§1395i–4. Essential access community hospital program

(a) In general

There is hereby established a program under which the Secretary-

(1) shall make grants to not more than 7 States to carry out the activities described in subsection (d)(1) of this section;

(2) shall make grants to eligible hospitals and facilities (or consortia of hospitals and facilities) to carry out the activities described in subsection (d)(2) of this section; and

(3) shall designate (under subsection (i) of this section) hospitals and facilities located in States receiving grants under paragraph (1) as essential access community hospitals or rural primary care hospitals.

(b) Eligibility of States for grants

A State is eligible to receive a grant under subsection (a)(1) of this section only 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 one or more rural health networks (as defined in subsection (g) of this section) in the State,

(ii) promotes regionalization of rural health services in the State,

(iii) improves access to hospital and other health services for rural residents of the State, and

(iv) enhances the provision of emergency and other transportation services related to health care;

(B) has developed the rural health care plan described in subparagraph (A) in consultation with the hospital association of the State and rural hospitals located in the State (or, in the case of a State in the process of developing such plan, that assures the Secretary that it will consult with its State hospital association and rural hospitals located in the State in developing such plan); and

(C) has designated, or is in the process of designating, rural non-profit or public hospitals or facilities located in the State as essential access community hospitals or rural primary care hospitals within such networks; and

(2) such other information and assurances as the Secretary may require.

(c) Eligibility of hospitals and consortia for grants

(1) In general

Except as provided in paragraph (3) or subsection (k) of this section, a hospital or facility is eligible to receive a grant under subsection (a)(2) of this section only if the hospital or facility-

(A) is located in a State receiving a grant under subsection (a)(1) of this section;

(B) is designated as an essential access community hospital or a rural primary care hospital by the State in which it is located or is a member of a rural health network (as defined in subsection (g) of this section);

(C) submits to the State in which it is located and to the Secretary, at such time and in such form as the Secretary may require, an application containing such information and assurances as the Secretary may require; and

(D) the State in which the hospital or facility is located certifies to the Secretary that-

(i) the receiving of such a grant by the hospital or facility is consistent with the State's rural health care plan (described in subsection (b)(1)(A) of this section), and

(ii) the State has approved the application submitted under subparagraph (C).

(2) Treatment of consortia

A consortium of hospitals or facilities each of which is part of the same rural health network is eligible to receive a grant under subsection (a)(2) of this section if each of its members would individually be eligible to receive such a grant.

(3) Eligibility of RPC hospitals not located in a State receiving grant

A facility designated as a rural primary care hospital by the Secretary under subsection (i)(2)(C) of this section shall be eligible to receive a grant under subsection (a)(2) of this section.

(d) Activities for which grants may be used

(1) Grants to States

A State shall use a grant received under subsection (a)(1) of this section to carry out the program established under this section in the State. Such grant may be used for engaging in activities relating to planning and implementing a rural health care plan and rural health networks, designating hospitals or facilities in the State as essential access community hospitals or rural primary care hospitals, and developing and supporting communication and emergency transportation systems.

(2) Grants to hospitals, facilities, and consortia

A hospital or facility shall use a grant received under subsection (a)(2) of this section to finance the costs it incurs in converting itself to a rural primary care hospital or an essential access community hospital or in becoming part of a rural health network in the State in which it is located, including capital costs, costs incurred in the development of necessary communications systems, and costs incurred in the development of an emergency transportation system. A consortium shall use a grant received under subsection (a)(2) of this section to finance the costs it incurs in converting hospitals or facilities that are part of the consortium into rural primary care hospitals or in developing and implementing a rural health network consisting of its members in the State in which it is located, including capital costs, costs incurred in the development of necessary communications systems, and costs incurred in the development of an emergency transportation system.

(e) Designation by State of essential access community hospitals

A State may designate a hospital as an essential access community hospital only if the hospital-

(1)(A) except in the case of a hospital located in an urban area, is located more than 35 miles from any hospital that either (i) has been designated as an essential access community hospital or (ii) is classified by the Secretary as a rural referral center under section 1395ww(d)(5)(C) of this title, or (B) meets such other criteria relating to geographic location as the State may impose with the approval of the Secretary;

(2) has at least 75 inpatient beds or is located more than 35 miles from any other hospital;

(3) has in effect an agreement to provide emergency and medical backup services to rural primary care hospitals participating in the rural health network of which it is a member and throughout its service area;

(4) has in effect an agreement, with each rural primary care hospital participating in the rural health network of which it is a member, to accept patients transferred from such primary care hospital, to receive data from and transmit data to such primary care hospital, and to provide staff privileges to physicians providing care at such primary care hospital; and

(5) meets any other requirements imposed by the State with the approval of the Secretary.

(f) Designation by State of rural primary care hospitals

(1) Criteria for designation

A State may designate a facility as a rural primary care hospital only if the facility-

(A) is located in a rural area (as defined in section 1395ww(d)(2)(D) of this title), 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;

(B) at the time such facility applies to the State for designation as a rural primary care hospital, 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),¹ with a participation agreement in effect under section 1395cc(a) of this title and had not been found, on the basis of a survey under section 1395aa of this title, to be in violation of any requirement to participate as a hospital under this subchapter;

(C) has ceased, or agrees (upon the approval of such application) to cease, providing inpatient care (except as required under subparagraph (F));

(D) in the case of a facility that is a member of a rural health network, has in effect an agreement to participate with other hospitals and facilities in the communications system of such network, including the network's system for the electronic sharing of patient data, including telemetry and medical records, if the network has in operation such a system;

(E) makes available 24-hour emergency care;

(F) subject to paragraph (4), provides not more than 6 inpatient beds (meeting such conditions as the Secretary may establish) for providing inpatient care to patients requiring stabilization before discharge or transfer to a hospital, except that the facility may not provide any inpatient hospital services-

(i) to any patient whose attending physician does not certify that the patient may reasonably be expected to be discharged or transferred to a hospital within 72 hours of admission to the facility; or

(ii) consisting of surgery or any other service requiring the use of general anesthesia (other than surgical procedures specified by the Secretary under section 1395l(i)(1)(A) of this title), unless the attending physician certifies that the risk associated with transferring the patient to a hospital for such services outweighs the benefits of transferring the patient to a hospital for such services.²

(G) 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 hours during a day, or days during a week, in which the facility must be open, except insofar as the facility is required to provide emergency care on a 24-hour basis under subparagraph (E),

(ii) the facility may provide any services otherwise required to be provided by a full-time, on-site dietician, pharmacist, laboratory technician, medical technologist, and radiological technologist on a part-time, off-site basis, and

(iii) the inpatient care described in subparagraph (F) may be provided by a physician's assistant or nurse practitioner, subject to the oversight of a physician; and

(H) meets the requirements of subparagraphs (C) through (J) of paragraph (2) of section 1395x(aa) of this title and of clauses (ii) and (iv) of the second sentence of that paragraph, 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.

(2) Preference given to hospitals or facilities participating in rural health network

In designating facilities as rural primary care hospitals under paragraph (1), the State shall give preference to hospitals or facilities participating in a rural health network.

(3) Permitting rural primary care hospitals to maintain swing beds

Nothing in this subsection shall be construed to prohibit a State from designating a facility as a rural primary care hospital solely 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.

(4) Limitation on average length of inpatient stays

The Secretary may terminate a designation of a rural primary care hospital under paragraph (1) if the Secretary finds that the average length of stay for inpatients at the facility during the previous year in which the designation was in effect exceeded 72 hours. In determining the compliance of a facility with the requirement of the previous sentence, there shall not be taken into account periods of stay of inpatients in excess of 72 hours to the extent such periods exceed 72 hours because transfer to a hospital is precluded because of inclement weather or other emergency conditions.

(g) "Rural health network" defined

For purposes of this section, the term "rural health network" means, with respect to a State, an organization-

(1) consisting of-

(A) at least 1 hospital that-

(i) the State has designated or plans to designate as an essential access community hospital under subsection (b)(1)(C) of this section,

(ii) is classified by the Secretary as a regional referral center under section 1395ww(d)(5)(C) of this title, or

(iii) is located in an urban area and meets the criteria for classification as a regional referral center under such section, and

(B) at least 1 facility that the State has designated or plans to designate as a rural primary care hospital, and

(2) the members of which have entered into agreements regarding-

(A) patient referral and transfer,

(B) the development and use of communications systems, including (where feasible) telemetry systems and systems for electronic sharing of patient data, and

(C) the provision of emergency and non-emergency transportation among the members.

(h) Limit on amount of grant to hospital or facility

A grant made to a hospital or facility under subsection (a)(2) of this section may not exceed $200,000.

(i) Eligibility of hospitals or facilities for designation by Secretary

(1) Essential access community hospital

(A) The Secretary shall designate a hospital as an essential access community hospital if the hospital-

(i) is located in a State receiving a grant under subsection (a)(1) of this section (except as provided in subsection (k) of this section);

(ii) is designated as an essential access community hospital by the State in which it is located (except as provided in subparagraph (B) or subsection (k) of this section); and

(iii) meets such other criteria as the Secretary may require.

(B) In the case of a hospital that is not eligible for designation as an essential access community hospital under this paragraph solely because it is not designated as an essential access community hospital by the State in which it is located, the Secretary may designate such hospital as an essential access community hospital under this paragraph if the hospital is not so designated by the State in which it is located solely because of its failure to meet the criteria described in paragraph (2) of subsection (e) of this section.

(2) Rural primary care hospital

(A) The Secretary shall designate a facility as a rural primary care hospital if the facility-

(i) is located in a State receiving a grant under subsection (a)(1) of this section (except as provided in subsection (k) of this section);

(ii) is designated as a rural primary care hospital by the State in which it is located (except as provided in subparagraph (B) or subsection (k) of this section); and

(iii) meets such other criteria as the Secretary may require.

(B) In the case of a facility that is not eligible for designation as a rural primary care hospital under this paragraph solely because it is not designated as a rural primary care hospital by the State in which it is located, the Secretary may designate such facility as a rural primary care hospital under this paragraph if the facility is not so designated by the State in which it is located solely because of its failure to meet the criteria described in subparagraphs ³ (C), (F), or (G) of subsection (f)(1) of this section.

(C) The Secretary may designate not more than 15 facilities as rural primary care hospitals under this paragraph that do not meet the requirements of clauses (i) and (ii) of subparagraph (A) if such a facility meets the criteria described in subparagraphs (A), (B), and (E) of subsection (f)(1) of this section, except that nothing in this subparagraph shall be construed to prohibit the Secretary from designating a facility as a rural primary care hospital solely 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. 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.

(j) Waiver of conflicting part A provisions

The Secretary is authorized to waive such provisions of this part and part C of this subchapter as are necessary to conduct the program established under this section.

(k) Eligibility of hospitals not located in participating States

Notwithstanding any other provision of this section-

(1) for purposes of including a hospital or facility as a member institution of a rural health network, a State may designate a hospital or facility that is not located in the State as an essential access community hospital or a rural primary care hospital if the hospital or facility is located in an adjoining State and is otherwise eligible for designation as such a hospital;

(2) the Secretary may designate a hospital or facility that is not located in a State receiving a grant under subsection (a)(1) of this section as an essential access community hospital or a rural primary care hospital if the hospital or facility is a member institution of a rural health network of a State receiving a grant under such subsection; and

(3) a hospital or facility designated pursuant to this subsection shall be eligible to receive a grant under subsection (a)(2) of this section.

(l) Authorization of appropriations

There are authorized to be appropriated from the Federal Hospital Insurance Trust Fund for each of the fiscal years 1990 through 1997-

(1) $10,000,000 for grants to States under subsection (a)(1) of this section; and

(2) $15,000,000 for grants to hospitals, facilities, and consortia under subsection (a)(2) of this section.

(Aug. 14, 1935, ch. 531, title XVIII, §1820, as added Dec. 19, 1989, Pub. L. 101–239, title VI, §6003(g)(1)(A), 103 Stat. 2145 ; amended Nov. 5, 1990, Pub. L. 101–508, title IV, §4008(d)(1)–(3), (m)(2)(B), 104 Stat. 1388–44 , 1388-45, 1388-53; Oct. 31, 1994, Pub. L. 103–432, title I, §102(a)(1), (2), (b)(1)(A), (2), (c), (f), (h), 108 Stat. 4401–4404 .)

References in Text

Part C of this subchapter, referred to in subsec. (j), is classified to section 1395x et seq. of this title.

Amendments

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).

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 1990 Amendment

Section 4008(d)(4) of Pub. L. 101–508 provided that: "The amendments made by paragraphs (1), (2), and (3) [amending this section] shall take effect on the date of the enactment of this Act [Nov. 5, 1990]."

GAO Reports

Section 102(a)(4) of Pub. L. 103–432 provided that: "Not later than 2 years after the date of the enactment of this Act [Oct. 31, 1994], the Comptroller General shall submit reports to Congress on-

"(A) the application of the requirements under section 1820(f) of the Social Security Act [subsec. (f) of this section] (as amended by this subsection) 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 an average length of inpatient stay during a year that does not exceed 72 hours; and

"(B) the extent to which such requirements have resulted in such hospitals providing inpatient care beyond their capabilities or have limited the ability of such hospitals to provide needed services."

Section Referred to in Other Sections

This section is referred to in sections 1395f, 1395x, 1395ww of this title.

¹ So in original. The comma probably should not appear.

² So in original. The period probably should be a semicolon.

³ So in original. Probably should be "subparagraph".