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 

November 21

Comments Requested: Transparency in Coverage Proposed Rule – January 14. On November 15, the U.S. Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury proposed requirements for group health plans and health insurance issuers in the individual and group markets. These proposals would require disclosure of cost-sharing information upon request, to a participant, beneficiary, or enrollee (or his or her authorized representative). If you are looking for information on health insurance in rural areas, visit RHIhubHRSA Exit Disclaimer

Comments Requested:  Medicaid Fiscal Accountability Proposed RuleJanuary 17.   The Centers for Medicare & Medicaid Services (CMS) proposed changes to state Medicaid reporting. Proposals focus on four payment areas: fee-for-service (FFS) supplemental provider payments; disproportionate share hospital (DSH) payments; financing for the non-Federal share of payments; and health care-related taxes and provider-related donations.  CMS seeks comment on all elements of this proposal.

CMS Issues Hospital Price Transparency Final Rule. On November 15, the Centers for Medicare & Medicaid Services (CMS) finalized policy changes to the CY 2020 Hospital Outpatient Prospective Payment System (OPPS) on price transparency requirements. This final rule establishes requirements for hospitals, including Critical Access Hospitals (CAHs) to publish a machine-readable file online that includes all standard charges along with discounted cash prices, payer-specific negotiated charges, and minimum and maximum negotiated charges for “shoppable services.” The effective date of the final rule will be January 1, 2021.

FCC Publishes Final Rule on Rural Health Care Program - The Federal Communications Commission (FCC) finalized regulations to promote transparency and efficient allocation Rural Health Care Program resources while guarding against waste, fraud and abuse. The FCC promotes telehealth in rural areas through the Rural Health Care Program (RHC Program), which provides financial support to help rural health care providers obtain broadband and other communications services at discounted rates. Most of the regulations went into effect on November 12.

November 7

Deadline for Critical Access Hospitals to Submit a Hardship Exception Application HRSA Exit Disclaimer – December 2.  CMS requires that all Critical Access Hospitals (CAHs) use either the 2014 or 2015 Edition certified electronic health record technology (CEHRT) to meet the Medicare Promoting Interoperability Program reporting requirements. CAHs that are not meaningful users of CEHRT may face Downward payment adjustments.  CAHs may avoid the Medicare downward payment adjustments by completing a hardship exception application by December 2.

Payment Updates for Home Health Agencies and Home Infusion Therapy Benefit. HRSA Exit Disclaimer CMS finalized the 2020 calendar year payment rates for home health agencies to implement the home infusion therapy benefit for calendar year 2021.  CMS modified regulations to allow therapist assistants to perform maintenance therapy in accordance with individual state practice requirements. They adopted a number of standardized patient assessment data elements (SPADEs) to assess cognitive function and mental status, medical conditions and comorbidities, and social determinants of health. Visit RHI Hub for more information on the importance of home health services in rural areasHRSA Exit Disclaimer

CMS Finalizes Payment Policies for CY2020 End-Stage Renal Disease (ESRD) and Durable Medical Equipment (DMEPOS). On October 31, CMS finalized payment policies and rates under the ESRD Prospective Payment System (PPS) and Quality Incentive Program (QIP) effective on or after January 1, 2020. CMS projects that updates to the CY 2020 ESRD PPS will result in a 1.8 percent increase in payments for rural ESRD facilities compared to CY 2019. CMS also established a method for pricing new Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items/services and streamlined requirements for ordering DMEPOS items.

CMS Finalizes Medicare Clinician Policy, Payment, and Quality Provisions for CY 2020. On November 1, CMS issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) effective on or after January 1, 2020. This includes three new telehealth codes to describe a bundled episode of care for treatment of opioid use disorders, The rule also updates Medicare’s Quality Payment Program. CMS included an interim final rule with comment period (IFC).Comments on that proposal are due no later than 5 pm on December 31, 2019.

Medicare Outpatient Payment Policies Finalized. On November 1, CMS finalized updates to the Medicare Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Care Center (ASC) Payment System for the 2020 calendar year. This rule updates payment rates, and finalizes completing the two-year phase-in of site neutral payment for clinic visits when provided at an off-campus provider-based department. This final rule also finalizes to pay Average Sale Price (ASP) minus 22.5 percent for 340B-acquired drugs for CY 2020. The reduction still exempts rural sole community hospitals and critical access hospitals. CMS plans to finalize these provisions on price transparency and requirements at a later date.  CMS is accepting comments on the APC payment classifications and/or new or replacement Level II HCPCS codes until 5 pm EST on December 2, 2019.

October 31

Comments Requested: Rural Eligibility for FORHP Funding – EXTENDED to November 23.  As part of an ongoing effort by the Federal Office of Rural Health Policy (FORHP) to assess the extent to which FORHP-administered grant programs align with the needs of rural communities, HRSA has published a Request for Information (RFI) soliciting public comment. RFI responses must be provided via email to and must reference “Rural Health Grants Eligibility RFI” in the title.  Submissions are due no later than 11:59 p.m. Eastern Time on November 23, 2019. HRSA will not accept hard-copy responses or other formats. 

HHS Request for Information: PreventionX – December 13. There is need to transform chronic disease prevention in the US by identifying community-wide prevention strategies and increasing financial investment in prevention. To help the U.S. Department of Health & Human Services (HHS) better understand the barriers to effective chronic disease prevention, email your responses to, with the subject line "PreventionX RFI Comment" by December 13, 2019.

Participate in Kidney Care Choices Model – January 22.  Last week, the Center for Medicare and Medicaid Innovation announced the Kidney Care Choices (KCC) Model Request for Applications. The voluntary payment model consists of four payment options: the Kidney Care First and three Comprehensive Kidney Care Contracting options. Rural providers may be eligible to participate if they meet requirements for the KCC Model option. They are accepting through January 22, 2020. They expect the Model  to run from January 1, 2020, through December 31, 2023.

Participate in Primary Care First Model Options – January 22.  Last week, the Center for Medicare and Medicaid Innovation announced the Primary Care First Model Options Request for Applications (RFA). Primary Care First Model Options is a set of voluntary five-year payment options that reward value and quality by offering an innovative payment structure to support delivery of advanced primary care. It is based on the underlying principles of the existing CPC+ model design Primary Care First Model. Options will be offered in 26 regions across the country in 2021. During the first six weeks of this application period to December 6, 2019, payers will have the option to submit a non-binding Statement of Interest form (PDF) signaling their interest in partnering in Primary Care First. 

October 10

Comments Requested: Proposed Reforms to Physician Self-Referral and Anti-Kickback Laws – December 31.  Yesterday, the Department of Health and Human Services released proposed reforms to two separate, but related, rules that interpret the Physician Self-Referral Law (or the Stark Law) and the Federal Anti-Kickback Statute.  The Stark Law protects patients from unnecessary services and referrals that benefit a provider’s self-interest while the Anti-Kickback Statute provides criminal penalties for soliciting or receiving reward from the referral of services under Medicare and Medicaid. The proposed changes are designed to promote coordinated care and support the transition to value-based arrangements while continuing to  protect against fraud and abuse.  

October 3

CMS Issues Omnibus Burden Reduction Final Rule. On September 26, CMS issued a final rule to remove or update Medicare regulations the agency has identified as unnecessary, obsolete, or excessively burdensome on hospitals and other healthcare providers. This includes regulatory updates for Critical Access Hospitals (CAHs), rural health clinics (RHCs) federally qualified health centers (FQHCs), and hospital and CAH swing-bed providers.

The final rule also makes changes to other requirements such as those pertaining to emergency preparedness. To see all the facility types and regulations affected, you may access the final rule in the Federal Register. These regulations will go into effect on November 29, 2019, except for the CAH QAPI and antibiotic stewardship requirements (March 30, 2021 and March 30, 2020, respectively).

CMS Issues Final Rule on Discharge Planning Requirements for Hospitals, CAHs, and HHAs. On September 26, CMS issued a final rule updating regulations for hospitals, Critical Access Hospitals (CAHs), and home health agencies (HHAs) on the transition from acute care into post-acute care (PAC), a process called “discharge planning.” For CAHs, the final rule adds a new, separate condition of participation (CoP) specific to discharge planning. The new regulatory language outlines the standards for the discharge planning process, beginning with identifying those patients (at an early stage of hospitalization) likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning. Detail on the specific requirements is provided in the Federal Register. These regulations will go into effect on November 29, 2019.

September 26

More Medicare Advantage and Prescription Drug Plans Expected in 2020.  CMS released this week detailed files to explore the 2020 Medicare Advantage and Prescription Drug plan offerings as well as state-level Fact Sheets detailing premiums and plan offerings for the coming year.  It is estimated that there will be about 1,200 more Medicare Advantage plans operating in 2020 than in 2018 and a 14 percent decrease in the average monthly Medicare Advantage premium compared to 2019.  About one-quarter of rural Medicare beneficiaries were enrolled in Medicare Advantage HRSA Exit Disclaimer in 2018.

Final Rule on Medicaid Disproportionate Share Hospital Allotment ReductionsHRSA Exit Disclaimer Per the Patient Protection and Affordable Care Act, CMS has issued the final rule detailing the methodology that will be used to reduce the allotments of federal funding for state Medicaid disproportionate share hospital (DSH) programs, which are intended to support hospitals serving low-income patients and incurring high uncompensated care costs.  According to the Medicaid and CHIP Payment and Access Commission (MACPAC), about 1,100 rural hospitals received Medicaid DSH funds in 2018.  The reductions are scheduled to take place October 1, but Congress is considering delaying the change.

September 12

Comments Requested:  PTAC Proposal on Remote Specialist Care – October 1.  The Physician-Focused Payment Model Technical Advisory Committee (PTAC) requests public comment on a proposal for a new payment model that would create either Regional Referral Centers (RRCs) or a single National Referral Center (NRC) to provide remote specialists and experts for most health issues. The specialists would support field providers such as visiting nurses, community providers, PCPs, or hospital doctors and would serve any geographic location. Comments can be emailed to with the subject line “Public Comment – [name of document].”

August 29

Comments Requested:  Proposed Changes to Confidentiality of Substance Use Disorder Patient RecordsOctober 25.  The Confidentiality of Substance Use Disorder Patient Records regulations (42 CFR Part 2), aka “Part 2,” protect patient privacy when receiving substance use disorder treatment.  The Substance Abuse and Mental Health Services Administration (SAMHSA) has proposed changes to these rules based on stakeholder feedback and to facilitate coordination of care.  The proposals include allowing non-opioid treatment program providers to become eligible to get information from prescription drug monitoring programs and changing the requirements for patient consent.  See this HHS Fact Sheet for a summary of the proposals and RHIhub for more information on substance use disorder treatment in rural areasHRSA Exit Disclaimer

August 22

Comments Requested: Bipartisan Policy Center Rural Health Task Force  HRSA Exit Disclaimer – September 7. The Bipartisan Policy Center (BPC) has launched a Rural Health Task Force HRSA Exit Disclaimer of leaders to develop and promote a rural health agenda. The task force will develop policy recommendations to:

  1. Shore up the current rural health care system, including transforming critical access hospitals, small rural clinics, and rural hospitals to meet community needs;
  2. Address barriers and opportunities for rural participation in new delivery models; and
  3. Build on successful rural workforce and graduate medical education proposals. The BPC is encouraging public comments for solutions in these three areas, as well as other ideas that support reforming America’s rural healthcare system.

Commentators may email policy ideas to

August 8

CMS Finalizes Medicare Payment Updates to Hospitals for FY2020.  CMS updated the Medicare payment policies and rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for the 2020 fiscal year, which begins October 1, 2019.  In addition to announcing payment rates for the upcoming year, this rule finalizes wage index calculations for low wage index hospitals, many of which are rural, to reduce disparities; adoption of the Safe Use of Opioids-Concurrent Prescribing measure for the inpatient quality reporting program (IQR); and updates to the Promoting Interoperability program.   A CMS Fact Sheet on these updates is available here. 
Comments Request: Current Use of Telemental Health for Suicide Prevention in Emergency Department Settings – August 29.  This request for information (RFI) jointly issued by several Federal offices, including Health and Human Services’ National Institutes for Health, Veterans Affairs, and the Department of Defense, seeks information about the use of telehealth in hospital emergency medical care settings to facilitate the care of individuals with suicide risk.  Topics of interest include what telehealth services are being used, what contributed to the selection and implementation of those services, what are the characteristics of the emergency department (i.e. urban/rural setting), and approaches used to identify suicide risk of patients in the emergency department.  In 2015, suicide death rates in rural counties were higher than the rates in larger metropolitan counties. 
CMS Finalizes Policies on Post-Acute and Hospice Care for FY2020. Last week, CMS published a number of final rules making updates to payment and policies for skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), and long-term care hospitals (LTCH) in fiscal year (FY) 2020. For FY 2020 compared to FY 2019, CMS projects aggregate payments will increase by 6.2 percent for rural SNFs, 4.4 percent for rural IRFs, and 2.7 percent for rural LTCH discharges paid using the LTCH PPS standard Federal payment rate. CMS also published a final rule updating hospice payment rates, wage index, and cap amount for FY 2020. For FY 2020, CMS projects rural hospice payment rates will increase by 1.8 percent.

CMS Finalizes Policies for Inpatient Psychiatric Facilities for FY2020. Last week, CMS published the final rule for inpatient psychiatric facilities (IPF) in fiscal year (FY) 2020. For FY 2020 compared to FY 2019, CMS projects aggregate payments will increase by 1.34% for rural IPFs. Rural IPFs have received a 17% percent payment adjustment since the inception of the IPF prospective payment system, and this will continue to apply in FY 2020.

August 1

Comments Requested:  Proposed VA Center for Innovation for Care and Payment – August 28.  The Department of Veterans Affairs (VA) seeks comments on their plans to implement a Center for Innovation for Care and Payment as authorized under the VA MISSION Act of 2018.  Modeled after the CMS Innovation Center, the VA Center would develop pilot programs to test innovative payment and service delivery models with the goals of reducing expenditures, preserving or enhancing the quality of care furnished by the VA, and improving access, quality, timeliness, and patient satisfaction of care and services.  As veterans face a variety of challenges to getting care, this rule seeks public input on how to define the terms ‘access’, ‘patient satisfaction’, and ‘quality’ in order to ensure the greatest benefit to veterans affected by the Center’s pilot programs.  About 2.9 million veterans live in rural areas and rely on the VA for health care. 

Comments Requested: Proposed Updates to Medicare Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment System – September 27. On July 29, the Centers for Medicare & Medicaid Services (CMS) released proposed changes to the outpatient prospective payment system and the ambulatory payment system for the 2020 calendar year. The proposals on price transparency are highlighted with CMS proposing that all hospitals, including rural PPS hospitals and critical access hospitals (CAHs) make pricing information publicly available. Proposals also include reducing payment differences between certain sites of services, using the inpatient wage index values to address wage index disparities, and changing the generally applicable minimum required level of supervision from direct supervision to general supervision for hospital outpatient therapeutic services furnished by all hospitals and CAHs.

Comments Requested: Medicare Physician Fee Schedule Proposed Policy, Payment, and Quality Provisions for CY 2020 – September 27. On July 29, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2020. Proposals that may be of interest to rural stakeholders include adding telehealth codes for bundled episodes of care in the treatment of opioid use disorders (OUDs); modifying the regulation on physician supervision of physician assistants (PAs) to give PAs greater flexibility; updating payment and/or codes for certain care management services; and implementing a new Medicare Part B benefit for OUD treatment services, including medication-assisted treatment (MAT), furnished by opioid treatment programs (OTPs).

Comments Requested: ESRD and DMEPOS CY 2020 Proposed Rule – September 27. On July 29, the Centers for Medicare & Medicaid Services (CMS) proposed updates to payment policies and rates under the End Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services and changes to the ESRD Quality Incentive Program (QIP) for CY 2020. The proposed CY 2020 ESRD PPS base rate is $240.27, reflecting a market basket and wage index adjustment. CMS projects that rural ESRD facilities will experience a 1.8 percent increase in their CY 2020 estimated payments compared to CY 2019. In addition, CMS proposes a methodology for pricing new Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items and services.

Date Last Reviewed:  November 2019


Guide for Rural Health Care Collaboration and Coordination (2019) (PDF - 2 MB) This Guide describes how rural hospitals, community health centers, local public health departments, and other rural stakeholders can work together to assess and address their rural communities’ health needs. 

Interim Report to Congress on Frontier Health Demonstration Project (2018) (PDF - 565 KB)

Questions about Policy Updates?