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

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.

June 27

Comments Requested: Methodology for FCC Broadband Fund – July 15.  The Federal Communications Commission (FCC) seeks feedback from the public on its proposed rule establishing a cap for the Universal Service Fund (USF) or methods for evaluating the financial impact of USF's 4 programs: Connect America Fund, the Lifeline program, the schools and libraries program, and the Rural Health Care program. These programs support access to high-speed broadband. 

CMS ET3 Model RFA Preview and Webinar Archive Now Available. On June 11, the Centers for Medicare & Medicaid Services (CMS) hosted an overview webinar on the Emergency Triage, Treat, and Transport (ET3) Model Request for Applications (RFA), which was released for preview on May 22. The ET3 Model is a voluntary five-year payment model that provides greater flexibility for ambulance care teams to implement alternate models of emergency medical services (e.g., telehealth treatment and transport to alternative destinations) that appropriately address the needs of Medicare beneficiaries following a 911 call. The recorded webinar is now available online and includes key components of the RFA (i.e., eligibility requirements, application timelines, and necessary information required for a complete application). The application portal for the RFA will open later this summer and the anticipated start date for the ET3 Model is January 2020.

June 20

Comments Requested:  CMS Issues Draft Guidance on Hospital Co-location – July 2. The Centers for Medicare & Medicaid Services (CMS) seeks public input on draft guidance regarding how CMS and State Agency surveyors will evaluate a hospital’s co-location of space and staff when assessing the hospital’s compliance with the Medicare Conditions of Participation (CoPs). It clarifies that sharing of staff may be done through a contractual arrangement where there are clear lines of authority and accountability and that sharing public areas, such as entrances and waiting rooms, would be permissible. RHIhub HRSA Exit Disclaimer highlights several programs in rural communities that have used co-location of services and staff to improve efficiencies, including lessons learned about this approach.

June 13

HRSA Requests Public Feedback on Health Center Service Areas – July 8.  The Health Resources and Services Administration (HRSA) is 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.   

Indian Health Service Requests Feedback on Community Health Aide Program – July 8.  The Community Health Aide Program (CHAP) is a multidisciplinary system of mid-level behavioral, community, and dental health professionals working alongside licensed providers to offer patients increased access to quality care in rural Alaskan areas. In 2016, The Indian Health Service (IHS) consulted with Tribes on expanding the program, and in 2018, formed the CHAP Tribal Advisory Group (CHAP TAG) to expand CHAP to the lower 48 states.  The IHS is requesting feedback from the public on its draft policy to expand the program

CMS Requests Feedback Reducing Regulatory Burden – August 12.  On June 6, the Centers for Medicare & Medicaid Services (CMS) issued a Request for Information (RFI) seeking new ideas from the public on how to reduce administrative and regulatory burden as part of the agency’s Patients over Paperwork initiative. CMS is especially seeking innovative ideas that broaden perspectives on potential solutions to relieve burden and ways to improve: reporting and documentation requirements; coding and documentation requirements for Medicare or Medicaid payment; prior authorization procedures; policies and requirements for rural providers, clinicians, and beneficiaries; policies and requirements for dually enrolled (i.e., Medicare and Medicaid) beneficiaries; beneficiary enrollment and eligibility determination; and CMS processes for issuing regulations and policies.

VA Announces Final Community Care Regulations under MISSION Act. On June 5, the U.S. Department of Veterans Affairs (VA) announced the publication of two final regulations as part of its new Veterans Community Care Program under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018. One of the rules focuses on a new urgent care benefit. VA also published the final regulation for the Veterans Community Care Program governing how eligible Veterans receive necessary hospital care, medical services, and extended care services from non-VA entities or providers in the community. The new Veterans Community Care Program replaces the Veterans Choice Program, which expired June 6, 2019. Of note, the final rule addresses payment of higher rates to health care providers in highly rural areas. The term “highly rural area” means an area located in a county that has fewer than seven individuals residing in that county per square mile.

June 6

New Opportunity to Apply to be a Medicare Shared Savings Program ACONotice of Intent June 28.  For provider groups interested in becoming a Medicare Shared Savings Program Accountable Care Organization (ACO) in 2020, CMS will accept Notices of Intent Apply (NOIA) between June 11 and June 28, 2019.  An NOIA is required in order to submit an application, which will be due by July 29.  The ACO Program was restructured for 2019 and offers rural providers a path to take on financial risk for shared savings and losses.   Email questions to SSPACO_Applications@cms.hhs.gov.

CMS Publishes PACE Final Rule- The Centers for Medicare & Medicaid Services (CMS) finalized a rule updating and modernizing the Programs of All-Inclusive Care for the Elderly (PACE), which provides comprehensive medical and social services to certain frail, elderly individuals (many of whom are “dually eligible” for both Medicare and Medicaid) who qualify for nursing home care but can still live safely in the community.  This rule strengthens protections for PACE participants,  provides administrative flexibility  for PACE organizations, and reduces administrative burden for  clinicians.  RHI Hub provides examples of PACE programs in rural HRSA Exit Disclaimer areas as well as toolkits on how to get started. 

CMS Beyond the Policy Podcast: New Episode on Value-Based Care. The episode features a discussion on the direction of the CMS Innovation Center with the CMS Administrator, Seema Verma and the CMS Innovation Center Director, Adam Boehler, that was moderated by Tom Corry, the CMS Director of the Office of Communications. This includes a mention of new models for rural health care.

May 30

CMS Announces Emergency Triage, Treat, and Transport (ET3) Model Request for Applications (RFA) – Last week, the CMS Innovation Center posted the ET3 Model RFA and Frequently Asked Questions online for potential applicants to review prior to the release of the application later this summer.  The ET3 Model permits ambulance care teams to use alternate models of emergency health care, e.g., telehealth treatment and transport to alternative destinations, to improve quality and lower costs of care. Rural Medicare-enrolled suppliers or hospital-based ambulance providers without current medical dispatch and/or telehealth are eligible to participate.

Comments Requested: Clarification of Ligature Risk Interpretive Guidance – June 17.  Last month, CMS proposed changes to the ligature risk guidance for rural and urban psychiatric facilities to ensure patients receive care in a safe environment.  CMS clarified and provided direction on identifying ligature risks, e.g., cord used to create an attachment point to a doorknob or hinge, for patients at risk for self-harm or harm to others.  In addition, a ligature extension request process was outlined for hospitals to correct compliance issues beyond the 60-day timeframe.  About 20 percent of rural residents were diagnosed with mental illness HRSA Exit Disclaimer and rural communities report having fewer behavioral healthcare providers than urban areas.

May 23

Nominations Requested: Secretary’s Tribal Advisory Committee HRSA Exit Disclaimer – June 21. The primary purpose of the Secretary’s Tribal Advisory Committee is to seek consensus, exchange views, share information, and provide recommendations to the Secretary of the U.S. Department of Health & Human Services. The committee accomplishes this through forums, meetings and conversations between federal officials and elected Tribal leaders from each of the twelve areas of the Indian health Service, as well as five at-large national representatives.  Vacancies are currently open for one delegate and one alternate for the Billings and Albuquerque locations.  Additionally, the committee seeks nominations for three (3) primary and one (1) alternate national at-large vacancies.

Hardship Exclusion for Medicare Interoperability HRSA Exit Disclaimer – July 1. Beginning in 2019, all eligible professionals (EPs), eligible hospitals, dual-eligible hospitals, and Critical Access Hospitals (CAHs) are required to use 2015 edition certified electronic health record technology (CEHRT) to meet the requirements of the Promoting Interoperability (PI) ProgramsEligible hospitals and CAHs may be exempted from the Medicare downward payment adjustment if they can show that compliance with the requirements would result in a significant hardship. Hardship exceptions are valid for only one payment adjustment year, so hospitals must submit an exclusion application each year.  The deadline to submit an application is July 1, 2019 for eligible hospitals and November 30, 2019 for CAHs.

CMS Finalizes Medicare Prescription Drug Pricing Rule.  Last week, CMS finalized a rule HRSA Exit Disclaimer that will improve the transparency of prescription drug costs in Medicare Part D and Medicare Advantage health plans and lower beneficiary out-of-pocket costs. For example, beginning in 2021, the Explanation of Benefits that Part D plans send members must display drug price increases as well as lower cost therapeutic alternatives.  In addition, beginning in 2020, Part D sponsors cannot prohibit or penalize a pharmacy from disclosing a lower cash price to an enrollee.  About 70 percent of rural Medicare beneficiaries had prescription drug coverage in 2017, HRSA Exit Disclaimer mostly through stand-alone Part D plans as opposed to Medicare Advantage plans.

May 16

Medicare Shared Savings Program: Submit Notice of Intent to Apply Beginning June 11 through June 28. CMS announced Notice of Intent to Apply (NOIA) and application cycle dates for a January 1, 2020 start date for the Medicare Shared Savings Program (MSSP). Beginning June 11, 2019, CMS will start accepting NOIAs via the Accountable Care Organization (ACO) Management System (ACO-MS). You must submit a NOIA if you intend to apply to the BASIC or ENHANCED track of the Shared Savings Program, apply for a Skilled Nursing Facility 3-Day Rule Waiver, and/or establish and operate a Beneficiary Incentive Program. MSSP fast facts from January 2018 highlight that 1,210 rural health clinics and 421 critical access hospitals were included on ACO participant lists.

May 9

Request for Information: Physician Geographic Population-Based Payment Model – May 23.   In April, CMS announced a new Primary Cares Initiative that will provide primary care practices and other providers with five new payment model options under two paths: Primary Care First (PCF) and Direct Contracting (DC). The three DC payment model options aim to engage a variety of organizations that have experience with financial risk and serving large patient populations.  To inform one DC payment model option—the Geographic Population-Based Payment (PBP) model option—CMS seeks public input on specific design parameters, such as what criteria should CMS consider for target regions; the types of entities; payment methodology parameters; and general model design questions.  In addition, CMS is interested in what safeguards are needed to preserve access and quality for rural beneficiaries and how would rural market forces (e.g., out-migration and hospital closures) affect the ability to lower cost and improve quality under this payment model option?

Comments Requested: Institutions for Mental Disease (IMD) – May 31.  The Medicaid and CHIP Payment and Access Commission (MACPAC) requests written comments to learn more about IMDs across the country.  For example, how many IMDs receive Medicaid payment and what services do they provide?  This information may be useful for rural communities where research suggests patients with substance use disorders have access to fewer options for treatment. HRSA Exit Disclaimer Rural stakeholders interested in submitting comments should email written responses to Erin McMullen at erin.mcmullen@macpac.gov.  Also see toolkits to improve mental health HRSA Exit Disclaimer and prevent and treat SUD HRSA Exit Disclaimer in rural communities for more information.

Comments Requested:  CMS Issues Draft Guidance on Hospital Co-location – July 2. The Centers for Medicare & Medicaid Services (CMS) seeks public input on draft guidance regarding how CMS and State Agency surveyors will evaluate a hospital’s co-location of space and staff when assessing the hospital’s compliance with the Medicare Conditions of Participation (CoPs).  It clarifies that sharing of staff may be done through a contractual arrangement where there are clear lines of authority and accountability and that sharing public areas, such as entrances and waiting rooms, would be permissible. RHIhub HRSA Exit Disclaimer highlights several programs in rural communities that have used co-location of services and staff to improve efficiencies, including lessons learned about this approach.

Request for Information: State Waivers for Health Insurance – July 2.   Section 1332 of the Patient Protection Affordable Care Act (PPACA) 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 requests additional ideas for innovative waiver concepts that could increase insurer participation and lower premiums, including how states might align these Section 1332 flexibilities with Section 1115 Medicaid waivers and state law.  In 2018, rural areas had fewer insurers offering individual health insurance HRSA Exit Disclaimer and higher average adjusted premiums compared to urban areas.

April 25

Comment Period Extended: Proposed Rules to Promote Interoperability of Health IT – June 3.  In February of this year, the U.S. Department of Health & Human Services (HHS) announced two proposed rules to support the seamless and secure access, exchange, and use of health information among electronic heath information networks, a goal known as interoperability. Together, these proposals would address factors that create barriers to interoperability and limit access essential health information.  Use of electronic health records can improve the quality of care by giving providers information about their patients and helping them find the best possible treatment.  In a recent study, HHS found that 94 percent of hospitals used electronic health records to inform their clinical practice, but small, rural and Critical Access Hospitals had the lowest rates for using electronic records.  In response to feedback from the public, HHS has extended the comment period by one month past its original deadline of May 3.

Comments Requested: Trusted Exchange Framework for Electronic Health Information – June 17.  The Office of the National Coordinator for Health Information Technology (ONC) is seeking feedback from the public on their second draft of the Trusted Exchange Framework and Common Agreement.  This document outlines a common set of principles, terms, and that would enable a nationwide exchange of electronic health information. 

Comments Requested: Proposed Changes to Payment and Policy for Inpatient Psychiatric Facilities – June 17. On April 18, CMS displayed the Fiscal Year (FY) 2020 Inpatient Psychiatric Facilities Propose Rule (CMS-1712-P). CMS is proposing to increase the payment rates by $75 million this year. CMS is also proposing to continue the 17 percent payment adjustment for IPFs located in rural areas that has been in place since 2004.

Comments Requested: Proposed Payment and Policy Changes for Medicare Inpatient Rehabilitation Facilities – June 17. On April 17, the Centers for Medicare & Medicaid Services (CMS) proposed a rule that would update Medicare payment policies for facilities under the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) and the Inpatient Rehabilitation Quality Reporting Program (IRF QRP) for fiscal year (FY) 2020. CMS projects that rural IRF payments overall will increase by 4.3 percent for FY 2020, relative to payments in FY 2019.

Comments Requested: Proposed Update to Hospice Payment Rate – June 18. On April 19, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that rule would, among other things, update the hospice payment rates, wage index, and cap amount for fiscal year (FY) 2020. As proposed, rural hospice payment rates are updated by 2.1 percent overall for FY 2020.

Comments Requested: Proposed Payment and Policy Changes for Medicare Skilled Nursing Facilities – June 18. Last week, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for fiscal year (FY) 2020 that updates the Medicare payment rates and the quality programs for skilled nursing facilities (SNFs). CMS’ Patient Driven Payment Model, focused on value rather than volume, will be effective October 1, 2019 under the SNF Prospective Payment System.  CMS projects aggregate payments to rural SNFs will increase by 6.4 percent, for FY 2020 compared to FY 2019.

HHS and CMS Announce New Value-Based Care Initiatives. This week, the U.S. Department of Health and Human Services (HHS) and Centers for Medicare & Medicaid Services (CMS) announced the CMS Primary Cares Initiative. Administered through the CMS Innovation Center, the new initiative will provide primary care practices and other providers with five new payment model options under two paths: Primary Care First (PCF) and Direct Contracting (DC). Both models provide incentives to reduce hospital utilization and total cost of care by adjusting payments to providers’ performance. While the PCF models focus on individual primary care practice sites, the three DC payment model options aim to engage a wider variety of organizations that have experience taking on financial risk and serving larger patient populations. Last year, the RUPRI Center for Rural Health Policy Analysis and Stratis Health published a policy brief on the priorities of rural health leaders about value-based payment modelsHRSA Exit Disclaimer

Final Rule for Health Insurance Benefit and Payment Parameters. Last week, the Centers for Medicare & Medicaid Services (CMS) released the final Notice of Benefit and Payment Parameters for the 2020 benefit year, a document that sets forth instructions to insurers participating in the Health Insurance Exchanges or “Marketplaces”.  Among the changes for 2020 are flexibilities related to the duties and training requirements for the Navigator program and opportunities for innovations in the direct enrollment process.  In 2018 and 2019, the percentage of enrollments in the federal exchange (healthcare.gov) by rural residents remained unchanged at 18 percent.

April 18

CMS releases Care Coordination Toolkit and series of ACO Case Studies. The Centers for Medicare & Medicaid Services (CMS) has released a public Accountable Care Organization (ACO) Care Coordination Toolkit highlighting innovative strategies that ACOs and End-Stage Renal Disease Care (ESRD) Seamless Care Organizations (ESCOs) use to collaborate with beneficiaries, clinicians, and post-acute care partners to ensure high-quality, effective care is provided at the right time and in the right setting. CMS has also released seven case studies to describe innovative initiatives from ACOs and ESRD ESCOs on a variety of topics including engaging beneficiaries, coordinating care in rural settings, and promoting health literacy. Each case study includes detailed results and lessons learned.

SIM Initiative Evaluation: Model Test Year Five Annual Report. In December 2018, the Center for Medicare & Medicaid Innovation released its fifth annual report on Round 1 of the CMS State Innovation Models (SIM) Initiative, which tests the ability of the governments in six states (Arkansas, Maine, Massachusetts, Minnesota, Oregon, and Vermont) to move providers to value-based payment. A number of these states had activities involving rural providers, including RHCs, FQHCs, and CAHs. As a key finding, states used SIM awards to provide resources to providers to enable provider participation in Medicaid alternative payment models. While most state-led models supported through SIM did not realize Medicaid savings, many results were promising considering the limited provider incentives. A 2017 guide from Rural Health Value HRSA Exit Disclaimer highlights the rural focus within select SIM awards from Rounds 1 and 2.

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 HealthCare.gov 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 Healthcare.gov 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

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: 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).

Date Last Reviewed:  August 2019


Reports

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?