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 21

Deadlines for Submitting 2017 Data for the Merit-based Incentive Payment System (MIPS). The 2017 submission period runs until March 31, 2018.  Exception: CMS Web Interface users have until March 16, 2018 at 8pm ET to submit their data. For step-by-step instructions on how to submit MIPS data, check out this video HRSA Exit disclaimer and fact sheet. Rural providers with questions about their participation status or MIPS data submission should contact the Quality Payment Program Service Center

Comments Requested: Changes to Short-Term, Limited Duration Health Insurance HRSA exit disclaimer – April 23. The Internal Revenue Service, Department of Labor, and  Department of Health and Human Services jointly proposed a rule that would amend the definition of short-term, limited-duration (STLD) health insurance. Currently, STLD plans can only provide coverage for three months or less, and they do not qualify as minimum essential health coverage.  This rule proposes to allow STLD plans to provide coverage for up to 12 months and seeks public input on the proposed length of coverage, how to streamline re-application processes, and the potential benefits and/or drawbacks of non-ACA compliant policies on risk pools and consumer costs.  This is an opportunity for rural stakeholders to provide feedback on this proposed policy change including the impact for rural household premiums and out-of-pocket costs. In 2014, about 1 in 5 rural families had health insurance premiums and out-of-pocket costs that exceeded 10 percent of family income. 

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.

AHRQ Seeks Input on Quality Indicators – March 8.  The Agency for Healthcare Research and Quality (AHRQ) seeks information from hospitals and other health care entities about how the Agency’s Quality Indicators (QI) have been used and how they can be improved. AHRQ developed QIs to improve quality at hospitals, and now they support local needs assessments and value-based purchasing programs.  Rural hospitals and others may comment on how the QIs have been used as well as why they are not being used if that’s the case. 

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

Comments Requested: Proposed CMS Quality Measures – February 9-27.  CMS seeks public input on a number of quality measures and electronic clinical quality measures (eCQMs).  Rural providers should examine these to determine if they capture relevant information and whether they appropriately capture provider performance. 

Comments Requested: Medicare Advantage/Prescription Drug Plan Updates – March 5.  CMS seeks comments on proposed payment rate increases and other updates to Medicare Advantage (MA) and Part D prescription drug plans.  Some proposals of interest to rural providers include an adjustment to the 2019 and 2020 quality Star Ratings to account for the effects of hurricanes and wildfires in 2017, adding new strategies to address the opioid epidemic, and allowing additional MA supplemental plan benefits if certain criteria are met. 

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.

January 25

New Medicare Episode Payment Model March 12.  The CMS Innovation Center is launching a new voluntary payment model called Bundled Payments for Care Improvement Advanced (BPCI Advanced).  This model includes financial risks as well as incentives, so it will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.  According to the BPCI Advanced Model Fact Sheet, certain Medicare beneficiaries will be excluded from the model, but many of the clinical episodes that will be tested are frequently encountered by rural providers, including COPD, sepsis, stroke, and fractures of the femur, hip or pelvis. The CMS Innovation Center will hold a Q&A Open Forum on the BPCI Advanced model on Tuesday, January 30, 2018 from 12 pm – 1 pm EST.

January 18

New Guidance to Promote Work and Community Engagement Among Medicaid Beneficiaries. CMS has issued guidance for states interested in Medicaid demonstrations that create incentives for able-bodied, working-age Medicaid beneficiaries to participate in work and community engagement activities, such as skills training, education, job search, volunteering or caregiving.  The CMS letter to state Medicaid directors describes considerations for states interested in these demonstrations,such as reasonable modifications for individuals with substance use disorders, and supports for beneficiaries in localities lacking transportation and/or facing economic stress.  Rural providers and stakeholders can find updated information on with guidance for states on how reform strategies should align with the core objective of serving the health and wellness of vulnerable and low-income individuals and families. 

Updated Policy Manual for RHCs and FQHCs. The 2018 update of Chapter 13 of the Medicare Benefit Policy Manual – Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) services – provides information on requirements and payment policies for RHCs and FQHCs, as authorized by Section 1861(aa) of the Social Security Act. This chapter now includes payment policy for Care Management Services in RHCs and FQHCs as finalized in the Calendar Year (CY) 2018 Physician Fee Schedule Final Rule. All other revisions serve to clarify existing policy.

January 11

Comments Requested:  Labor Redefines Association Health Plans – March 6.  The Department of Labor has proposed broadening the definition of ‘employer’ to allow businesses to form Association Health Plans (AHPs) that would be regulated under Federal large group health plan rules, which are exempt from State regulation and some ACA requirements.  The rule also would allow small employers, including those in rural communities, to form an AHP on the basis of geography or industry, so a health plan could serve employers in a state, city, county, or a multi-state metro area, or it could serve all the businesses in a particular industry nationwide.

Hospitals and CAHS Must Now Use QualityNet for AttestationHRSA exit discliamer As of January 2, 2018, Medicare eligible hospitals and Critical Access Hospitals (CAHs) attesting to CMS for the Electronic Health Record (EHR) Incentive Program must use QualityNet (QNet) for any calendar year 2017 attestations and future reporting periods. QNet is the same system Medicare eligible hospitals and CAHs currently use for clinical quality measure (CQM) reporting. If you need help with registration or attestation processesHRSA exit discliamer you must now contact the QNet Help Desk between 8 a.m. - 8 p.m. ET, Monday through Friday.

January 4

CMS Updates Hospital Star RatingsCMS recently announced revisions to the hospital star ratings reported on Hospital Compare, the website providing patients and families with information on how well hospitals deliver care.  Under the previous rating system, more than one-third of rural hospitals had no rating exit disclaimer.   A technical expert panel was formed to update the star ratings in response to stakeholders’ concerns about the underlying scoring.  See the CMS QualityNet website exit disclaimer for details about the new methodology.

December 21

Comments Requested: FDA Opioid Prescribing Guidelines – March 16The Food and Drug Administration (FDA) established the Opioid Policy Steering Committee (OPSC) to explore and develop strategies to combat the opioid crisis.  OPSC will hold a public meeting on January 30 to collect stakeholder input on new approaches FDA might adopt to promote the safe use of opioid painkillers and reduce overprescribing that may contribute to new addiction.  New ideas may benefit rural communities where CDC research shows rates of prescription opioid misuse and overdose death are highest.  Comments will be accepted through March 16.  Rural health care providers may also consider implementing promising strategies Exit disclaimerand models for preventing and treating opioid misuse Exit disclaimer.

CMS Seeks Hospitals to Test Patient Safety Measures. CMS has developed multiple measures of adverse patient safety events that can be improved with high-quality care, on including hypoglycemia, hospital-acquired pressure injury, opioid-related adverse events, and acute kidney injury.  Participating hospitals will submit patient data extracted from electronic health records (EHR) and will receive feedback reports on data verification and rates of patient harm.  Testing these measures may inform future rulemaking about their implementation.  Greater rural participation can help ensure the measures are feasible and relevant in rural settings.  Interested hospitals should contact Shari Glickman or Kirsten Barrett for more information.



Date Last Reviewed:  February 2018

Questions about Policy Updates?