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Regulations Focused on Rural Health Facilities During COVID-19


Timothy Jones, associate director of federal relations and Chad Larson, MBA, executive director, hospital business development

Public policymakers have long raised attention to the number of rural hospital closures in the United States.

Right now, more than 450 of U.S. rural hospitals are currently at risk of closing. Even if 50% of the hospitals at risk closed their doors, patients in their community would need to travel between 20-25 miles on average to their next closest hospital with access to emergency care.

Rural hospitals face numerous challenges to remain open including:

  • lack of resources
  • administrative burden 
  • funding gaps
  • workforce shortages
  • low inpatient volumes

The COVID-19 pandemic has further raised concerns about the current capacity of rural hospitals to meet the increased patient demand for health care services. The closure of these facilities has created access issues to high quality care, particularly emergency services. The U.S. Department of Health and Human Services Assistant Secretary for Preparedness and Response’s Technical Resources, Assistance Center, and Information Exchange has published extensive background information detailing additional barriers this virus has imposed on rural providers.

CMS Waivers for Critical Access Hospitals
The Centers for Medicare and Medicaid Services (CMS) has utilized its authority as a result of the COVID-19 Public Health Emergency (PHE) declaration to waive certain requirements for those facilities designated as Critical Access Hospital Hospitals (CAH) under the Medicare program. 

CMS has specifically provided these flexibilities to CAHs during the PHE:

  • CAHs are permitted to have more than 25 inpatient beds
  • CAHs are permitted to have patient length of stays last more than 96 hours
  • CAHs are not required to be located in a rural area, which would allow them flexibility in the establishment of surge site locations
  • CAH off-campus and co-location requirements are waived, including being located 35 miles from other hospitals, which would allow them flexibility in establishing off-site locations.

CMS has also relaxed many requirements during the COVID-19 PHE regarding the delivery of telemedicine services. Most notably, CAH off-site hospital agreements for credentialing and privileging of telemedicine physicians and practitioners are waived. 

Lastly, some policymakers have advocated for the passage of legislation that would grant Medicare status for certain hospitals that provide only emergency and outpatient services. While this legislation has not passed, CMS has recognized the ability of licensed, independent freestanding emergency departments (ED) to expand access to inpatient and outpatient services during the PHE. As a result, CMS has allowed these EDs the option to enroll as a:

  • hospital-affiliated ED
  • Medicaid-certified clinic under the state’s clinic benefit
  • Medicare-certified hospital by attestation

It should be noted that only four states issue licenses to independent, freestanding EDs to operate without hospital affiliation: 

  • Colorado
  • Delaware
  • Rhode Island
  • Texas

The Joint Commission will continue to track these efforts and will provide its thoughts to policymakers. In the meantime, we’d love to know your thoughts. Please comment on our social media pages and share your opinion with our community.

Tim Jones serves as associate director, federal relations in The Joint Commission’s Washington, DC office. Jones has over 18 years of government relations experience and has worked at Humana, Change Healthcare, and Children’s National Health System.  He began his career on Capitol Hill working for former Senator George Voinovich. 

Chad Larson, MBA, is executive director of hospital business development. He served as director of Business Operations in the Division of Support Operations, where he led the administration and management of operational, financial and planning activities. He also was a project lead on the Malcolm Baldrige National Quality Award, utilizing Baldrige Excellence Framework and Lean Six Sigma methodology to identify gaps in internal processes to promote organizational culture transformation.