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 

January 9

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

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.

November 21

Comments Requested: Transparency in Coverage Proposed Rule – January 14. On November 15, the U.S. Department of Health and Human Services (HHS), the Department of Labor, and the Department of the Treasury proposed requirements for group health plans and health insurance issuers in the individual and group markets. These proposals would require disclosure of cost-sharing information upon request, to a participant, beneficiary, or enrollee (or his or her authorized representative). If you are looking for information on health insurance in rural areas, visit RHIhubHRSA Exit Disclaimer

Comments Requested:  Medicaid Fiscal Accountability Proposed RuleJanuary 17.   The Centers for Medicare & Medicaid Services (CMS) proposed changes to state Medicaid reporting. Proposals focus on four payment areas: fee-for-service (FFS) supplemental provider payments; disproportionate share hospital (DSH) payments; financing for the non-Federal share of payments; and health care-related taxes and provider-related donations.  CMS seeks comment on all elements of this proposal.

CMS Issues Hospital Price Transparency Final Rule. On November 15, the Centers for Medicare & Medicaid Services (CMS) finalized policy changes to the CY 2020 Hospital Outpatient Prospective Payment System (OPPS) on price transparency requirements. This final rule establishes requirements for hospitals, including Critical Access Hospitals (CAHs) to publish a machine-readable file online that includes all standard charges along with discounted cash prices, payer-specific negotiated charges, and minimum and maximum negotiated charges for “shoppable services.” The effective date of the final rule will be January 1, 2021.

FCC Publishes Final Rule on Rural Health Care Program - The Federal Communications Commission (FCC) finalized regulations to promote transparency and efficient allocation Rural Health Care Program resources while guarding against waste, fraud and abuse. The FCC promotes telehealth in rural areas through the Rural Health Care Program (RHC Program), which provides financial support to help rural health care providers obtain broadband and other communications services at discounted rates. Most of the regulations went into effect on November 12.

November 7

Deadline for Critical Access Hospitals to Submit a Hardship Exception Application HRSA Exit Disclaimer – December 2.  CMS requires that all Critical Access Hospitals (CAHs) use either the 2014 or 2015 Edition certified electronic health record technology (CEHRT) to meet the Medicare Promoting Interoperability Program reporting requirements. CAHs that are not meaningful users of CEHRT may face Downward payment adjustments.  CAHs may avoid the Medicare downward payment adjustments by completing a hardship exception application by December 2.

Payment Updates for Home Health Agencies and Home Infusion Therapy Benefit. HRSA Exit Disclaimer CMS finalized the 2020 calendar year payment rates for home health agencies to implement the home infusion therapy benefit for calendar year 2021.  CMS modified regulations to allow therapist assistants to perform maintenance therapy in accordance with individual state practice requirements. They adopted a number of standardized patient assessment data elements (SPADEs) to assess cognitive function and mental status, medical conditions and comorbidities, and social determinants of health. Visit RHI Hub for more information on the importance of home health services in rural areasHRSA Exit Disclaimer

CMS Finalizes Payment Policies for CY2020 End-Stage Renal Disease (ESRD) and Durable Medical Equipment (DMEPOS). On October 31, CMS finalized payment policies and rates under the ESRD Prospective Payment System (PPS) and Quality Incentive Program (QIP) effective on or after January 1, 2020. CMS projects that updates to the CY 2020 ESRD PPS will result in a 1.8 percent increase in payments for rural ESRD facilities compared to CY 2019. CMS also established a method for pricing new Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items/services and streamlined requirements for ordering DMEPOS items.

CMS Finalizes Medicare Clinician Policy, Payment, and Quality Provisions for CY 2020. On November 1, CMS issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) effective on or after January 1, 2020. This includes three new telehealth codes to describe a bundled episode of care for treatment of opioid use disorders, The rule also updates Medicare’s Quality Payment Program. CMS included an interim final rule with comment period (IFC).Comments on that proposal are due no later than 5 pm on December 31, 2019.

Medicare Outpatient Payment Policies Finalized. On November 1, CMS finalized updates to the Medicare Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Care Center (ASC) Payment System for the 2020 calendar year. This rule updates payment rates, and finalizes completing the two-year phase-in of site neutral payment for clinic visits when provided at an off-campus provider-based department. This final rule also finalizes to pay Average Sale Price (ASP) minus 22.5 percent for 340B-acquired drugs for CY 2020. The reduction still exempts rural sole community hospitals and critical access hospitals. CMS plans to finalize these provisions on price transparency and requirements at a later date.  CMS is accepting comments on the APC payment classifications and/or new or replacement Level II HCPCS codes until 5 pm EST on December 2, 2019.

Date Last Reviewed:  January 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?