CMS issues final rule on access

CMS just released a final rule for the Methods for Assuring Access to Covered Medicaid Services, finalizing a proposed rule issued in 2011.

The final rule require state Medicaid agencies collect data to demonstrate access to care by examining enrollee needs, the availability of care and providers, and the utilization of services. Beneficiary experiences are to be a primary determinant of whether access is sufficient. While the rule includes guidelines for this review, it demurred on the issue of a core set of measures, indicating no measures received a consensus and were universally applicable. Rate reductions must be supported by a data review and public process, or may be rejected by CMS.

The final rule clearly indicated that the Supreme Court’s decision in Armstrong v. Exceptional Child Center, Inc., (2015), which found that Medicaid statute does not provide a private right of action in federal court to providers to challenge whether a state’s Medicaid program is designed to ensure sufficient provider participation to ensure access to care for beneficiaries, was not anticipated in the original 2011 proposed rule. This ruling indicated CMS is ultimately responsible for enforcing the statutory requirement that state’s Medicaid programs must be structured to ensure sufficient participation by providers to provide access to care for beneficiaries.

CMS made it clear more is to come on this topic, as they are concurrently issuing a request for information (RFI) soliciting feedback on core access measures, thresholds, and appeals processes to ensure access to care for Medicaid beneficiaries.

NRHA is pleased CMS is working to ensure Medicaid programs are structured to ensure access for the vulnerable rural Americans who rely on Medicaid for access to health care and will continue to review the final rule and the RFI to help ensure the rule will improve access to care for Medicaid beneficiaries in rural America.

Get to know NRHA’s 2016 candidates

Two members are vying to be NRHA’s president-elect and two more for NRHA’s Board of Trustees secretary position.

Multiple others are nominated for Board of Trustees and Rural Health Congress positions.

Please review each officer candidate’s nomination submission below in advance of the voting period beginning Nov. 3 for NRHA members.

The president-elect will serve in that role in 2016 and as president in 2017.

Tommy Barnhart for president-electBarnhart 200
“In my 40-plus year health care career I have seen tremendous change but none as dramatic or all-encompassing as we are now experiencing or about to undergo. In my consulting experience, I have been extensively involved with rural providers of all types and would leverage that experience in my NRHA presidency. NRHA is the strongest voice for rural health and needs strong leadership during these changing times.

“NRHA must continue to advocate for sustainable payment systems while new systems are developed, tested and implemented while advocating for sustainable rural workforce and delivery programs.

“The rural delivery system was developed by complex regulatory and payment “silo” provisions that inhibit the development of new high quality patient-centered systems of care that are more cost effective. Through a thoughtful approach we can develop new systems of care and payment.

“I can provide leadership necessary to guide NRHA into the future.”

Dave Schmitz, MD, for president-electSchmitz 200  
“I ask for your vote for NRHA’s president-elect. The Save Rural Hospitals Act is but one example of what we are doing together through NRHA, making a difference for rural health care today and for the future.

“I ask for your vote to allow me to continue serving NRHA by leading our rural health mission at a time of unprecedented importance. NRHA is the one place where our collective experience and expertise can benefit those we are serving.

“Together at NRHA our voice is louder and smarter. As a constituency group chair, leading NRHA issues groups, in policy writing and through our NRHA projects, I am constantly inspired by our organization and our members.

Spanning my time from being an NRHA Rural Health Fellow to being humbled by the 2014 NRHA Volunteer of the Year Award, I have continued to channel my energies and experience toward this next step in NRHA leadership. Thank you for your support.”

Don Kelso for secretaryKelso200
“I am asking for your support by voting for me to be the secretary of the NRHA Board of Trustees.

“I have been blessed to be the executive director of the Indiana Rural Health Association for the past eight years. We have grown our association substantially during that time and continue to find creative and proactive ways to serve the rural population and health care providers in rural Indiana.

“Before this opportunity I worked in administration at two Indiana rural hospitals for 17 years. We have modeled IRHA after NRHA in many ways, and I have personally attended each NRHA Annual Conference and Policy Institute since 2008. I have also had the pleasure of serving on the NRHA Services Corporation board for the past four years.

“I would appreciate your vote to expand my involvement with NRHA.”

Pat Schou for secretarySchou 200
“Rural health has been my passion for many years.  I live and work in a rural community and see firsthand the value and importance of the rural health care system not only for care but for maintaining the local economy.

“I very concerned the impact of today’s changing health care landscape and our struggling economy will have on the long-term viability of rural communities and preserving their access to local care. I believe one of the most significant strategies is for rural to work together to tell our story and speak as a loud voice. NRHA provides that opportunity for rural providers and leaders nationally to advocate as a group and offer ideas and solutions as well as raise tough issues and address disparities.

“I have served on NRHA committees and the Rural Health Congress for several years and have seen the commitment of members to keep rural strong. It would be an honor and privilege to serve as secretary and represent NRHA and its many constituents in our joint effort to help ensure rural health has a better tomorrow.”

Rep. Ryan selected as nominee for Speaker

Rep. Paul Ryan (R-WI) was selected as the nominee for Speaker of the House today by the House Republicans. Rep. Ryan defeated Rep. Daniel Webster (R-FL) during a closed-door election of the House Republican Conference.

Rep. Ryan is expected to be ratified by the full House Thursday. He will replace John Boehner  (R-OH) who will be stepping down later this week.

NRHA disappointed in tentative budget deal

Late Monday night, Congressional leaders and the White House reached a tentative budget deal that would raise the debt limit, avoid a shutdown in December, and would set spending levels through September 2017.

The National Rural Health Association is disappointed that the Bipartisan Budget Act of 2015 includes site-neutral payment cuts on hospital outpatient departments (HOPDs) and the extension of sequestration for Medicare payments. Rural hospitals play a critical role in providing 24/7 access to care and are the safety net providers for rural America.

The extension of the 2 percent cut in Medicare payments, which was first passed under the sequester, comes during a time when rural hospitals are already closing because of drastic cuts.

“Rural hospitals are closing at a record rate,” says Maggie Elehwany, NRHA’s vice president of government affairs. “We have seen 57 rural hospitals close since 2010, and another 283 rural hospitals are on the brink. Since the start of 2013, more rural hospitals have closed than in the previous 10 years combined, and rural communities across the nation are feeling the crisis in tragic ways. Our rural hospitals cannot shoulder any more cuts.”

The deal would provide $50 billion in fiscal year 2016 and $30 billion in fiscal year 2017 in sequester relief for both defense and non-defense spending, but hospitals would be left out in the cold.  Raising spending now in return for cuts further down the road has serious consequences for hospitals and providers that depend on Medicare reimbursements to keep their doors open to serve the older, poorer and sicker rural population.

NRHA will continue to advocate for strong funding for the rural health care safety net. Members of Congress must hear from you in support of critical rural health programs and to protect access points that will be impacted by this deal. Continue to follow NRHA’s blog for the latest news from Capitol Hill.

Join the fight to protect health care in your community. Contact your members of Congress today and let them know how important your facility is to your community. And plan now to meet with the Obama administration, your congressional members and national experts at NRHA’s 27th annual Rural Health Policy Institute Feb. 2-4 in D.C. Rural America is counting on you. Register today and save $100.

Help make 340B work for rural

The Health Resources and Services Administration (HRSA) recently released a proposed guidance about the 340B program, the long-anticipated so-called “mega guidance.” It’s comprehensive and discusses virtually all aspects of the 340B program. It includes restatements, clarifications, and proposed changes to current 340B policy.

The “mega guidance” is only a proposal at this point, meaning HRSA is asking for your input about its enforcement policy. This is your opportunity to make your voice heard about what is and is not working in the current system and on your perception of the proposed changes.

While not every change impacts rural, it’s important that there are many voices from rural America commenting to HRSA about the importance of 340B in rural America and the barriers and burdens to rural covered entities participating and receiving the greatest benefit.

The guidance covers eight broad areas: covered entity eligibility, covered outpatient drug definition/eligibility, patient definition/eligibility, covered entity responsibility, contract pharmacy, manufacturer responsibility, rebate option for AIDS Drug Assistance Program, and program integrity. A brief overview of some changes and areas of concerns are outlined below.

For patient definition/eligibility, HRSA is proposing a change from a three-prong, to a six-prong test.

  1. Individual receives service at covered entity site
  1. from a provider employed  or contractor (such that  the covered entity may bill for services on behalf of the provider). This is particularly concerning to the many provides that have a contracted physician that the hospital does not bill.
  2. individual receives a drug ordered by the covered entity provider as a result of the service described in the second prong. This would exclude patients who are only receiving drugs or infusions from the covered entity, a major concern for rural providers that provide infusion services for patients that see a specialist that prescribed the infusions.
  3. health care service consistent with scope of grant, project, or contract. For covered entities eligible due to a grant this could present some line drawing questions. For example, if a provider under a grant for family planning services prescribes a birth control pill, it’s unclear whether they could also use 340B for the blood pressure medication prescribed since the patient’s high blood pressure is counter-indicated for use of the birth control.
  4. The individual is classified as an outpatient when the drug is ordered. This language seems to disallow the use of 340B for discharge prescriptions, even though they are for use as an outpatient, since the drug was ordered while the patient was an inpatient.
  5. covered entity maintains access to auditable health care records, which demonstrate a provider-to-patient relationship, must be met for each 340B drug.

Covered outpatient drug definition/eligibility is in many ways the same with one main concern: that 340B drugs can not be used for Medicaid-bundled payments. It is unclear what the impacts of this change will be for bundled arrangements outside of Medicaid, a major concern given the move toward bundled arrangement in health care.


Covered entity responsibility places a new responsibility on covered entities to avoid duplication of discounts, especially for Medicaid managed care.

Although there was a lot of talk about contract pharmacies prior to the release of the guidance, the proposed guidance leave the use of contract pharmacies largely intact. However, HRSA proposed additional oversight in the form of a quarterly review with disclosure of all non-compliance (not just material breaches).

For covered entity eligibility the proposed guidance largely restates current policy. However, the self disclosure of any 340B violations is now required for all violations and not just “material breaches.”  It’s unclear why HRSA has made this change, but it seems that it will create a great deal of paperwork without a clear benefit. HRSA is seeking an alternative to requiring a child site be listed on the Medicare cost report before being 340B eligible (the current policy). This is important for covered entities opening new child sites and could potentially allow them to begin using 340B drugs at new locations much faster.

If you have questions or would like help preparing comments, please email Diane Calmus. NRHA is happy to help you draft comments and would like to include your information in our letter as well. Comments are due Oct. 27 and can be submitted online at

CMS finalizes Meaningful Use stage 3 and flexibility for 2015

CMS released the Stage 3 Meaningful Use (MU) final rule and finalized a 90-day reporting period for 2015 while adding other flexibility on Tuesday.

NRHA has continued to engage with CMS throughout the implementation of its MU stages, urging attention to rural-specific considerations. While we are pleased with the addition of flexibility for the 2015 reporting period, this should have been announced well in advance and should provide similar flexibilities moving forward into Stage 3.

Looking toward the future of electronic health records, CMS indicated in the rule that MU Stage 3 would likely be incorporated into the new Merit-Based Incentive Payment System (MIPS) included as a part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that was passed in April to replace the Sustainable Growth Rate (SGR). Currently, CMS has an open request for information about the MIPS program.

Help NRHA ensure rural is considered as CMS implements new Medicare programs

CMS recently released a request for information (RFI) regarding the implementation of the Merit-based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models. Essentially, CMS is working on implementing the last of the “doc fixes” that Congress passed in April to repeal the Sustainable Growth Rate (SGR).

NRHA needs your help to make sure rural is considered and that the new replacement program works for rural.

The RFI is essentially a brief explanation of the program CMS is required to implement, followed by a long list of questions about how it should be implemented. Your response can be answers to these questions or anything else you think CMS should know or consider when they are implementing these programs.

There are three major areas discussed:

  1. Merit-based Incentive Payment System (MIPS) –  This program must include measures for quality, resource use, clinical practice improvement activities and meaningful use of certified electronic health records. The program is intended to be a streamlined combination of the three existing physician quality programs, with the addition of a measure of clinical practice improvement activities.
  2. Alternative Payment Models (APMs) and Physician Focused Payment Models (PFPMs) – There are 5 percent bonuses for providers receiving a significant portion of their revenues from an APM or PFPM (not to mention Secretary Burwell has set Medicare goals of increasing participation in APMs to 30 percent in 2016 and 50 percent by 2018).
  3. Technical assistance to small practices with preference to this in health professional shortage areas and rural areas

It is essential that we ensure the specific needs of rural providers and patients are considered in all three of these. For rural to be well-represented, CMS must hear from not only NRHA but from all of you.

Email Diane Calmus if you’d like assistance on your response and send your responses to her so they can be included in an NRHA letter.

Comments are due Nov. 2 and can be submitted electronically at

White House names Rural IMPACT demonstration sites

The White House today announced the 10 sites participating in the Rural IMPACT demonstration, an initiative to help address rural child poverty. More than six million rural Americans live in poverty, including about 1.5 million children.

The 10 rural and tribal communities participating in the demonstration are:

  • Berea (KY), Partners for Education at Berea College (Serving Knox County, KY)
  • Blanding (UT), The San Juan Foundation (Serving San Juan County, UT)
  • Blytheville (AR), Mississippi County, Arkansas Economic Opportunity Commission, Inc. (Serving Mississippi County, AR)
  • Hillsboro (OH), Highland County Community Action Organization, Inc. (Serving Highland County, OH)
  • Hugo (OK), Little Dixie Community Action Agency, Inc. (Serving Choctaw, McCurtain and Pushmataha Counties)
  • Jackson (MS), Friends of Children of Mississippi, Inc. (Serving Issaquena, Sharkey and Humphreys Counties, MS)
  • Machias (ME), Community Caring Collaborative (Serving Washington County, ME)
  • Marshalltown (IA), Mid‐Iowa Community Action, Inc. (Serving Marshalltown, IA)
  • Oakland (MD), Garrett County Community Action Committee and the Allegany Human Resources Commission (Serving Garrett and Allegany Counties, MD)
  • White Earth (MN), White Earth Reservation Tribal Council (Serving Mahnomen County and portions of Clearwater and Becker Counties)