CAH Metropolitan Issue
Memo from John Rigg, CHA Vice President, Federal Regulatory Affairs

From: John Rigg
To: Harriet McKechnie ( <>
Sent: Mon May 17 08:02:40 2010
Subject: The CAH Metropolitan Issue

Ms. McKechnie –

On the phone last Thursday we discussed a growing concern on the part of California’s CAHs who have heard “through the grapevine” that their status as a CAH may be in danger from CMS action unless they are located: (1) in a county designated by OMB as non-metropolitan; or, (2) in a census tract within an OMB-designated metropolitan county that has been designated by CMS as rural.

I think I have tracked down the source of this anxiety:

  • The IPPS Final Rule for FFY 2005 instructs CAHs that are located in an area designated by OMB as metropolitan (an MSA) but believe themselves to be in a rural area to seek redesignation under 42 CFR § 412.103. I have included relevant pages from the FFY 2005 IPPS final rule as an attachment for your reference.
  • Similarly, 42 CFR § 485.610 (b) requires that a CAH be located either in a nonmetropolitan county or to seek redesignation by CMS (under the aforementioned 42 CFR § 412.103) as being in a rural area of an OMB-designated metropolitan county. Note that (b)(4) of this section further updates the location requirements for FFY 2009. This may explain some of the newfound anxiety among California’s CAHs. (this CFR reference can be located at )

My analysis of our currently-certified CAHs indicates that the following institutions are currently in counties designated as metropolitan, and thus may soon seek reclassification by CMS as rural:

  • Hospital Name CAH Number Census Tract Number County
  • Biggs-Gridley Memorial Hospital 051311 003500 Butte
  • Catalina Island Medical Center 051307 599000 Los Angeles
  • Colorado River Medical Center 051323 010700 San Bernardino
  • Kern Valley Hospital District 051314 005202 Kern
  • Mayers Memorial Hospital 051305 012702 Shasta
  • Mountain County Community Hospital 051312 011000 San Bernardino
  • Healdsburg District Hospital 051321 153902 Sonoma
  • Tehachapi Valley Healthcare District 051301 006100 Kern

Of these facilities only two, Mountains Community Hospital and Healdsburg District hospital, are “necessary provider” CAHs. All the others met the distance requirements at the time they were designated as CAHs and (as far as I know) continue to do so.

I have already heard from several of these institutions who cannot locate correspondence to or from CMS indicating that they have received designation under 42 CFR § 412.103 as being in a rural area and are interested in rectifying the situation as soon as possible. From our conversation last week I am led to believe that one (Mayers Memorial) has already sought and received this status through the Region IX office. Can you confirm that these other institutions can (if needed) submit similar requests to your office and have a reasonable expectation that their applications will be approved?

Thank you for your assistance.


John Rigg, MHA MPA
Vice President, Federal Regulatory Affairs
California Hospital Association


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