Rural Health Policy

Regulatory Review

The Federal Office of Rural Health Policy is charged in Section 1102(b) of the Social Security Act with advising the Secretary of the U.S. Department of Health and Human Services on the effect that federal health care policies and regulations may have on rural communities. Monitoring current and proposed changes, including programs established under titles XVIII and XIX (Medicare and Medicaid), FORHP analyzes their impact on the financial viability of small rural hospitals and clinics, on the ability of rural areas to attract health professionals, and on rural areas’ access to high quality care.

Data collection and analysis is essential to understanding the challenges in rural communities, how those communities are impacted by policy, and setting policy for the future. For this reason, the work of the Rural Health Research Centers informs that of FORHP’s policy team and vice versa.

Policy Announcements

September 19

Call for Nominations. The National Quality Forum (NQF) will conduct a multi-stakeholder review of existing and potential telehealth metrics to identify measurement gaps and develop a measure framework and set of guiding principles for future telehealth measurement. The purpose of this work is to ensure clinical measures are applied appropriately to telehealth encounters in order to measure quality of care and to guide the future development of telehealth related measures.  NQF is seeking nominees with relevant expertise in telehealth, including providers working low-volume settings (physicians and representatives of facility providers, including Critical Access Hospitals, Rural Health Clinics, Community Health Centers and other Rural Hospitals) and subject matter experts from organizations such as academia, measure developers, health plans, and patient advocacy groups, etc.  Up to 25 members will be selected. All nominations must be submitted by 6:00pm ET on Monday September 26, 2016 using NQF's online nomination form

Pick Your Pace: Reporting Flexibility for the Quality Payment Program.  The Centers for Medicare & Medicaid Services (CMS) announced it will allow providers to choose the level and pace at which they comply with the new payment reform model aimed at emphasizing quality patient care over volume.  The announcement comes after feedback from physicians and other clinicians to ease implementation of the Quality Payment Program, set to begin January 1, 2017.  Next year, eligible physicians and other clinicians, including rural providers, will be given four options to comply with new payment models –
Option 1: Test the Quality Payment Program;
Option 2: Participate for part of the calendar year;
Option 3: Participate for the full calendar year; or
Option 4: Participate in an Advanced Alternative Payment Model in 2017. 
Note: These options and other supporting details will be described fully in the final rule.  No other further information about the final rule for the Quality Payment Program has been published by CMS. 

September 12

New Essential Community Provider Petition – submit by October 15. For the 2018 benefit year, health insurance plans sold in the Federal marketplace must offer contracts to providers serving predominantly low-income individuals in medically-underserved areas.  CMS maintains a non-exhaustive list of these Essential Community Providers (ECPs), and updates it annually to help insurance issuers find providers that can be included in their plan networks. Providers included on the draft HHS ECP list for the benefit year 2018 reflect those providers who submitted an ECP petition between December 9, 2015 and July 11, 2016 and were approved by CMS for inclusion through the ECP petition review process. In the ECP petition for the 2018, rural providers, including Rural Health Clinics, Federally Qualified Health Centers, and Critical Access Hospitals can check to see if they are on the list (in the Requested Action section) and determine if they should re-submit their petition to include any changes/updates or missing information. CMS solicits providers who do not yet appear on the ECP list but believe they satisfy the criteria for inclusion. Get help with designation from the ECP Frequently Asked Questions or by sending your question to EssentialCommunityProviders@cms.hhs.gov.

CMS Seeks Nominations for MACRA Quality Plan - Technical Expert Panel – Due September 15. The Centers for Medicare & Medicaid Services (CMS) is currently soliciting nominations for technical expert panel members to support the CMS Quality Measure Development Plan (MDP) project. The MDP is mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which also requires the preparation of an annual report on the development of measures for the CMS Quality Payment Program. The panel will consist of representatives of stakeholder organizations, including physician and non-physician practitioners, patients and families/caregivers, consumer advocates, and technical experts in quality measurement and health information technology, among other areas of knowledge. This is an opportunity for rural stakeholders and providers to provide input to CMS on rural considerations for quality measure development. For more information, visit the CMS Technical Expert Panels Web page. Scroll down to the Project Title -  CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Comment: Changes to ACA parameters – October 6. CMS has posted for public inspection the proposed rule for the 2018 benefits and payment parameters for the ACA health insurance marketplace.  CMS proposes changes to the risk adjustment program, cost-sharing parameters, and cost-sharing reductions.  They also propose to refine the guidance on standardized benefits options; consumer assistance tools; network adequacy; guaranteed renewability, and eligibility and enrollment.  Rural stakeholders will be especially interested in the proposed changes to the standardized benefits options, including the addition of a health savings account-eligible high deductible health plan, as well as proposed changes to the requirements for Essential Community Providers.  Comments are due to CMS by October 6, 2016.

September 2 

Proposed Changes to Black Lung Clinics Program – comment by September 21.  HRSA has released a federal register notice soliciting public comment on proposed changes to the Black Lung Clinics Program (BLCP).  The BLCP aims to reduce the morbidity and mortality of occupationally-related coal mine dust lung disease through the provision of screening, diagnosis, and treatment services to active, inactive, retired, and disabled coal miners.  BLCP grantees and external stakeholders are encouraged to review the notice and submit their feedback to blacklung@hrsa.gov.

Rate Changes for Long Term Care Hospitals. On August 22, CMS published its final rule updating payment rates and rules for long-term care hospitals (LTCHs) for fiscal year (FY) 2017. CMS estimates total payments to LTCHs will decrease by 7.1%, or $363 million, compared to FY 2016. In this second year of the three-year transition to the dual-rate LTCH payment system required by statute, discharges qualifying for site-neutral payment (approx. 45% of cases) will see a decrease of 23%, or $388 million, while those qualifying for standard LTCH payment rates (approx. 55% of cases) will see an increase of 0.7%, or $24 million. In addition to payment changes, CMS updated the LTCH Quality Reporting Program to include four new measures required by the IMPACT Act, and streamlined its rules under the 25% threshold policy, which adjusts payments when the number of cases an LTCH admits from a single hospital exceeds a specified threshold, generally 25%, though this limit is 50% for rural LTCHs given the relative scarcity of providers in rural communities. Finally, CMS also finalized its interim final rule establishing a temporary exception from the site-neutral payment rate for certain severe wound care discharges from certain rural LTCHs, which likely increases payment by $5 million for two providers. These changes are effective October 1, 2016.

Rate Changes for Hospital Inpatient Services. On August 22, CMS published its final rule updating payment rates and rules for hospital inpatient services for fiscal year (FY) 2017. CMS estimates total payments for inpatient services will increase by 0.95%, or about $746 million, compared to FY 2016, including changes due to the permanent withdrawal of the controversial two-midnight policy. CMS also made significant changes to the Medicare Disproportionate Share Hospital (DSH) payment adjustment. Beginning FY 2017, CMS will use the average of hospitals’ uncompensated care costs over three years, rather than only one. Beginning FY 2021, after editing the instructions for Worksheet S-10, CMS will phase in direct accounting of uncompensated care costs reported on the worksheet, replacing the current method which uses proxy data. Of note for rural providers, changes in the calculation and distribution of uncompensated care may benefit providers serving rural communities where patients continue to lack health insurance. CMS also implements several statutory provisions, including the requirement for hospitals and CAHs a to notify individuals receiving outpatient observation services for more than 24 hours using the standard Medicare Outpatient Observation Notice, and the extension of both the Low-Volume Hospital payment adjustment and the Medicare-Dependent Hospital program through FY 2017. These changes are effective October 1, 2016.

August 11

Bundled Payments for Cardiac Care and Hip Fractures – Comment by October 3. On August 2, CMS published a proposed rule for bundled payment models for high-quality, coordinated cardiac and hip fracture care similar to the Comprehensive Care for Joint Replacement (CJR) model which began in April 2016.  Under the proposed episode payment models (EPM), a hospital in which a patient is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge. For the new cardiac bundles, hospitals in 98 randomly-selected metropolitan statistical areas would be required to participate in the bundled care model.  Although rural counties are excluded from the models, providers and suppliers such as physicians, non-physician practitioners, skilled nursing facilities, critical access hospitals, and accountable care organizations can be EPM collaborators in providing post discharge care.  Through this proposed rule, rural providers also have the opportunity to propose future condition-specific EPMs and event-based EPMs for procedures and medical conditions that may be more applicable to rural areas. For more information on the proposed rule visit: https://innovation.cms.gov/initiatives/epm/.  

Final Rule for Skilled Nursing Facilities – Effective on October 1. On August 5, CMS published its final rule updating payment and policy for skilled nursing facilities (SNFs) for fiscal year 2017. Total payment for SNFs will increase by 2.4%, or $920 million, compared to FY 2016, with rural SNFs experiencing slightly larger payment increases than urban SNFs: 2.6% vs. 2.4%. In addition to annual payment revisions, the rule contains changes to the quality measures and administrative procedures under the SNF value-based purchasing (VBP) program, which begins FY 2019, and SNF quality reporting program (QRP), including four new measures required by the IMPACT Act. Of note, CMS has clarified that both the SNF VBP and SNF QRP apply to swing beds at rural PPS hospitals, but not swing beds at critical access hospitals.

Final Rule for Medicare Hospice Benefit – Effective on October 1. On August 5, CMS published its final rule updating hospice payment and policy for fiscal year (FY) 2017. Total payments to hospices will increase by 2.1%, or $350 million, compared to FY 2016, with similar payment increases for both rural and urban hospices: 2.0% vs. 2.1%, respectively. The rule also updates the hospice quality reporting program (HQRP) to add two new measures to begin FY 2019, including one measure set assessing hospice visits in the last week of life and one composite measure of comprehensive patient care at admission. Of note, CMS announced plans to consider a new hospice patient assessment instrument to expand upon and replace the current hospice item set chart abstraction tool. These regulations are effective October 1, 2016. For more information, please see the CMS fact sheet.

View Archived Policy Announcements

Please send your questions to FORHP's Policy Team at RuralPolicy@hrsa.gov.

Last Reviewed: September 2016