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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 

September 17

Obstetric Emergencies in Rural Hospitals: Challenges and Opportunities HRSA Exit Disclaimer. This policy brief from the University of Minnesota Rural Health Research Center describes the challenges rural hospitals face in providing emergency obstetric care and highlights resources that could help rural hospitals more safely respond to obstetric emergencies.

September 10

New Guidance to Improve Care for Infants with Neonatal Abstinence Syndrome (PDF - 433 KB)Last week, the Centers for Medicare & Medicaid Services (CMS) released an informational bulletin outlining the various service and financing options that state Medicaid and CHIP programs can use to improve care for infants with neonatal abstinence syndrome (NAS) and their families.  It also highlights Federal resources, tools, and models of care available to assist states, such as the HRSA Rural Health Integration Models for Parents and Children to Thrive (IMPACT) (PDF - 170 KB) program.

September 3

Comments Requested: CMS Policy and Regulatory Revisions in Response to COVID-19 (PDF - 596 KB) – November 1. On September 2,  the Centers for Medicare & Medicaid Services (CMS) published an Interim Final Rule with Comment Period that includes new requirements in the hospital and Critical Access Hospital (CAH) Conditions of Participation (CoPs) for daily reporting of COVID-19 data. These regulations are effective on September 2, 2020 and are applicable for the duration of the Public Health Emergency for COVID–19.  While many hospitals are voluntarily reporting this information now, not all are. Hospitals, including Critical Access Hospitals, will face possible termination of Medicare and Medicaid payment if unable to correct reporting deficiencies. The rule also includes updates to Extraordinary Circumstances Exceptions (ECE) for several quality reporting programs and a revised policy on repeated COVID-19 testing.

New Guidance on Provider Relief Funds and Hospital Cost Reports (PDF - 960 KB). On August 26, the Centers for Medicare & Medicaid Services updated their COVID-19 Frequently Asked Questions (FAQs) on Medicare Billing to include guidance on how hospitals should treat CARES Act Provider Relief Funds (PRF) in upcoming cost reports.  Beginning in April, funds were distributed to providers, including targeted disbursements to rural providers, to support COVID-19 relief efforts.  The new guidance on pages 99-101 of the FAQs informs hospitals, Critical Access Hospitals, and other providers on how to report the PRF payments on the Medicare Cost Report and whether those payments should offset expenses.

Rural Crosswalk for COVID Waivers and Flexibilities (PDF - 1.76 MB)Last week, the Centers for Medicare & Medicaid Services (CMS) published a summary of all current COVID-19-related waivers and flexibilities that affect Rural Health Clinics, Federally Qualified Health Centers, Critical Access Hospitals, skilled nursing facilities, and rural hospitals generally. It also describes the significance of each provision for these rural providers and facilities.

Final rule:  Medicare FY2021 Hospital Payment and Policy Updates.  Yesterday, the Centers for Medicare & Medicaid Services (CMS) issued the Medicare Inpatient Prospective Payment System (IPPS) and Long-Term Acute Care Hospital Final Rule.  It includes increases in payment rates for hospitals, new requirements for hospitals to report payer-specific negotiated charges, and policy changes when a graduate medical teaching hospital or residency program closes.  CMS is also adopting the most recent Office of Management and Budget (OMB) statistical area delineations (PDF - 1.03 MB), which results in 34 urban counties becoming rural, 47 rural counties becoming urban, and several urban counties shifting between existing and new urban statistical areas.  These shifts may impact the payment rates for hospitals located in those areas

August 13

CMS Finalizes FY2021 Payment Rule for Inpatient Rehabilitation Facilities. Last week, the Centers for Medicare & Medicaid Services (CMS) finalized payment policy updates for Inpatient Rehabilitation Facilities (IRF). The final rule includes a 2.8 percent payment increase ($260 million total) which rural areas will experience as an average increase of 3.0 percent. CMS is amending the regulations to remove the post-admission physician evaluation requirement and to allow non-physician practitioners to perform certain requirements that currently a rehabilitation physician must perform. The rule also allows for a transition period that applies a 5 percent cap on wage index decreases as CMS adopts the most recent Office of Management and Budget (OMB) statistical area delineations (PDF - 1.03 MB) with 34 urban counties becoming rural, 47 rural counties becoming urban, and several urban counties shifting between existing and new urban statistical areas.

August 6

Medicare Finalizes FY2021 Payment Rules for IPFs, SNFs, and Hospices. Last week, the Centers for Medicare & Medicaid Services (CMS) finalized payment policy updates for inpatient psychiatric facilities (IPFs), skilled nursing facilities (SNFs), and hospices.  These updates are focused on essential payment policies recognizing the impact of the COVID-19 public health emergency and the limited capacity of providers to review extensive policy changes.  One such change is adopting the September 14, 2018 OMB Bulletin (PDF - 1.03 MB) for delineations for Care-Based Statistical Areas (CBSAs), which results in several urban counties becoming rural, rural counties becoming urban, and existing CBSAs getting split apart.  These changes may impact providers’ wage index values when calculating payments, so CMS has finalized transition periods for each provider type to mitigate any decreases in payments.

Expanded List of Telehealth Codes to Care for SNF ResidentsThe Centers for Medicare & Medicaid Services recently added three new telehealth codes that will be covered during the COVID-19 public health emergency.  These codes designate different time increments of telephone evaluation and management services provided by a physician (99441, 99442, and 99443) when furnished to a Skilled Nursing Facility’s Part A resident.  Medicare Administrative Contractors will reprocess claims for these codes with dates of service on or after March 1, 2020 that were previously denied due to SNF residence.

Comments Requested: Proposed Changes to Medicare Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment System – October 5. On August 4, the Centers for Medicare & Medicaid Services released proposed changes to the outpatient prospective payment system and the ambulatory payment system for the 2021 calendar year. Proposals that may be of interest to rural providers include changes to how drugs acquired under the 340B program are reimbursed and updates to how the Overall Hospital Quality Star Ratings can be calculated to include Critical Access Hospitals.

Comments Requested:  Proposed Updates to the CY2021 Medicare Physician Fee Schedule (PDF - 7.21 MB) – October 5.  This week, CMS released proposed updates to how physician and other service providers are reimbursed by Medicare.   In addition to several technical updates to how payment rates are set, CMS is proposing to add several telehealth services to their current list as well as to the list under the COVID-19 public health emergency; to allow direct supervision to be provided using real-time, interactive audio and video technology; and to make permanent the public health emergency waiver allowing nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), and certified nurse-midwives (CNMs) to supervise the performance of diagnostic tests. CMS is also proposing revisions to simplify coding and billing requirements for Evaluation and Management (E/M) visits including office/outpatient visits.

Executive Order on Improving Rural Health and Telehealth Access. On August 3, the President issued an Executive Order that seeks to improve health care in rural areas by expanding access to telehealth.  Within 30 days of the order, the U.S. Department of Health & Human Services (HHS) will launch a new payment model and develop strategies for improving the physical and communications health care infrastructure available in rural areas.  HHS will submit a report with existing and upcoming initiatives to reduce regulatory burden on providers, improve maternity morbidity and mortality, and improve mental health care.  Within 60 days of the order, HHS will review specified temporary measures put in place during the public health emergency (PHE) and propose a regulation to extend these measures, as appropriate, beyond the duration of the PHE. 

July 30

ASPE Issue Brief: Medicare Beneficiary Use of Telehealth Visits: Early Data From The Start Of The Covid-19 Pandemic. On July 28, the HHS Office of the Assistance Secretary for Planning and Evaluation (ASPE) released an issue brief examining changes in Medicare fee-for-service primary care visits and use of telehealth at the start of the COVID-19 public health emergency (PHE). This brief seeks to address the issue of how and whether the Medicare telehealth flexibilities introduced to address the COVID-19 pandemic may have helped maintain access to primary health care during the PHE. The analysis found Medicare primary care visits dropped precipitously from mid-March at the start of the pandemic, at the same telehealth visits increased for primary care. However, telehealth use was lower in rural areas.

HHS Study: Strategies Rural Communities Use to Address Substance Misuse Among Families In The Child Welfare System. The Office for Planning and Evaluation at the U.S. Department of Health & Human Services (HHS) describes nine programs serving child welfare-involved parents with substance use issues, with a particular focus on their applicability to rural communities. These programs offered various types of services, including parent mentoring, case management, home visiting, and treatment for opioid use disorders.

July 23

Updated FAQs on RHC COVID-19 Testing Funds. Recently, the Federal Office of Rural Health Policy (FORHP) issued an update to its frequently asked questions (FAQs) on COVID-19 Testing Funds for Rural Health Clinics (RHCs). The update addresses questions on the use of funds, insurance payments, links to key information, and other technical details. Technical assistance (TA) for this program is provided by the National Association of Rural Health Clinics HRSA Exit Disclaimer (NARHC) under a cooperative agreement with FORHP, and archived TA webinars are available on the NARHC and Rural Health Information Hub HRSA Exit Disclaimer websites.

Final Rule: Confidentiality of Substance Use Disorder Patient RecordsEffective August 14, 2020, this final rule makes changes to the U.S. Department of Health & Human Services’ regulations governing these records to facilitate information exchange for safe and effective SUD care, while addressing the legitimate privacy concerns of patients seeking treatment for a SUD.

July 9

Comments Requested: ESRD CY 2021 Proposed RuleSeptember 4.  On July 6, 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 CY 2021. The proposal includes an expansion of the transitional add-on payment adjustment for new and innovative equipment and supplies (TPNIES) to qualifying home dialysis machines to support greater access and innovation for dialysis in the home setting.  Proposed changes also include an ESRD base rate increase, updates to the outlier policy and adoption of new OMB delineations.  CMS projects that rural ESRD facilities will experience a 0.6 percent increase in their CY 2021 estimated payments.  The proposed rule is currently on display and will be published in the federal register on July 13, 2020.

Quality Measure Workspace Series of Webinars (PDF - 140 KB) HRSA Exit Disclaimer Beginning July 15.  CMS is hosting a series of webinars in July and August for hospitals, Critical Access Hospitals, and clinicians reporting electronic clinical quality measures (eCQM).  The first webinar will describe the resources available for the 2021 reporting period.  Subsequent webinars will cover clinical flow (July 29) and the data element repository (August 12). 

CMS Updates Guidance for RHCs and FQHCs during the Public Health Emergency (PDF - 223 KB). On July 6, CMS released its latest round of updates to the article, New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE). CMS updated the article to provide additional guidance on telehealth services that have cost-sharing waived and additional claim examples along with an additional section on the RHC Productivity Standard.

July 2

Comments Requested: CMS Proposed Rule for Home Health Providers – August 31.  On June 30, the Centers for Medicare & Medicaid Services (CMS) published a proposed rule for the FY 2021 Home Health Prospective Payment System (PPS). The proposed rule includes a payment increase for fiscal year (FY) 2021 of 2.7 percent ($540 million total), which rural areas will experience as 2.3 percent. CMS also included a summary of the methodology for rural add-on payments. The rule also adopts the most recent Office of Management and Budget (OMB) statistical area delineations with 34 urban counties becoming rural and 47 rural counties becoming urban.

Date Last Reviewed:  September 2020


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?