Flexibilities for Rural Health Centers, Federally Qualified Health Centers During COVID-19

The Centers for Medicare and Medicaid Services (CMS) recently released guidance to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) regarding additional flexibility afforded during the Coronavirus (COVID-19) pandemic national emergency.

Of note is the expanded opportunity under the Coronavirus Aid, Relief, and Economic Security (CARES) Act for RHCs and FQHCs to serve as distant site telehealth providers for Medicare beneficiaries. RHCs and FQHCs also can provide visiting nursing services at a Medicare patient’s home with fewer requirements. Like other Medicare providers, RHCs and FQHCs are also eligible for accelerated/advanced payments from Medicare. The Accelerated and Advance Payment Program provides immediate cash payments to eligible RHCs and FQHCs of amounts up to the amount of payments received from Medicare during the last quarter of 2019. For more information on the program, see our prior article “CMS Expands Accelerated and Advance Payment Program to All Medicare Providers, Suppliers.”

RHCs and FQHCs are an important part of the healthcare safety net, providing outpatient services in underserved areas. CMS released a fact sheet (see here and here) regarding flexibilities afforded to RHCs and FQHCs during the COVID-19 pandemic to help them continue to serve Medicare beneficiaries.

Staffing Requirements

CMS is temporarily waiving the requirement that a physician provide supervision of nurse practitioners (NPs) at the RHC and FQHC, but only to the extent that state law allows NPs to practice without supervision of a physician. The physician must still provide medical direction of the RHC and FQHC, as well as consultation for and supervision of other healthcare staff at the RHC and FQHC. Physicians can provide this direction, consultation and supervision via telehealth, so long as that is consistent with state supervision requirements for other healthcare staff.

For RHCs, CMS is also waiving the requirement that an NP, physician assistant (PA) or certified nurse midwife (CNM) be available to furnish patient care services at least 50% of the time the RHC operates. CMS has not, however, waived the requirement for RHCs and FQHCs to have practitioners (e.g., physician, NP, PA, CNM, or clinical social worker or psychologist) available to furnish patient care services at all times the RHC or FQHC operates.

Telehealth Services

Generally, healthcare services reimbursed by Medicare must be provided by the RHC and FQHC in a face-to-face encounter between the healthcare professional and the patient. Prior to the current crisis, RHCs and FQHCs could only provide telehealth services to the Medicare beneficiary as the “originating site” of the visit, and only if certain additional location criteria were met. “Originating site” is the site where the patient is located during the service. “Distant site” is where the practitioner is located during the time of the telehealth service.

During the period of the COVID-19 national emergency declaration, RHCs and FQHCs can serve as “distant site” telehealth providers. The otherwise applicable Medicare restrictions regarding geographic qualifications also have been temporarily removed during the national emergency, so that telehealth services can be furnished regardless of the Medicare patient’s location. For more information, see our prior article “Bipartisan Bill Relaxes Federal Telehealth Requirements in the Wake of COVID-19.”

The standard methods of Medicare payment—an all-inclusive rate for RHCs and a prospective payment system for FQHCs—will not be used for the RHC and FQHC distant site telehealth services. Instead, CMS will create a methodology to calculate a fee-for-service rate. While CMS has not yet issued specific guidance, the CARES Act provides that RHCs and FQHCs will be paid at rates similar to the national average payment rates for comparable telehealth services under the physician fee schedule.

In addition to allowing RHCs and FQHCs to serve as distant site telehealth providers, CMS has expanded the CPT codes eligible for payment under the coverage of “E-visits” with established patients that was implemented beginning in 2019.

This guidance does not extend to Medicaid payments, and coverage of telehealth services is within each state’s discretion. RHCs and FQHCs should review state-specific guidance to determine what is covered by Medicaid.

Home Nursing Visits

Previously, RHCs and FQHCs could only provide services to homebound Medicare patients when the RHC or FQHC was located in an area with a shortage of home health agencies (HHAs). CMS has removed this restriction during the national emergency declaration and temporarily declared that any area typically served by a RHC or included in an FQHC’s service plan has a shortage of HHAs. CMS has also revised the definition of “homebound” to include Medicare patients when (1) a physician has determined it is medically necessary for a patient to remain home because he/she has been diagnosed with COVID-19, or (2) a physician has determined that is it medically necessary for a patient to remain home because he/she has a condition that may make him more susceptible to contracting COVID-19. A physician’s certification in the patient’s medical record is essential; self-quarantine or social distancing alone is not sufficient to render a Medicare patient “homebound” for this purpose.

These changes permit significant flexibility for the expansion of home nursing visits by RHCs and FQHCs. RHCs and FQHCs should determine whether patients requesting visiting nursing services are already receiving services under a home health plan of care by an HHA. The expanded opportunities for RHC/FQHC visiting nurse services do not extend to coverage if the services overlap with a home health period of care already being provided to the patient by an HHA. CMS also clarified that a home visit that is conducted only to collect a nasal swab or throat culture for COVID-19 testing purposes is not sufficient to be considered a nursing service; however, the swab or throat culture can be combined with other services provided for the purpose of the nursing visit paid by Medicare.

Key Takeaways: For the period of the COVID-19 national emergency, CMS has afforded RHCs and FQHCs significant expansion in the type and scope of services they may provide to Medicare beneficiaries. During this time, RHCs and FQHCs can serve as distant site telehealth Medicare providers. CMS also has expanded the services eligible for coverage under the existing “E-visit” benefit for established patients of RHCs and FQHCs. RHCs and FQHCs are permitted more flexibility to provide visiting nursing services to Medicare beneficiaries, so long as the Medicare beneficiary is not also receiving services under a home health period of care from an HHA. RHCs and FQHCs should review applicable state guidance for coverage by Medicaid for both telehealth and home nursing services.

For more information:

The Health Resources & Services Administration also published a list of COVID-19 FAQs, which can be found here.