needs of veterans of Operation
Iraqi Freedom and Operation Enduring Freedom living in rural areas (as defined for purposes of section 1395ww(d) of this title and
including areas that are rural census tracks,

§ 1395i–4

as defined by the Administrator of the
Health Resources and Services Administration), including for the provision of crisis
intervention services and the detection of
post-traumatic stress disorder, traumatic
brain injury, and other signature injuries of
veterans of Operation Iraqi Freedom and Operation Enduring Freedom, and for referral
of such veterans to medical facilities operated by the Department of Veterans Affairs,
and for the delivery of such services to other
residents of such rural areas.
(B) Application
(i) In general
An application is in accordance with this
subparagraph if the State submits to the
Secretary at such time and in such form as
the Secretary may require an application
containing the assurances described in
subparagraphs (A)(ii) and (A)(iii) of subsection (b)(1).
(ii) Consideration of regional approaches,
networks, or technology
The Secretary may, as appropriate in
awarding grants to States under subparagraph (A), consider whether the application submitted by a State under this subparagraph includes 1 or more proposals
that utilize regional approaches, networks,
health information technology, telehealth,
or telemedicine to deliver services described in subparagraph (A) to individuals
described in that subparagraph. For purposes of this clause, a network may, as the
Secretary determines appropriate, include
Federally qualified health centers (as defined in section 1395x(aa)(4) of this title),
rural health clinics (as defined in section
1395x(aa)(2) of this title), home health
agencies (as defined in section 1395x(o) of
this title), community mental health centers (as defined in section 1395x(ff)(3)(B) of
this title) and other providers of mental
health services, pharmacists, local government, and other providers deemed necessary to meet the needs of veterans.
(iii) Coordination at local level
The Secretary shall require, as appropriate, a State to demonstrate consultation with the hospital association of such
State, rural hospitals located in such
State, providers of mental health services,
or other appropriate stakeholders for the
provision of services under a grant awarded under this paragraph.
(iv) Special consideration of certain applications
In awarding grants to States under subparagraph (A), the Secretary shall give
special consideration to applications submitted by States in which veterans make
up a high percentage (as determined by the
Secretary) of the total population of the
State. Such consideration shall be given
without regard to the number of veterans
of Operation Iraqi Freedom and Operation
Enduring Freedom living in the areas in
which mental health services and other

§ 1395i–4

TITLE 42—THE PUBLIC HEALTH AND WELFARE

health care services would be delivered
under the application.
(C) Coordination with VA
The Secretary shall, as appropriate, consult with the Director of the Office of Rural
Health of the Department of Veterans Affairs in awarding and administering grants
to States under subparagraph (A).
(D) Use of funds
A State awarded a grant under this paragraph may, as appropriate, use the funds to
reimburse providers of services described in
subparagraph (A) to individuals described in
that subparagraph.
(E) Limitation on use of grant funds for administrative expenses
A State awarded a grant under this paragraph may not expend more than 15 percent
of the amount of the grant for administrative expenses.
(F) Independent evaluation and final report
The Secretary shall provide for an independent evaluation of the grants awarded
under subparagraph (A). Not later than 1
year after the date on which the last grant
is awarded to a State under such subparagraph, the Secretary shall submit a report to
Congress on such evaluation. Such report
shall include an assessment of the impact of
such grants on increasing the delivery of
mental health services and other health
services to veterans of the United States
Armed Forces living in rural areas (as so defined and including such areas that are rural
census tracks), with particular emphasis on
the impact of such grants on the delivery of
such services to veterans of Operation Enduring Freedom and Operation Iraqi Freedom, and to other individuals living in such
rural areas.
(7) Critical access hospitals transitioning to
skilled nursing facilities and assisted living
facilities
(A) Grants
The Secretary may award grants to eligible critical access hospitals that have submitted applications in accordance with subparagraph (B) for assisting such hospitals in
the transition to skilled nursing facilities
and assisted living facilities.
(B) Application
An applicable critical access hospital seeking a grant under this paragraph shall submit an application to the Secretary on or before such date and in such form and manner
as the Secretary specifies.
(C) Additional requirements
The Secretary may not award a grant
under this paragraph to an eligible critical
access hospital unless—
(i) local organizations or the State in
which the hospital is located provides
matching funds; and
(ii) the hospital provides assurances that
it will surrender critical access hospital
status under this subchapter within 180
days of receiving the grant.

Page 2588

(D) Amount of grant
A grant to an eligible critical access hospital under this paragraph may not exceed
$1,000,000.
(E) Funding
There are appropriated from the Federal
Hospital Insurance Trust Fund under section
1395i of this title for making grants under
this paragraph, $5,000,000 for fiscal year 2008.
(F) Eligible critical access hospital defined
For purposes of this paragraph, the term
‘‘eligible critical access hospital’’ means a
critical access hospital that has an average
daily acute census of less than 0.5 and an average daily swing bed census of greater than
10.0.
(h) Grandfathering provisions
(1) In general
Any medical assistance facility operating in
Montana and any rural primary care hospital
designated by the Secretary under this section
prior to August 5, 1997, shall be deemed to
have been certified by the Secretary under
subsection (e) as a critical access hospital if
such facility or hospital is otherwise eligible
to be designated by the State as a critical access hospital under subsection (c).
(2) Continuation of medical assistance facility
and rural primary care hospital terms
Notwithstanding any other provision of this
subchapter, with respect to any medical assistance facility or rural primary care hospital
described in paragraph (1), any reference in
this subchapter to a ‘‘critical access hospital’’
shall be deemed to be a reference to a ‘‘medical assistance facility’’ or ‘‘rural primary care
hospital’’.
(3) State authority to waive 35-mile rule
In the case of a facility that was designated
as a critical access hospital before January 1,
2006, and was certified by the State as being a
necessary provider of health care services to
residents in the area under subsection
(c)(2)(B)(i)(II), as in effect before such date,
the authority under such subsection with respect to any redesignation of such facility
shall continue to apply notwithstanding the
amendment made by section 405(h)(1) of the
Medicare Prescription Drug, Improvement,
and Modernization Act of 2003.
(i) Waiver of conflicting part A provisions
The Secretary is authorized to waive such provisions of this part and part E as are necessary
to conduct the program established under this
section.
(j) Authorization of appropriations
There are authorized to be appropriated from
the Federal Hospital Insurance Trust Fund for
making grants to all States under subsection
(g), $25,000,000 in each of the fiscal years 1998
through 2002, for making grants to all States
under paragraphs (1) and (2) of subsection (g),
$35,000,000 in each of fiscal years 2005 through
2008, for making grants to all States under paragraphs (1) and (2) of subsection (g), $55,000,000 in
each of fiscal years 2009 and 2010, for making

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TITLE 42—THE PUBLIC HEALTH AND WELFARE

grants to all States under paragraph (6) of subsection (g), $50,000,000 in each of fiscal years 2009
and 2010, to remain available until expended and
for making grants to all States under subsection
(g), such sums as may be necessary in each of
fiscal years 2011 and 2012, to remain available
until expended.
(Aug. 14, 1935, ch. 531, title XVIII, § 1820, as added
Pub. L. 101–239, title VI, § 6003(g)(1)(A), Dec. 19,
1989, 103 Stat. 2145; amended Pub. L. 101–508, title
IV, § 4008(d)(1)–(3), (m)(2)(B), Nov. 5, 1990, 104
Stat. 1388–44, 1388–45, 1388–53; Pub. L. 103–432,
title I, § 102(a)(1), (2), (b)(1)(A), (2), (c), (f), (h),
Oct. 31, 1994, 108 Stat. 4401–4404; Pub. L. 105–33,
title IV, §§ 4002(f)(1), 4201(a), Aug. 5, 1997, 111
Stat. 329, 369; Pub. L. 106–113, div. B, § 1000(a)(6)
[title III, § 321(a), title IV, §§ 401(b)(2), 403(a)(1),
(b), (c), 409], Nov. 29, 1999, 113 Stat. 1536,
1501A–365, 1501A–369, 1501A–370, 1501A–375; Pub. L.
108–173, title I, § 101(e)(1), title IV, § 405(e)(1), (2),
(f), (g)(1), (h), Dec. 8, 2003, 117 Stat. 2150,
2267–2269; Pub. L. 110–275, title I, § 121, July 15,
2008, 122 Stat. 2511; Pub. L. 111–148, title III,
§ 3129(a), (b), Mar. 23, 2010, 124 Stat. 426.)
REFERENCES IN TEXT
The matter following clause (v) of section
1395ww(d)(1)(B) of this title, referred to in subsec.
(c)(2)(E)(i),
now
follows
cl.
(vi)
of
section
1395ww(d)(1)(B) of this title following the redesignation
of subcl. (II) of cl. (iv) of subsec. (d)(1)(B) as cl. (vi) by
Pub. L. 114–255, div. C, title XV, § 15008(a)(2)(B), Dec. 13,
2016, 130 Stat. 1321.
The Balanced Budget Act of 1997, referred to in subsec. (g)(3)(A), is Pub. L. 105–33, Aug. 5, 1997, 111 Stat. 251.
For complete classification of this Act to the Code, see
Tables.
The Patient Protection and Affordable Care Act, referred to in subsec. (g)(3)(A), (E), is Pub. L. 111–148,
Mar. 23, 2010, 124 Stat. 119. For complete classification
of this Act to the Code, see Short Title note set out
under section 18001 of this title and Tables.
Section 405(h)(1) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003, referred
to in subsec. (h)(3), is section 405(h)(1) of Pub. L.
108–173, which amended this section. See 2003 Amendment note below.
AMENDMENTS
2010—Subsec. (g)(3)(A). Pub. L. 111–148, § 3129(b)(1), inserted ‘‘and to assist such hospitals in participating in
delivery system reforms under the provisions of and
amendments made by the Patient Protection and Affordable Care Act, such as value-based purchasing programs, accountable care organizations under section
1395jjj of this title, the National pilot program on payment bundling under section 1395cc–4 of this title, and
other delivery system reform programs determined appropriate by the Secretary’’ before period at end.
Subsec. (g)(3)(E). Pub. L. 111–148, § 3129(b)(2), substituted ‘‘, to offset’’ for ‘‘, and to offset’’ and inserted
‘‘and to participate in delivery system reforms under
the provisions of and amendments made by the Patient
Protection and Affordable Care Act, such as valuebased purchasing programs, accountable care organizations under section 1395jjj of this title, the National
pilot program on payment bundling under section
1395cc–4 of this title, and other delivery system reform
programs determined appropriate by the Secretary’’ before period at end.
Subsec. (j). Pub. L. 111–148, § 3129(a), substituted ‘‘2010,
for’’ for ‘‘2010, and for’’ and inserted ‘‘and for making
grants to all States under subsection (g), such sums as
may be necessary in each of fiscal years 2011 and 2012,
to remain available until expended’’ before period at
end.

§ 1395i–4

2008—Subsec. (g)(1)(D). Pub. L. 110–275, § 121(d), added
subpar. (D).
Subsec. (g)(5). Pub. L. 110–275, § 121(b)(2), which directed insertion of ‘‘and, of the total amount appropriated for grants under paragraphs (1), (2), and (6) for
a fiscal year (beginning with fiscal year 2009)’’ after
‘‘2005)’’, was executed by making the insertion after
‘‘2008)’’ to reflect the probable intent of Congress and
the amendment by section 121(b)(1) of Pub. L. 110–275.
See note below.
Pub. L. 110–275, § 121(b)(1), substituted ‘‘for each of fiscal years 2005 through 2008’’ for ‘‘beginning with fiscal
year 2005’’.
Subsec. (g)(6). Pub. L. 110–275, § 121(a), added par. (6).
Subsec. (g)(7). Pub. L. 110–275, § 121(e), added par. (7).
Subsec. (j). Pub. L. 110–275, § 121(c), substituted ‘‘2002,
for’’ for ‘‘2002, and for’’ and inserted ‘‘, for making
grants to all States under paragraphs (1) and (2) of subsection (g), $55,000,000 in each of fiscal years 2009 and
2010, and for making grants to all States under paragraph (6) of subsection (g), $50,000,000 in each of fiscal
years 2009 and 2010, to remain available until expended’’
before period at end.
2003—Subsec.
(c)(2)(B)(i)(II).
Pub.
L.
108–173,
§ 405(h)(1), inserted ‘‘before January 1, 2006,’’ after ‘‘is
certified’’.
Subsec. (c)(2)(B)(iii). Pub. L. 108–173, § 405(e)(1), substituted ‘‘25’’ for ‘‘15 (or, in the case of a facility under
an agreement described in subsection (f) of this section,
25)’’.
Subsec. (c)(2)(E). Pub. L. 108–173, § 405(g)(1), added subpar. (E).
Subsec. (f). Pub. L. 108–173, § 405(e)(2), struck out ‘‘and
the number of beds used at any time for acute care inpatient services does not exceed 15 beds’’ after ‘‘does
not exceed 25 beds’’.
Subsec. (g)(4), (5). Pub. L. 108–173, § 405(f)(2), added
pars. (4) and (5).
Subsec. (h). Pub. L. 108–173, § 405(h)(2)(A), substituted
‘‘provisions’’ for ‘‘of certain facilities’’ in heading.
Subsec. (h)(3). Pub. L. 108–173, § 405(h)(2)(B), added par.
(3).
Subsec. (i). Pub. L. 108–173, § 101(e)(1), substituted
‘‘part E’’ for ‘‘part D’’.
Subsec. (j). Pub. L. 108–173, § 405(f)(1), inserted before
period at end ‘‘, and for making grants to all States
under paragraphs (1) and (2) of subsection (g), $35,000,000
in each of fiscal years 2005 through 2008’’.
1999—Subsec. (c)(2)(A). Pub. L. 106–113, § 1000(a)(6)
[title IV, § 403(c)(1)], substituted ‘‘subparagraphs (B),
(C), and (D)’’ for ‘‘subparagraph (B)’’.
Subsec. (c)(2)(B)(i). Pub. L. 106–113, § 1000(a)(6) [title
IV, § 403(b)], substituted ‘‘hospital’’ for ‘‘nonprofit or
public hospital’’.
Pub. L. 106–113, § 1000(a)(6) [title IV, § 401(b)(2)], inserted ‘‘or is treated as being located in a rural area
pursuant to section 1395ww(d)(8)(E) of this title’’ after
‘‘section 1395ww(d)(2)(D) of this title)’’.
Pub. L. 106–113, § 1000(a)(6) [title III, § 321(a)], substituted ‘‘that is located in a county (or equivalent
unit of local government) in a rural area (as defined in
section 1395ww(d)(2)(D) of this title), and that’’ for ‘‘and
is located in a county (or equivalent unit of local government) in a rural area (as defined in section
1395ww(d)(2)(D) of this title) that’’.
Subsec. (c)(2)(B)(iii). Pub. L. 106–113, § 1000(a)(6) [title
IV, § 403(a)(1)], substituted ‘‘for a period that does not
exceed, as determined on an annual, average basis, 96
hours per patient;’’ for ‘‘for a period not to exceed 96
hours (unless a longer period is required because transfer to a hospital is precluded because of inclement
weather or other emergency conditions), except that a
peer review organization or equivalent entity may, on
request, waive the 96-hour restriction on a case-by-case
basis;’’.
Subsec. (c)(2)(C), (D). Pub. L. 106–113, § 1000(a)(6) [title
IV, § 403(c)(2)], added subpars. (C) and (D).
Subsec. (g)(3). Pub. L. 106–113, § 1000(a)(6) [title IV,
§ 409], added par. (3).
1997—Pub. L. 105–33, § 4201(a), amended section catchline and text generally, substituting provisions relating

§ 1395i–4

TITLE 42—THE PUBLIC HEALTH AND WELFARE

to medicare rural hospital flexibility program for provisions relating to essential access community hospital
program.
Subsec. (j). Pub. L. 105–33, § 4002(f)(1), substituted
‘‘part D’’ for ‘‘part C’’.
1994—Subsec. (c)(1). Pub. L. 103–432, § 102(b)(2)(B)(i),
substituted ‘‘paragraph (3) or subsection (k) of this section’’ for ‘‘paragraph (3)’’.
Subsec. (e)(1). Pub. L. 103–432, § 102(b)(1)(A)(i), redesignated par. (2) as (1) and struck out former par. (1) which
read as follows: ‘‘is located in a rural area (as defined
in section 1395ww(d)(2)(D) of this title);’’.
Subsec. (e)(1)(A). Pub. L. 103–432, § 102(b)(1)(A)(ii), substituted ‘‘except in the case of a hospital located in an
urban area, is located’’ for ‘‘is located’’ in introductory
provisions, substituted ‘‘or (ii)’’ for ‘‘, (ii)’’, and struck
out ‘‘or (iii) is located in an urban area that meets the
criteria for classification as a regional referral center
under such section,’’ after ‘‘section 1395ww(d)(5)(C) of
this title,’’.
Subsec. (e)(2) to (6). Pub. L. 103–432, § 102(b)(1)(A)(i),
redesignated pars. (2) to (6) as (1) to (5), respectively.
Subsec. (f)(1)(F). Pub. L. 103–432, § 102(a)(1), amended
subpar. (F) generally. Prior to amendment, subpar. (F)
read as follows: ‘‘provides not more than 6 inpatient
beds (meeting such conditions as the Secretary may establish) for providing inpatient care for a period not to
exceed 72 hours (unless a longer period is required because transfer to a hospital is precluded because of inclement weather or other emergency conditions) to patients requiring stabilization before discharge or transfer to a hospital;’’.
Subsec. (f)(1)(H). Pub. L. 103–432, § 102(f), inserted before period at end ‘‘, except that in determining whether a facility meets the requirements of this subparagraph, subparagraphs (E) and (F) of that paragraph
shall be applied as if any reference to a ‘physician’ is
a reference to a physician as defined in section
1395x(r)(1) of this title’’.
Subsec. (f)(3). Pub. L. 103–432, § 102(c), substituted ‘‘because, at the time the facility applies to the State for
designation as a rural primary care hospital, there is in
effect an agreement between the facility and the Secretary under section 1395tt of this title under which the
facility’s inpatient hospital facilities are used for the
furnishing of extended care services, except that the
number of beds used for the furnishing of such services
may not exceed the total number of licensed inpatient
beds at the time the facility applies to the State for
such designation (minus the number of inpatient beds
used for providing inpatient care pursuant to paragraph
(1)(F)). For purposes of the previous sentence, the number of beds of the facility used for the furnishing of extended care services shall not include any beds of a unit
of the facility that is licensed as a distinct-part skilled
nursing facility at the time the facility applies to the
State for designation as a rural primary care hospital.’’
for ‘‘because the facility has entered into an agreement
with the Secretary under section 1395tt of this title
under which the facility’s inpatient hospital facilities
may be used for the furnishing of extended care services.’’
Subsec. (f)(4). Pub. L. 103–432, § 102(a)(2), added par.
(4).
Subsec. (i)(1)(A). Pub. L. 103–432, § 102(b)(2)(B)(ii), in
cl. (i) inserted ‘‘(except as provided in subsection (k) of
this section)’’ and in cl. (ii) inserted ‘‘or subsection (k)
of this section’’.
Subsec. (i)(1)(B). Pub. L. 103–432, § 102(b)(1)(A)(iii),
substituted ‘‘paragraph (2)’’ for ‘‘paragraph (3)’’.
Subsec. (i)(2)(A). Pub. L. 103–432, § 102(b)(2)(B)(ii), in
cl. (i) inserted ‘‘(except as provided in subsection (k) of
this section)’’ and in cl. (ii) inserted ‘‘or subsection (k)
of this section’’.
Subsec. (k). Pub. L. 103–432, § 102(b)(2)(A)(ii), added
subsec. (k). Former subsec. (k) redesignated (l).
Subsec. (l). Pub. L. 103–432, § 102(h), substituted ‘‘1990
through 1997’’ for ‘‘1990, 1991, and 1992’’ in introductory
provisions.
Pub. L. 103–432, § 102(b)(2)(A)(i), redesignated subsec.
(k) as (l).

Page 2590

1990—Subsec. (d)(1). Pub. L. 101–508, § 4008(m)(2)(B)(i),
struck out ‘‘demonstration’’ before ‘‘program’’.
Subsec. (f)(1)(A). Pub. L. 101–508, § 4008(d)(3), inserted
before semicolon at end ‘‘, or is located in a county
whose geographic area is substantially larger than the
average geographic area for urban counties in the
United States and whose hospital service area is characteristic of service areas of hospitals located in rural
areas’’.
Subsec. (f)(1)(B). Pub. L. 101–508, § 4008(d)(2), which directed the substitution of ‘‘is a hospital (or, in the case
of a facility that closed during the 12-month period
that ends on the date the facility applies for such designation, at the time the facility closed),’’ for ‘‘is a hospital,’’ was executed by making the substitution for ‘‘is
a hospital’’ to reflect the probable intent of Congress.
Subsec. (g)(1)(A)(ii). Pub. L. 101–508, § 4008(m)(2)(B)(ii),
substituted ‘‘regional referral center’’ for ‘‘rural referral center’’.
Subsec. (i)(2)(C). Pub. L. 101–508, § 4008(d)(1), inserted
at end ‘‘In designating facilities as rural primary care
hospitals under this subparagraph, the Secretary shall
give preference to facilities not meeting the requirements of clause (i) of subparagraph (A) that have entered into an agreement described in subsection (g)(2)
of this section with a rural health network located in
a State receiving a grant under subsection (a)(1) of this
section.’’
Subsec. (j). Pub. L. 101–508, § 4008(m)(2)(B)(iii), inserted ‘‘and part C of this subchapter’’ after ‘‘this
part’’.
EFFECTIVE DATE OF 2010 AMENDMENT
Pub. L. 111–148, title III, § 3129(c), Mar. 23, 2010, 124
Stat. 427, provided that: ‘‘The amendments made by
this section [amending this section] shall apply to
grants made on or after January 1, 2010.’’
EFFECTIVE DATE OF 2003 AMENDMENT
Pub. L. 108–173, title IV, § 405(e)(3), Dec. 8, 2003, 117
Stat. 2267, provided that: ‘‘The amendments made by
this subsection [amending this section] shall apply to
designations made before, on, or after January 1, 2004,
but any election made pursuant to regulations promulgated to carry out such amendments shall only apply
prospectively.’’
Amendment by section 405(g)(1) of Pub. L. 108–173 applicable to cost reporting periods beginning on or after
Oct. 1, 2004, see section 405(g)(3) of Pub. L. 108–173, set
out as a note under section 1395f of this title.
EFFECTIVE DATE OF 1999 AMENDMENT
Amendment by section 1000(a)(6) [title III, § 321(a)] of
Pub. L. 106–113 effective as if included in the enactment
of the Balanced Budget Act of 1997, Pub. L. 105–33, except as otherwise provided, see section 1000(a)(6) [title
III, § 321(m)] of Pub. L. 106–113, set out as a note under
section 1395d of this title.
Pub. L. 106–113, div. B, § 1000(a)(6) [title IV, § 401(c)],
Nov. 29, 1999, 113 Stat. 1536, 1501A–369, provided that:
‘‘The amendments made by this section [amending this
section and sections 1395l and 1395ww of this title] shall
become effective on January 1, 2000.’’
Pub. L. 106–113, div. B, § 1000(a)(6) [title IV, § 403(a)(2)],
Nov. 29, 1999, 113 Stat. 1536, 1501A–370, provided that:
‘‘The amendment made by paragraph (1) [amending this
section] takes effect on the date of the enactment of
this Act [Nov. 29, 1999].’’
EFFECTIVE DATE OF 1997 AMENDMENT
Amendment by section 4201(a) of Pub. L. 105–33 applicable to services furnished on or after Oct. 1, 1997, see
section 4201(d) of Pub. L. 105–33, set out as a note under
section 1395f of this title.
EFFECTIVE DATE OF 1990 AMENDMENT
Pub. L. 101–508, title IV, § 4008(d)(4), Nov. 5, 1990, 104
Stat. 1388–45, provided that: ‘‘The amendments made by
paragraphs (1), (2), and (3) [amending this section] shall

Page 2591

TITLE 42—THE PUBLIC HEALTH AND WELFARE

take effect on the date of the enactment of this Act
[Nov. 5, 1990].’’
DEMONSTRATION PROJECT ON COMMUNITY HEALTH
INTEGRATION MODELS IN CERTAIN RURAL COUNTIES
Pub. L. 110–275, title I, § 123, July 15, 2008, 122 Stat.
2514, as amended by Pub. L. 111–148, title III, § 3126, Mar.
23, 2010, 124 Stat. 425, provided that:
‘‘(a) IN GENERAL.—The Secretary shall establish a
demonstration project to allow eligible entities to develop and test new models for the delivery of health
care services in eligible counties for the purpose of improving access to, and better integrating the delivery
of, acute care, extended care, and other essential health
care services to Medicare beneficiaries.
‘‘(b) PURPOSE.—The purpose of the demonstration
project under this section is to—
‘‘(1) explore ways to increase access to, and improve
the adequacy of, payments for acute care, extended
care, and other essential health care services provided under the Medicare and Medicaid programs in
eligible counties; and
‘‘(2) evaluate regulatory challenges facing such providers and the communities they serve.
‘‘(c) REQUIREMENTS.—The following requirements
shall apply under the demonstration project:
‘‘(1) Health care providers in eligible counties selected to participate in the demonstration project
under subsection (d)(3) shall (when determined appropriate by the Secretary), instead of the payment
rates otherwise applicable under the Medicare program, be reimbursed at a rate that covers at least the
reasonable costs of the provider in furnishing acute
care, extended care, and other essential health care
services to Medicare beneficiaries.
‘‘(2) Methods to coordinate the survey and certification process under the Medicare program and the
Medicaid program across all health service categories
included in the demonstration project shall be tested
with the goal of assuring quality and safety while reducing administrative burdens, as appropriate, related to completing such survey and certification process.
‘‘(3) Health care providers in eligible counties selected to participate in the demonstration project
under subsection (d)(3) and the Secretary shall work
with the State to explore ways to revise reimbursement policies under the Medicaid program to improve
access to the range of health care services available
in such eligible counties.
‘‘(4) The Secretary shall identify regulatory requirements that may be revised appropriately to improve access to care in eligible counties.
‘‘(5) Other essential health care services necessary
to ensure access to the range of health care services
in eligible counties selected to participate in the
demonstration project under subsection (d)(3) shall be
identified. Ways to ensure adequate funding for such
services shall also be explored.
‘‘(d) APPLICATION PROCESS.—
‘‘(1) ELIGIBILITY.—
‘‘(A) IN GENERAL.—Eligibility to participate in
the demonstration project under this section shall
be limited to eligible entities.
‘‘(B) ELIGIBLE ENTITY DEFINED.—In this section,
the term ‘eligible entity’ means an entity that—
‘‘(i) is a Rural Hospital Flexibility Program
grantee under section 1820(g) of the Social Security Act (42 U.S.C. 1395i–4(g)); and
‘‘(ii) is located in a State in which at least 65
percent of the counties in the State are counties
that have 6 or less residents per square mile.
‘‘(2) APPLICATION.—
‘‘(A) IN GENERAL.—An eligible entity seeking to
participate in the demonstration project under this
section shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require.
‘‘(B) LIMITATION.—The Secretary shall select eligible entities located in not more than 4 States to

§ 1395i–4

participate in the demonstration project under this
section.
‘‘(3) SELECTION OF ELIGIBLE COUNTIES.—An eligible
entity selected by the Secretary to participate in the
demonstration project under this section shall select
eligible counties in the State in which the entity is
located in which to conduct the demonstration
project.
‘‘(4) ELIGIBLE COUNTY DEFINED.—In this section, the
term ‘eligible county’ means a county that meets the
following requirements:
‘‘(A) The county has 6 or less residents per square
mile.
‘‘(B) As of the date of the enactment of this Act
[July 15, 2008], a facility designated as a critical access hospital which meets the following requirements was located in the county:
‘‘(i) As of the date of the enactment of this Act,
the critical access hospital furnished 1 or more of
the following:
‘‘(I) Home health services.
‘‘(II) Hospice care.
‘‘(ii) As of the date of the enactment of this
Act, the critical access hospital has an average
daily inpatient census of 5 or less.
‘‘(C) As of the date of the enactment of this Act,
skilled nursing facility services were available in
the county in—
‘‘(i) a critical access hospital using swing beds;
or
‘‘(ii) a local nursing home.
‘‘(e) ADMINISTRATION.—
‘‘(1) IN GENERAL.—The demonstration project under
this section shall be administered jointly by the Administrator of the Office of Rural Health Policy of
the Health Resources and Services Administration
and the Administrator of the Centers for Medicare &
Medicaid Services, in accordance with paragraphs (2)
and (3).
‘‘(2) HRSA DUTIES.—In administering the demonstration project under this section, the Administrator of the Office of Rural Health Policy of the
Health Resources and Services Administration
shall—
‘‘(A) award grants to the eligible entities selected
to participate in the demonstration project; and
‘‘(B) work with such entities to provide technical
assistance related to the requirements under the
project.
‘‘(3) CMS DUTIES.—In administering the demonstration project under this section, the Administrator of
the Centers for Medicare & Medicaid Services shall
determine which provisions of titles XVIII and XIX of
the Social Security Act (42 U.S.C. 1395 et seq.; 1396 et
seq.) the Secretary should waive under the waiver authority under subsection (i) that are relevant to the
development of alternative reimbursement methodologies, which may include, as appropriate, covering at least the reasonable costs of the provider in
furnishing acute care, extended care, and other essential health care services to Medicare beneficiaries
and coordinating the survey and certification process
under the Medicare and Medicaid programs, as appropriate, across all service categories included in the
demonstration project.
‘‘(f) DURATION.—
‘‘(1) IN GENERAL.—The demonstration project under
this section shall be conducted for a 3-year period beginning on October 1, 2009.
‘‘(2) BEGINNING DATE OF DEMONSTRATION PROJECT.—
The demonstration project under this section shall be
considered to have begun in a State on the date on
which the eligible counties selected to participate in
the demonstration project under subsection (d)(3)
begin operations in accordance with the requirements
under the demonstration project.
‘‘(g) FUNDING.—
‘‘(1) CMS.—
‘‘(A) IN GENERAL.—The Secretary shall provide for
the transfer, in appropriate part from the Federal

§ 1395i–4

TITLE 42—THE PUBLIC HEALTH AND WELFARE

Hospital Insurance Trust Fund established under
section 1817 of the Social Security Act (42 U.S.C.
1395i) and the Federal Supplementary Medical Insurance Trust Fund established under section 1841
of such Act (42 U.S.C. 1395t), of such sums as are
necessary for the costs to the Centers for Medicare
& Medicaid Services of carrying out its duties
under the demonstration project under this section.
‘‘(B) BUDGET NEUTRALITY.—In conducting the
demonstration project under this section, the Secretary shall ensure that the aggregate payments
made by the Secretary do not exceed the amount
which the Secretary estimates would have been
paid if the demonstration project under this section
was not implemented.
‘‘(2) HRSA.—There are authorized to be appropriated to the Office of Rural Health Policy of the
Health Resources and Services Administration
$800,000 for each of fiscal years 2010, 2011, and 2012 for
the purpose of carrying out the duties of such Office
under the demonstration project under this section,
to remain available for the duration of the demonstration project.
‘‘(h) REPORT.—
‘‘(1) INTERIM REPORT.—Not later than the date that
is 2 years after the date on which the demonstration
project under this section is implemented, the Administrator of the Office of Rural Health Policy of
the Health Resources and Services Administration, in
coordination with the Administrator of the Centers
for Medicare & Medicaid Services, shall submit a report to Congress on the status of the demonstration
project that includes initial recommendations on
ways to improve access to, and the availability of,
health care services in eligible counties based on the
findings of the demonstration project.
‘‘(2) FINAL REPORT.—Not later than 1 year after the
completion of the demonstration project, the Administrator of the Office of Rural Health Policy of the
Health Resources and Services Administration, in coordination with the Administrator of the Centers for
Medicare & Medicaid Services, shall submit a report
to Congress on such project, together with recommendations for such legislation and administrative
action as the Secretary determines appropriate.
‘‘(i) WAIVER AUTHORITY.—The Secretary may waive
such requirements of titles XVIII and XIX of the Social
Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as may
be necessary and appropriate for the purpose of carrying out the demonstration project under this section.
‘‘(j) DEFINITIONS.—In this section:
‘‘(1) EXTENDED CARE SERVICES.—The term ‘extended
care services’ means the following:
‘‘(A) Home health services.
‘‘(B) Covered skilled nursing facility services.
‘‘(C) Hospice care.
‘‘(2) COVERED SKILLED NURSING FACILITY SERVICES.—
The term ‘covered skilled nursing facility services’
has the meaning given such term in section
1888(e)(2)(A) of the Social Security Act (42 U.S.C.
1395yy(e)(2)(A)).
‘‘(3) CRITICAL ACCESS HOSPITAL.—The term ‘critical
access hospital’ means a facility designated as a critical access hospital under section 1820(c) of such Act
(42 U.S.C. 1395i–4(c)).
‘‘(4) HOME HEALTH SERVICES.—The term ‘home
health services’ has the meaning given such term in
section 1861(m) of such Act (42 U.S.C. 1395x(m)).
‘‘(5) HOSPICE CARE.—The term ‘hospice care’ has the
meaning given such term in section 1861(dd) of such
Act (42 U.S.C. 1395x(dd)).
‘‘(6) MEDICAID PROGRAM.—The term ‘Medicaid program’ means the program under title XIX of such Act
(42 U.S.C. 1396 et seq.).
‘‘(7) MEDICARE PROGRAM.—The term ‘Medicare program’ means the program under title XVIII of such
Act (42 U.S.C. 1395 et seq.).
‘‘(8) OTHER ESSENTIAL HEALTH CARE SERVICES.—The
term ‘other essential health care services’ means the
following:

Page 2592

‘‘(A) Ambulance services (as described in section
1861(s)(7) of the Social Security Act (42 U.S.C.
1395x(s)(7))).
‘‘(B) Physicians’ services (as defined in section
1861(q) of the Social Security Act (42 U.S.C.
1395x(q))[)].
‘‘(C) Public health services (as defined by the Secretary).
‘‘(D) Other health care services determined appropriate by the Secretary.
‘‘(9) SECRETARY.—The term ‘Secretary’ means the
Secretary of Health and Human Services.’’
[Pub. L. 111–148, title III, § 3126(b)(1), Mar. 23, 2010, 124
Stat. 426, which directed amendment of section 123 of
Pub. L. 111–275, set out above, by striking out subsec.
(d)(4)(B)(i)(3)(III), was executed by striking out subsec.
(d)(4)(B)(i)(III) to reflect the probable intent of Congress.]
GAO STUDY ON CERTAIN ELIGIBILITY REQUIREMENTS
FOR CRITICAL ACCESS HOSPITALS
Pub. L. 106–554, § 1(a)(6) [title II, § 206], Dec. 21, 2000,
114 Stat. 2763, 2763A–483, provided that:
‘‘(a) STUDY.—The Comptroller General of the United
States shall conduct a study on the eligibility requirements for critical access hospitals under section 1820(c)
of the Social Security Act (42 U.S.C. 1395i–4(c)) with respect to limitations on average length of stay and number of beds in such a hospital, including an analysis
of—
‘‘(1) the feasibility of having a distinct part unit as
part of a critical access hospital for purposes of the
medicare program under title XVIII of such Act [this
subchapter]; and
‘‘(2) the effect of seasonal variations in patient admissions on critical access hospital eligibility requirements with respect to limitations on average
annual length of stay and number of beds.
‘‘(b) REPORT.—Not later than 1 year after the date of
the enactment of this Act [Dec. 21, 2000], the Comptroller General shall submit to Congress a report on the
study conducted under subsection (a) together with recommendations regarding—
‘‘(1) whether distinct part units should be permitted
as part of a critical access hospital under the medicare program;
‘‘(2) if so permitted, the payment methodologies
that should apply with respect to services provided
by such units;
‘‘(3) whether, and to what extent, such units should
be included in or excluded from the bed limits applicable to critical access hospitals under the medicare
program; and
‘‘(4) any adjustments to such eligibility requirements to account for seasonal variations in patient
admissions.’’
TRANSITION FOR MAF
Pub. L. 105–33, title IV, § 4201(c)(6), Aug. 5, 1997, 111
Stat. 374, provided that:
‘‘(A) IN GENERAL.—The Secretary of Health and
Human Services shall provide for an appropriate transition for a facility that, as of the date of the enactment
of this Act [Aug. 5, 1997], operated as a limited service
rural hospital under a demonstration described in section 4008(i)(1) of the Omnibus Budget Reconciliation
Act of 1990 [Pub. L. 101–508] (42 U.S.C. 1395b–1 note) from
such demonstration to the program established under
subsection (a) [amending this section]. At the conclusion of the transition period described in subparagraph
(B), the Secretary shall end such demonstration.
‘‘(B) TRANSITION PERIOD DESCRIBED.—
‘‘(i) INITIAL PERIOD.—Subject to clause (ii), the transition period described in this subparagraph is the period beginning on the date of the enactment of this
Act and ending on October 1, 1998.
‘‘(ii) EXTENSION.—If the Secretary determines that
the transition is not complete as of October 1, 1998,
the Secretary shall provide for an appropriate extension of the transition period.’’

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TITLE 42—THE PUBLIC HEALTH AND WELFARE
GAO REPORTS

Pub. L. 103–432, title I, § 102(a)(4), Oct. 31, 1994, 108
Stat. 4402, directed Comptroller General to submit to
Congress, not later than 2 years after Oct. 31, 1994, reports on application of requirements under subsec. (f)
of this section that rural primary care hospitals provide inpatient care only to those individuals whose attending physicians certify may reasonably be expected
to be discharged within 72 hours after admission and
maintain average length of inpatient stay during a
year that does not exceed 72 hours, and extent to which
such requirements have resulted in such hospitals providing inpatient care beyond their capabilities or have
limited ability of such hospitals to provide needed services.

§ 1395i–5. Conditions for coverage of religious
nonmedical health care institutional services
(a) In general
Subject to subsections (c) and (d), payment
under this part may be made for inpatient hospital services or post-hospital extended care
services furnished an individual in a religious
nonmedical health care institution and for home
health services furnished an individual by a religious nonmedical health care institution only
if—
(1) the individual has an election in effect
for such benefits under subsection (b); and
(2) the individual has a condition such that
the individual would qualify for benefits under
this part for inpatient hospital services, extended care services, or home health services,
respectively, if the individual were an inpatient or resident in a hospital or skilled nursing facility, or receiving services from a home
health agency, that was not such an institution.
(b) Election
(1) In general
An individual may make an election under
this subsection in a form and manner specified
by the Secretary consistent with this subsection. Unless otherwise provided, such an
election shall take effect immediately upon
its execution. Such an election, once made,
shall continue in effect until revoked.
(2) Form
The election form under this subsection
shall include the following:
(A) A written statement, signed by the individual (or such individual’s legal representative), that—
(i) the individual is conscientiously opposed to acceptance of nonexcepted medical treatment; and
(ii) the individual’s acceptance of nonexcepted medical treatment would be inconsistent with the individual’s sincere religious beliefs.
(B) A statement that the receipt of nonexcepted medical services shall constitute a
revocation of the election and may limit further receipt of services described in subsection (a).
(3) Revocation
An election under this subsection by an individual may be revoked by voluntarily notifying the Secretary in writing of such revoca-

§ 1395i–5

tion and shall be deemed to be revoked if the
individual receives nonexcepted medical treatment for which reimbursement is made under
this subchapter.
(4) Limitation on subsequent elections
Once an individual’s election under this subsection has been made and revoked twice—
(A) the next election may not become effective until the date that is 1 year after the
date of most recent previous revocation, and
(B) any succeeding election may not become effective until the date that is 5 years
after the date of the most recent previous
revocation.
(5) Excepted medical treatment
For purposes of this subsection:
(A) Excepted medical treatment
The term ‘‘excepted medical treatment’’
means medical care or treatment (including
medical and other health services)—
(i) received involuntarily, or
(ii) required under Federal or State law
or law of a political subdivision of a State.
(B) Nonexcepted medical treatment
The term ‘‘nonexcepted medical treatment’’ means medical care or treatment (including medical and other health services)
other than excepted medical treatment.
(c) Monitoring and safeguard against excessive
expenditures
(1) Estimate of expenditures
Before the beginning of each fiscal year (beginning with fiscal year 2000), the Secretary
shall estimate the level of expenditures under
this part for services described in subsection
(a) for that fiscal year.
(2) Adjustment in payments
(A) Proportional adjustment
If the Secretary determines that the level
estimated under paragraph (1) for a fiscal
year will exceed the trigger level (as defined
in subparagraph (C)) for that fiscal year, the
Secretary shall, subject to subparagraph (B),
provide for such a proportional reduction in
payment amounts under this part for services described in subsection (a) for the fiscal
year involved as will assure that such level
(taking into account any adjustment under
subparagraph (B)) does not exceed the trigger level for that fiscal year.
(B) Alternative adjustments
The Secretary may, instead of making
some or all of the reduction described in subparagraph (A), impose such other conditions
or limitations with respect to the coverage
of covered services (including limitations on
new elections of coverage and new facilities)
as may be appropriate to reduce the level of
expenditures described in paragraph (1) to
the trigger level.
(C) Trigger level
For purposes of this subsection—
(i) In general
Subject to adjustment under paragraph
(3)(B), the ‘‘trigger level’’ for a year is the