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 

March 26, 2020

CMS Telehealth Tool Kit for General Practitioners. The Centers for Medicare & Medicaid Services (CMS) created a toolkit with information on telehealth and telemedicine, resources for providers who may want to establish a telemedicine program, and temporary telehealth services that can be used to treat patients.  CMS created a separate Telehealth Tool Kit for End-Stage Renal Disease (ESRD) Providers

CMS Announces Quality Reporting Program Relief in Response to COVID-19. In response to COVID-19, the Centers for Medicare & Medicaid Services (CMS) announced relief for clinicians, providers, hospitals, and facilities that participate in the Quality Reporting Programs. These updates would apply to rural providers that participate in these programs. For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.

CMS Information Related to Coronavirus.  The Centers for Medicare & Medicaid Services (CMS) has a website with guidance and information that is updated daily. 

March 12, 2020

HHS Finalizes Rules for Interoperability and Patient Access to Health Data. On March 9, the U.S. Department of Health & Human Services (HHS) released two rules that implement interoperability and patient access provisions to improve patient access and advance electronic data exchange: the Interoperability and Patient Access final rule from the Centers for Medicare & Medicaid Services, and the 21st Century Cures Act final rule from the Office of the National Coordinator for Health Information Technology (ONC).  Provisions that apply specifically to hospitals, including Critical Access Hospitals, include policies on public reporting, prevention of information blocking, and requirements regarding electronic notification when a patient is admitted, discharged, or transferred.

March 5, 2020

Comments Requested: DEA Proposes Registration Changes for Mobile Narcotic Treatment Programs – April 27.  On February 26, the Drug Enforcement Administration (DEA) published a proposed rule to ease registration requirements for narcotic treatment programs (NTPs) that dispense methadone, a schedule II controlled substance.  DEA proposes to allow registered NTPs to deliver methadone maintenance or detoxification treatment in remote locations without requiring separate registration at each location.  More than 1,700 NTPs are registered with DEA, including all SAMHSA-certified opioid treatment programs (OTPs).  DEA explains that the change could make methadone treatment more widely available in rural and other underserved communities.  In 2011, 88.6% of non-metropolitan counties had a shortage of OTPs HRSA Exit Disclaimer in 2011 compared to 68.6% of metropolitan counties, and residents of non-metro counties in five states had to drive more than 40 minutes longer HRSA Exit Disclaimer than their metropolitan peers to reach an OTP in 2017.

New Medicare ACO Beneficiary Engagement Case Studies and Video.  The Centers for Medicare & Medicaid Services released a new video and case studies that provide ideas and strategies promoting value-based care in current and prospective Accountable Care Organizations (ACOs).  These resources highlight how ACOs can provide nonclinical support for beneficiaries with end-stage renal disease (ESRD); maintain patient advisory committees to improve care for beneficiaries with ESRD; and leverage health navigators to identify and resolve care gaps for beneficiaries in rural areas.

February 20, 2020

Request for Information Regarding Maternal and Infant Health Care in Rural Communities HRSA Exit Disclaimer - April 12.  The Centers for Medicare & Medicaid Services (CMS) seek public comments regarding rural maternal health care. Specifically, the CMS Office of Minority Health is seeking information related to opportunities to improve health care access, quality, and outcomes for women and infants in rural communities, before, during, and after pregnancy. This includes the reduction of maternal health disparities across this timeframe between rural and urban communities, within rural communities, and racial and ethnic disparities within rural communities. This notice also seeks public comments regarding readiness of rural providers, including emergency medical services to handle obstetric emergencies (i.e., emergencies related to pregnancy, birth, and after birth) in rural areas.  

Nominations:  HRSA Tribal Advisory Council – May 7.  The Health Resources and Services Administration (HRSA) is seeking comments and recommendations on its intent to create the HRSA Tribal Advisory Council (TAC), as well as nominations of tribal officials for consideration as voluntary delegates to serve on the HRSA TAC. The council will meet to discuss policies that have tribal implications and a substantial direct effect on Indian tribes, and to assist in the determination of the impact of HRSA programs on American Indian/Alaska Native populations.

February 13, 2020

Comments Requested: HRSA Telehealth Resource Center Program – March 6. The Health Resources and Services Administration (HRSA) is requesting feedback from the public about a future funding opportunity for Telehealth Resource Center (TRC) Program. Specific questions pertain to use of TRC services and their effectiveness.  HRSA may use the responses collected to inform policy development and program decision making, among other purposes. We will share the responses and/or a summary of the responses with the Office for the Advancement of Telehealth in HRSA’s Federal Office of Rural Health Policy.

Comments Requested: Proposed Updates to Medicare Advantage and Part D Plan PaymentsMarch 6.    Through this CY 2021 Advance Notice Part II, CMS is proposing updates and changes to the methodologies used to pay Medicare Advantage plans, PACE organizations, and Part D sponsors. They are soliciting input on Quality Star measures for End-Stage Renal Disease, prior authorizations, physical functioning activities of daily living, and initial opioid prescribing.  About one-quarter of rural Medicare beneficiaries are enrolled in a Medicare Advantage plan.HRSA Exit Disclaimer
Comments Requested: Changes to Medicare Advantage (MA) Network Adequacy – April 6.  CMS seeks comments on proposed changes to the standards used to determine if an MA plan has an adequate network of providers within a specified time and distance to ensure beneficiaries are able to access care.  CMS proposes to codify the current specialty areas as well as the time and distance standards by geographic area.  To encourage more MA offerings in rural areas, they also propose to reduce the percentage of beneficiaries that must reside within the time and distance standards in non-urban counties and to modify these standards for plans that contract with certain specialty telehealth providers. 

February 6, 2020

Nominations: HRSA National Advisory Committee on Infant Mortality – February 24.  The Health Resources and Services Administration (HRSA) seeks nominations for the Advisory Committee on Infant Mortality. This committee is a public-private partnership advising the U.S. Department of Health & Human Services on reducing infant mortality and improving the health status of pregnant women.  Last month, the Centers for Disease Control and Prevention issued data about infant deaths in metropolitan and nonmetropolitan counties

Comments Requested: Proposed Changes to 2021 Health Insurance Marketplace – March 2.   Last week, CMS posted its proposed changes to the Notice of Benefits and Payment Parameters and its draft Annual Letter to Issuers. Both of which provide guidance to states and insurers for the administration of the American Health Benefit Exchanges (aka “the Marketplace”) in 2021.  Proposals address the cost of prescription drugs, determining eligibility for other public programs, the user fee rate, and the display of quality rating information on State-based Exchanges.  Application submission dates and requirements for Essential Community Providers (e.g., Rural Health Clinics, Critical Access Hospitals) are unchanged from 2020.   CMS also extended for one year the policy allowing issuers to continue offering plans that do not meet all Marketplace reforms, if approved by the State.

New Opportunity for Medicaid to Serve Healthy AdultsCMS announced last week a new demonstration opportunity for States to offer Medicaid coverage to adults under age 65 who are not otherwise eligible. As part of this, one of many design options for States is to create value-based payment designs for Federally Qualified Health Centers (FQHC) and potentially other safety net providers, such as Rural Health Clinics.  Financing for these demonstrations would be through a defined budget target, set on either a total expenses or per-enrollee basis. 

January 23, 2020

Comments Requested: Coordinating Out-of-State Care for Chronically Ill Children – March 23.  CMS requests input from rural and urban advocates, caregivers, providers, and States on best practices for using out-of-state providers to care for Medicaid-eligible children with medically complex conditions. Input may address how to coordinate care when providers are out-of-state; how to reduce barriers from receiving out-of-state care in a timely fashion; and best practices for screening and enrolling out-of-state providers in Medicaid.

January 16, 2020

Nominations for the U.S. Preventive Services Task Force – March 15.  The Agency for Healthcare Research and Quality is seeking nominations to the U.S. Preventive Services Task Force, an independent, volunteer panel of national experts in prevention and evidence-based medicine. HRSA Exit Disclaimer Specific areas of expertise being sought include

  • public health
  • health equity and the reduction of health disparities
  • application of science to health policy
  • dissemination and implementation
  • behavioral medicine, and
  • communication of scientific findings to diverse audiences.

Nominations of individuals clinical expertise in family medicine, internal medicine, pediatrics, and obstetrics and gynecology will receive the strongest consideration.

January 9, 2020

Request for Information: National Institute of Mental Health Strategic Plan for Research – EXTENDED to January 15.  The National Institute of Mental Health (NIMH) seeks feedback from the public about the draft 2020 NIMH Strategic Plan for Research. The plan will guide the Institute’s research efforts and priorities over the next five years.  Strategy 4.3.A specifies testing innovative approaches for rural areas. 

Feedback on Medicare Scope of Practice Regulations —January 17.  CMS seeks input and recommendations regarding elimination of specific Medicare regulations that are more stringent than existing state scope of practice laws for Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs).  Nurse Practitioners (NPs) and PAs are an important part of the rural workforce and are more likely than physicians to work in rural areas.  Send recommendations to with the phrase “Scope of Practice” in the subject line

Comments Extension: Proposed Rule for Transparency in Coverage The due date for comments regarding the proposed requirements for group health plans and health insurance issuers in the individual and group markets to disclose cost-sharing information upon request, to a participant, beneficiary, or enrollee (or his or her authorized representative has been extended to January 29.  About 6 in 10 rural residents have private health insurance coverage provided through an employer, purchased directly, or TRICARE.

Comments Extension:  Proposed Rule for Medicaid Fiscal Accountability – The due date for comments on proposed changes to state Medicaid reporting and clarifications of key definitions in order to improve payment transparency and program integrity has been extended to February 1.  CMS seeks comment on whether supplemental provider payments should be capped, if there should be a separate cap for rural areas and/or HRSA-designated geographic health professional shortage areas, and whether there should be other special considerations for providers in underserved areas.

Accepting Nominations: CMS Technical Expert Panels on Quality Measure Development – Due dates vary by panel, January 9-31. CMS is currently accepting nominations for six technical expert panels that are developing quality measures for monitoring care received by beneficiaries receiving total hip and knee arthroplasty (THA/TKA), home and community based services (HCBS), chronic kidney disease treatment, and home health care.  CMS seeks involvement from a wide range of stakeholders from rural and urban areas.

Comments Requested: Medicare Advantage Advance Notice for 2021 Plan Year Risk Adjustment – March 6. CMS seeks comment on proposed updates to the hierarchical condition categories (HCC) model and the use of encounter data for risk adjusting MA plan payments in the 2021 plan year.  The proposed changes to the risk adjustment methodology are intended to better predict the cost to care for Medicare Advantage enrollees based on their health status and other factors   Research has found that HCC risk scores vary between rural and urban providersHRSA Exit Disclaimer  Other proposed payment methodology changes for the 2021 plan year will be released in Part II of the Advance Notice. 

Nominations for Federal Advisory Commission on HIV, Viral Hepatitis, and Sexually Transmitted Diseases – Ongoing.  The Health Resources and Services Administration (HRSA) is accepting nominations for this group that advises HRSA, the U.S. Department of Health and Human Services, and the Centers for Disease Control and Prevention. Applications will be accepted at any time; however, interested candidates are encouraged to submit their nomination packages as soon as possible for consideration in the next round of nominations.

New Guidance on Providing Opioid Treatment Services to Dually-Eligible Enrollees
This Guidance to State Medicaid Agencies clarifies that opioid treatment programs (OTPs) must enroll with Medicare in order to receive payment for services provided to beneficiaries who are dually-eligible for Medicare and Medicaid.  It also provides States with interim reimbursement solutions while OTPs go through the Medicare enrollment process.  There are few OTPs in rural areasHRSA Exit Disclaimer yet rural health providers are hopeful that increased access to medication assisted therapy, such as that provided in OTPs, can have a positive impact on rural opioid use.

December 12, 2019

Accepting Applications: CMS Direct Contracting Model Options Implementation Period – February 25. CMS is accepting applications for the Implementation Period of its Direct Contracting Model Options. This is the first of two application submission periods. The second application period opens in Spring 2020.
Direct Contracting is a set of three voluntary payment model options aimed at reducing expenditures and enhancing care for Medicare fee-for-service (FFS) beneficiaries. A key aspect of Direct Contracting is providing new opportunities for organizations (Direct Contracting Entities or DCEs) to participate in value-based care arrangements in Medicare FFS. The DCE must be a legal entity that contracts with DC Participant Providers, which may include but are not limited to Rural Health Clinics, Critical Access Hospitals, and Federally Qualified Health Centers. Rural DCEs, defined in the Request for Applications, may participate in the model.

Date Last Reviewed:  March 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?