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 Updates 

May 10

Comments Requested: EMS Agenda 2050 HRSA exit disclaimer – May 31.  The project team for the Emergency Medical Services (EMS) Agenda 2050 created a draft document envisioning the future of this essential component of the rural health care safety net, and request comment from healthcare and public health professionals to finalize it.

Comments Requested: Policy Updates for Skilled Nursing Facilities – June 26.  CMS displayed its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for Skilled Nursing Facilities (SNFs) and non-Critical Access Hospital (CAH) swing beds. The rule includes an overall proposed payment rate increase of 2.4 percent, with rural SNFs and non-CAH swing beds experiencing this payment rate increase as 2.5 percent. CMS has also proposed replacing the current case-mix system with a new system called the Patient Driven Payment Model (PDPM) to be implemented by October 2019, which is projected to increase payments to small and rural SNFs and non-CAH swing beds. The proposed rule also includes changes to the SNF quality reporting program, changes to the SNF value-based purchasing program, and a request for information regarding electronic health information and interoperability.

Comments Requested: Policy Updates for Rehabilitation Facilities – June 26.  CMS displayed its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for Inpatient Rehabilitation Facilities (IRFs). In addition to a payment rate increase of 0.9 percent ($75 million) compared to last year, the proposed rule solicits comments about removing the face-to-face requirement for rehabilitation physician visits, expanding the use of nurse practitioners and physician assistants in meeting the IRF coverage requirements.  The proposal would update the IRF quality reporting program, including adding a new quality measure removal factor and removing two measures from the measure set. Several IRF-Patient Assessment Instrument items have also been proposed for removal, and there is a request for information in the rule related to electronic health information and interoperability.

Comments Requested: Policy Updates to Psychiatric Facilities – June 26.  CMS displayed its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for Inpatient Psychiatric Facilities (IPF). The rule includes an overall proposed increase in the payment rate by 1.25 percent, or $50 million for FY 2019. CMS has proposed to continue to apply the 17 percent payment adjustment for IPFs located in rural areas, which has been in place since 2004.The rule also updates the IPF quality reporting program by proposing the removal of eight (8) measures beginning with the FY 2020 payment determination. Additionally, the proposed rule includes technical changes to some of the IPF regulations and a request for information related to electronic health information exchange and interoperability.

Comments Requested: Policy Updates to Medicare Hospice – June 26.  CMS displayed its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for hospices.  The rule includes an overall proposed payment increase of 1.8 percent ($340 million). CMS also proposed changes to the regulation text allowing physician’s assistants to be recognized by Medicare as an attending physician in addition to physicians and nurse practitioners. The rule also includes a request for information related to electronic health information exchange and interoperability, and proposed changes to the quality reporting program that include removal of routine individual public reporting of 7 hospice item set measures and instead displaying them as a composite.

May 3

Comments Requested: Direct Provider Contracting in Medicare and Medicaid – May 25.   
The CMS Innovation Center seeks input on stakeholders’ experiences and perspectives about testing a direct provider contracting (DPC) model in Medicare and Medicaid. Under a DPC model, CMS would enter into arrangements with primary care practices whereby these practices would be receive a fixed per beneficiary per month payment to cover primary care services. Topics to comment on include how to design a model to attract small, independent practices/physicians and what safeguards can ensure that a DPC model would not negatively affect small or rural providers.

Comments Requested: CMS Updates Payment and Policy for Hospitals – June 25. CMS issued its proposed rule for fiscal year (FY) 2019 updating payment rates and rules for hospital inpatient services.  Rural hospitals are expected to receive smaller payment increases (1.1 percent) than urban hospitals (2.1 percent), with larger rural hospitals faring better than their smaller counterparts.  The rule reduces the number of quality measures hospitals are required to report across the five quality and value-based purchasing programs, including 39 measures from the Hospital Inpatient Quality Reporting Program and 10 measures from the Hospital Value-Based Purchasing Program.  Rural Health Value can help rural hospitals continue the transition to value-based careHRSA exit disclaimer  Also of note for rural providers, CMS has implemented provisions of the Bipartisan Budget Act of 2018 which extend the Medicare-Dependent Hospital program and Low-Volume Hospital Payment Adjustment for FY 2018 (further described at 83 FR 18301) through FY 2022. 

Comments Requested: HRSA Burden Reduction – July 2.  FORHP’s parent agency, the Health Resources and Services Administration (HRSA) seeks feedback for its ongoing work to reduce public and stakeholder burden.  Comments are open to the public and encouraged for entities significantly affected by HRSA regulations and policy, including state, local and Tribal governments, health care providers, small businesses, consumers, non-governmental organizations and trade associations.

Comments Requested: Improving Prehospital Trauma Care – July 26.  The National Highway Traffic Safety Administration is seeking comment and response to 24 specific questions from the public, governmental agencies, and professional and public interest groups on improving prehospital trauma care in all locations, including rural, suburban, urban, and wilderness areas.

April 19

CMS Releases 2018 MIPS Eligibility Tool. You can now use the updated CMS MIPS Participation Lookup Tool to check on your 2018 eligibility for the Merit-based Incentive Payment System (MIPS). Rural providers can enter their National Provider Identifier (NPI) to find out whether they’re re required to participate during the 2018 performance year.

April 12

2019 Health Insurance Marketplace Updates. CMS finalized guidance to states and insurers for administration of the American Health Benefit Exchanges (aka Marketplaces) in 2019.  The Benefits and Payment Parameters outlines increased flexibility for states HRSA exit disclaimer to review qualified health plans, determine network adequacy standards, and operate navigator programs.  The Annual Letter to Issuers updates the technical guidance to issuers to be able to participate in Marketplaces, including application submission dates and requirements for Essential Community Providers (i.e. Rural Health Clinics, Critical Access Hospitals).  About 18 percent of consumers live in rural areas.  

New Guidance Expands Hardship Exemptions for Insurance. Under this hardship exemption guidance, rural or urban individuals who live in counties with no issuers or only one issuer will qualify for a hardship exemption from paying the penalty for not having health insurance coverage.  The guidance also allows CMS to consider a broad range of circumstances that result in consumers needing hardship exemptions.   To apply for this exemption, consumers must complete a hardship exemption application found on   Use form for exemption #14 “You had another hardship.” 

April 5

Updates to Medicare Advantage (MA) and Prescription Drug Benefit (Part D) Programs – CMS finalized policy changes and plan payment rate increases to improve quality of care and provide more plan choices for MA and Part D enrollees.  The policy changes focus on putting “patients over paperwork” by reducing regulatory burdens, improving quality ratings for MA plans, and adding a new tool for Part D plans to combat the opioid epidemic. The rate announcement and call letter explains the 2019 plan payment rates and the regulatory flexibilities plans can use to improve access to benefits and services.  In 2017, about one-quarter of rural Medicare beneficiaries were enrolled in MAHRSA exit disclaimer and almost 70 percent had Part D coverageHRSA exit disclaimer

New Evaluation Report on the CMS State Innovation Model (SIM) Initiative.  In the SIM Initiative, the CMS Innovation Center is testing the ability of states to accelerate statewide health care system transformation into value-based payment models (VPMs). This Year 4 Annual Report describes how Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont leveraged their roles to move providers into VPMs as well as how providers in rural and urban areas, health systems, consumers, payers, and state officials fared during the final implementation year (spring 2016 to spring 2017) of the initiative.   

March 29

Comments Requested: CMS Proposal Reducing State Medicaid Reporting Burden – May 22.  This proposed rule would exempt state Medicaid programs from requirements to analyze certain data and monitor access when the vast majority of their covered lives receive services through managed care plans. CMS regulations separately provide for access requirements in managed care programs. Additionally, the proposed rule would provide flexibility to states when they make nominal rate reductions to fee-for-service payment rates.  As Medicaid is an important source of insurance in rural areas, State Offices of Rural Health and other rural advocates may be interested in whether this rule could impact their state’s reporting burden, enrollees’ access to care, or provider payment rates.

March 22

Nominations: Advisory Committee on HIV, Viral Hepatitis and STD Prevention – May 30. HRSA seeks broad representation of geographic areas, gender, ethnic and minority groups for the 18 members and two co-chairs of this committee that will advise federal leadership on strategies, policies, and priorities for HIV, viral hepatitis, and other STD prevention and treatment efforts.  Last year, the Centers for Disease Control and Prevention (CDC) reported that new cases of blood-borne viral infections are disproportionately impacting rural areas affected by the opioid epidemic and many new diagnoses of HIV have been found in rural and suburban areas

March 8

Nominations for the U.S. Preventive Services Task Force (USPSTF) – May 15.  The Agency for Healthcare Research and Quality (AHRQ) is seeking nominees for the USPSTF, an independent body of experts in prevention and evidence-based medicine. The recommendations made by the USPSTF address clinical preventive services for adults and children, and include screening tests, counseling services, and preventive medications.  A rural perspective from clinicians would broaden the expertise of the task force and the scope of its recommendations.  Experts in rural health research would also add value to USPSTF work, providing critical evaluation of research and methods of evidence review through a rural lens.   

VA Revises Policy for Emergency Treatment Payment.  The Veterans Administration (VA) revised its regulations concerning payment or reimbursement for emergency treatment for non-service connected conditions at non-VA facilities.  As such, the VA will begin processing claims for reimbursement for reasonable costs that were only partially paid by the Veteran’s other health insurance.  Those costs may include hospital charges, professional fees and emergency transportation such as ambulances.  For more details, refer to the fact sheet for VA payment for emergency treatment.  According to the VA’s Office of Rural Health, a quarter of all U.S. veterans - about 5.2 million – live in rural communities

VA Launches Online Resource for Community Care Providers. The Veterans Health Administration has launched a new web resource for community care providers as it works to improve the timeliness of payments and customer service. The website features a reference library with fact sheets, forms, training videos and other provider resources such as contact information for the VHA Office of Community Care and other Department of Veterans Affairs divisions. It also offers resources for providers seeking prompt payment of their claims, including a new Vendor Inquiry System that lets providers check their claim status online

February 28

Public Reporting of CAHPS® Hospice Survey Results Now AvailableIn 2015, nearly a quarter of all hospices in the US were in rural areasHRSA exit disclaimer Now rural patients, families, and providers can see how patients rated hospice services in their area and compare them to the national average by reviewing Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey results, now available on the CMS Hospice Compare site.  The survey results include all Medicare-certified hospices that had at least 30 completed surveys during the reporting period of April 1, 2015 through March 31, 2017. Interactive datasets of the survey results are also available.

February 21

CMS Seeking Primary Care Practices to Participate in Testing Opportunity. CMS is currently seeking primary care practices to help test a potential change to an electronic clinical quality measure (eCQM) related to clinician referrals. Honoraria will range from $2,000-$4,000, depending on practices’ level of testing participation. Interested practices should be reporting this eCQM under the Merit-Based Incentive Payment System (MIPS). For more information or if you are interested in assisting with this activity, please contact Shari Glickman and Omoniyi Adekanmbi.

February 14

CMS Annual Call for Medicare EHR Incentive Program Measures  – June 29.   CMS is accepting proposals for new Medicare Electronic Health Record (EHR) Incentive Program measures that advance meaningful use of Certified EHR Technology (CEHRT).  They encourage participating eligible hospitals and Critical Access Hospitals to submit ideas for new measures that emphasize patient outcomes and patient safety as well as improved program efficiency. 

Essential Community Providers for 2019.   CMS posted the list of Essential Community Providers (ECPs) approved for the 2019 plan year for the Health Insurance Marketplace. ECPs are providers serving low-income, medically-underserved individuals and include Rural Health Clinics, Critical Access Hospitals, and Federally Qualified Health Centers.  Insurers offering Qualified Health Plans are required to contract with at least 20 percent of ECPs in medically underserved areas.  Insurers may “write in” providers not included on this list after the provider submits a petition for inclusion

CMS Updates List of Alternative Payment Models (APMs). CMS recently published a list of all APMs the agency operates. Rural providers can review this document to learn more about which APMs qualify as Advanced APMs for the purposes of the Quality Payment Program (QPP). The table shows which APMs are medical home models and whether the APMs require certified EHR technology, quality measures comparable to those used in the Merit-based Incentive Payment System (MIPS), and financial risk. 

February 7 

Update to State Operations Manual for Rural Health Clinics. Last month, CMS released a new version of the State Operations Manual Appendix G - Guidance for Surveyors: Rural Health Clinics (RHCs). This document provides updates to guidelines for RHC survey and certification.

Beneficiary Engagement and Incentives Model Canceled – The CMS Innovation Center has cancelled the Direct Decision Support Model after also ending the Shared Decision Making Model last year.  Both models were part of the larger Beneficiary Engagement and Incentives Initiative, which was intended to strengthen beneficiary engagement in health care decisions.  The Direct Decision Support Model, which would have used telephonic support and other tools to inform beneficiaries on their health conditions in rural and urban areas, was determined to create undue participant burden.  The Shared Decision Making Model, which targeted Accountable Care Organizations, did not have sufficient participant interest.  

February 1

New Evaluation Results on the State Innovation Models (SIM) Initiative.  The CMS Innovation Center recently released evaluation results for the SIM Initiative Round Two Model Test Awards.  Participating states – Colorado,  Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Ohio, Rhode Island, Tennessee, and Washington – were awarded over $622 million to implement health policy and regulatory innovations tailored to the needs of their state’s residents.   The SIM Initiative has created federal-state partnerships with states, territories, and the District of Columbia to design and test strategies that meet the goals of higher quality/lower cost health care delivery.  The Innovation Center received considerable input from rural stakeholders to help shape the initiative.

Request for Nominations: Advisory Panel on Hospital Outpatient PaymentHRSA exit disclaimer CMS is accepting nominations on a continuous basis for two vacancies on the Advisory Panel on Medicare Hospital Outpatient Payment (HOP). The Panel may include urban and rural representatives of hospitals, hospital systems, or other Medicare outpatient providers and advises the Secretary of Health & Human Services and the Administrator of the CMS on Medicare outpatient payment systems.  The Panel also includes representatives of Critical Access Hospitals who advise on the level of supervision of hospital outpatient services.  Please submit nominations  electronically to

Medicare EHR Incentive Program Payment Adjustment Fact Sheet for CAHs. This fact sheet provides the payment reductions for Critical Access Hospitals (CAHs) that do not meet the meaningful use of Certified Electronic Health Record Technology (CEHRT) requirements. Beginning in FY2016, CAHs that don’t meet the requirements, or qualify for a hardship exemption, will be reimbursed 100.33% of reasonable costs.  For each subsequent year, reimbursements will be reduced to 100% of reasonable costs.

Date Last Reviewed:  May 2018

Questions about Policy Updates?