[Congressional Record Volume 154, Number 153 (Thursday, September 25, 2008)]
[Senate]
[Pages S9478-S9479]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




      CMS CERTIFICATIONS OF HRSA RURAL HEALTH CLINIC DESIGNATIONS

  Mr. BAUCUS. Mr. President, yesterday we passed the Health Care Safety 
Net Act, which reauthorizes multiple programs within the jurisdiction 
of the Committee on Health, Education, Labor and Pensions, HELP. This 
bill does include one section that changes the timeframe for the 
Centers for Medicare and Medicaid Services, CMS, to certify rural 
health clinic, RHC, shortage area designations from 3 years to 4 years. 
We have worked closely with the chairman and ranking member of the HELP 
Committee to have language included in H.R. 3343 to align the timeframe 
for CMS certifications of rural health clinic designations with the 
timeframe for HRSA designations. This provision is crucial to 
maintaining access to primary care and other necessary medical services 
in rural areas. I know that several rural health clinics in Montana 
would be forced to close their doors if the CMS rule were permitted to 
go forth. I am proud to stand with my colleagues on both sides of the 
aisle to ensure that these important parts of our health care delivery 
system are protected.
  We are most appreciative of the efforts of the HELP Committee to 
include this language at our request. As chairman of the Finance 
Committee, I am obligated to point out for the record that Medicare is 
exclusively governed by title XVIII of the Social Security Act, which 
is under the exclusive jurisdiction of the Finance Committee. Inclusion 
of these Medicare provisions in H.R. 3343 does not represent any waiver 
of the Finance Committee's jurisdiction on this subject. In the absence 
of the Chairman of the HELP Committee, Senator Kennedy, I would ask the 
distinguished ranking member, Senator Enzi, to acknowledge that 
Medicare is governed by title XVIII of the Social Security Act and is 
under the exclusive jurisdiction of the Finance Committee. Again, I 
would like to extend our thanks to the chairman and ranking member of 
the HELP Committee for graciously agreeing to our request to include 
this language in H.R. 3343.
  Mr. ENZI. It is a great pleasure to work with my distinguished 
colleagues on H.R. 3343, the Health Care Safety Net Act. The Committee 
on Health, Education, Labor and Pensions has a long and distinguished 
history of championing legislation improving our health care system. 
Reauthorization of the health center program, the National Health 
Service Corps, rural health care programs, and dental workforce 
programs are a handful of examples of the successful programs the HELP 
Committee governs. I have had the pleasure of working with Senators 
Kennedy and Hatch on this bill, and I very much appreciate the work of 
Senators Smith, Barrasso, Roberts, and the other sponsors of S. 3367, 
which was the genesis of the rural health clinic provision included in 
this bill. I also sincerely appreciate the contributions of Senators 
Baucus and Grassley, as the rural health provision is under the 
jurisdiction of the Finance Committee. I look forward to strengthening 
our relationship next year as our two great committees work together on 
health care reform, and I am pleased the passage of this bill puts us 
one step closer to a higher quality health care system.
  Mr. GRASSLEY. I agree with my colleague, Chairman Baucus, and would

[[Page S9479]]

also like to extend my thanks to the chairman and ranking member of the 
HELP Committee, Senator Kennedy and Senator Enzi, for working with us 
on this issue. In my 7 years as chairman and ranking member of the 
Finance Committee, I have worked to preserve the committee's 
jurisdiction over legislation amending the Social Security Act, as 
Senator Baucus is doing now. In this case, the CMS certification 
requirement for rural health clinic designations is governed by title 
XVIII of the Social Security Act, which, as the Chairman has noted, is 
within the exclusive jurisdiction of the Finance Committee. The 
Balanced Budget Act of 1997 required that rural health clinics be 
located in an underserved or shortage area that were designated or 
updated within the previous 3 years but the 3-year requirement has only 
been applied to new facilities seeking to be designated as rural health 
clinics. The Centers for Medicare and Medicaid Services, CMS, recently 
issued a rule proposing changes in the requirements for rural health 
clinics. One of the proposed changes would apply the 3-year designation 
requirement to all rural health clinics and decertify RHCs located in 
communities where the shortage area designation is more than 3 years 
old.
  The Health Resources and Services Administration, HRSA, and most 
States update their shortage area designations every 4 years. We need 
to align the timeframes for HRSA and CMS shortage area designations so 
that CMS certifications of rural health clinic designations would be 
valid for a 4-year period, consistent with the 4-year period used for 
HRSA designations. Otherwise, many rural health clinics in Iowa and 
other States throughout the country could lose their RHC designation 
simply because their State is not able to comply with the new CMS 3-
year timeframe for certification.
  Under the CMS proposal, if an RHC loses its designation or the State 
has not renewed its shortage area designation within 3 years, the RHC 
must request an exception within 90 days or it will be decertified 180 
days after the 3-year period ends. Unless the statutory 3-year CMS 
certification period is changed to 4 years, many RHCs could be subject 
to being decertified in the near future unless they are deemed 
``essential.'' Rural health clinics should not be jeopardized with 
closure because a shortage area designation has not been updated in a 
timely fashion by the State or Federal Government.
  CMS has estimated that approximately 500 of the 3,700 rural health 
clinics operating today no longer meet the existing location 
requirements for RHCs, either because they are not in an area 
designated by the U.S. Census Bureau as ``nonurban'' or they are not 
designated by HRSA as being located in an eligible shortage area. 
Others believe that this estimate is too low. The National Rural Health 
Association has estimated that the proposed changes to the location 
requirements could result in up to 45 percent of RHCs being ineligible 
to continue in the program unless they are granted an exception. If 
this estimate holds true for RHCs throughout the country, over 1,600 
RHCs could be decertified. This would severely impact access to health 
care for those in rural and medically underserved areas where rural 
health clinics provide the only access to critical medical services.
  We are most appreciative of the efforts of our colleagues, Senator 
Kennedy and Senator Enzi, to amend H.R. 3343 to change the CMS 
certification period for shortage area designations from 3 to 4 years 
in order to align the CMS certification period for shortage area 
designations with HRSA's designation review period.

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