CAH
Frequently Asked Questions
Question:
What is a Critical Access Hospital?
Answer:
A Critical Access Hospital (CAH) is a hospital that is certified
to receive cost-based reimbursement from Medicare. The reimbursement
that CAHs receive is intended to improve their financial performance
and thereby reduce hospital closures. Each hospital must review
its own situation to determine if CAH status would be advantageous.
CAHs are certified under a different set of Medicare Conditions
of Participation (CoP) that are more flexible than the
acute care hospital CoPs.
Question: How
many CAHs are there and where are they located?
Answer: As of August 2007, there are
1,283 certified Critical Access Hospitals located throughout the
United States. 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. You can
also view a map
of CAHs.
Question: What
is the Medicare Rural Hospital Flexibility Program and how is
it related to the CAH program?
Answer: The Medicare Rural Hospital
Flexibility Program (Flex Program) was created by the Balanced
Budget Act of 1997 and is intended to strengthen rural health care
by encouraging states to take a holistic approach. A major requirement
for participation in the Flex Program is the creation of a state
rural health plan. The Flex Program provides grants to each state
which are used to implement a Critical Access Hospital program,
to encourage the development of rural health networks, to assist
with quality improvement efforts, and improve rural emergency medical
services. The Flex Program promotes a process for improving rural
health care, using the Critical Access Hospital (CAH) program as
one method of promoting strength and longevity through CAH conversion
for appropriate facilities.
Question: What
types of facilities are eligible for CAH status?
Answer: Facilities applying to become
Critical Access Hospitals must have a current status as a licensed
acute care hospital. Hospitals closed after 11/29/89 and hospitals
that have downsized to health clinic or health center status also
may qualify for CAH status if they meet all of the CAH Conditions
of Participation.
Question: What
are the location requirements for CAH status?
Answer: CAHs must be located in a rural
area and meet one of the following criteria:
Question: Can
a CAH add an off-campus provider based entity
that does not meet the CAH distance requirements?
Answer: As of January 1, 2008,
all CAHs, including necessary provider CAHs, that create or
acquire an off-campus provider-based facility such as a clinic,
or a psychiatric or rehabilitation distinct part unit, must
meet the CAH distance requirement of a 35-mile drive to the
nearest hospital or CAH (or 15 miles in the case of mountainous
terrain). This provision excludes Rural Health Clinics, as
defined under 405.2401(b), from the list of provider-based
facilities that must comply with this requirement. Details
about this requirement are available in a Final Rule published
in the November 27, 2007 issue of the Federal Register as part
of the Medicare
Program: Changes to the Hospital Outpatient Prospective Payment
System and CY 2008 Payment Rates. See
Section XVIII. Changes Affecting Critical Access Hospitals
(CAHs) and Hospital Conditions of Participation (CoPs), starting
on page 66877.
Question: What
are the requirements for relocating an existing CAH under the
Necessary Provider replacement rules?
Answer: CAHs that have been granted
Necessary Provider status and want to rebuild in a new
location that does not meet the distance requirements of the 35-mile
rule will be treated in the same manner as if they were building
a replacement facility at the previous location. The
new CAH facility will have to continue to meet the same criteria
that led to its original state designation, serve at least 75%
of the same service area, offer 75% of the same services, and utilize
at least 75% of the same staff in its new location. See
the September 7, 2007 letter from CMS to State Survey Agency Directors
titled Critical
Access Hospitals (CAHs): Distance from Other Providers and Relocation
of CAHs with a Necessary Provider Designation for
more detailed information.
Question:
What are the benefits of CAH status?
Answer:
Some benefits of conversion to CAH status include:
- Cost-based reimbursement from Medicare, which has the potential to increase
revenues. As of January 1, 2004, CAHs are eligible for cost plus 1% reimbursement.
- Focus on community needs.
- CAH network with an acute care hospital for support
and expansion of services.
- Flexible staffing and services, to the extent that
state licensure laws permit.
- Capital improvement
costs included in allowable costs for determining Medicare reimbursement.
- Access to Flex Program grant money.
Question: Are
all the benefits of CAH status
available in every state?
Answer:
No. Not all CAHs may take advantage of the more flexible Medicare
Conditions of Participation (CoP) and the related cost savings.
In states that license CAHs under the same licensure rules as other
hospitals, CAHs must comply with those licensure rules. If those
rules are stricter than the CAH CoP, the CAH is unable to benefit
from the Medicare
flexibility. In addition, five states, Connecticut, Delaware, Maryland, New Jersey and Rhode Island, do not participate in the Flex Program and therefore
hospitals in those states are not eligible for CAH status.
Question:
Will CAH conversion guarantee a better financial return?
Answer:
No. Some hospitals will find the cost-based reimbursement advantageous,
and some will not. Each hospital must perform its own financial
analysis to determine if CAH conversion would result in a better
financial return. For financially distressed hospitals, even if
CAH conversion results in increased reimbursement, it may not put
the
hospital "in the black." Some hospitals that have converted
to CAH have since closed.
Question:
Will CAH conversion solve all the problems at our hospital?
Answer:
No. The CAH program is a reimbursement status, and in some states
CAH status allows more flexible staffing and services. It will
not address organizational problems such as problems within the
organization's culture, leadership, community issues, and so on.
A hospital should convert to CAH status only if it is appropriate
for the community need and hospital service area. In particular,
consideration should be given to the bed
limit for CAHs and whether that is a good match for community
need.
Question:
Is CAH conversion a downgrade for our facility?
Answer:
No. CAH is a change in provider designation, not a downgrade. Conversion
to CAH status does not necessarily mean losing services. In some
cases, hospitals that have converted to CAH may even choose to
expand their range
of services to better meet community needs.
Question:
Is there a limit on the length of stay for
patients at CAHs?
Answer:
CAHs must maintain an annual average length of stay of 96 hours or
less for their acute care patients. There is no length of stay
limit for swing bed patients.
Question:
How many beds are allowed?
Answer:
CAHs may have a maximum of 25 beds. For CAHs with swing bed agreements, any of its beds may be used for either inpatient acute care or swing bed services. Any hospital-type bed located in or adjacent to any location where the bed could be used for inpatient care counts toward the 25 bed limit.
Certain beds do not count toward the 25 bed limit, including examination or procedure beds, stretchers, operating room tables, and others. For a complete list of beds that do not count toward the 25 bed limit, please see Section C-0211, §485.620(a) Standard: Number of Beds: Interpretive Guidelines of the CMS State Operations Manual: Appendix W.
Question:
What emergency services are CAHs required
to provide?
Answer:
CAHs must provide 24-hour emergency services, with medical staff
on-site; or on-call and available on-site within 30 minutes,
60 minutes if certain frontier area criteria are met.
The staff on-site or on call must meet state licensure
requirements, but Medicare Conditions of Participation specify
the coverage could be a doctor of medicine or osteopathy, a physician
assistant,
a
nurse
practitioner, or a clinical nurse specialist, with training or experience in emergency care. In
certain very limited circumstances, the coverage could be provided
temporarily by a registered nurse.
As of October 1, 2007, CMS requires that any hospital, including a CAH, that does not have a physician on site 24 hours per day, 7 days per week, provide a notice to all patients upon admission. The notice must address how emergency
services are provided when a physician is not on site. For
more information, please see page 47413 of the August 22, 2007
Federal Register notice, Medicare
Program; Changes to the Hospital Inpatient Prospective Payment
Systems and Fiscal Year 2008 Rates; Final Rule.
Question:
What kinds of agreements does a
CAH need to have with an acute care hospital?
Answer:
A CAH must develop agreements with an acute care hospital related
to patient referral and transfer, communication, emergency and
non-emergency patient transportation. The CAH may also have an
agreement with their referral hospital for quality improvement or
choose to have that agreement with another organization. State networking
requirements vary.
Question:
How do staffing requirements differ for CAHs, compared to general acute care hospitals?
Answer:
There are two main ways that staffing requirements are more flexible
for CAHs under the Medicare Conditions of Participation (CoP):
- Medical Staff: A CAH must have at least one physician,
but he or she is not required to be on-site. Midlevel practitioners
can be an active, independent part of the CAH medical staff and
provide direct
service to patients. CAHs are required to provide
oversight by a physician, but the oversight provisions are very
liberal. This can be especially useful in communities that have
had difficulty recruiting physicians.
- Nursing Staff: General acute care hospitals
are required to have an RN on-site 24 hours a day, 7 days a week.
CAHs have
more flexibility regarding staffing levels for nurses. The federal
requirements allow for the hospital to close (and so have no
RN on staff) if the facility is empty. State requirements vary.
Some states may offer flexibility by allowing an LPN to cover
a shift in
place of an RN when there are no acute patients, for example.
Contact your state
survey agency for details.
However, CAHs must continue to meet their state licensure laws if those are stricter than the Medicare CoP.
Question:
Are other requirements for CAHs different from those for general acute care hospitals?
Answer:
Except for the staffing flexibility mentioned above, requirements
are very similar for CAHs and general acute care hospitals. CAHs
must
meet the requirements
for the services they choose
to provide. So, for example, if a CAH provides surgical services,
it must meet the relevant surgery requirements just as a general
acute care hospital would.
You may want to consult several sources to address
questions you have about CAH requirements. Some issues may vary
from state to state based on state licensure laws and other factors,
and interpretation of the federal requirements is not always straightforward.
To find out more about your state's requirements, begin by contacting
your State
Office of Rural Health.
Question:
Does Medicaid provide special reimbursement
to CAHs?
Answer:
Each state decides if it will provide special reimbursement to
Critical Access Hospitals for Medicaid services. Consult your State
Rural Hospital Flexibility Program Contact for information
about your state's policies.
Question:
How can we decide if CAH conversion is right for our hospital?
Answer:
Contact your State
Rural Hospital Flexibility Program Contact for guidance in
evaluating whether CAH conversion is the right choice for your
facility. A financial analysis is necessary to determine whether
cost-based reimbursement will be advantageous.
Question: How
do we involve our staff and our community in the CAH conversion
process?
Answer:
It is very important to keep the hospital staff and community informed about what CAH
conversion means and how it will impact them. The hospital's CEO should learn the basics about CAH
and transfer that knowledge to the medical staff and board of directors. This group will then share
information about the CAH conversion with the hospital staff and the community.
Your State
Rural Hospital Flexibility Program Contact can help you plan
your approach. There is also a tool available that helps you
adapt to your situation:
Question: What
is the CAH survey process?
Answer:
A facility interested in CAH status should contact its state
survey agency to request application materials. The state agency
will review and forward the application to a CMS regional office.
The CMS regional
office will authorize a survey, and the state agency will then
contact the facility to arrange a survey date. The survey will
verify that the CAH meets the federal facility requirements. Details
about the survey process are available in Appendix
W of the CMS
State Operations Manual.
CAH accreditation is also available through The Joint Commission or
the American
Osteopathic Association's Healthcare Facilities Accreditation Program.
Question: What
are the quality assurance options for CAHs?
Answer:
Critical Access Hospitals must have arrangements with respect to
quality assurance, either with a hospital that is part of a network,
with another CAH, or a private organization or through a credentialing
body like The Joint Commission or
the
American
Osteopathic Association's Healthcare Facilities Accreditation
Program. The QA agreement includes credentialing, which can be a program
review of the CAH procedures or a core credentialing process,
which is then used by the CAH to privilege staff.
Question: How
do provisions in the Medicare Prescription Drug Improvement and
Modernization Act (MMA) impact Critical Access Hospitals (CAHs)?
Answer: While there are many provisions
in the Medicare
Prescription Drug Improvement and Modernization Act (MMA) that
will impact CAH operations, there are several provisions that specifically
relate to CAHs. They are found in Section 405 of the MMA. The provisions:
- Increase CAH reimbursement to cost plus 1%;
- Provide cost-based reimbursement for emergency room physician
assistants, nurse practitioners and clinical nurse specialists
who are on-call;
- Reinstate the Periodic Interim Payments (PIPs);
- Expand eligibility for the Method Two/All-Inclusive payment
for outpatient services (which provides payments of physician
fee schedule plus 15%) to any practitioner in the CAH who assigns
billing rights to the hospital;
- Flexibility to designate up to 25 beds as acute care inpatient
beds;
- Permit CAHs to operate Psychiatric and/or Rehabilitation Distinct
Part Units (DPUs) of up to 10 beds; and
- Eliminate the state authority to waive the 35-mile rule (effective
January 1, 2006).
Question: Who
should I call if I have questions about CAH status or reimbursement
issues?
Answer: Your State
Rural Hospital Flexibility Program Contact can provide ongoing
guidance about CAH issues. Other important contacts include:
Credits
Last revised 10/22/2007
