Introduction
The Flex Monitoring Team maintains a list of Critical Access Hospitals which includes the hospital name, city, state, zip code and effective date of CAH status.
The Critical Access Hospitals (CAH) program was
designed to improve rural health care access and reduce hospital
closures. Critical Access Hospitals provide essential services to
a community and are reimbursed by Medicare on a "reasonable
cost basis" for services provided to Medicare patients.
Frequently Asked Questions
Tools
AHA Issues: Critical Access Hospitals
Web site
Information on American Hospital Association (AHA) advocacy activities related to Critical Access Hospitals (CAHs). Includes news, resources, and more.
CAH Financial Performance Indicators by State
Web site
State-level reports on the financial condition and performance of Critical Access Hospitals (CAHs).
CAH Information
Web site
Lists Critical Access Hospitals (CAHs) for the entire country and by state, as well as a map of CAH locations and quarterly data by state on conversion to the CAH program.
CAH Legislative History
Web site
Describes pieces of legislation that have resulted in the creation and modification of the critical access hospital (CAH) program.
Certification & Compliance: Critical Access Hospitals
Web site
Provides basic information about being certified as a Medicare Critical Access Hospital (CAH) provider and includes links to applicable laws, regulations, and compliance information.
CMS Critical Access Hospitals Center
Web site
Federal regulations and notices, press releases, program memorandums, and other information from CMS related to the Critical Access Hospitals (CAH) program.
CMS Recovery Audit Contractor (RAC)
Web site
Provides information on the Recovery Audit Contractor (RAC) project, implementation strategies, who the RACs are, RAC jurisdictions, RAC expansion and provider outreach schedules, and FAQs.
CMS Rural Health Open Door Forum
Web site
Provides information on a series of CMS forums addressing rural health issues. Covers Rural Health Clinic (RHC), Community Access Hospital (CAH) and Federally Qualified Health Center (FQHC) issues, as well as some inclusion of other questions and concerns that occur in clinical practice pertaining to other CMS payment systems that also extends into these settings. Includes call-in instructions for the next call and how to register for the mailing list.
CMS State Survey Agency Directory
Web site
Directory of state agencies that handle survey and certification of certain health care facilities for compliance with the Medicare health and safety standards.
Code of Federal Regulations (CFR)
Web site
A searchable database of the Code of Federal Regulations (CFR); the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the Federal Government.
EMS Resource Guide for Critical Access Hospitals
Web site
Provides information and resources to Critical Access Hospitals (CAHs) to help them strengthen and improve rural emergency medical services (EMS) capacity in local communities. Covers infrastructure, human resources, funding sources, legislation and regulation, and more.
Innovators' Guide to Navigating CMS
Web site
Assist stakeholders in understanding the processes used to determine coverage, coding, and payment for new technologies under the Medicare fee-for-service program. Guide is intended as a general summary.
Joint Commission: Critical Access Hospital Accreditation
Web site
Information on the Joint Commission survey process for certification of Critical Access Hospitals (CAHs).
Medicaid Treatment of CAHs by State
Other
Lists Medicaid payment information for Critical Access Hospitals (CAHs) by state, in an Excel spreadsheet format.
Medicare Modernization Act
Web site
Information on CMS implementation of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). Includes links to CMS fact sheets and press releases, as well as other resources for understanding the impact of the MMA.
Rural Health Research: Critical Access Hospitals and Rural Hospital Flexibility Program
Web site
Provides summaries of current and completed rural health research projects and related publications addressing the topic of Critical Access Hospitals and the Rural Hospital Flexibility Program, produced by the Office of Rural Health Policy's funded rural health research centers.
Rural Hospital Performance Improvement Education and Training Gateway
Web site
Lists distance and web-based educational resources for rural hospitals.
Rural Hospitals: Enough Stimulus for IT?
Web site
Website offers access to a recording of a webcast that originally aired in May 2009 along with the associated presentation files. Presenters discuss differences in stimulus package IT incentives in relation to critical access hospitals (CAHs).
Technical Assistance and Services Center Web Site
Web site
TASC provides technical assistance to 47 states that administer the Medicare Rural Hospital Flexibility Program. The TASC web site includes a variety of tools, publications and resources on the Flex Program, as well as contact information for further assistance.
Funding
HUD 242 (FHA Section 242) - Helping Hospitals Get Capital Financing
Loan program to help hospitals finance new construction, refinancing, and modernization or to purchase major movable equipment such as hospital beds, wheeled equipment, and office machines.
Medicare Rural Hospital Flexibility Program
Grants to improve and sustain access to appropriate healthcare services of high quality in rural America by supporting conversion of small rural hospitals to critical access status, helping develop rural health care networks, and strengthening rural EMS.
Small Health Care Provider Quality Improvement Grant Program (SHCPQI)
Grant program designed to assist rural providers with the implementation of quality improvement strategies, while improving patient care and chronic disease outcomes.
Stimulus Simplicity Program
Grant program designed to help hospitals and physician offices accelerate Electronic Medical Records (EMR) adoption.
USAC Rural Health Care Service Discounts
Provides discounts to rural health care providers to obtain Internet and telecommunications access.
USDA Community Facilities Loan and Grant Program
Funding to construct, enlarge, or improve essential community facilities for health care, public safety, and public services in rural areas.
William Randolph Hearst Foundations Health Grants
Provides funding to improve access to quality health care for underserved populations in rural and urban areas.
Inactive Funding
Inactive Funding Opportunities -
Lists additional funding programs for this topic that are not currently accepting applications. Programs that are inactive may be offered again in the future.
Maps & Map Collections
Critical Access Hospitals (CAHs)
Geographic coverage: United States
Printable map that shows the location of CAHs nationwide. Data source: Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services.
Date: 2008
Location of Critical Access Hospitals
Geographic coverage: United States
U.S. map showing Critical Access Hospitals (CAHs). Updated quarterly.
Date: 2009
Regulations, Forms & Other Useful Documents
Capital Investment Needs of CAHs: Fire and Life Safety Code Compliance and Organizational Performance
Author(s): Walter Gregg
Sponsoring organization: Flex Monitoring Team
Describes current CAH capital needs and their experiences obtaining the capital critical for remaining compliant with fire and life safety codes and essential for maintaining effective and efficient operations.
Date: 11 / 2008
Capital Investment Needs of Critical Access Hospitals (CAHs): Results of the 2007 National CAH Survey
Author(s): Walter Gregg
Sponsoring organization: Flex Monitoring Team
Describes the findings of a national telephone survey of CAHs to determine the nature of their capital needs and experiences in accessing capital to meet those needs.
Date: 02 / 2009
CMS State Operations Manual: Appendix W
Sponsoring organization: Centers for Medicare and Medicaid Services
Detailed information about the state survey process for Critical Access Hospitals (CAHs).
Date: 06 / 2009
Code of Federal Regulations. 42 CFR 485.601-645: Subpart F, Conditions of Participation: Critical Access Hospitals (CAHs)
Sets forth the conditions that a hospital
must meet to be designated as a Critical Access Hospital (CAH).
Community Benefit and Impact of Critical Access Hospitals: The Results of the 2007 CAH Survey
Sponsoring organization: Flex Monitoring Team
Reports on a survey of 381 critical access hospital administrators covering a wide variety of questions concerning hospitals' community benefit and impact activities.
Date: 03 / 2008
Community Benefit Reporting Toolkit for Critical Access Hospitals
Sponsoring organization: Flex Monitoring Team
Provides guidance to the staffs of Critical Access Hospitals (CAHs) in collecting and reporting community benefit data to comply with federal and/or state community benefit reporting requirements or to prepare community benefit reports for internal and external audiences.
Date: 10 / 2009
Community Impact of Critical Access Hospitals
Author(s): John A. Gale, Andrew F. Coburn, Victoria Freeman, Walter R. Gregg, Rebecca Slifkin
Sponsoring organization: Flex Monitoring Team
Discusses the findings of a project to understand the community involvement and impact of Critical Access Hospitals (CAHs) and the Medicare Rural Hospital Flexibility Program (Flex
Program).
Date: 02 / 2007
Critical Access Hospital Fact Sheet
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides information about Critical Access Hospital (CAH) providers; CAH designation; CAH payments; reasonable cost payment principles that do not apply to CAHs; election of Standard Payment Method or Optional (Elective) Payment Method; Medicare Rural Pass-Through funding for certain anesthesia services; Health Professional Shortage Area Incentive payments; Physician Scarcity Area Bonus payments; Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provisions that impact CAHs; and grants to states under the Medicare Rural Hospital Flexibility Program.
Date: 04 / 2009
Critical Access Hospital Quality Improvement Activities and Reporting on Quality Measures: Results of the 2007 National CAH Survey
Author(s): Michelle Casey
Sponsoring organization: Flex Monitoring Team
Indicates that Critical Access Hospitals continue to be actively involved in a wide range of quality improvement initiatives, with patient safety and medication safety in particular as major areas of focus.
Date: 03 / 2008
Critical Access Hospital Year 4 Hospital Compare Participation and Quality Measure Results (Briefing Paper)
Author(s): Michelle Casey, Michele Burlew, Ira Moscovice
Sponsoring organization: Flex Monitoring Team
Examines the fourth year participation and quality measure results for Critical Access Hospitals (CAHs) in the Centers for Medicare and Medicaid Services (CMS) Hospital Compare public reporting database for hospital quality measures.
Date: 09 / 2009
Critical Access Hospital Year 4 Hospital Compare Participation and Quality Measure Results (Policy Brief)
Author(s): Michelle Casey, Michele Burlew, Ira Moscovice
Sponsoring organization: Flex Monitoring Team
Examines the fourth year participation and quality measure results for Critical Access Hospitals (CAHs) in the Centers for Medicare
and Medicaid Services (CMS) Hospital Compare public reporting database.
Date: 09 / 2009
Critical Access Hospitals (CAHs): Distance from Other Providers and Relocation of CAHs with a Necessary Provider Designation
Sponsoring organization: Centers for Medicare and Medicaid Services
September 7, 2007 letter from CMS to State Survey Agency Directors. Explains the criteria to determine whether a Critical Access Hospital (CAH) applicant satisfies the regulatory requirement. Explains the criteria to determine whether a
CAH with a necessary provider designation remains essentially the same provider, serving the same service area after relocation. Supersedes the November 14, 2005 guidance on this topic.
Date: 09 / 2007
Critical Access Hospitals and Financial Benchmark Performance
Author(s): George Pink, Mark Holmes, Rebecca Slifkin
Sponsoring organization: Flex Monitoring Team
Presents the results of application of the benchmarks to recent Critical Access Hospital (CAH) data. Very few CAHs performed better than benchmark on all five indicators in both 2004 and 2006.
Date: 11 / 2009
Critical Access Hospitals' Experience with Medicare Advantage Plans
Sponsoring organization: NORC Walsh Center for Rural Health Analysis
Details findings from a survey of 60 critical access hospital (CAH) administrators regarding their experiences with Medicare Advantage (MA) plans.
Date: 03 / 2008
Critical Access Hospitals: The Value of Membership in the American Hospital Association
Author(s): AHA Section for Small or Rural Hospitals
Sponsoring organization: American Hospital Association
Describes the benefits of membership in the American Hospital Association (AHA) for Critical Access Hospitals (CAHs). Includes information on AHA's work in the areas of representation, advocacy, and policy development. Also discusses member benefits for hospitals.
Date: 2007
Current Status of Health Information Technology Use in CAHs
Author(s): Michelle Casey, Jill Klingner, Walt Gregg, Ira Moscovice, Emily Nicholson, Tami Lichtenberg, Terry Hill
Sponsoring organization: Flex Monitoring Team
Examines the use of Health Information Technology (HIT) in Critical Access Hospitals (CAHs). Includes information on HIT infrastructure and the computerization of different functions within CAHs.
Date: 05 / 2006
Developing Indicators to Document the Community Impact of Critical Access Hospitals
Author(s): John A. Gale, Jennifer Lenardson, Andrew Cobum, Melanie Race
Sponsoring organization: Flex Monitoring Team
Provides tools for Critical Access Hospitals to strategically manage, monitor, and report their community impact activities.
Date: 05 / 2008
Developing Rural Federally Qualified Health Center and Critical Access Hospital Collaboration in Appalachia: A Demonstration Project
Sponsoring organization: National Rural Health Association
Examines the process of an Federally Qualified Health Center and a rural hospital coming together to consider joint activities that would mutually benefit them and their community.
Date: 10 / 2007
Doing Ethics in Rural Health Care Institutions
Author(s): Jacqueline J. Glover
Sponsoring organization: Board of Trustees of Dartmouth College
This fourth chapter of "Handbook for Rural Health Care Ethics," provides basic information about ethics and ethics deliberation and the challenges to ethics deliberation in rural areas. Provides a model template for ethical decision-making plus three mechanisms for supporting ethics deliberation.
Date: 2009
Experiences of Critical Access Hospitals in the Provision of Emergency Medical Services (Policy Brief)
Author(s): Janet P. Sutton, June Eichner
Sponsoring organization: NORC Walsh Center for Rural Health Analysis
Examines the experiences of Critical Access Hospitals in operating an emergency medical services (EMS) unit. Discusses the benefits and challenges that CAH providers face in operating EMS services.
Date: 10 / 2008
Hospitals Rising to the Challenge: The First Five Years of the U.S. Hospital Preparedness Program and Priorities Going Forward
Author(s): Eric Toner, Richard Waldhorn, Crystal Franco, Brooke Courtney, Kunal Rambhia, Ann Norwood, Thomas V. Inglesby, Tara O’Toole
Sponsoring organization: U.S. Department of Health and Human Services
Reports on the status of the Hospital Preparedness Program, which is designed to increase the ability of hospitals and healthcare systems to prepare for and respond to bioterror attacks on civilians and other public health emergencies, including pandemic influenza and natural disasters. Includes information on Critical Access Hospitals and rural areas.
Date: 03 / 2009
Impact of CAH Conversion on Hospital Finances and Mix of Inpatient Services
Author(s): Julie A. Schoenman, Janet P. Sutton
Sponsoring organization: NORC Walsh Center for Rural Health Analysis
Examines pre and post conversion data for hospitals that became CAHs during the first three years of the Flex Program in order to understand how CAH conversion affects not only hospital finances, but also inpatient service mix.
Date: 08 / 2008
Impact of Conversion to Critical Access Hospital Status on Hospital Financial Performance and Condition
Author(s): Mark Holmes, George H. Pink, Rebecca T. Slifkin
Sponsoring organization: Flex Monitoring Team
Policy brief analyzing financial ratios associated with Critical Access Hospitals' profitability, liquidity, and capital structure.
Date: 11 / 2006
Lessons Learned from Electronic Health Record Implementation at Three North Dakota Critical Access Hospitals
Sponsoring organization: JSI Research and Training Institute
Highlights common successes and challenges experienced during an electronic health
record (EHR) implementation project involving three Critical Access Hospitals (CAHs) in North Dakota. Offers recommendations for future Health Information Technology implementation processes.
Date: 03 / 2009
List of Critical Access Hospitals
Sponsoring organization: Flex Monitoring Team
Lists Critical Access Hospitals (CAHs). Includes city, state, zip and effective date.
Date: 07 / 2009
Measuring Regional Variation in Service Use
Sponsoring organization: Medicare Payment Advisory Commission
A report to Congress that presents data on the difference between regional variation in Medicare spending and regional variation in the use of Medicare-covered services. Date used was adjusted due to differences in small rural hospital and critical access hospital Medicare payment rates.
Date: 12 / 2009
Medicare Billing Information for Rural Providers, Suppliers, and Physicians
Sponsoring organization: Centers for Disease Control and Prevention
Medicare billing charts and information on where to submit claims for Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), Skilled Nursing Facilities, Home Health Agencies, Critical Access Hospitals, and Swing Bed services.
Date: 10 / 2008
Medicare Payment Basics: Critical Access Hospitals Payment System
Sponsoring organization: Medicare Payment Advisory Commission
Overview of how Critical Access Hospitals (CAHs) are paid by Medicare. Compares differences in Medicare payments for CAHs, Sole Community Hospitals (SCHs), and Medicare-dependent Hospitals (MDHs).
Date: 10 / 2009
Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule
Sponsoring organization: Centers for Medicare and Medicaid Services
Revises the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs. Implements
certain provisions made by the Deficit Reduction Act of 2005 (Pub. L. 109–171), the Medicare Improvements and Extension Act under Division B, Title I of the Tax Relief and Health Care Act of
2006 (Pub. L. 109–432), and the Pandemic and All Hazards Preparedness Act (Pub. L. 109–417). In the Addendum to this final rule with comment period, describes changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs.
Journal citation: Federal Register Volume 72 Issue 162 Pages: 47129-48175
Date: 08 / 2007
Number of Critical Access Hospitals (CAHs) per State
Sponsoring organization: Flex Monitoring Team
Data by state listing the total number of Critical Access Hospitals (CAHs) for each state, and the number of CAHs in each state with a Psychiatric DPUs (Distinct Part Units) and with Rehabilitation DPUs.
Date: 08 / 2007
Promoting Rural Health Care Quality Through Health Disparities Collaboratives: Columbia Valley Community Health
Author(s): Thomas D. Rowley
Sponsoring organization: National Rural Health Association
Describes a collaboration between a Federally Qualified Health Center (FQHC) and a Critical Access Hospital (CAH) in Washington state to help improve access to health care.
Date: 12 / 2005
Raising Funds for Rural Health Care: An Introductory Manual
Sponsoring organization: Rural Health Resource Center Technical Assistance and Services Center
Provides the basics for establishing a structured process of ongoing philanthropic resource development for health care facilities.
Rural Hospital Emergency Department Quality Measures: Aggregate Data Report
Author(s): Jill Klingner, Ira Moscovice
Sponsoring organization: Flex Monitoring Team
Reports findings from a project that tested emergency department quality measures in a voluntary sample of critical access hospitals (CAHs) in Washington State.
Date: 03 / 2007
Rural Hospital Replacement Facility Study, 2008
Author(s): Eric K. Shell, Brian R. Haapala
Summarizes the results of a study that explored the successes and barriers experienced by rural communities and their Critical Access Hospitals during hospital replacement projects.
Date: 2008
Summary of Changes in Critical Access Hospital Interpretive Guidance: Distance from Other Providers and Relocation of Critical Access Hospitals with a Necessary Provider Designation
Comparison chart of the September 7, 2007 revised Critical Access Hospital (CAH) location and relocation interpretive guidelines with the previous guidelines on this topic, which were issued November 14, 2005.
Date: 09 / 2007
Swing Bed Fact Sheet
Sponsoring organization: Centers for Medicare and Medicaid Services
Provides information about the requirements Critical Access Hospitals must meet in order to enter into a swing bed agreement under which they can use beds, as needed, to provide either acute or Skilled Nursing Facility care.
Date: 04 / 2009
Trends over Time in the Provision of Skilled Nursing Care in Critical Access Hospitals
Author(s): Kathleen Dalton, Rebecca Slifkin, Jeongyoung Park, Hilda Ann Howard
Sponsoring organization: North Carolina Rural Health Research and Policy Analysis Center (Cecil G. Sheps Center)
Examines trends in the delivery of skilled nursing facility services in both hospital-based units and swing beds during a period of dramatic change in Medicare payments for post-acute care, focusing on critical access hospitals (CAHs).
Date: 02 / 2006
Value-Based Purchasing and Critical Access Hospitals: Summary of Recommendations
Sponsoring organization: Rural Policy Research Institute (RUPRI) Rural Health Panel
Summarizes recommendations from the Rural Health Panel's report, CMS Value-Based Purchasing Program and Critical Access Hospitals.
Journal citation: RUPRI Rural Policy Brief
Date: 01 / 2009
Organizations
American Hospital Association (AHA)
National organization
Represents and serves all types of hospitals, health care networks, patients and communities.
American Hospital Association Section for Small or Rural Hospitals
National organization
Represents the interests of small and rural hospitals and ensures that the unique needs of this segment of AHA's membership are a national priority.
Centers for Medicare and Medicaid Services (CMS)
Federal government
Runs the Medicare and Medicaid programs - two national health care programs that benefit about 75 million Americans. Part of the U.S. Department of Health and Human Services.
Flex Monitoring Team
National organization
Performance monitoring project for the Medicare Rural Hospital Flexibility Program (Flex Program) conducted by the Rural Health Research Centers at the Universities of Minnesota, North Carolina, and Southern Maine.
National Rural Health Association (NRHA)
National organization
Promotes leadership, ideas, information, communication, education, research, advocacy, and methods to improve rural health. Composed of individual and organizational members who share a common interest in rural health.
NRHA: Hospitals and Community Systems Constituency Group
National organization
National Rural Health Association subgroup focused on hospitals and community systems.
Office of Rural Health Policy (ORHP)
Federal government
Promotes better health care service in rural America. Part of the Health Resources and Services Administration, U.S. Department of Health and Human Services. Focuses on matters affecting rural hospitals and health care, coordinating activities within the department that relate to rural health care, and maintaining a national information clearinghouse.
Rural Health Resource Center Technical Assistance and Services Center (TASC)
National organization
Assists states with all aspects of the Medicare Rural Hospital Flexibility Program (Flex Program), including CAH conversion, networking, EMS and performance improvement. TASC is the technical assistance center for the Flex Program.
Terms & Acronyms
CMS (Centers for Medicare and Medicaid Services) Federal agency responsible for the Medicare and Medicaid programs. Part of the U.S. Department of Health & Human Services.
Cost-based Reimbursement Method of reimbursing medical services based on the total costs incurred providing services to a patient.
Critical Access Hospital (CAH) Rural hospital that provides essential services to a community and receives cost-based reimbursement from Medicare. Requirements include a maximum of 25 beds (swing or acute care) and a maximum 96 hour average length of stay for acute care patients.
DRG (Diagnosis-related Groups) Reimbursement method where the hospital receives a fixed payment for each type of medical procedure, regardless of the hospital's cost.
Fiscal Intermediary (FI) Company designated by CMS to process claims and make payment for services.
Medicare Conditions of Participation (CoP) CMS conditions that health care organizations must meet to participate in the Medicare and Medicaid programs. Used to improve quality and protect the health and safety of beneficiaries.
Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) Legislation passed in 2003 that included significant Medicare reforms including a prescription drug benefit for Medicare beneficiaries and reimbursement improvements for rural healthcare facilities.
Medicare Rural Hospital Flexibility Program (Flex Program) Federal initiative created by the Balanced Budget Act of 1997 that provides funding to State Governments to strengthen rural health. Requires the development of state rural health plan. Provides funding to States network development, quality improvement, designation of Critical Access Hospitals (CAHs), and improvement of rural EMS.
PIP (Periodic Interim Payment) A regular payment made to a Critical Access Hospital based on an estimate of annual revenue to help maintain cash flow until cost reports from the current cost reporting period are settled and an annual payment adjustment is made.
Prospective Payment System (PPS) Medicare reimbursement method in which rates for services are established in advance, based on the patient's diagnosis.
Quality Improvement Organization (QIO) QIOs review Medicare services. They work with consumers, physicians, hospitals, and other caregivers to make sure patients get the right care at the right time, particularly among underserved populations.
Swing beds Licensed acute-care beds designated by a hospital to provide either acute or long-term care services. A swing bed hospital is a hospital or critical access hospital (CAH) participating in Medicare that has CMS approval to provide post-hospital skilled nursing facility care and meets certain requirements.
TASC (Technical Assistance and Services Center) The technical assistance center for the Medicare Rural Hospital Flexibility Program (Flex Program). Provides information, tools and resources on all aspects of the Flex Program, including CAH, networking, EMS, and quality improvement. TASC is run by the Rural Health Resource Center in Duluth, MN.
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