Critical Access Hospitals

This page provides basic information about being certified as a Medicare Critical Access Hospital (CAH) provider and includes links to applicable laws, regulations, and compliance information.

CAHs represent a separate provider type with their own Medicare Conditions of Participation (CoP) as well as a separate payment method. The CoPs for CAHs are listed in the “Code of Federal Regulations” at 42 CFR 485 subpart F.

The following providers may be eligible to become CAHs:

• Currently-participating Medicare hospitals;
• Hospitals that ceased operations on or after November 29, 1989; or
• Health clinics or centers (as defined by the State) that previously operated as a hospital before being downsized to a health clinic or center.

A Medicare-participating hospital must meet the following criteria to be designated by CMS as a CAH:

• Be located in a State that has established a State Medicare Rural Hospital Flexibility Program;
• Be designated by the State as a CAH;
• Be located in a rural area or an area that is treated as rural;
• Be located either more than 35-miles from the nearest hospital or CAH or more than 15 miles in areas with mountainous terrain or only secondary roads; OR prior to January 1, 2006, were certified as a CAH based on State designation as a “necessary provider” of health care services to residents in the area.
• Maintain no more than 25 inpatient beds that can be used for either inpatient or swing-bed services;
• Maintain an annual average length of stay of 96 hours or less per patient for acute inpatient care (excluding swing-bed services and beds that are within distinct part units);
• Demonstrate compliance with the CAH CoPs found at 42 CFR Part 485 subpart F; and
• Furnish 24-hour emergency care services 7 days a week;

A CAH may also be granted "swing-bed" approval to provide post-hospital Skilled Nursing Facility-level care in its inpatient beds.

In the case of hospice care, a hospice may contract with a CAH to provide the Medicare hospice hospital benefit. Reimbursement from Medicare is made to the hospice. The CAH may dedicate beds to the hospice, but the beds must be counted toward the 25-bed maximum. However, the hospice patient is not included in the calculation of the 96-hour annual average length of stay. The hospice patient can be admitted to the CAH for any care involved in their treatment plan or for respite care. The CAH negotiates reimbursement through an agreement with the hospice.

In addition to the 25 inpatient CAH beds, a CAH may also operate a psychiatric and/or a rehabilitation distinct part unit of up to 10 beds each. These units must comply with the Hospital Conditions of Participation.