Critical Access Hospital (CAH)

On this page, view the below information.

What is a CAH?

  • Legislation enacted as part of the Balanced Budget Act (BBA) of 1997 authorized States to establish a State Medicare Rural Hospital Flexibility Program (Flex Program) under which certain facilities participating in Medicare can become CAHs
    • The Flex Program was designed to improve access and quality and relieve some of the financial pressures on rural hospitals and emergency medical services
  • To become a CAH, the enrollment must already be established in Medicare as a hospital
  • A Medicare participating hospital must meet the following criteria to be designated as a CAH:
    • Be in a State that has established a State rural health plan for the State Flex Program (as of September 2011, only Connecticut, Delaware, Maryland, New Jersey, and Rhode Island do not have a State Flex Program);
    • Be in a rural area or be treated as rural under a special provision that allows qualified hospital providers in urban areas to be treated as rural for purposes of becoming a CAH;
    • Demonstrate compliance with the Conditions of Participation found at 42 CFR Part 485 subpart F at the time of application for CAH status;
    • Furnish 24-hour emergency care services 7 days a week, using either on-site or on-call staff;
    • Provide no more than 25 inpatient beds that can be used for either inpatient or swing bed services; however, it may also operate a distinct part rehabilitation or psychiatric unit, each with up to 10 beds;
    • Have an average annual length of stay of 96 hours or less per patient for acute care (excluding swing bed services and beds that are within distinct part units);
    • Be located either more than a 35-mile drive from the nearest hospital or CAH or more than a 15-mile drive in areas with mountainous terrain or only secondary roads or certified as a CAH prior to January 1, 2006, based on State designation as a necessary provider of health care services to residents in the area. ---state verifies
  • For CAHs to elect to be Method II they need to send in a written statement electing to be Method II no less than 30 days before the start of their cost reporting period, this should state whether the CAH chooses to include any CRNAs in Method II
    • CAH may send in an 855I for the providers to be Method II Billing providers this needs to be sent in by paper application to Audit
    • If a CAH has received the CRNA exemption (also known as "pass-through") but chooses to include CRNA's in Method II, they give up the exemption for both outpatient as well as inpatient services
    • Method II remains in effect until the CAH wishes to terminate

Billing for CAH

  • For more information regarding billing, go to the billing portion of the website.

Application Requirements

Application Tips
PECOS application
  • "Institutional Provider" (e.g., Hospital, Skilled Nursing Facility, Hospice, Home Health Agency)
  • Complete questionnaire to ensure correct applications (CMS-855A and CMS 588-EFT) populate.
  • Complete all form sections
  • Attach all supporting documentation such as IRS documents
  • List all directors, board members, and contracted or W-2 managing employee
  • Visit the Application Fee webpage to access CMS link to pay application fee
  • Submit completed CMS-588 EFT and voided check/bank letter. EIN required to be on application in Tax Identification Number (TIN) field

Application Time Frame

Application Type Processing Time
PECOS On average, it can take 15 to 50 calendar days before application is sent to state and CMS for approval
Paper On average, it can take 30 to 65 calendar days before application is sent to state and CMS for approval


  1. Once Noridian has completed the reviewal of the application, a Recommendation for Approval Letter is sent to the State Agency and CMS. There is no set timeframe for their review.
  2. Additional days after State and CMS approval Noridian will have additional days to finalize enrollment records.
Last Updated Dec 26 , 2023