Bill Text: IA HF13 | 2023-2024 | 90th General Assembly | Introduced
Bill Title: A bill for an act relating to rural emergency hospitals, including licensing requirements and fees, making penalties applicable, providing emergency rulemaking authority, and including applicability and effective date provisions.(See HF 144.)
Spectrum: Partisan Bill (Republican 39-0)
Status: (Introduced - Dead) 2023-01-26 - Committee report approving bill, renumbered as HF 144. [HF13 Detail]
Download: Iowa-2023-HF13-Introduced.html
House
File
13
-
Introduced
HOUSE
FILE
13
BY
GRABER
,
HOLT
,
GOLDING
,
STONE
,
A.
MEYER
,
MOMMSEN
,
DUNWELL
,
FISHER
,
COLLINS
,
MOORE
,
GUSTOFF
,
CARLSON
,
JENEARY
,
VONDRAN
,
WULF
,
BRADLEY
,
SHERMAN
,
KNIFF
MCCULLA
,
DEYOE
,
WILLS
,
RINKER
,
JOHNSON
,
BODEN
,
GUSTAFSON
,
NORDMAN
,
SORENSEN
,
GEHLBACH
,
KAUFMANN
,
FRY
,
YOUNG
,
HENDERSON
,
WILZ
,
WOOD
,
SIEGRIST
,
OSMUNDSON
,
WINDSCHITL
,
GRASSLEY
,
BOSSMAN
,
and
GERHOLD
A
BILL
FOR
An
Act
relating
to
rural
emergency
hospitals,
including
1
licensing
requirements
and
fees,
making
penalties
2
applicable,
providing
emergency
rulemaking
authority,
and
3
including
applicability
and
effective
date
provisions.
4
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
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Section
1.
Section
135B.1,
Code
2023,
is
amended
by
adding
1
the
following
new
subsections:
2
NEW
SUBSECTION
.
5.
“Rural
emergency
hospital”
means
a
3
facility
that
provides
rural
emergency
hospital
services
in
4
the
facility
twenty-four
hours
per
day,
seven
days
per
week;
5
does
not
provide
any
acute
care
inpatient
services
with
the
6
exception
of
any
distinct
part
of
the
facility
licensed
as
a
7
skilled
nursing
facility
providing
posthospital
extended
care
8
services;
and
meets
the
criteria
specified
in
section
135B.1A
9
and
the
federal
Consolidated
Appropriations
Act,
Pub.
L.
No.
10
116-260,
§125.
11
NEW
SUBSECTION
.
6.
“Rural
emergency
hospital
services”
12
means
the
following
services
provided
by
a
rural
emergency
13
hospital
that
do
not
exceed
an
annual
per
patient
average
of
14
twenty-four
hours
in
such
a
rural
emergency
hospital:
15
a.
Emergency
department
services
and
observation
care.
16
For
purposes
of
providing
emergency
department
services,
an
17
emergency
department
of
a
rural
emergency
hospital
shall
18
be
considered
staffed
if
a
physician,
nurse
practitioner,
19
clinical
nurse
specialist,
or
physician
assistant
is
available
20
to
furnish
rural
emergency
hospital
services
in
the
facility
21
twenty-four
hours
per
day.
22
b.
At
the
election
of
the
rural
emergency
hospital,
with
23
respect
to
services
furnished
on
an
outpatient
basis,
other
24
medical
and
health
services
as
specified
in
regulations
adopted
25
by
the
United
States
secretary
of
health
and
human
services.
26
Sec.
2.
Section
135B.2,
Code
2023,
is
amended
to
read
as
27
follows:
28
135B.2
Purpose.
29
The
purpose
of
this
chapter
is
to
provide
for
the
30
development,
establishment
and
enforcement
of
basic
standards
31
for
the
care
and
treatment
of
individuals
in
hospitals
and
32
rural
emergency
hospitals
and
for
the
construction,
maintenance
33
and
operation
of
such
hospitals,
which,
in
the
light
of
34
existing
knowledge,
will
promote
safe
and
adequate
treatment
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of
such
individuals
in
such
hospitals,
in
the
interest
of
the
1
health,
welfare
and
safety
of
the
public.
2
Sec.
3.
Section
135B.3,
Code
2023,
is
amended
to
read
as
3
follows:
4
135B.3
Licensure.
5
No
person
or
governmental
unit,
acting
severally
or
jointly
6
with
any
other
person
or
governmental
unit
shall
establish,
7
conduct
or
maintain
a
hospital
or
rural
emergency
hospital
in
8
this
state
without
a
license.
9
Sec.
4.
NEW
SECTION
.
135B.3A
Rural
emergency
hospital
10
licensure.
11
1.
The
department
shall
adopt
rules
pursuant
to
chapter
12
17A
to
establish
minimum
standards
for
the
licensure
of
rural
13
emergency
hospitals
consistent
with
the
federal
Consolidated
14
Appropriations
Act,
Pub.
L.
No.
116-260,
§125,
and
with
15
regulations
issued
by
the
United
States
secretary
of
health
and
16
human
services
for
rural
emergency
hospitals.
17
2.
To
be
eligible
for
a
rural
emergency
hospital
license,
a
18
facility
shall
have
been,
on
or
before
December
27,
2020,
one
19
of
the
following:
20
a.
A
licensed
critical
access
hospital.
21
b.
A
general
hospital
with
not
more
than
fifty
licensed
22
beds
located
in
a
county
in
a
rural
area
as
defined
in
section
23
1886(d)(2)(D)
of
the
federal
Social
Security
Act.
24
c.
A
general
hospital
with
no
more
than
fifty
licensed
beds
25
that
is
deemed
as
being
located
in
a
rural
area
pursuant
to
26
section
1886(d)(8)(E)
of
the
federal
Social
Security
Act.
27
Sec.
5.
Section
135B.4,
Code
2023,
is
amended
to
read
as
28
follows:
29
135B.4
Application
for
license.
30
Licenses
shall
be
obtained
from
the
department.
31
Applications
shall
be
upon
forms
and
shall
contain
information
32
as
the
department
may
reasonably
require,
which
may
include
33
affirmative
evidence
of
ability
to
comply
with
reasonable
34
standards
and
rules
prescribed
under
this
chapter
.
Each
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application
for
license
shall
be
accompanied
by
the
license
1
fee,
which
shall
be
refunded
to
the
applicant
if
the
license
2
is
denied
and
which
shall
be
deposited
into
the
state
treasury
3
and
credited
to
the
general
fund
if
the
license
is
issued.
4
Hospitals
and
rural
emergency
hospitals
having
fifty
beds
or
5
less
shall
pay
an
initial
license
fee
of
fifteen
dollars;
6
hospitals
of
more
than
fifty
beds
and
not
more
than
one
hundred
7
beds
shall
pay
an
initial
license
fee
of
twenty-five
dollars;
8
all
other
hospitals
shall
pay
an
initial
license
fee
of
fifty
9
dollars.
10
Sec.
6.
Section
135B.5,
subsection
1,
Code
2023,
is
amended
11
to
read
as
follows:
12
1.
Upon
receipt
of
an
application
for
license
and
the
13
license
fee,
the
department
shall
issue
a
license
if
the
14
applicant
and
hospital
facilities
comply
with
this
chapter
,
15
chapter
135
,
and
the
rules
of
the
department.
Each
licensee
16
shall
receive
annual
reapproval
upon
payment
of
five
hundred
17
dollars
and
upon
filing
of
an
application
form
which
is
18
available
from
the
department.
The
annual
licensure
fee
shall
19
be
dedicated
to
support
and
provide
educational
programs
on
20
regulatory
issues
for
hospitals
and
rural
emergency
hospitals
21
licensed
under
this
chapter
.
Licenses
shall
be
either
general
22
or
restricted
in
form.
Each
license
shall
be
issued
only
23
for
the
premises
and
persons
or
governmental
units
named
in
24
the
application
and
is
not
transferable
or
assignable
except
25
with
the
written
approval
of
the
department.
Licenses
shall
26
be
posted
in
a
conspicuous
place
on
the
licensed
premises
as
27
prescribed
by
rule
of
the
department.
28
Sec.
7.
Section
135B.5A,
Code
2023,
is
amended
to
read
as
29
follows:
30
135B.5A
Conversion
of
a
hospital
relative
to
certain
31
hospitals
.
32
1.
A
conversion
of
a
long-term
acute
care
hospital,
33
rehabilitation
hospital,
or
psychiatric
hospital
as
defined
by
34
federal
regulations
to
a
general
hospital
or
to
a
specialty
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hospital
of
a
different
type
is
a
permanent
change
in
bed
1
capacity
and
shall
require
a
certificate
of
need
pursuant
to
2
section
135.63
.
3
2.
A
conversion
of
a
critical
access
hospital
or
general
4
hospital
to
a
rural
emergency
hospital
or
a
conversion
of
a
5
rural
emergency
hospital
to
a
critical
access
hospital
or
6
general
hospital
shall
not
require
a
certificate
of
need
7
pursuant
to
section
135.63.
8
Sec.
8.
Section
135B.7,
Code
2023,
is
amended
to
read
as
9
follows:
10
135B.7
Rules
and
enforcement.
11
1.
a.
The
department,
with
the
approval
of
the
state
12
board
of
health,
shall
adopt
rules
setting
out
the
standards
13
for
the
different
types
of
hospitals
and
for
rural
emergency
14
hospitals
to
be
licensed
under
this
chapter
.
The
department
15
shall
enforce
the
rules.
16
b.
Rules
or
standards
shall
not
be
adopted
or
enforced
17
which
would
have
the
effect
of
denying
a
license
to
a
hospital
,
18
rural
emergency
hospital,
or
other
institution
required
to
be
19
licensed,
solely
by
reason
of
the
school
or
system
of
practice
20
employed
or
permitted
to
be
employed
by
physicians
in
the
21
hospital,
rural
emergency
hospital,
or
other
institution
if
the
22
school
or
system
of
practice
is
recognized
by
the
laws
of
this
23
state.
24
2.
a.
The
rules
shall
state
that
a
hospital
or
rural
25
emergency
hospital
shall
not
deny
clinical
privileges
to
26
physicians
and
surgeons,
podiatric
physicians,
osteopathic
27
physicians
and
surgeons,
dentists,
certified
health
service
28
providers
in
psychology,
physician
assistants,
or
advanced
29
registered
nurse
practitioners
licensed
under
chapter
148
,
30
148C
,
149
,
152
,
or
153
,
or
section
154B.7
,
solely
by
reason
of
31
the
license
held
by
the
practitioner
or
solely
by
reason
of
32
the
school
or
institution
in
which
the
practitioner
received
33
medical
schooling
or
postgraduate
training
if
the
medical
34
schooling
or
postgraduate
training
was
accredited
by
an
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organization
recognized
by
the
council
on
higher
education
1
accreditation
or
an
accrediting
group
recognized
by
the
United
2
States
department
of
education.
3
b.
A
hospital
or
rural
emergency
hospital
may
establish
4
procedures
for
interaction
between
a
patient
and
a
5
practitioner.
The
rules
shall
not
prohibit
a
hospital
or
6
rural
emergency
hospital
from
limiting,
restricting,
or
7
revoking
clinical
privileges
of
a
practitioner
for
violation
8
of
hospital
rules,
regulations,
or
procedures
established
9
under
this
paragraph,
when
applied
in
good
faith
and
in
a
10
nondiscriminatory
manner.
11
c.
This
subsection
shall
not
require
a
hospital
or
rural
12
emergency
hospital
to
expand
the
hospital’s
current
scope
of
13
service
delivery
solely
to
offer
the
services
of
a
class
of
14
providers
not
currently
providing
services
at
the
hospital
15
or
rural
emergency
hospital
.
This
section
shall
not
be
16
construed
to
require
a
hospital
or
rural
emergency
hospital
17
to
establish
rules
which
are
inconsistent
with
the
scope
of
18
practice
established
for
licensure
of
practitioners
to
whom
19
this
subsection
applies.
20
d.
This
section
shall
not
be
construed
to
authorize
the
21
denial
of
clinical
privileges
to
a
practitioner
or
class
of
22
practitioners
solely
because
a
hospital
or
rural
emergency
23
hospital
has
as
employees
of
the
hospital
or
rural
emergency
24
hospital
identically
licensed
practitioners
providing
the
same
25
or
similar
services.
26
3.
The
rules
shall
require
that
a
hospital
or
rural
27
emergency
hospital
establish
and
implement
written
criteria
28
for
the
granting
of
clinical
privileges.
The
written
criteria
29
shall
include
but
are
not
limited
to
consideration
of
all
of
30
the
following:
31
a.
The
ability
of
an
applicant
for
privileges
to
provide
32
patient
care
services
independently
and
appropriately
in
the
33
hospital
or
rural
emergency
hospital
.
34
b.
The
license
held
by
the
applicant
to
practice.
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c.
The
training,
experience,
and
competence
of
the
1
applicant.
2
d.
The
relationship
between
the
applicant’s
request
for
the
3
granting
of
privileges
and
the
hospital’s
or
rural
emergency
4
hospital’s
current
scope
of
patient
care
services,
as
well
as
5
the
hospital’s
or
rural
emergency
hospital’s
determination
of
6
the
necessity
to
grant
privileges
to
a
practitioner
authorized
7
to
provide
comprehensive,
appropriate,
and
cost-effective
8
services.
9
4.
The
department
shall
also
adopt
rules
requiring
10
hospitals
and
rural
emergency
hospitals
to
establish
and
11
implement
protocols
for
responding
to
the
needs
of
patients
who
12
are
victims
of
domestic
abuse,
as
defined
in
section
236.2
.
13
5.
The
department
shall
also
adopt
rules
requiring
14
hospitals
and
rural
emergency
hospitals
to
establish
and
15
implement
protocols
for
responding
to
the
needs
of
patients
who
16
are
victims
of
elder
abuse,
as
defined
in
section
235F.1
.
17
Sec.
9.
Section
135B.7A,
Code
2023,
is
amended
to
read
as
18
follows:
19
135B.7A
Procedures
——
orders.
20
The
department
shall
adopt
rules
that
require
hospitals
21
and
rural
emergency
hospitals
to
establish
procedures
for
22
authentication
of
all
verbal
orders
by
a
practitioner
within
23
a
period
not
to
exceed
thirty
days
following
a
patient’s
24
discharge.
25
Sec.
10.
Section
135B.8,
Code
2023,
is
amended
to
read
as
26
follows:
27
135B.8
Effective
date
of
rules.
28
Any
hospital
or
rural
emergency
hospital
which
is
in
29
operation
at
the
time
of
promulgation
of
any
applicable
30
rules
or
minimum
standards
under
this
chapter
shall
be
given
31
a
reasonable
time,
not
to
exceed
one
year
from
the
date
of
32
such
promulgation,
within
which
to
comply
with
such
rules
and
33
minimum
standards.
34
Sec.
11.
Section
135B.9,
Code
2023,
is
amended
to
read
as
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follows:
1
135B.9
Inspections
and
qualifications
for
hospital
and
rural
2
emergency
hospital
inspectors
——
protection
and
advocacy
agency
3
investigations.
4
1.
The
department
shall
make
or
cause
to
be
made
inspections
5
as
it
deems
necessary
in
order
to
determine
compliance
with
6
applicable
rules.
Hospital
and
rural
emergency
hospital
7
inspectors
shall
meet
the
following
qualifications:
8
a.
Be
free
of
conflicts
of
interest.
A
hospital
or
rural
9
emergency
hospital
inspector
shall
not
participate
in
an
10
inspection
or
complaint
investigation
of
a
hospital
or
rural
11
emergency
hospital
in
which
the
inspector
or
a
member
of
the
12
inspector’s
immediate
family
works
or
has
worked
within
the
13
last
two
years.
For
purposes
of
this
paragraph,
“immediate
14
family
member”
means
a
spouse;
natural
or
adoptive
parent,
15
child,
or
sibling;
or
stepparent,
stepchild,
or
stepsibling.
16
b.
Complete
a
yearly
conflict
of
interest
disclosure
17
statement.
18
c.
Biennially,
complete
a
minimum
of
ten
hours
of
continuing
19
education
pertaining
to
hospital
or
rural
emergency
hospital
20
operations
including
but
not
limited
to
quality
and
process
21
improvement
standards,
trauma
system
standards,
and
regulatory
22
requirements.
23
2.
In
the
state
resource
centers
and
state
mental
health
24
institutes
operated
by
the
department
of
human
services,
the
25
designated
protection
and
advocacy
agency
as
provided
in
26
section
135C.2,
subsection
4
,
shall
have
the
authority
to
27
investigate
all
complaints
of
abuse
and
neglect
of
persons
28
with
developmental
disabilities
or
mental
illnesses
if
the
29
complaints
are
reported
to
the
protection
and
advocacy
agency
30
or
if
there
is
probable
cause
to
believe
that
the
abuse
has
31
occurred.
Such
authority
shall
include
the
examination
of
all
32
records
pertaining
to
the
care
provided
to
the
residents
and
33
contact
or
interview
with
any
resident,
employee,
or
any
other
34
person
who
might
have
knowledge
about
the
operation
of
the
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institution.
1
Sec.
12.
Section
135B.12,
Code
2023,
is
amended
to
read
as
2
follows:
3
135B.12
Confidentiality.
4
The
department’s
final
findings
or
the
final
survey
findings
5
of
the
joint
commission
on
the
accreditation
of
health
care
6
organizations
or
the
American
osteopathic
association
with
7
respect
to
compliance
by
a
hospital
or
rural
emergency
hospital
8
with
requirements
for
licensing
or
accreditation
shall
be
made
9
available
to
the
public
in
a
readily
available
form
and
place.
10
Other
information
relating
to
a
hospital
or
rural
emergency
11
hospital
obtained
by
the
department
which
does
not
constitute
12
the
department’s
findings
from
an
inspection
of
the
hospital
13
or
rural
emergency
hospital
or
the
final
survey
findings
of
14
the
joint
commission
on
the
accreditation
of
health
care
15
organizations
or
the
American
osteopathic
association
shall
16
not
be
made
available
to
the
public,
except
in
proceedings
17
involving
the
denial,
suspension,
or
revocation
of
a
license
18
under
this
chapter
.
The
name
of
a
person
who
files
a
complaint
19
with
the
department
shall
remain
confidential
and
shall
not
20
be
subject
to
discovery,
subpoena,
or
other
means
of
legal
21
compulsion
for
its
release
to
a
person
other
than
department
22
employees
or
agents
involved
in
the
investigation
of
the
23
complaint.
24
Sec.
13.
Section
135B.14,
Code
2023,
is
amended
to
read
as
25
follows:
26
135B.14
Judicial
review.
27
Judicial
review
of
the
action
of
the
department
may
be
sought
28
in
accordance
with
chapter
17A
.
Notwithstanding
the
terms
of
29
chapter
17A
,
the
Iowa
administrative
procedure
Act,
petitions
30
for
judicial
review
may
be
filed
in
the
district
court
of
the
31
county
in
which
the
hospital
or
rural
emergency
hospital
is
32
located
or
to
be
located,
and
the
status
quo
of
the
petitioner
33
or
licensee
shall
be
preserved
pending
final
disposition
of
the
34
matter
in
the
courts.
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Sec.
14.
Section
135B.15,
Code
2023,
is
amended
to
read
as
1
follows:
2
135B.15
Penalties.
3
Any
person
establishing,
conducting,
managing,
or
operating
4
any
hospital
or
rural
emergency
hospital
without
a
license
5
shall
be
guilty
of
a
serious
misdemeanor,
and
each
day
of
6
continuing
violation
after
conviction
shall
be
considered
a
7
separate
offense.
8
Sec.
15.
Section
135B.16,
Code
2023,
is
amended
to
read
as
9
follows:
10
135B.16
Injunction.
11
Notwithstanding
the
existence
or
pursuit
of
any
other
12
remedy,
the
department
may,
in
the
manner
provided
by
law,
13
maintain
an
action
in
the
name
of
the
state
for
injunction
14
or
other
process
against
any
person
or
governmental
unit
to
15
restrain
or
prevent
the
establishment,
conduct,
management
or
16
operation
of
a
hospital
or
rural
emergency
hospital
without
a
17
license.
18
Sec.
16.
Section
135B.20,
subsection
3,
Code
2023,
is
19
amended
to
read
as
follows:
20
3.
“Hospital”
shall
mean
means
all
hospitals
and
rural
21
emergency
hospitals
licensed
under
this
chapter
.
22
Sec.
17.
Section
135B.33,
subsection
1,
unnumbered
23
paragraph
1,
Code
2023,
is
amended
to
read
as
follows:
24
Subject
to
availability
of
funds,
the
Iowa
department
of
25
public
health
shall
provide
technical
planning
assistance
to
26
local
boards
of
health
and
hospital
or
rural
emergency
hospital
27
governing
boards
to
ensure
access
to
hospital
such
services
in
28
rural
areas.
The
department
shall
encourage
the
local
boards
29
of
health
and
hospital
or
rural
emergency
hospital
governing
30
boards
to
adopt
a
long-term
community
health
services
and
31
developmental
plan
including
the
following:
32
Sec.
18.
Section
135B.34,
subsection
7,
Code
2023,
is
33
amended
to
read
as
follows:
34
7.
For
the
purposes
of
this
section
,
“comprehensive
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preliminary
background
check”
:
1
a.
“Comprehensive
preliminary
background
check”
means
the
2
same
as
defined
in
section
135C.1
.
3
b.
“Hospital”
means
a
hospital
or
rural
emergency
hospital
4
licensed
under
this
chapter.
5
Sec.
19.
EMERGENCY
RULEMAKING
AUTHORITY.
The
department
6
may
adopt
emergency
rules
under
section
17A.4,
subsection
3,
7
and
section
17A.5,
subsection
2,
paragraph
“b”,
to
implement
8
the
provisions
of
this
Act
and
the
rules
shall
be
effective
9
immediately
upon
filing
unless
a
later
date
is
specified
in
the
10
rules.
Any
rules
adopted
in
accordance
with
this
section
shall
11
also
be
published
as
a
notice
of
intended
action
as
provided
12
in
section
17A.4.
13
Sec.
20.
APPLICABILITY.
This
Act
applies
to
a
facility
14
that
was,
on
or
before
December
27,
2020,
a
general
hospital
15
with
no
more
than
fifty
licensed
beds,
located
in
a
county
in
a
16
rural
area
as
specified
in
section
135B.3A,
as
enacted
in
this
17
Act,
with
a
population
between
thirty
thousand
and
thirty-five
18
thousand
according
to
the
2020
federal
decennial
census,
19
operating
under
a
valid
certificate
of
need
on
and
prior
to
20
September
1,
2022.
Notwithstanding
any
provision
to
the
21
contrary,
and
in
accordance
with
section
135B.5A,
as
amended
22
in
this
Act,
the
conversion
of
a
general
hospital
as
specified
23
under
this
section
to
a
rural
emergency
hospital
under
this
24
Act
shall
not
be
subject
to
certificate
of
need
requirements
25
pursuant
to
section
135.63.
26
Sec.
21.
EFFECTIVE
DATE.
This
Act,
being
deemed
of
27
immediate
importance,
takes
effect
upon
enactment.
28
EXPLANATION
29
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
30
the
explanation’s
substance
by
the
members
of
the
general
assembly.
31
This
bill
provides
for
state
licensure
of
rural
emergency
32
hospitals.
Under
the
federal
Consolidated
Appropriations
Act
33
of
2021
(federal
Act),
rural
emergency
hospitals
(REHs)
were
34
established
as
a
new
provider
type.
Effective
January
1,
2023,
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REHs
will
be
eligible
to
enroll
in
Medicare
and
to
receive
an
1
enhanced
reimbursement
rate
for
eligible
services
consisting
2
of
the
outpatient
prospective
payment
system
rate
plus
a
5
3
percent
add-on
and
a
fixed
monthly
payment.
In
order
to
be
4
classified
as
an
REH
under
the
federal
Act,
a
facility
must
5
meet
certain
requirements,
including
applicable
state
licensing
6
requirements.
The
bill
provides
a
process
for
such
licensure.
7
The
bill
provides
emergency
rulemaking
authority
to
8
implement
the
bill.
9
The
bill
includes
applicability
provisions.
The
bill
10
applies
to
a
facility
that
was,
on
or
before
December
27,
2020,
11
a
general
hospital
with
no
more
than
50
licensed
beds,
located
12
in
a
county
in
a
rural
area
as
specified
in
the
bill
with
a
13
population
between
30,000
and
35,000
according
to
the
2020
14
federal
decennial
census,
operating
under
a
valid
certificate
15
of
need
on
and
prior
to
September
1,
2022.
Notwithstanding
16
any
provision
to
the
contrary,
the
conversion
of
the
specified
17
general
hospital
to
a
rural
emergency
hospital
shall
not
be
18
subject
to
certificate
of
need
requirements.
19
The
bill
takes
effect
upon
enactment.
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