Mariposa, California
Sierra Sun Times file photo

November 3, 2023 - The Biden-Harris Administration is taking actions to improve the health of rural communities and help rural health care providers stay open. These actions:

• Build on the Affordable Care Act and Inflation Reduction Act to increase access to affordable health coverage and care for those living in rural communities
• Keep more rural hospitals open in the long run to provide critical services in their communities
• Bolster the rural health workforce, including for primary care and behavioral health providers
• Support access to needed care such as behavioral health and through telehealth services.

The Biden-Harris Administration is lowering health care costs for rural Americans and supporting access to high quality care in rural America. Over sixty million people live in rural America. Compared to their urban counterparts, rural Americans are more likely to live in poverty, be older, be uninsured, have disabilities - PDF , and have fewer health care providers available within their area. The Affordable Care Act (ACA) has helped to reduce the rates - PDF  of uninsured rural individuals - PDF  nationally, with the rate of uninsured rural individuals falling from 19% in 2012 to 13% in 2019; the rate of uninsured individuals living in rural areas in non-Medicaid expansion states, however, has fallen at a slower rate than those living in Medicaid expansion states, from 38% to 32% over the same timeframe. Over 150 rural hospitals have either closed their doors entirely  or stopped providing inpatient hospital services since 2010, and being in a Medicaid expansion state decreased the likelihood of a rural hospital closing by more than half. Rural communities often have fewer local health care providers available, with over 50% of rural counties having no access to hospital-based maternity care and 70% lacking even a single psychiatrist - PDF , often requiring patients to travel long distances to access care.

The Department of Health and Human Services (HHS) is helping to ensure people in rural America have access to high quality health care.

INCREASING HEALTH COVERAGE FOR RURAL AMERICANS. Rural communities rely on the Marketplace, Medicaid, and Medicare; 1 in 3 rural adults are enrolled in Medicare, 1 in 6 are enrolled in state Medicaid programs, and 1 in 10 are covered by Marketplace coverage - PDF. This is particularly true for children – 47% of children living in small towns and rural areas are enrolled in Medicaid , compared to 40% of children in urban areas. Medicaid expansion has played a key role in expanding health coverage in rural communities. In 2019, rural uninsured rates were nearly twice as high - PDF in non-expansion states as expansion states. These actions will help improve access to health coverage that greatly benefit rural communities.

• More outreach to rural Americans on ACA Marketplace enrollment. HHS, through the Centers for Medicare & Medicaid Services (CMS), will launch a $5 million pilot to conduct rural-focused outreach and health insurance enrollment activities during this year’s Open Enrollment. These resources will be used for activities such as conducting mobile and virtual outreach in rural communities and offering in-person appointments in more rural areas, which will help to reduce the barriers faced by individuals who would otherwise have to travel long distances to receive enrollment assistance. This is in addition to the $98.6 million in Navigator funding available for plan year 2024 to help consumers understand new coverage options and find the most affordable coverage that meets their health care needs in Federally-facilitated or State Partnership Marketplaces.
• Increasing access to the Low-Income Subsidy under the Medicare Part D prescription drug program. With a disproportionate number of seniors living in rural America, rural Americans stand to benefit from the Inflation Reduction Act’s policies to lower prescription drug costs in Medicare. Thanks to the new law, starting on January 1, 2024, more people with Medicare will qualify for full benefits under the Part D Low-Income Subsidy program – also known as Extra Help – and benefit from no premiums, no deductible, and fixed lower copayments for certain prescription drugs under Medicare Part D. Up to 3 million people with Medicare are eligible for the subsidy but not enrolled in the program. HHS will conduct specific outreach to reach these individuals, including those living in rural areas, through local media and direct mail, so that they can enroll in the program to access more affordable prescription drug coverage, if eligible. Additionally, CMS finalized historic administrative changes to the Medicare Savings Program to make Medicare coverage more affordable for an estimated 860,000 people – including those living in rural America. These changes will simplify many government processes so people already receiving Supplemental Security Income (SSI) benefits will automatically be enrolled to receive assistance with their Medicare premiums and cost sharing, if eligible.
• Closing the Medicaid Coverage gap. Since the enactment of the Affordable Care Act, the rate of uninsured, low-income rural individuals in Medicaid expansion states fell by more than 50% (from 35% to 16%). However, the rate of uninsured low-income rural Americans living in non-expansion states declined by only 6 percentage points (from 38% to 32%) during that same timeframe. A state expanding Medicaid also decreases the likelihood of a rural hospital closing by more than half. Four states have expanded Medicaid since President Biden took office, including North Carolina where expansion takes effect on December 1.  In addition, the President’s FY 2024 budget proposed - PDF Medicaid-like coverage to individuals in states that have not adopted Medicaid expansion under the ACA, paired with financial incentives to ensure states with existing expansions maintain them, so more individuals in rural areas can have better coverage opportunities and access to services.

KEEPING MORE RURAL HOSPITALS OPEN SO THEY CAN PROVIDE CRITICAL SERVICES IN THEIR COMMUNITIES. The Administration has made billions of dollars available to rural communities, including funding to small rural hospitals and Medicare-certified Rural Health Clinics in response to the COVID-19 pandemic, and to improve access to care. With the concerning trend of rural hospital closures, the Biden-Harris Administration is taking action to give rural hospitals support and flexibility to stay open to provide needed services for their community.

• Public consultation on Medicare policies rural providers and beneficiaries. Rural hospitals are more likely to serve patients on Medicare and Medicaid, and therefore are more heavily reliant on those payments. To help address financial conditions of rural hospitals and ensure access to care in rural areas, Medicare currently provides some increased payments for facilities in rural areas. In order to determine other ways to assist rural hospitals, HHS expects to engage in public consultation to inform potential ways to support the needs of rural hospitals and the communities they serve through Medicare payment and coverage policies.
• Supporting rural hospitals by helping them avoid closing their doors and instead converting to Rural Emergency Hospitals. Eligible hospitals (critical access hospitals (CAHs) and small hospitals in rural areas) have a new option to convert to a Rural Emergency Hospital (REH), a new Medicare provider type, to continue to provide emergency and outpatient care in their communities. CMS established an expedited process for these hospitals to convert to REHs. CMS has also finalized changes to the REH payment methodology for Tribal and Indian Health Services (IHS) operated REHs, to address certain barriers that may have discouraged Tribal and IHS operated hospitals from converting to REHs. Beginning in FY 2022, HHS, through the Health Services and Resources Administration (HRSA), dedicated $5 million to provide technical assistance to rural hospitals that are considering converting to the REH designation, as well as coordinated with USDA on technical assistance and education on USDA funding resources available to support in the conversion.
• Funding to rural providers to join value-based care initiatives. Medicare’s largest value-based care program, the Medicare Shared Savings Program, encourages providers to collaborate to provide coordinated, high-quality care to people with Medicare by forming or joining Accountable Care Organizations (ACOs). However, upfront capital to form an ACO and start to make the necessary investments to provide accountable care is often a barrier for rural providers to join value-based care programs. Starting January 1, 2024, CMS will provide upfront payments to certain ACOs to help them succeed in expanding accountable care to rural ACOs and others serving historically underserved populations. These upfront payments could be used by ACOs to invest in staffing, such as hiring community health workers, invest in health care infrastructure (such as certified electronic health record technology), or to help manage health-related social needs of persons with Medicare, such as food insecurity, housing insecurity, and transportation problems.
• Grants to rural hospitals and communities to provide health care services. HHS has several grant opportunities to support rural communities, including $28 million to provide direct health services and expand infrastructure and $16 million to provide technical assistance to rural hospitals facing financial distress. This year, sixty rural hospitals will receive technical assistance to maintain financial viability and ensure continued access to care.
• Completing vital sanitation construction projects across Indian Country. The IHS recently announced allocation decisions for over $700 million from the Infrastructure Investment and Jobs Act, part of a total $3.5 billion appropriation providing critical water and wastewater services to thousands of homes across Indian Country. These funds support IHS' vital work providing American Indian and Alaska Native homes and communities, including rural tribal communities, with essential water wells, wastewater disposal, and connections to community water supply and wastewater disposal systems. Improvements to these sanitation facilities can reduce inpatient and outpatient visits related to respiratory, skin and soft tissue, and gastroenteric disease. Every $1 spent on water and sewer infrastructure is estimated to save $1.23 in avoided direct health care costs in these facilities.
• Understanding rural health providers’ cybersecurity needs. Health care cyber incidents are among the fastest growing type of cyber-crime, jeopardizing patient care and financial security of health care providers. Rural health providers are particularly challenged in protecting their information technology systems. Despite growing understanding of sector-wide risks, the precise cybersecurity landscape and resource needs for rural health providers are poorly understood. HHS worked directly with a broad range of health care providers – including rural health care providers – to develop the Hospital Cyber Resiliency Initiative Landscape Analysis in order to better understand the current state of cybersecurity practices and inform future efforts to support and protect providers and their patients. HHS will build upon this analysis to inform future cybersecurity protocols and policies to benefit health care providers in rural areas targeted by cyber-crime.

• The President’s FY 2024 budget put forth several policies to support rural providers, including $30 million to provide technical assistance to rural hospitals at risk of closure and to support expansion of hospital services lines to meet rural communities’ needs, $13 million for rural health care workforce development and training programs, and nearly $45 million for services provided via telehealth. Recognizing that rural communities, which represent nearly 60% of Mental Health, Health Professional Shortage Areas, have higher rates of suicide, and high rates of overdose deaths and mental illness, the Budget provides $10 million in dedicated funding for a new Rural Health Clinic Behavioral Health Initiative to expand access to behavioral health services in rural communities.

BOLSTER RURAL WORKFORCE CAPACITY. With fewer health care providers in rural areas, the Biden-Harris Administration is announcing a set of actions to develop the pipeline of health care workers, including increasing incentives for health care providers to train and work in rural communities.

• Increase resident training opportunities in rural hospitals. Medicare is allocating 1,000 new training slots for medical residents and is prioritizing rural and underserved areas. CMS is also working to implement another 200 slots, which includes at least 100 slots specifically for psychiatry residencies in 2026, as enacted in the Consolidated Appropriations Act, 2023. HHS expects to do additional outreach and technical assistance to rural hospitals to encourage them to apply for these new residency positions. HHS also awarded over $11 million through the Rural Residency Planning and Development Program (RRPD) to help establish new rural residency programs. Accredited RRPD-funded programs are already training over 300 resident physicians in family medicine, internal medicine, psychiatry, and general surgery. Further, this summer, HRSA published an opportunity for $5 million in FY 2024 to develop and implement clinical rotations for physician assistant students in rural areas that will integrate behavioral health with primary care services through the Primary Care Training and Enhancement – Physician Assistant Rural Training in Mental and Behavioral Health Program. Lastly, CMS will continue to expand the rural workforce by allowing Medicare-funded rural residency training at Rural Emergency Hospitals. These changes will help address health care provider shortages by supporting the training of more clinicians in rural areas.
• Expanding the workforce and recognizing the role of community health workers Community health workers have been shown to be successful at addressing disparities in health care and connecting patients with local resources to address social needs, which can be particularly challenging in rural and tribal areas. Building on the Administration’s $225 million investment to train over 13,000 community health workers, CMS finalized policies to recognize, and for the first time, separately pay for community health integration services performed by personnel such as community health workers.
• Developing and investing in the nursing workforce.Nurses play a critical role in primary care, mental health care and maternal health care, particularly in rural areas. HHS announced more than $100 million in awards to address the increasing demand for registered nurses, nurse practitioners, certified nurse midwives and nurse faculty nationwide.
• New Office of Rural Health to Address Workforce Needs. The Centers for Disease Control and Prevention (CDC) has established an Office of Rural Health in its National Center for State, Tribal, Local and Territorial Public Health Infrastructure and Workforce. Given the health disparities facing rural communities, this new office will administer CDC’s rural health portfolio, coordinate efforts across CDC programs, and develop a strategic plan for rural health efforts at the CDC. Lastly, this office will continue to work closely with HRSA and USDA on rural health projects and initiatives to benefit individual living in rural areas.
• Virtual Physician Supervision. CMS finalized policies continuing to allow physicians caring for Medicare patients to supervise patient care for some types of facilities virtually through the end of 2024. Virtual supervision has been a COVID-19 public health emergency flexibility recognized to promote access to care in rural and underserved areas.
• Prioritizing rural communities in funding of community economic grant competition. HHS, through the Administration for Children and Families (ACF), runs the Community Economic Development grant competition, a grant program that funds projects in low-income communities to support job development. In their upcoming round of awards, ACF will award bonus points to grant applicants to support the creation of sustainable employment opportunities in rural communities.
• Addressing the Water and Wastewater Infrastructure Needs of Rural Communities. HHS, through the Administration for Children and Families (ACF), runs the Rural Community Development program, which funds regional and tribal training and technical assistance grants to support the development and management of safe and affordable water and wastewater systems for low-income rural and tribal communities. Eight multi-state, regional non-profit organizations were awarded five-year grants in fiscal year 2020, and collectively they serve all regions of the United States.

SUPPORTING ACCESS TO CARE. The Biden-Harris Administration will support rural communities having access to reliable care, through approaches that expand access to outpatient behavioral health and telehealth services.

• Expanding access to services provided via telehealth. During the first year of the COVID-19 public health emergency (PHE), Medicare telehealth visits increased 63-fold, especially benefiting patients in rural communities. CMS is extending many of the Medicare telehealth flexibilities provided during the COVID-19 PHE through December 31, 2024, based on requirements in the Consolidated Appropriations Act, 2023. CMS also created new requirements for Medicare Advantage organizations to develop and maintain procedures to offer digital health education to enrollees to improve access to medically-necessary covered telehealth benefits. Furthermore, the Bipartisan Safer Communities Act (BSCA) requires CMS to provide technical assistance and issue guidance to states on how to improve access to services delivered via telehealth to beneficiaries enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). This will help people in rural communities by granting access to services without having to travel long distances to see a provider in person.  
• Improving access to high-speed internet. Internet access is important to accessing telehealth and the Biden-Harris Administration has committed to connecting everyone in the country to affordable, high-speed internet. Rural communities, including tribal communities, represent 93% of all locations unserved by affordable, high-speed internet across the country. President Biden’s Bipartisan Infrastructure Law provided $2 billion in funding, through the Tribal Broadband Connectivity Program, to fill this infrastructure gap and aid adoption efforts to Tribes. This funding is in addition to $2 billion for ReConnect funding, a program for high-speed infrastructure projects on rural and tribal land. To further support access, IHS is partnering with digital navigators to come to local rural health care facilities to sign up tribal members for the Affordable Connectivity Program which provides a discount for internet bills.
• Increasing access to and payment for behavioral health services. Rural communities face higher rates of behavioral health conditions and shortages of behavioral health providers that make it harder for people to access treatment. HHS has taken a series of actions to help expand access to behavioral health providers within rural communities. This also includes efforts to leverage telehealth flexibilities and mobile units to reach underserved populations. CMS is also working to implement provisions of the CAA, 2023, which expands Medicare coverage and payment to new behavioral health providers such as marriage and family therapists and mental health counselors. CMS finalized policies to allow rural health clinics to provide intensive outpatient services for behavioral health and to increase payment for certain types of mental health services. The President’s FY 2024 Budget Request also calls for an increase in the funding going to rural communities to respond to the behavioral health crisis. This includes $165 million through the Rural Communities Opioid Response Program (RCORP) to focus on opioid and substance use prevention, increase access to behavioral health services, increase access to new medication-assisted treatment services, and to grow and train the behavioral health workforce.
• Improving access to treatment for opioid use disorders. Access to opioid use treatment services in rural areas is vital. To address the need for these services in rural areas, HRSA’s National Health Service Corps Rural Community Loan Repayment Program issues loan repayment awards in coordination with the RCORP from the Federal Office of Rural Health Policy. In an effort to support evidence-based substance use disorder treatment, assist in recovery, and prevent overdose deaths across the nation, an additional $80 million has been invested by the RCORP. Additionally, HRSA will continue to make loan repayment awards to National Health Service Corps Rural Community Loan Repayment Program participants serving at National Health Service Corps-approved sites that are RCORP service sites. Medicare also clarified that it will cover opioid use disorder treatment services delivered by mobile units of registered opioid treatment programs, and beneficiaries can now access behavioral health services via telehealth or audio-only communications in certain circumstances. Building upon the President’s commitment to furthering access to these types of treatments, HHS proposed a rule on addressing telemedicine treatment services to individuals with opioid use disorder within opioid treatment programs, and DEA and HHS/SAMHSA continue to work on rules related to telemedicine induction of controlled medications, including Schedule III-V approved medications to treat opioid use disorder in other settings.
• Advancing network adequacy for behavioral health providers. Ensuring rural Americans have health insurance provider networks that support their behavioral health needs is vital to improving access to these services. Under Medicare Advantage, CMS finalized a new rule with policies that strengthen network adequacy requirements, beginning with plan year 2024, and reaffirm Medicare Advantage organizations’ responsibilities to provide behavioral health services networks. These new requirements include establishing appointment wait time standards for behavioral health and primary care providers and adding network standards for licensed clinical social workers and clinical psychologists. This rule supports rural Americans enrolled in Medicare Advantage plans by ensuring they receive timely access to behavioral health services. CMS also remains interested in network adequacy standards for other types of behavioral health providers. With respect to the Marketplace, CMS finalized revisions to the network adequacy and essential community provider (ECP) requirements for plan year 2024 to include two new ECP categories that are critical to delivering needed behavioral health care: Substance Use Disorder Treatment Centers and Mental Health Facilities. CMS also added rural emergency hospitals as an ECP category to better ensure consumer access to a sufficient choice of providers and increase provider types that rural consumers can choose from. CMS also revised network adequacy requirements in the Marketplace to evaluate qualified health plans for compliance with quantitative network adequacy standards based on time and distance standards, and will begin to evaluate qualified health plans for compliance with appointment wait time standards in plan year 2025. Additionally, for plan year 2024 and beyond, CMS retains the overall 35% provider participation threshold and also extends the 35% threshold to two major ECP categories: Federally Qualified Health Centers and Family Planning Providers, further benefiting rural beneficiaries.
• Improving access to providers for Medicaid beneficiaries in rural areas. In April 2023, CMS issued two proposed rules that would help address access challenges, including ones that rural communities disproportionately experience. For example, these rules, if finalized, would make provider payments more transparent, potentially helping to increase such payments, which could encourage more providers – including rural providers – to participate in Medicaid. The proposals would also help ensure that Medicaid beneficiaries – including those in rural areas – can access services in a timely manner by imposing appointment wait time standards for beneficiaries receiving certain services through managed care, including routine primary care, OB-GYN services, and outpatient mental health and substance use disorder services.
• Access to care in Medicare Advantage in rural areas. People in rural communities are increasingly enrolling in Medicare Advantage. In addition to the telehealth and network adequacy policies described above, CMS has created new policies requiring that prior authorization procedures in Medicare Advantage don’t inappropriately inhibit access to necessary services. New CMS regulations, applicable beginning 2024, limit the use of prior authorization to confirming the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service, and medical necessity of covered services for an enrollee (or clinical appropriateness for certain supplemental benefits).   
• School-Based Services in Rural Communities. In May 2023, CMS released an informational bulletin and a comprehensive guide and the Department of Education (ED) released a proposed rule, that will help make it easier for schools to deliver and bill Medicaid for health care services they provide to children eligible for Medicaid. This summer, CMS, in conjunction with the ED, launched the School-Based Services (SBS) Technical Assistance Center to support State Medicaid agencies, State and local education agencies, and school-based entities in expanding and improving the delivery of Medicaid and CHIP services in schools. The CMS guidance and SBS Technical Assistance Center support rural and low-resource schools by making it easier to bill for Medicaid services as they frequently have less administrative capacity to do so and the Technical Assistance Center develops resources specifically designed to help support small and rural local educational agencies.
• Supporting Access to Rural Maternal Care. As described in the Biden-Harris Administration’s Blueprint for Addressing the Maternal Health Crisis - PDF, women in rural communities experience challenges accessing maternal care locally, and have higher rates of maternal mortality and morbidity than their urban counterparts. As described in the Maternal Health Blueprint, the HRSA Rural Maternity and Obstetrics Management Strategies (RMOMs) Program will improve rural health care networks and will uplift maternal and obstetrics care in rural communities. In FY 2023, the RMOMs program invested $2 million in new awards to serve rural communities. The IHS is also developing training curriculum for IHS hospitals, including rural hospitals, to be “obstetrics ready” in the event they need to perform an emergency delivery and have triage and transfer protocols in place if needed. The CMS Innovation Center is also exploring ways to improve maternal health outcomes and access through the testing of innovative payment and service delivery models, which could directly impact access to obstetrics care in rural America. Lastly, as of September, CMS has approved requests from 37 states, the District of Columbia, and the U.S. Virgin Islands to provide continuous Medicaid and CHIP coverage for 12 months after pregnancy to postpartum individuals.
  Source: HHS