HAP Resource Center

Advocacy Correspondence: CMS Comment Letter, Conditions of Participation (CoP) for Rural Emergency Hospitals and Critical Access Hospital CoP Updates

August 29, 2022

The Honorable Chiquita Brooks-LaSure
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-1772-P
P. O. Box 8013
Baltimore, MD 21244-1850

RE: CMS-3419-P, Medicare and Medicaid Program; Conditions of Participation (CoPs) for Rural Emergency Hospitals (REH) and Critical Access Hospital CoP Updates: Proposed Rule (Vol. 87, No. 128), July 6, 2022

Dear Administrator Brooks-LaSure:

On behalf of The Hospital and Healthsystem Association of Pennsylvania (HAP), which represents approximately 235 member hospitals, we appreciate the opportunity to comment on the Centers for Medicare & Medicaid Services’ (CMS) Conditions of Participation (CoP) for Rural Emergency Hospitals (REH) and Critical Access Hospitals (CAH) CoP updates proposed rule.

HAP is primarily interested in commenting with respect to CMS’ proposal to further clarify the definition of “primary roads” for purposes of CAH eligibility. In its proposed rule, CMS proposes adding a definition for “primary roads” to its location and distance requirements and clarifying that the location distance for a CAH is more than a 35-mile drive on primary roads from another hospital or another CAH. Under the proposal, a “primary road” would be specified as “a numbered federal highway; or a numbered state highway with two or more lanes each way.”

If the rule is finalized, CMS intends to establish a centralized, data-driven review process of all hospitals and CAH within a 50-mile radius of each CAH with a follow-up investigation on expanded health care capacity and access within a 35-mile radius of the CAH. CAH with no new hospitals in a 50-mile radius will be automatically recertified, while those with new hospitals within the 50-mile radius will be subject to additional review.

The current definition of a “primary road” as any federally designated highway (regardless of location, number of lanes, terrain, or condition) has been problematic and is the only reason one particular Pennsylvania hospital has not been able to secure CAH designation.

There are many U.S. highways in Pennsylvania that are far from any sort of high-speed, multi- lane interstates. It is widely felt that federal highways are not any better maintained or easier to travel than state-designated highways.

HAP is happy to support the finalization of CMS’ proposal to clarify the distance requirements by adding the definition of primary roads but respectfully requests CMS consider further clarifications, specifically:

  • Excluding federal numbered highways with one lane in each direction as in many cases, federal one-lane highways do not differ from state one-lane highways, which are already excluded from the proposed definition.
  • Clarifying how CMS will be approaching the 50-mile radius around CAH for purposes of CAH certification (miles vs. “as the crow flies”).

The CAH designation is intended to support vulnerable, rural hospitals and keep essential health care services in rural communities. Further clarifying the definition of primary roads is imperative to continue to protect access to health care in Pennsylvania’s rural communities by enabling hospitals that have long been disadvantaged by the vague definition of federal highways to pursue this important designation.

The previous comments provide areas of emphasis that HAP otherwise incorporates by referencing all comprehensive comments submitted by the American Hospital Association.

Thank you for your consideration of HAP’s comments regarding this proposed rule. If you have any questions, contact Kate Slatt, vice president, innovative payment and care delivery, at (717) 561-5317.



Jeffrey W. Bechtel
Senior Vice President, Health Economics and Policy














Topics: Access to Care, Medicare, Rural Health Care

Revision Date: 8/29/2022

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