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 

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.

July 25

Medicaid and CHIP Scorecard Updated.  Last year, the Centers for Medicare & Medicaid Services (CMS) created a scorecard to improve public transparency and accountability of two state-based programs, Medicaid and the Children’s Health Insurance Program (CHIP), and recently added new data.  The Scorecard reports measures on State Health System Performance (i.e. postpartum care and follow-up after hospitalization for mental illness), State Administrative Accountability (i.e., days to get information on State Plan Amendments), and Federal Administrative Accountability (i.e., time to approve waiver requests) with the intent of driving improvement in beneficiary outcomes and administration of the programs.  Medicaid is an important source of health coverage for rural populations HRSA Exit Disclaimer covering about a quarter of nonelderly rural individuals.   

July 18

Comments Requested: FCC Proposes $100 Million Connected Care Pilot Program.  The Federal Communications Commission (FCC), under its existing Rural Health Care Program authority, is proposing a three-year, $100 million Connected Care Pilot program that would support bringing telehealth services directly to low-income patients and veterans.  It would provide an 85 percent discount on connectivity for broadband-enabled telehealth services that connect patients directly to their doctors and are used to treat a wide range of health conditions.  The Notice of Proposed Rulemaking (NPRM) adopted by the Commission seeks comment on testing the new program. In particular, the NPRM seeks comment on the appropriate budget, duration, and structure of the Pilot, along with other issues. Comments are due 30 days after publication in the Federal Register, and reply comments are due 60 days after publication in the Federal Register. For more information, visit the Center for Connected Health PolicyHRSA Exit Disclaimer part of the HRSA/FORHP-supported National Telehealth Policy Research Center.

Comments Requested: CY 2020 Home Health Proposed Rule – September 9. On July 11, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the Home Health Prospective Payment System (Home Health PPS). This includes routine updates to the home health payment rates for calendar year (CY) 2020 and a proposal to implement a new home infusion benefit for beneficiaries in CY 2021. The proposed rule would also increase Medicare payments to home health agencies (HHAs) by 1.3 percent ($250 million) overall, which reflects a 0.2 percent decrease in CY 2020 payments due to the rural add-on percentages mandated through CY 2022 by the Bipartisan Budget Act of 2018. Unlike previous rural add-ons, which were applied to all rural areas uniformly, the extension provided varying add-on amounts depending on the rural county (or equivalent area) classification. The average increase in payments to rural providers overall is 4.7 percent. RHIhub HRSA Exit Disclaimer provides additional information on Rural Home Health Services as well as helpful FAQs.

Comments Requested: Methods for Assuring Access to Covered Medicaid Services-Rescission – September 13. On July 11, CMS released a proposed rule that would remove the regulatory text that sets forth the current required process for states to document whether Medicaid payments in fee-for-service systems are sufficient to enlist enough providers to assure beneficiary access to covered care and services consistent with the Medicaid statute. In the proposed rule, CMS noted that states have raised concerns over the administrative burden associated with the current regulatory requirements. CMS also issued on July 11 an informational bulletin announcing the agency’s strategy to measure and monitor beneficiary access to care across Medicaid. For more information on rural Medicaid issues in general, the Rural Health Research Gateway HRSA Exit Disclaimer provides a selection of policy briefs on the topic.

Comments Requested: Specialty Care Models to Improve Quality of Care and Reduce Expenditures – September 16. On July 10, CMS put on public display a proposed rule that would implement two new mandatory Medicare payment models under section 1115A of the Social Security Act—the Radiation Oncology Model (RO Model) and the End-Stage Renal Disease (ESRD) Treatment Choices Model (ETC Model). The proposed RO Model is an innovative payment model designed to improve the quality of care for cancer patients receiving radiotherapy treatment and reduce provider burden by moving toward a simplified and predictable payment system. The ETC Model  is one of five new payment models CMS announced last week aimed at transforming kidney care to improve access to high quality care and reducing Medicare expenditures. The rule details the proposed geographic units of section for model participation, Core Based Statistical Areas (CBSAs) for the RO Model and Hospital Referral Regions (HRRs) for the ETC Model, with implications for rural participation. The proposed rule is scheduled to be published in the Federal Register on July 18, and public comments are due 60 days after publication.

HHS To Transform Care Delivery for Patients with Chronic Kidney Disease. On July 10, CMS announced five new payment models aimed at transforming kidney care to improve access to high quality care and reducing Medicare expenditures. One of the new proposed models, the End-Stage Renal Disease (ESRD) Treatment Choices (ETC) Model, is a mandatory model focused on encouraging greater utilization of home dialysis and kidney transplants through Medicare payment adjustments for selected ESRD facilities and clinician, including rural providers. The adjustments will apply to applicable Medicare claims with dates from January 1, 2020 through June 30, 2026. CMS will review public comments on the proposed mandatory model. CMS also proposed four voluntary payment models: the Kidney Care First (KCF) Model and three Comprehensive Kidney Care Contracting (CKCC) Models. These models will build upon an existing model and provide new incentives for providers to better manage and coordinate the care of Medicare beneficiaries with chronic kidney disease stages 4 or 5 and for those on dialysis. Applications will be accepted in Fall 2019, and the models are expected to run from January 1, 2020 through December 31, 2023.

CMS Issues New Guidance on State Waiver for Health Insurance. Section 1332 of the Patient Protection and Affordable Care Act permits states to apply for State Innovation Waivers (aka Section 1332 Waivers or State Relief and Empowerment Waivers) to pursue innovative strategies for providing high value and affordable individual health insurance regardless of income, geography, age, gender, or health status.  As a follow-up to the guidance released last year, CMS has created concept papers and templates for four waiver concepts to help states develop new approaches to providing health coverage: State Specific Premium Assistance, Adjusted Plan Options, Account-Based Subsidies, and Risk Stabilization Strategies.  In 2018, rural areas had fewer insurers offering individual health insurance HRSA Exit Disclaimer and higher average adjusted premiums compared to urban areas.

Date Last Reviewed:  October 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?