November 2016

November 2016

The Federal Office of Rural Health Policy's (FORHP’s) Policy Team is ready to answer any questions you may have about these updates at

Request for Information (RFI): Home and Community-Based Services

On November 9, 2016, the Centers for Medicare and Medicaid Services (CMS) issued a request for information (RFI) seeking public input on additional reforms and policy options the Agency can consider to accelerate access to home and community-based services (HCBS) by Medicaid beneficiaries. The provision of HCBS is critical to support individuals remaining in their communities, but there are stressors on the delivery of care in the form of home care worker recruitment and retention, program integrity challenges, state fiscal constraints and varying quality measurement and improvement strategies.  

What do rural stakeholders need to know?

The provision of HCBS services in rural areas entails a number of distinct challenges not seen in urban areas, including different workforce issues, so the RFI explicitly requests comments on how to best ensure access to HCBS services for Medicaid beneficiaries living in rural areas. In addition, it solicits input on the following general topic areas:

  • What actions can CMS take, independently or in partnership with states and stakeholders, to ensure quality of HCBS including beneficiary health and safety?
  • What program integrity safeguards should states have in place to ensure beneficiary safety and reduce fraud, waste and abuse in HCBS?
  • What are specific steps CMS could take to strengthen the HCBS home care workforce, including establishing requirements, standards or procedures to ensure rates paid to home care providers are sufficient to attract enough providers to meet service needs of beneficiaries and that wages supported by those rates are sufficient to attract enough qualified home care workers

CMS encourages respondents to address the questions outlined in the RFI, but a response to every question is not required. Rural policymakers and stakeholders should consider providing suggestions on ways to improve HCBS in rural areas, including actions/activities that CMS or the state may take to improve the home care workforce in rural areas. For more information on HCBS, visit Comments are due by January 9, 2017.

Calendar 2017 Home Health Prospective Payment System Update

On November 3, 2016, CMS published a final rule updating policy and payment rates for home health agencies (HHAs) for 2017. The final rule revises the quality measures, reporting requirements and scoring methodology for the home health value-based purchasing (HHVBP) demonstration, which began January 1, 2016, for all Medicare-certified HHAs in MA, MD, NC, FL, WA, AZ, IA, NE and TN. This rule also updates the home health quality reporting program (HH QRP), including the addition of four new measures required by the IMPACT Act and provides for a new version of the home health patient assessment instrument to be implemented January 1, 2017: OASIS-C2.

Of note for rural HHAs: 

  • The rule implements the final year of the extension of the 3% rural payment boost, which will expire January 1, 2018, unless extended by Congress.
    • CMS cites the 3% rural add-on as potentially covering the additional travel-related expenses for rural-serving HHAs. However, CMS does not currently track transportation or other administrative costs for each visit or episode.
  • In total, payment changes for 2017 reduce net payment to all HHAs by 0.7%, or $130 million, compared to 2016, with approximately 9,209 urban HHAs (-0.7%) losing more than approximately 1,952 rural HHAs (-0.4%).
  • Given their smaller volumes, rural HHAs may be more likely than urban HHAs to yield an insufficient number of measures to calculate a HHVBP total performance score. As such, rural HHAs may be disproportionately exempted from the HHVBP payment adjustment.
  • The HHVBP also combines the smaller- and larger-volume cohorts for five participating states (MA, MD, NC, TN, and WA) where the smaller-volume cohort has fewer than eight HHAs, for the CY 2018 payment adjustment only. As such, smaller-volume HHAs that are likely rural-serving may be subject to VBP achievement thresholds and benchmarks that are not representative of their performance or the performance of their peer agencies.
  • Three of the new measures required by the IMPACT Act include minimum thresholds for reporting and inclusion in the HH QRP that could exclude rural HHAs with smaller volumes from reporting on such measures: Medicare Spending Per Beneficiary-Post-Acute Care (MSPB-PAC) HH QRP (20 episodes), discharge to community (20 eligible episodes) and potentially preventable 30-day post-discharge readmissions (20 eligible episodes).

These regulations are effective on January 1, 2017. For more information, see the fact sheet.

Final Rule for Health IT Certification Program

On October 19, 2016, the Office of the National Coordinator for Health IT published the final rule for the ONC Health IT Certification Program, which gives the agency more direct oversight of the health IT testing labs. The rule highlights the importance of protecting public health and safety while also strengthening transparency and accountability in the certification program. It will also enable the ONC Health IT Certification Program to better support physicians and hospitals – the vast majority of whom use electronic health records – and the rapid pace of innovation in the health information technology market, according to ONC

Rural providers are encouraged to review the final rule with their EHR vendors in order to ensure compliance of the changes to the ONC Health IT Certification Program. The final rule became effective on December 19, 2016. 

Calendar Year 2017 Physician Fee Schedule 

On November 2, 2016, CMS displayed the final rule that revises payment policies under the Medicare Physician Fee Schedule (PFS) and makes other policy changes related to Medicare Part B payment.  

Of note for rural providers, this rule:

  • Revises provisions for chronic care management and transitional care management services in rural health clinics (RHCs) and federally qualified health centers (FQHCs) by changing supervision requirements from direct to general for auxiliary staff (e.g. nurse, medical assistant, or other clinical staff)  
  • Adds advance care planning and end-stage renal disease (ESRD)-related services for dialysis to the list of telehealth services
  • Adds a new telehealth place of service (POS) code for distant site practitioner claims
  • Allows separate payment for behavioral health integration provided by a primary care team (primary care doctor and behavioral health specialist) 
  • Implements a new Medicare Diabetes Prevention Program (MDPP) with payment starting in 2018

For the MDPP, CMS also clarifies that this service is not a RHC and FQHC service. However, RHCs and FQHCs can furnish MDPP services at their facilities as long as such costs are excluded from its cost report. This rule is effective is on January 1, 2017. For more information, please see the fact sheet.

Calendar Year 2017 Medicare Hospital Outpatient Payment Rule 

On November 1, 2016, CMS displayed the final rule with comment period for the Medicare hospital outpatient prospective payment system (OPPS).  

Of note for rural providers, this rule:

  • Continues the adjustment of 7.1% to the OPPS payments to certain rural sole community hospitals (SCHs), including essential access community hospitals (EACHs)  
  • Implements section 603 of the Bipartisan Budget Act of 2015, which provides that certain items and services provided by certain hospital off-campus provider-based departments (PBDs) no longer be paid under the OPPS beginning January 1, 2017  
    • Critical access hospitals (CAHs) are exempted; however, all other rural hospitals may be subjected to policy changes
    • Payment will be based on the Medicare Physician Fee Schedule (MPFS) for the majority of the items and services furnished by off-campus PBDs that are not exempted from this policy change
    • Physicians furnishing services in these departments would be paid based on the professional claim and would be paid at the facility rate for services which they are permitted to bill  
  • Finalizes a 90-day electronic health record (EHR) reporting period in 2016 and 2017 for the EHR Incentive Program for all returning eligible professionals, eligible hospitals and CAHs that have previously demonstrated meaningful use in the Medicare and Medicaid EHR Incentive Programs
  • Removes the pain management dimension from the Hospital Value-Based Purchasing program to eliminate any potential financial pressure clinicians may feel to overprescribe pain medications

This rule is effective January 1, 2017 and comments due by December 31, 2016.  For more information, please see the fact sheet.

Final Rule for Family Violence Prevention and Services Programs

On November 2, 2016, the Administration for Children and Families (ACF) published a final rule to enhance access to services and programs for survivors of family violence, domestic violence, and dating violence as authorized by the Family Violence Prevention and Services Act (FVPSA). FVPSA is the primary Federal funding source dedicated to the support of emergency shelter and related assistance for victims of domestic violence and their children.

Of note for rural communities this rule: 

  • Allows states and tribes to use their own definition of “urban” and “rural” in their service plans, as long as the definition achieves an equitable distribution of funds within the state and between urban and rural areas 
  • Authorizes new grant programs, including (1) specialized services for abused parents and their children and (2) resource centers to reduce disparities in domestic violence in states with large American Indian populations
  • Provides guidance for state and tribal domestic violence needs assessments to promote greater inclusion of underserved communities, including populations who face barriers in accessing services because of geographic location, religion, sexual orientation, gender identity, underserved racial and ethnic populations, language barriers, disabilities, immigration status, age, criminal history due to victimization and individuals with substance use disorders and mental health issues
  • Prohibits shelters from requiring violence survivors to meet certain conditions before receiving services, such as criminal background checks, sobriety, or participation in counseling, parenting classes, or other services

Changes in this rule are effective January 3, 2017.

Final Rule on Independent Living Services

On October 27, 2016, the Administration for Community Living (ACL) published a final rule amending its independent living services (ILS) programs, which facilitate the transition of persons with disabilities from nursing homes and other institutions to home and community-based settings, including resident-directed centers for independent living (CIL) programs

Of note for rural communities, this rule: 

  • Finalizes the definition of “unserved and underserved populations,” which specifically cites rural residents and other “individuals from underserved geographic areas” 
  • Authorizes ILS programs to spend federal dollars providing outreach to unserved and underserved populations and allows funding for new CILs programs that plan to serve these populations in priority areas identified by state plans for independent living

This rule also includes the following key provisions: 

  • Adds new independent living “core services,” per the Workforce Innovation and Opportunity Act (WIOA), which specify that all CILs must
    • Facilitate the transition of individuals with significant disabilities from nursing homes and other institutions to home and community-based settings, including the provision of consumer-controlled supports and services and the advocacy needed to move from an institutional setting to community-based setting;
    • Provide assistance, services and supports to individuals with significant disabilities who self-identify as being at risk of entering institutions so that the individuals may remain in the community; and
    • Facilitate the transition of youth with significant disabilities who are no longer in school and no longer receiving services under §614(d) of the Individuals with Disabilities Education Act (IDEA).  
  • Expands the role of state independent living councils (SILCs) and CILs in developing state plans for independent living, including resource development to support CILs (e.g., annual fund drives, grant applications).

This final rule is effective November 28, 2017; however, ACL will continue to accept feedback at For more information, please see the ACL press release on this rule.

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.