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

May 24

Call for Nominations: Mental Illness Coordinating Committee – June 2. The Substance Abuse and Mental Health Services Administration (SAMHSA) seeks non-Federal government nominations for individuals to serve on the Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC), which will report to the Secretary of HHS and Congress on advances in serious mental illness (SMI) and serious emotional disturbance (SED), research related to the prevention of, diagnosis of, intervention in, and treatment and recovery of SMI, SED, and advances in access to services and support for adults with SMI or children with SED.  HHS encourages geographic diversity on the committee, so rural providers, researchers, advocates, persons who have received mental health treatment, and parents/guardians of children with a history of SMI or SED could provide helpful input on issues before the committee.  A cover letter and a current curriculum vitae or resume should be e-mailed to by the due date.

Comments Requested: CAH Accreditation – June 18. Regulations require that The Joint Commission (TJC), a national organization accrediting Critical Access Hospitals (CAHs) for participation in the Medicare program, reapply for this function every six years.  The current term expires November 21, 2017. CMS seeks comments on TJC’s requirements for accreditation, survey and monitoring procedures, and ability to provide CMS with the necessary data for validation.

Rural Health Experts Wanted – July 3.  The Centers for Disease Control and Prevention (CDC) seeks new members for the Community Preventive Services Task Force (CPSTF), an independent, nonpartisan panel that identifies and recommends population health interventions scientifically proven to save lives, increase lifespans, and improve quality of life. CPSTF reports its recommendations in The Community Guide to help states, communities, and organizations select relevant, evidence-based interventions. In this round of nominations, CDC announces its strong consideration of nominees with expertise and experience in systematic review methods, economic analysis, substance abuse and violence prevention, aging, and rural health. 

May 17

Comments Requested: Updated Hospital Rates and Reducing Regulatory Burden – June 13.   CMS has proposed updates to the Medicare Hospital Inpatient Prospective Payment System (IPPS) and requests feedback from the public on efforts to reduce regulatory burden. This is an opportunity for rural stakeholders to provide CMS with a rural perspective on reducing regulatory burden and improving quality of care for rural patients.   Rural hospitals should note that two programs, the Medicare-Dependent Hospital (MDH) program and the Low-Volume Hospital (LVH) payment adjustment, will expire on October 1, 2017. CMS projects that the sunset of the MDH program, as required by MACRA, will reduce payments to current MDHs by $119 million. The proposed update would also establish an uncompensated care pool of $7 billion for Disproportionate Share Hospitals (DSH).  Changes to the distribution methodology are estimated to increase uncompensated care payments to rural hospitals by 31%.  For inpatient services at Critical Access Hospital (CAH) payable under Medicare Part A, the statute requires that a physician certify that an individual may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission.  This update proposes to de-emphasize review of the 96-hour requirement on or after October 1, 2017.  Medicare contractors including Quality Improvement Organizations (QIOs), Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractor (SMRC), and Recovery Audit Contractors (RACs) would not review medical records unless there are concerns of probable fraud, waste or abuse of the coverage requirement.  

Comments Requested:  Long-Term Care Hospital Payments – June 13.  Along with the IPPS update, CMS has proposed updates to the Long-Term Acute Care Hospital (LTCH) Prospective Payment System (PPS) and the related LTCH Quality Reporting Program (LTCH QRP).  Nationwide, most inpatients are treated in acute care hospitals, but some are admitted to LTCHs. This proposal would update the LTCH PPS payment rate by 1%, consistent with the provisions of MACRA.  The overall impact on rural LTCHs would be a reduction of 0.7%.  Proposed changes to the FY 2020 LTCH QRP would add measures assessing pressure ulcer changes, compliance with a spontaneous breathing trial, and ventilator liberation rates.  

Comments Requested: Interoperability Standards – July 31. Rural providers with experience using electronic health records can provide feedback to the Office of the National Coordinator for Health Information Technology (ONC) on a proposed framework for measuring and assessing healthcare interoperability standards. This framework would help health IT developers, health information exchange (HIE) organizations, and health care providers move towards a set of uniform measures to assess interoperability progress. 

Participating in MIPS? CMS has released an interactive tool on the CMS Quality Payment Program website for clinicians to determine if they should participate in the Merit-based Incentive Payment System for 2017.  Rural clinicians that bill Medicare Part B more than $30,000 a year AND see more than 100 Medicare patients a year qualify for participation in 2017.  To learn more about participation criteria, review the MIPS Participation Fact Sheet or email questions to

Criteria for Home and Community-Based SettingsCMS released an informational bulletin that extends the transition period for states to demonstrate compliance with the home and community-based settings criteria until March 17, 2022 for settings that were operating before March 17, 2014.  States should continue progress in assessing existing operations and identifying milestones for compliance that result in final Statewide Transition Plan approval by March 17, 2019. Rural providers, State Offices of Rural Health, and other key stakeholders are encouraged to continue to work with states to ensure HCBS compliance activities are collaborative, transparent, and timely.

May 10

Comments Requested: Hospice Payment Rates and Policy – June 26. CMS has issued a proposed rule to update 2018 Medicare payment and polices. The proposal includes a 1.0% or $180 million increase in payments (rural areas would experience an average 1.1% increase compared to FY 2017); outlines requirements for the Hospice Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey; and solicits comments on a clarifying change to regulation for certifying a life expectancy of six months or less.  A fact sheet regarding this proposed rule is available on the CMS website for more information.

Comments Requested: Skilled Nursing Facility (SNF) Payment Rates - June 26. CMS has issued a proposed rule to update 2018 Medicare payment rates and polices for skilled nursing facilities (SNFs). Changes include a payment rate increase of 1.0% ($390 million), proposals for the SNF Value-Based Purchasing Program, revisions to the SNF Quality Reporting Program, and clarification of the regulatory requirements for team composition for complaint investigation surveys. The proposed rule also includes a Request for Information to encourage continued feedback on improvements to the Medicare program including ideas for regulatory, sub-regulatory, policy, practice and procedural changes. A fact sheet is available on the CMS website for more information.

Comments Requested: Inpatient Rehabilitation Facility (IRF) payment rates –June 27. CMS has issued a proposed rule to update 2018 Medicare payment and polices for IRFs. Changes include an overall update of 1.0% (or $80 million), removal of the voluntary swallowing status item (Item 27) from the IRF-PAI, removal of the 25 percent payment penalty for late transmissions of the IRF-patient assessment instrument (IRF-PAI), changes to the IRF Quality Reporting Program (QRP), and changes to the 60 percent rule presumptive methodology. The proposed rule also includes a specific request for comments on the 60 percent rule regarding the criteria used to classify facilities for payment under the IRF PPS and announces that FY 2018 is the third and final year of the phase-out of the 14.9 percent rural adjustment for the 20 IRF providers that were designated as rural in FY 2015 and changed to urban under the new Office of Management and Budget (OMB) delineations in FY 2016: therefore CMS will no longer apply a rural adjustment for these IRFs. Additionally, the proposed rule includes a Request for Information to encourage continued feedback on improvements to the Medicare program including ideas for regulatory, sub-regulatory, policy, practice and procedural changes. A fact sheet is available on the CMS website for more information. 

May 2

Comment requested: universal education for opioid prescribers – July 10. The Food and Drug Administration (FDA) announced a public workshop to obtain input on issues and challenges associated with Federal efforts to support training for health care providers on pain management and the safe prescribing, dispensing, and patient use of opioids. The Centers for Disease Control and Prevention has reported that rural areas are affected by higher rates of opioid misuse and overdose.  FDA will host the workshop May 9-10 at the Sheraton Hotel in Silver Spring, Md. Participants must register online before May 1. FDA welcomes public comment and suggestions on promising approaches in prescriber education and training programs. 

April 12

Comment: Delayed Rules For Home Health Agencies– June 2. CMS finalized new rules for home health agencies (HHAs) participating in Medicare and Medicaid to incorporate recent advances and practices that focus on patient-centered, data-driven, and outcome-oriented care. In the first update to home health rules since 1989, CMS revised its policy to allow licensed practical nurses acting within their state licensure and scope-of-practice requirements to receive verbal orders for home health services, which may benefit HHAs in rural areas disproportionately affected by physician shortages. On April 3, CMS delayed the effective date of these new rules from July 13, 2017 to January 13, 2018.

Last Reviewed: May 2017

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