EDPMA Submits Two Comment Letters Addressing New Rural Emergency Hospital (REH) Proposed Policies

The Centers for Medicare and Medicaid Services (CMS) recently issued two rulemaking vehicles to implement the new facility enrollment designation of Rural Emergency Hospitals (REHs) as created by Congress when it passed the Consolidated Appropriations Act, 2021. The statutory provision allows for the establishment of REHs by essentially allowing already-existing critical access hospitals (CAHs) and certain rural hospitals to convert to REHs. Eligible facilities will be able to enroll as REHs under statute for January 1, 2023 services. In preparation for the rules, EDPMA created a work group tasked with developing policies and requests for changes where needed. As a result of these efforts, EDPMA responded to both REH proposed rule comment solicitations:

  • REH Conditions of Participation (CoPs): On August 25th, EDPMA responded to the CMS proposed rule related to the creation of CoPs for REHs. The proposals were largely based on already-existing CoPs for critical access hospitals and rural hospitals. EDPMA made several requests as part of its response:
    • EDPMA urged CMS to provide an enrollment option for those CAHs or rural hospitals that otherwise meet the REH eligibility criteria but closed subsequent to December 27, 2020 to enroll as an REH.
    • EDPMA emphasized the importance of clinical services delivered at an REH being led by a physician with, at the minimum, experience in the practice of emergency medicine, noting that the expertise of a board-certified emergency physician should be relied upon whenever medically necessary and available.
    • EDPMA encouraged express guidance from CMS on the ability of emergency physicians who are performing the medical director and other supervisory responsibilities to meet these requirements remotely (provided all remote requirements are met).
    • EDPMA recommended that CMS clarify its staffing requirements so that the expertise of a physician be available 24 hours a day/7 days a week.
    • EDPMA urged CMS to work with Congress and state governments to address the complexities and variations in the abilities of physicians to provide telemedicine services across state lines.
    • EDPMA recommended that CMS add provisions to the REH CoP that require the “written agreements” with Level 1 and Level 2 trauma centers and the “system . . . for referral from an REH to different levels of care” to include the capacity for telemedicine capabilities with a physician with, at the minimum, experience in the practice of emergency medicine.

You can review the full EDPMA response to the REH CoP proposed rule here.

  • REH Enrollment, Payment, Quality Reporting, and Other Provisions: As part of the calendar year (CY) 2023 Hospital Outpatient Prospective Payment System (OPPS) proposed rule, CMS issued proposals related to several other policies for REHs for the January 1, 2023 effective date. EDPMA made several requests in response to these proposals:
    • EDPMA reiterated its request that CMS provide an enrollment option for those CAHs or rural hospitals that otherwise meet the REH eligibility criteria but closed subsequent to December 27, 2020 to enroll as an REH.
    • Statute sets payments for “REH Services” at 105% of the rate that would otherwise be paid in a hospital outpatient department. EDPMA recommended that CMS define “REH services” more broadly in order to implement these regulations more in line with Congressional intent and recommended that CMS modify its proposal so as to reimburse the professional (and not just the facility) claim for outpatient services at 105% of traditional fee-for-service payment.
    • EDPMA recommended that CMS issue explicit guidance about the Medicare Physician Fee Schedule claims submission process for professional services delivered in the REH setting.
    • EDPMA requested that CMS explicitly include CAH emergency physician availability costs as part of its methodology for calculating Monthly REH Facility Payments or, in the alternative, to administer this funding to REHs via a mechanism that will allow REHs to dedicate these resources to staffing their emergency departments.
    • EDPMA supported CMS’ proposals to allow REH utilization of the “change of information” enrollment form and for REH placement in the “limited risk” screening category.
    • EDPMA encouraged CMS to finalize its proposal that the Medicare Outpatient Observation Notice (MOON) will not be required for use in the REH setting.
    • EDPMA supported CMS’ proposal to ensure that physician REH ownership and investment interests are specifically safeguarded through a new Stark exception.
    • EDPMA expressed concern about the list of potential measures under consideration for the REH Quality Reporting (REHQR) program, which largely consists of current or past Hospital Outpatient Quality Reporting (OQR) Program measures and does not accurately reflect care in REH settings and recommended that CMS look beyond the OQR measures and instead work with clinical and patient stakeholders to develop a new, custom set of measures that better reflects the unique challenges associated with providing care in the REH setting.

The full EDPMA CY 2023 OPPS comment letter on these REH provisions is available here.