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Clarification of Critical Access Hospital (CAH) Rural Status, Location and Distance Requirements
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 CAH Rural Status & Location/Distance Requirements:  Update of S&C 11-33-Hospital/CAH/RHC: This memorandum supersedes the portion of the guidance of policy memorandum S&C 11-33 which addresses metropolitan statistical areas (MSAs). That guidance is being updated to reflect the new CAH regulation at 42 CFR 485.610(b)(5). Under the new regulation, a Medicare-participating CAH that previously was located in a rural area, based on adoption by the Centers for Medicare & Medicaid Services (CMS) of the Office of Management and Budget’s (OMB) delineations of MSAs, may no longer be located in a rural area when CMS adopts the most recent OMB delineations. Such CAHs are permitted to retain their CAH status up to two years from the effective date of CMS’ latest adoption of the OMB delineations. During this grace period, the CAHs are expected either to reclassify as rural under one of the alternatives permitted at §485.610(b)(2), or to convert to a Medicare-participating hospital.  Minimum Distance to Other CAHs/Hospitals: The guidance found in Chapter 2 and Appendix W of the State Operations Manual (SOM) is being updated to specify that the proximity to each other of IHS/Tribal hospitals/CAHs and non-IHS/Tribal hospitals/CAHs is not considered when a CAH location determination is made.  CAHs Located on Islands: The guidance in Chapter 2 and Appendix W of the SOM is also being updated to reflect the location and distance requirements relative to CAHs located on islands.  Primary Roads: The criteria for a primary road have been refined with respect to numbered US highways. • Continued Compliance with CAH Location Requirements: All parties are being reminded that S&C-13-20, issued March 15, 2013, updated the interpretive guidelines for §485.610 and §485.610(c) to clarify that a CAH must meet the location and distance requirements not only at the time of initial conversion to CAH status, but at all times the facility participates as a CAH. The CAH’s compliance with these requirements must be reassessed at the time of each recertification.