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

February 14

Comments Requested: Proposed Updates to Interoperability & Patient Access to Health Data – Early April. On February 11, the Centers for Medicare & Medicaid Services (CMS) proposed policy changes supporting its MyHealthEData initiative to improve patient access and advance electronic data exchange and care coordination throughout the healthcare system. The proposed rule solicits comments on policies that would affect hospitals, including critical access hospitals (CAHs). This includes policies on public reporting and prevention of information blocking and requiring Medicare-participating hospitals, psychiatric hospitals, and CAHs to send electronic notifications when a patient is admitted, discharged or transferred. In addition to the policy proposals, CMS is releasing two related Requests for Information (RFIs). CMS will accept comments on the major provisions in this proposed rule and the RFIs (CMS-9115-P) until early April (exact date will be updated upon posting at the Federal Register).

February 7

Nominations:  Medicaid and CHIP Payment and Access Commission (MACPAC) – February 20.  The Government Accountability Office (GAO) seeks nominations for the Medicaid and Children’s Health Insurance Programs (CHIP) Payment and Access Commission (MACPAC) for terms beginning May 2019. This commission advises Congress, the Secretary of Health and Human Services, and the States on Medicaid and CHIP on issues related to payment, services, and access to care.  By statute, Commission membership should provide a mix of different professions, broad geographic representation, and a balance between urban and rural representation.  They may include 

  • Medicaid or CHIP enrollees (or caregivers of enrollees), 
  • experts in Federal safety net health programs, health finance and economics, actuarial science, health plans, reimbursement for health care, health information technology, or
  • providers of health services, public health, and other related fields.

Comments Requested:  Proposed Updates to the Medicare Advantage (MA) and Part D Programs – March 1.  Last week, CMS released Part II of the Advanced Notice and Draft Call Letter for the MA and Part D programs, which updates the payment methods for these programs.  In conjunction with Part I released in December, CMS proposes to update the risk adjustment model, revise the measures in the quality Star Rating program, and offer guidance on how plans can offer non-health related supplemental benefits, such as transportation for non-medical needs.  As of March 2017, almost one-quarter of rural Medicare beneficiaries were enrolled HRSA Exit Disclaimer in some type of Medicare Advantage plan.

Nominations:  Medicare Payment Advisory Commission (MedPAC) – March 8.  The Government Accountability Office (GAO) seeks nominations for the Medicare Payment Advisory Commission (MedPAC) for terms beginning May 2019.  This commission advises Congress on payment methodologies, issues related to access to care, quality of care, and other issues affecting Medicare.  Commission members should include individuals with expertise in the financing and delivery of health care services and have a broad geographic representation, including rural and urban. They may include physicians and other health professionals, employers, third-party payers, researchers with a variety of health-related expertise, and representatives of consumers and the elderly.

January 24

Comments Requested: Proposed Changes to the 2020 Health Insurance Marketplace – February 19.   Last week, the Centers for Medicare & Medicaid Services (CMS) posted its proposed guidance to states and insurers for the administration of the American Health Benefit Exchanges (aka Marketplaces) in 2020.  The proposed Notice of Benefits and Payment Parameters includes several proposals that would impact the cost of prescription drugs; a request for comment on the amount of time Navigator grantees spend providing post-enrollment assistance and the impact of making these services optional; and proposals to expand the roles of web-brokers and enrollment websites other than The draft Annual Letter to Issuers  includes application submission dates and requirements for Essential Community Providers (i.e. Rural Health Clinics, Critical Access Hospitals).  In 2018, about 18 percent of consumers lived in rural areas.  

Comments Requested: Accrediting Organizations Conflict of Interest and Consulting Services in Medicare – February 19. CMS recently issued a request for information (RFI) seeking public comment regarding the appropriateness of the practices of some Medicare-approved Accrediting Organizations (AOs) to provide fee-based consultative services for Medicare-participating providers and suppliers as part of their business model. This would include AOs that certify and survey rural health clinics (RHCs) and critical access hospitals (CAHs). CMS intends to consider information received in response to this RFI to assist in future rulemaking.  

CMS Updates Medicare Advantage Value-Based Insurance Design Model. Last week, CMS announced a broad array of Medicare Advantage (MA) health plan innovations that the CMS Innovation Center will test in the Value-Based Insurance Design (VBID) model for calendar year 2020. Among other updates, beginning in 2020, CMS will allow plans to use access to telehealth services instead of in-person visits to meet a range of network requirements, as long as an in-person option remains. CMS expects that the use of telehealth in this model will provide MA plans with an opportunity to enter into underserved markets, including rural areas where there may be few to no MA plan choices. 

CMS Introduces Part D Payment Modernization Model. In January 2020, the CMS Innovation Center will begin the Part D Payment Modernization model to test the impact of a revised Part D program design and incentive alignment on overall Part D prescription drug spending and beneficiary out-of-pocket costs. The model is open to eligible standalone Prescription Drug Plans (PDPs) and Medicare Advantage-Prescription Drug Plans (MA-PDs). Research in 2015 from the University of Minnesota Rural Health Research Center HRSA Exit Disclaimer found that urban beneficiaries tended to have access to more plans and lower cost burdens than rural residents. More rural-specific research on Medicare Part D is available from the Rural Health Research GatewayHRSA Exit Disclaimer

January 10

Comments Requested: Proposed Changes to the Medicare Advantage Risk Adjustment Model – February 19.  CMS requests comments on its proposed changes to the risk adjustment model used to calculate payments to Medicare Advantage plans.  Proposed changes to the methodology include increased use of diagnoses reported on Medicare Advantage encounter claims, additional condition categories for mental health, substance use disorder, and chronic kidney disease, and incorporating a variable that counts the number of conditions a beneficiary has.  This methodology is also used to determine provider payments in other CMS programs, and research has found rural and urban differences HRSA Exit Disclaimer in the resulting provider risk scores. 

10 Opportunities for States to Better Serve Dual Eligibles.  This letter from CMS to State Medicaid Directors outlines 10 ways to improve care for beneficiaries dually eligible for Medicare and Medicaid without using a demonstration or a waiver.  For example, states can bolster integrated care through Dual Special Needs Plans (D-SNPs) and reviewing payment rates for Programs of All-Inclusive Care for the Elderly (PACE).  There are also strategies to simplify eligibility and enrollment processes.  Rural beneficiaries are more likely to be dually-eligible HRSA Exit Disclaimer than their urban counterparts.

December 20

All Hospitals Must Make Standard Charges Public – Effective January 1.  CMS released responses to Frequently Asked Questions regarding the policy that hospitals must establish, update, and make public a list of their standard charges for all items and services, effective January 1, 2019.  This policy applies to all hospitals operating in the U.S., including critical access hospitals, inpatient rehabilitation facilities, and inpatient psychiatric facilities.  The charges must be provided in a machine-readable format that can be easily imported/read into a computer system (e.g., XML, CSV). A PDF does not satisfy this definition.  The policy was finalized in the 2019 Inpatient Prospective Payment System (IPPS) rule published on August 2, 2018.

Date Last Reviewed:  February 2019

Questions about Policy Updates?