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

April 11

HRSA Requests Public Feedback on Health Center Service Areas.  The Health Resources and Services Administration (HRSA) recently announced an upcoming request for information (RFI) on its Health Centers Program. HRSA will be seeking input from the public on service area considerations that may inform decisions to expand the program through the addition of new service delivery sites onto existing health centers.  The considerations include factors such as proximity to existing health centers, parameters for unmet need, and consultation with other local providers.   The Service Area RFI announcement will begin with a 30-day preview period. Instructions on how to submit feedback are forthcoming. Following the preview period, HRSA will accept public feedback for 60 days.

Latest CMS Podcast Episode Features Rural Providers. Last week, CMS released the latest episode of their podcast, CMS: Beyond the Policy. This episode brings highlights from the 2019 CMS Quality Conference, including perspectives from rural providers at the conference. The theme of this year’s conference was “Innovating for Value and Results.”

Additional Telehealth Benefits for Medicare Advantage Finalized. To implement provisions of the Bipartisan Budget Act of 2018, CMS has finalized provisions allowing Medicare Advantage (MA) plans to offer additional telehealth benefits as part of the basic benefits.  While Medicare Advantage plans have always been able to offer more telehealth benefits than traditional Medicare, this rule gives MA plans even more flexibility with paying for these services, which could expand telehealth further.  For example, enrollees in urban and rural areas may be able to receive telehealth from their homes. In 2017, about one in four rural Medicare beneficiaries were enrolled in an MA planHRSA Exit Disclaimer

Enhancements to the CMS Mapping Medicare Disparities (MMD) Tool. The MMD tool provides interactive maps to illustrate disparities between subgroups of beneficiaries on key measures of health outcomes, use, and spending.  CMS recently added rural and urban data to the population view, so users can view and compare across rural and urban counties. They also added four opioid use disorder indicators, including hospital and ER visits and medication-assisted therapy utilization.

April 4

Rural Enrollment in 2019 Health Insurance Exchanges – CMS’ latest Health Insurance Exchange Enrollment fact sheet reports that overall enrollment in the 39 states that use the and in the 12 State-Based Exchanges (SBEs) that use their own eligibility and enrollment platforms decreased from 11.8 million in 2018 to 11.4 million in 2019. The proportion of enrollments in the states by rural residents remained at its 2018 rate of 18 percent in 2019. 

Medicare Advantage (MA) and Prescription Drug Program 2020 Payment and Policy Updates – The 2020 Rate Notice and Call Letter for the MA and Prescription Drug Programs details what plans and consumers can expect for the upcoming plan benefit year.  In addition to updating payment methodologies and rates, it finalizes policies to address the opioid epidemic and provides guidance on how MA plans can tailor supplemental benefits to improve or maintain the health of an enrollee with a chronic condition or illness, such as by providing meals or transportation for non-medical needs.  In 2017, about 25 percent of rural Medicare beneficiaries were enrolled in a Medicare Advantage plan HRSA Exit Disclaimer and about 70 percent enrolled in a Prescription Drug planHRSA Exit Disclaimer through either their MA plan or a stand-alone drug plan.

March 28

CMS Issues Report on Quality Payment Program Clinician ExperienceHRSA Exit Disclaimer The Centers for Medicare & Medicaid Services (CMS) has published information on clinician participation, reporting, and performance in year one (2017) of the Quality Payment Program (QPP). Among the findings, CMS noted that rural clinicians eligible for the Merit-Based Incentive Payment System (MIPS) had a participation rate (94 percent) virtually equal to the overall average, and 93 percent of rural clinicians participating in MIPS received a positive payment adjustment. CMS also reiterated their commitment to alleviating barriers and creating pathways for improvement and success for rural clinicians through the Small, Underserved, and Rural Support initiativeHRSA Exit Disclaimer

CMS Issues New Frequently Asked Questions (FAQs) Regarding Medicaid Home and Community-Based Services (HCBS).  The Centers for Medicare & Medicaid Services (CMS) has issued Frequently Asked Questions (FAQs) that provide more information to State Medicaid programs on what settings have the qualities of an institution and are ineligible for Home and Community Based Services (HCBS), which settings qualify for HCBS, and under what circumstances CMS needs to conduct a review with heightened scrutiny to determine if the setting qualifies for HCBS.  The guidance clarifies that while rural settings may appear to meet the criteria to conduct a heightened scrutiny review, States should only request such a review if a setting has the qualities of an institution and if individuals qualifying for HCBS in a rural area do not have the same access to engage in the community as enrollees not receiving Medicaid HCBS in the same area. 

March 14

Comments Requested: Changes to Hospital Star Ratings – March 29. The Centers for Medicare & Medicaid Services (CMS) is proposing changes to the Hospital Star Ratings System, a tool that provides consumers and patients with information on the safety and quality of hospitals, including rural hospitals. On March 6, CMS hosted a national call to discuss the changes. The recording will be available online.

Policy Barriers to Telehealth. HRSA Exit Disclaimer This report from the Center for Connected Health Policy (CCHP) gives a broad overview of the primary policy concerns relating to telehealth, including reimbursement, prescribing, malpractice coverage, licensing, and privacy and security.  A second release from CCHP is a Fact Sheet on Telehealth Reimbursement HRSA Exit Disclaimer focusing on the policy concerns related to Medicare, Medicaid, and private payer telehealth coverage.  As the federally designated National Telehealth Resource Center on policy HRSA Exit Disclaimer, the CCHP provides legislative and regulatory updates, expert analysis through policy briefs, as well as research catalogs and fact sheets on all matters that advance telehealth policy.

HHS: Best Practices and Barriers to SUD Treatment.  A patient’s initiation with treatment for substance use disorder (SUD) and subsequent engagement with recovery is used as a performance measure in this report from the analysis and evaluation arm of the U.S. Department of Health & Human Services.  Looking at data on Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET), commonly reported by health plans and used by Medicaid and Medicare programs, the study aimed to determine what variables may contribute to patients’ initiation and engagement in treatment, including individual, provider, health plan, and market and environmental factors. The study examines how these factors affect health plan performance on the IET measures for both commercial and Medicaid health plans and how initiation and engagement may be improved.

March 7

Comments Requested:  Physician-focused Payment Model for Rural Emergencies – March 22.  The Physician-focused Payment Model Technical Advisory Panel (PTAC) requests public comment on an alternative payment model proposal to bundle payments for emergency cerebral neurological conditions through telemedicine.  It would expand on the rural hospital neuro-emergent telemedicine platform and payment model, ACCESS, used in New Mexico.  Comments can be emailed to with subject line “Public Comment – ACCESS Telemedicine”.

Comments Requested: Draft Report on Best Practices for Pain Management – April 1.  A task force within the U.S. Department of Health & Human Services is seeking input from the public on a Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations.  The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.  Their recommendations are focused on a multi-modal, multi-disciplinary approach to chronic pain management and will be finalized and submitted to Congress in 2019.  One recommendation included in the draft is exploration of the use of technology, particularly in rural areas, as a method of delivering patient education and support for acute and chronic pain.

Comments Requested: ONC Proposal for Interoperability of Health IT – May 3.  The Office of the National Coordinator for Health Information Technology (ONC) leads the federal effort to support the adoption of health information technology (Health IT) and the promotion of nationwide health information exchange to improve health care.  ONC’s proposed rule promotes secure and more immediate access to health information for patients and their healthcare providers, and new tools allowing for more choice in care and treatment. The proposal aims to align requirements for payers, health care providers (including rural providers), and health IT developers to drive an interoperable health IT infrastructure across systems. ONC published a report in 2016 on interoperability for hospitals across the U.S. that revealed a substantially lower engagement rate for small, rural hospitals.   In a separate announcement last month, the Centers for Medicare & Medicaid Services (CMS) requested comments on a proposal to support the MyHealthEData initiative, aiming to increase the flow of health information, reduce burden on patients and providers, and provide data for researchers and innovators.  Comments from the public on CMS’ Proposed Updates to Interoperability & Patient Access to Health Data are also due on May 3.

February 21

CMS Launches New Podcast Series. This week, the Centers for Medicare & Medicaid Services (CMS) launched “CMS: Beyond the Policy,” a new podcast highlighting updates and changes to policies and programs in an easily accessible and conversational format.  The podcast was created as a new method to explain the agency’s policies and programs. The first episode focuses on Evaluation and Management Coding (E/M Codes) changes finalized in the Calendar Year 2019 Physician Fee Schedule, and also touches on the new telehealth and virtual services finalized in the 2019 rule. This episode will be available for download on iTunes and Google Play in the coming days.

CMS to Test New Model for Emergency Medical Services. On February 14, the Center for Medicare and Medicaid Innovation (CMS Innovation Center) announced the new Emergency Triage, Treat, and Transport (ET3) Model. This voluntary, five-year payment model is designed to provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare beneficiaries following a 911 call. CMS anticipates releasing a Request for Applications in Summer 2019 to solicit Medicare-enrolled ambulance suppliers and providers. A recent study from the Rural & Underserved Health Research Center HRSA Exit Disclaimer examined differences in ambulance usage among Medicare beneficiaries by state.

February 14

Comments Requested: Proposed Updates to Interoperability & Patient Access to Health Data – Early April. On February 11, the Centers for Medicare & Medicaid Services (CMS) proposed policy changes supporting its MyHealthEData initiative to improve patient access and advance electronic data exchange and care coordination throughout the healthcare system. The proposed rule solicits comments on policies that would affect hospitals, including critical access hospitals (CAHs). This includes policies on public reporting and prevention of information blocking and requiring Medicare-participating hospitals, psychiatric hospitals, and CAHs to send electronic notifications when a patient is admitted, discharged or transferred. In addition to the policy proposals, CMS is releasing two related Requests for Information (RFIs). CMS will accept comments on the major provisions in this proposed rule and the RFIs (CMS-9115-P) until early April (exact date will be updated upon posting at the Federal Register).

February 7

Comments Requested:  Proposed Updates to the Medicare Advantage (MA) and Part D Programs – March 1.  Last week, CMS released Part II of the Advanced Notice and Draft Call Letter for the MA and Part D programs, which updates the payment methods for these programs.  In conjunction with Part I released in December, CMS proposes to update the risk adjustment model, revise the measures in the quality Star Rating program, and offer guidance on how plans can offer non-health related supplemental benefits, such as transportation for non-medical needs.  As of March 2017, almost one-quarter of rural Medicare beneficiaries were enrolled HRSA Exit Disclaimer in some type of Medicare Advantage plan.

January 24

CMS Updates Medicare Advantage Value-Based Insurance Design Model. Last week, CMS announced a broad array of Medicare Advantage (MA) health plan innovations that the CMS Innovation Center will test in the Value-Based Insurance Design (VBID) model for calendar year 2020. Among other updates, beginning in 2020, CMS will allow plans to use access to telehealth services instead of in-person visits to meet a range of network requirements, as long as an in-person option remains. CMS expects that the use of telehealth in this model will provide MA plans with an opportunity to enter into underserved markets, including rural areas where there may be few to no MA plan choices. 

CMS Introduces Part D Payment Modernization Model. In January 2020, the CMS Innovation Center will begin the Part D Payment Modernization model to test the impact of a revised Part D program design and incentive alignment on overall Part D prescription drug spending and beneficiary out-of-pocket costs. The model is open to eligible standalone Prescription Drug Plans (PDPs) and Medicare Advantage-Prescription Drug Plans (MA-PDs). Research in 2015 from the University of Minnesota Rural Health Research Center HRSA Exit Disclaimer found that urban beneficiaries tended to have access to more plans and lower cost burdens than rural residents. More rural-specific research on Medicare Part D is available from the Rural Health Research GatewayHRSA Exit Disclaimer

January 10

10 Opportunities for States to Better Serve Dual Eligibles.  This letter from CMS to State Medicaid Directors outlines 10 ways to improve care for beneficiaries dually eligible for Medicare and Medicaid without using a demonstration or a waiver.  For example, states can bolster integrated care through Dual Special Needs Plans (D-SNPs) and reviewing payment rates for Programs of All-Inclusive Care for the Elderly (PACE).  There are also strategies to simplify eligibility and enrollment processes.  Rural beneficiaries are more likely to be dually-eligible HRSA Exit Disclaimer than their urban counterparts.

December 20

All Hospitals Must Make Standard Charges Public – Effective January 1.  CMS released responses to Frequently Asked Questions regarding the policy that hospitals must establish, update, and make public a list of their standard charges for all items and services, effective January 1, 2019.  This policy applies to all hospitals operating in the U.S., including critical access hospitals, inpatient rehabilitation facilities, and inpatient psychiatric facilities.  The charges must be provided in a machine-readable format that can be easily imported/read into a computer system (e.g., XML, CSV). A PDF does not satisfy this definition.  The policy was finalized in the 2019 Inpatient Prospective Payment System (IPPS) rule published on August 2, 2018.

Date Last Reviewed:  April 2019

Questions about Policy Updates?