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 19

2018 Marketplace Stabilization Rule Finalized CMS finalized policy changes for the Health Insurance Marketplace 2018 benefit year to help lower premiums, stabilize the market place, and increase choices such as in rural areas with only one insurer.  Key changes that may impact rural providers, stakeholders, and State Offices of Rural Health include a shortened open enrollment period for the 2018 benefit year, increased variation in the actuarial values for plan levels, the Essential Community Provider standard lowered to 20%; and shifting network adequacy plan reviews to States.

April 12

Ideas Requested:  Medicare Advantage and Part D Plan – April 24.  CMS has finalized 2018 payment and policy updates for Medicare Advantage and Part D plans, including policies that encourage safeguards when prescribing opioids.  CMS is also requesting public input on how these programs can be improved.  The request for information is an opportunity for rural providers, stakeholders, and consumers to offer ideas on benefit design, network composition flexibility, supporting doctor-patient relationships, and monitoring and measuring plans.  Provide feedback at and include “2017 Transformation Ideas” in the subject line.   

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.

CMS Pauses Anti-Fraud Home Health Demonstration. CMS previously announced a three-year demonstration testing a pre-claim review process for home health services in five states with high rates of improper payments (IL, FL, TX, MI, and MA). Beginning in Illinois, the demonstration aimed to review home health claims to make sure that services are medically necessary before providing payment. On March 31, CMS announced a delay of at least 30 days to the home health pre-claim review demonstration in Illinois. Moreover, CMS will not expand the demonstration to Florida on April 1 as planned. Home health agencies should submit claims as normal during this pause. Further announcements will be posted on the demonstration website.

Final Rule:  Uncompensated Care Costs for Disproportionate Share Hospitals (DSH).  In this final rule, CMS clarifies that the Medicaid hospital-specific DSH limit is based only on uncompensated care costs.  That is, only those costs remaining after accounting for Medicare and other third party payments by or on behalf of Medicaid-eligible individuals.  This rule applies to all hospitals receiving Medicaid DSH funds, including Medicare-dependent hospitals, rural facilities, critical access hospitals, sole community hospitals, and Indian Health Service (IHS) areas.

Final Rule: Broadband Funding for Rural Areas. On March 28, the Federal Communications Commission (FCC) released a final rule describing its new funding model for 4G LTE service in remote areas of the country. An abbreviated term for Fourth Generation Long Term Evolution, 4G LTE is the fastest available broadband connection speed for mobile phones and wireless devices. Rather than funding legacy subsidies, the FCC will distribute up to $4.53 billion over the next ten years to preserve existing 4G LTE service and aid deployment in remote rural areas where high costs have deterred private sector investment. The FCC will soon list areas eligible for funding.   See Events section below for an upcoming webinar on broadband planning and funding.

April 5

AHRQ Telehealth Information Request – April 24. The Agency for Healthcare Research and Quality (AHRQ) is seeking information from the public to identify studies that report on Telehealth for Acute and Chronic Care Consultations, including those that describe adverse events. AHRQ is requesting this information as part of its systematic review under Evidence-based Practice Centers (EPC) Program. This is an opportunity for rural telehealth providers to submit data, which can support FORHP’s shared goal with AHRQ in enhancing the evidence base for telehealth activities.

March 29

AHRQ Telehealth Information Request - April 23. The Agency for Healthcare Research and Quality (AHRQ) is seeking information from the public to identify studies that report on Telehealth for Acute and Chronic Care Consultations, including those that describe adverse events. AHRQ is requesting this information as part of its systematic review under Evidence-based Practice Centers (EPC) Program.

March 22, 2017

HHS highlights opportunities for state flexibilities. The U.S. Department of Health & Human Services highlighted opportunities for states to foster health care innovation through two letters to governors last week.  The first letter encourages states to consider applying for Section 1332 of the Affordable Care Act (ACA) waivers to pursue strategies for providing residents with access to high quality, affordable individual and small group health insurance, including high-risk pool/state-operated reinsurance programs. The second letter affirms the federal and state partnership to support the Medicaid  program and outlines key areas where collaboration can be improved.   Rural stakeholders, including State Offices of Rural Health, will be interested in learning more about these opportunities in the event their state decides to pursue either of them. 

Comment:  New bundled payment programs delayed – April 19. The Centers for Medicare & Medicaid Services (CMS) has delayed the effective date of the Comprehensive Care for Joint Replacement (CJR) expansion and episode payment models (EPM) to improve cardiac care from March 21 to May 20. CMS also delayed the date when hospitals would be responsible for implementing these programs from July 1 to October 1. Most rural hospitals are unable to participate in the CJR or EPM models as the primary site of orthopedic surgery or heart attack care and bypass surgery, but are able to collaborate as post-acute care providers. CMS seeks public comments on the “appropriateness of this delay,” as well as its consideration to delay these implementation dates even further, perhaps until January 1, 2018.  

March 13, 2017

HIT Advisory Committee Nominations - April 14.  The Government Accountability Office (GAO) is accepting nominations of individuals for the Health Information Technology Advisory Committee. The Committee, established by the 21st Century Cures Act, provides recommendations to the National Coordinator for Health Information Technology on policies, standards, implementation of HIT, certification criteria, use of health information, and more. Letters of nomination and resumes should be submitted by April 14, 2017, and appointments will be made in July 2017.

March 8, 2017

Comment: Requirements for Home Health Beneficiaries – April 3. CMS has issued an emergency information collection request to enforce rules and standards designed to ensure home health agencies (HHAs) protect the health and safety of beneficiaries, such as providing a notice of rights to patients and assuring the proper training of home health aides prior hands-on care. State surveyors and MACs will use this information to ensure compliance with the Medicare conditions of participation and to ensure the quality of home health care. For rural-serving HHAs, which are often already struggling to meet federal requirements, CMS estimates its information collection will require roughly 473 hours of information collection per HHA per year, on average.

Episode Payment Models (EPMs) Delayed.  On February 17, CMS announced that the effective date of the Episode Payment Models has been delayed per the Executive Memorandum of January 20, 2017.  These models were to become effective on February 18, 2017, but the effective date is now March 21, 2017. The final rule, published in January, implements three new episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model, and changes to the existing Comprehensive Care for Joint Replacement model. Under the three new episode payment models, acute care hospitals in select geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-for-service beneficiaries, and care provided within 90 days of discharge (which may occur in rural areas) will be included in the episode of care.

Last Reviewed: April 2017

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