6. The Safety Net

This page contains additional references for Chapter 6 of Responding to Healthcare Reform: A Strategy Guide for Heatlhcare Leaders.  The most current additions are at the top of the page.  It also includes the annotated references from the book and their associated hyperlinks.

Current References

CMS State Operations Manual – Chapter 2 – The Certification Process.

Critical Access Hospitals
This page provides basic information about being certified as a Medicare Critical Access Hospital (CAH) provider and includes links to applicable laws, regulations, and compliance information.

A facility that meets the following criteria may be designated by CMS as a CAH:

• Is located in a State that has established with CMS a Medicare rural hospital flexibility program; and
• Has been designated by the State as a CAH; and
• Is currently participating in Medicare as a rural public, non-profit or for-profit hospital; or was a participating hospital that ceased operation during the 10-year period from November 29, 1989 to November 29, 1999; or is a health clinic or health center that was downsized from a hospital; and
• Is located in a rural area or is treated as rural; and
• Is located more than a 35-mile drive from any other hospital or CAH (in mountainous terrain or in areas with only secondary roads available, the mileage criterion is 15 miles); and
• Maintains no more than 25 inpatient beds; and
• Maintains an annual average length of stay of 96 hours per patient for acute inpatient care; and
• Complies with all CAH Conditions of Participation, including the requirement to make available 24-hour emergency care services 7 days per week.

A CAH may also be granted “swing-bed” approval to provide post-hospital Skilled Nursing Facility-level care in its inpatient beds.

In the case of hospice care, a hospice may contract with a CAH to provide the Medicare hospice hospital benefit. Reimbursement from Medicare is made to the hospice. The CAH may dedicate beds to the hospice, but the beds must be counted toward the 25-bed maximum. However, the hospice patient is not included in the calculation of the 96-hour annual average length of stay. The hospice patient can be admitted to the CAH for any care involved in their treatment plan or for respite care. The CAH negotiates reimbursement through an agreement with the hospice.

In addition to the 25 inpatient CAH beds, a CAH may also operate a psychiatric and/or a rehabilitation distinct part unit of up to 10 beds each. These units must comply with the Hospital Conditions of Participation.

Critical Access Fact Sheet


Excerpt: Critical Access Hospital Payments Medicare pays CAHs for most inpatient and outpatient services to Medicare beneficiaries on the basis of reasonable cost. Under the Medicare ambulance benefit, if a CAH or an entity that is owned and operated by the CAH is the only provider or supplier of ambulance service located within a 35 mile drive of that CAH or entity, the CAH is paid based on reasonable cost for the ambulance services. CAHs are not subject to the Inpatient Prospective Payment Systems (IPPS) and Hospital Outpatient Prospective Payment System (OPPS).

Annotated References from Responding to Reform

United States Central Intelligence Agency CIA World Fact Book
82% of the US population resides in urban areas.

Blanchfield, B. B., J. L. Heffernan, B. Osgood, R. R. Sheehan, and G. S. Meyer. 2010. “Saving Billions of Dollars—and Physicians’ Time—by Streamlining Billing Practices. Health Affairs 29 (6): 1248.

 CMS. 2011a. “Critical Access Hospitals.”  www.cms.gov/CertificationandComplianc/04_CAHs.asp

 “Federally Qualified Health Center (FQHC) Center.”  www.cms.gov/center/fqhc.asp.

 Rural Assistance Center. 2011a. Critical Access Hospitals.”  www.raconline.org/info_guides/hospitals/cah.php.

“Federally Qualified Health Centers  www.raconline.org/info_guides/clinics/fqhc.php.

Sommers, B. D. 2007. “Why Millions of Children Eligible for Medicaid and SCHIP are Uninsured: Poor Retention Versus Poor Take-Up.” Health Affairs 26 (5): w560.

US Department of Health and Human Services (DHHS). 2011. “National Health Services Corps.”   http://nhsc.hrsa.gov/.
The NHSC is a network of 7,500 primary healthcare professionals and 10,000 sites as of September 30, 2010 working in underserved communities across the country. To support their service, the NHSC provides clinicians with financial support in the form of loan repayment and scholarships.

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