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 15

Scope of Practice Policies for Clinicians by State. HRSA Exit Disclaimer The National Conference of State Legislatures provides this interactive map to educate state policymakers about scope of practice issues for behavioral health providers, nurse practitioners, oral health providers and physician assistants.  The site features an in-depth look at three professions that are essential for recovery from opioid misuse: peer support specialists, licensed professional counselors, as well as nurse practitioners and physician assistants who can prescribe buprenorphine-containing products. While more than 60% of rural counties lack a physician with a waiver to prescribe buprenorphine, rural communities tend to have more providers like these, who require fewer years of education and training (PDF - 103 KB). 

CMS Releases 2017 Quality Payment Program Results. The Centers for Medicare & Medicaid Services (CMS) recently released performance information from the first year of the Quality Payment Program (QPP). Results show rural practices performed well in the QPP’s Merit-based Incentive Payment System (MIPS). Overall, 93 percent of rural practices earned positive payment adjustments, including 65 percent who earned additional adjustments for exceptional performance. CMS continues to offer options to help rural and small practices participate in the QPP, including no-cost, customized technical assistance and the opportunity to participate in MIPS through the virtual group option.

Comments Requested:  Proposals for Medicaid and CHIP Managed Care Regulations – January 14.  In response to stakeholder feedback, CMS proposes to revise and streamline the final rule on Medicaid and Children’s Health Insurance Program (CHIP) managed care published in 2016.  Of interest to rural stakeholders and State Offices of Rural Health are proposals to allow states flexibility in establishing network adequacy standards, to change requirements for quality reporting systems, and to revise requirements for the dissemination of information to enrollees. 
Medicaid Guidance for Expanding Behavioral Health.  CMS issued a letter to State Medicaid Directors outlining opportunities to design innovative service delivery systems for Adults with a Serious Mental Illness or Children with a Serious Emotional Disturbance using strategies already available under current authority and strategies available through 1115 demonstration waivers.  For example, improving access to mental health services in schools could include partnerships with Federally Qualified Health Centers (FQHCs) and Rural Health Clinics or reimbursement of school-based providers through managed care plans.  Medicaid is an important source of health insurance in rural areas HRSA Exit Disclaimer covering almost one-quarter of non-elderly rural individuals.

November 8

Comments Requested: Expanding Telehealth for Substance Use Disorder Treatment – December 31. As part of the Medicare Physician Fee Schedule and Quality Payment Program final rule, CMS incorporated an Interim Final Rule to implement part of the SUPPORT of Patients and Communities Act addressing Medicare telehealth provisions. This includes removing the originating site geographic requirements and adds the home as an originating site for the treatment of a substance use disorder or co-occurring mental health disorder on or after July 1, 2019. Additionally, the SUPPORT for Patients and Communities Act establishes a new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) under Medicare Part B, beginning on or after January 1, 2020.

Medicare Clinician Payment Policies Finalized. On November 1, CMS finalized updates to Medicare’s payment of clinicians for calendar year 2019 under the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP). Highlights under the PFS for rural providers include 

  • new virtual communication services billable by clinicians and RHCs/FQHCs,
  • two new telehealth codes for prolonged preventive services,
  • telehealth updates for ESRD and acute stroke,
  • practice flexibility for radiologist assistants, and
  • updates to evaluation and management payment in 2021 and documentation in 2019.

Updates to the QPP’s Merit-Based Incentive Payment System (MIPS) include

  • an expansion of eligible clinician types (physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, and registered dieticians or nutrition professionals),
  • a new element added to the low-volume threshold (200 covered professional services under the PFS),
  • an opportunity for eligible clinicians to opt-in to MIPS,
  • updates to health IT policies to promote interoperability, and
  • an increased contribution of cost to the overall MIPS score (15 points).

The final rule also covers some provisions related to the Medicare Shared Savings Program including a reduction in the number of quality measures and a six-month extension for existing ACOs with participation agreements expiring on December 31.

CMS Delays Finalizing Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health AgenciesOn November 3, 2015, CMS published a proposed rule, “Medicare and Medicaid Program; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals (CAHs), and Home Health Agencies (HHAs)” that would update the discharge planning requirements for hospitals, CAHs, and HHAs and implement the discharge planning requirements of the IMPACT Act of 2014 (Pub. L. 113-185).  In general, CMS must finalize Medicare rules within 3 years; however, CMS needs more time to address issues raised by public comments in the proposed rule.  Therefore, CMS is extending the timeline for publication of the final rule until November 3, 2019.  

Medicare Outpatient Payment Policies FinalizedOn November 2, CMS finalized updates to the Medicare Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Care Center (ASC) Payment System for 2019.  In addition to updating payment rates, the rule continues the 7.1 percent adjustment to OPPS payments for certain rural Sole Community Hospitals (SCHs), including Essential Access Community Hospitals (EACHs). It finalizes a method to control increases in hospital outpatient department services by applying a Physician Fee Schedule (PFS)-equivalent payment rate for the clinic visit service when provided at an off-campus provider-based department (PBD) that is paid under the OPPS.  It also removes nine quality measures from the ASC and hospital outpatient department quality reporting programs.   

CMS Updates Home Health Payments and Policy –  CMS displayed its final rule for calendar year (CY) 2019 updates to payment rates and rules for home health agencies.  Over 1,100 comments were received on the proposed rule. In addition to a payment rate increase of 2.2 percent ($420 million), which rural areas will experience as 2.4, the final rule makes changes to the methodology for rural add-on payments mandated by statute, proposes case-mix methodology refinements to be implemented for home health services beginning January 1, 2020, and changes the unit of payment from 60-day episodes of care to 30-day periods of care. Also of interest for rural areas, CMS updated the definition of remote patient monitoring which can now be included as an allowable operation expense; changed requirements for accrediting organizations to ensure access to and burden reduction for small or rural non-certified providers and suppliers; and established health safety standards and transitional payment for qualified home infusion therapy suppliers.

CMS Updates Dialysis and Durable Medical Equipment Payments and Policy – CMS displayed its final rule for calendar year (CY) 2019 updates to payment rates and rules for providers of dialysis services and durable medical equipment. Over 150 comments were received on the proposed rule. In addition to a payment rate increase of 1.3 percent for providers of dialysis, the final rule also makes updates to the competitive bidding program (CBP) for Durable Medical Equipment, Prosthetics, and Oxygen Suppliers (DMEPOS). CMS finalized an increase in DMEPOS fee schedule rates using a blend of adjusted and unadjusted fee amounts to protect access to needed durable medical equipment in rural areas that are not subject to the DMEPOS CBP. Rural providers of dialysis for end-stage renal disease will experience the payment increase as the full 1.3 percent, and rural providers of dialysis for acute kidney injury will experience the payment increase as 1.0 percent.

November 1

Comments Requested:  Implementing Provisions of the Bipartisan Budget Act (BBA) of 2018 – December 31.  The Centers for Medicare & Medicaid Services (CMS) seeks comments on several proposals to improve quality and access to care in the Medicare Advantage (MA) and Prescription Drug Programs by implementing provisions from the BBA of 2018.  For example, the BBA allows MA plans to offer “additional telehealth benefits” not otherwise available in Original Medicare starting in 2020.  CMS proposes to give MA plans more flexibility in how they pay for “additional telehealth benefits” to satisfy this provision. By allowing services such as such as live-interactive videoconferencing and remote monitoring, telehealth connects rural providers and their patients to services at a distant site.  CMS also solicits comment on how to implement the statutory provision that if an MA plan covers a Part B service as an “additional telehealth benefit,” then the MA plan must also provide the enrollee access to such service through an in-person visit.  Comments can be submitted through by December 31.

Comments Requested: Medicare Part B Drug Pricing – December 31  Last week, CMS issued an Advanced Notice of Proposed Rulemaking (ANPRM) seeking comment on potential options for testing changes to payment for certain separately payable Part B drugs and biologicals.  Among the questions CMS is seeking feedback on is the potential approach to selecting geographic areas for the intervention and comparison groups in the model, and whether particular regions of the country would need adjustments or exclusions from the model (for example, rural areas).

October 11

Evaluating the Bundled Payment for Care Improvement (BPCI) Initiative.  CMS released the fifth evaluation report for the BPCI Initiative, which tests whether linking payments for all providers that furnish Medicare-covered services during an episode of care related to an inpatient hospitalization can reduce expenditures while maintaining or improving quality of care.  For Model 2, the most comprehensive model, 8 percent of hospitals initiating episodes were in rural areas.  Rural participants reported challenges with scarcity of potential partners (e.g., primary care physicians, specialists, and community services); lack of knowledge of programs such as BPCI among providers; and limited internal staffing resources.  However, they also reported that being a rural provider did not affect their ability to collaborate with post-acute care providers because they had developed relationships or collaborative efforts prior to BPCI.  The Innovation Center also announced participants to the new BPCI-Advanced Model.  

October 4

GAO Report on Rural Hospital Closures. In response to a request from Congress, the US Government Accountability Office (GAO) analyzed how the Department of Health and Human Services supports and monitors rural hospitals' financial viability and rural residents' access to hospital services as well as the characteristics of rural hospitals that have closed in recent years.  From 2013 to 2017, 64 rural hospitals closed, more than twice as many as during the previous 5-year period.  Closures disproportionately occurred in the South, among for-profit hospitals, and among Medicare Dependent Hospitals—small rural hospitals with Medicare beneficiaries accounting for a certain percentage of their business.  Financial distress was the primary reason for closure, with multiple factors exacerbating the distress, including a decrease in patients seeking inpatient care and across-the-board Medicare payment reductions.

Hospital Readmission Reduction Program Changes for Safety Net Hospitals. As of October 1, 2018, CMS began a new methodology to assess hospital performance under the Hospital Readmission Reduction Program (HRRP), which reduces payments to inpatient prospective payment system (IPPS) hospitals with excess readmissions.  The new method evaluates hospital performance relative to other hospitals with similar proportions of patients that are dually eligible for Medicare and full-benefit Medicaid.  Critical Access Hospitals HRSA Exit Disclaimerare exempt from the HRRP, but tracking readmissions in CAHs is an area of focus of the Medicare Beneficiary Quality Improvement Project (MBQIP)HRSA Exit Disclaimer

September 27

Updated Survey and Certification Procedures for Hospitals with Swing Beds. The Centers for Medicare & Medicaid Services (CMS) recently updated the Appendices in the State Operations Manual (SOM) to reflect revisions to the regulations and guidelines for survey procedures for hospitals and critical access hospitals (CAHs) that operate swing beds. They updated Appendix A, Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, and Appendix W, Survey Protocol, Regulations and Interpretive Guidelines for CAHs and Swing Beds in CAHs, to reflect significant revisions to the Survey Protocol and deleted Appendix T.  These revised policies are effective immediately.  

September 20

Comments Requested: Reducing Regulations for Healthcare Providers – November 19.  The Centers for Medicare & Medicaid Services seeks comments on a proposed rule to reform Medicare regulationsHRSA Exit Disclaimer conditions of participation (CoPs), and conditions for coverage (CfCs) for health care providers and suppliers.  The proposals seek to simplify and streamline processes, reduce the frequency of activities, and remove obsolete, duplicative, or unnecessary requirements for Critical Access Hospitals, Community Mental Health Clinics, Rural Health Clinics, and Federally Qualified Health Centers, among others. Submit comments to

NQF Final Report:  Rural-Relevant Measures for Healthcare Quality. HRSA Exit Disclaimer  The National Quality Forum (NQF) released their first set of quality measures for rural hospitals and ambulatory care facilities to improve quality of care and access in rural areas. The Measures Application Partnership (MAP) formed a Rural Health Workgroup that provides recommendations from a rural perspective and developed these measures.   

2018 Rural Hospital and Clinic Financial Summit Report. HRSA Exit Disclaimer The National Rural Health Resource Center, with the support of the Federal Office of Rural Health Policy, developed this report following a Summit of key rural hospital and clinic stakeholders to identify the most important financial indicators and strategies to transition to value-based payment. This report is designed to help rural hospital and clinic leaders meet this transition with financial success. 

Call for National Advisory Committee NominationsHRSA seeks nominations for new members to serve on its Health Workforce National Advisory Committees. The five committees advise the HHS Secretary and Congress on health workforce policies and programs. HRSA accepts nominations on a continuous basis and considers them as vacancies occur. You may nominate yourself or others. Professional associations and organizations may also nominate qualified candidates.  As with all of HRSA’s Federal Advisory Committees, diverse geographic representation can strengthen the work and recommendations of each group.

September 13

FCHIP Interim Report to Congress.  Since August 1, 2016, ten Critical Access Hospitals (CAHs) in Montana, Nevada, and North Dakota have participated in the Frontier Community Health Integration Project Demonstration (FCHIP) to test how changes in Medicare payment for ambulance, skilled nursing, and telehealth services affect health outcomes in sparsely populated frontier communities. Last month, FORHP and CMS released a joint report to Congress detailing the CAHs’ progress and experiences in the first year of the demonstration.   The report finds little change for ambulance or skilled nursing services while telehealth services encountered credentialing, licensing, scheduling, and other common administrative challenges. FCHIP will conclude on July 31, 2019, unless extended by Congress.  FORHP and CMS must submit a final report to Congress by July 31, 2020.

USPSTF Recommendation to Prevent Youth Substance AbuseHRSA Exit Disclaimer The U.S. Preventive Services Task Force (USPSTF) conducts rigorous evaluations of existing peer-reviewed studies to inform evidence-based recommendations about clinical preventive services, such as screenings, counseling, and other primary care services.  USPSTF released its final research plan on how primary care providers can prevent illicit and nonmedical drug use, including opioid abuse, among children, adolescents, and young adults.  Before issuing its final recommendation on these services, USPSTF will review the evidence to determine whether counseling interventions referred by primary care providers improve health outcomes and related social, educational, and behavioral outcomes.

Date Last Reviewed:  November 2018

Questions about Policy Updates?