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May 2, 2023

End of COVID-19 Public Health Emergency Brings Changes for Rural Health Clinics (RHCs)

The Biden Administration has announced that the COVID-19 Public Health Emergency (PHE) will end on May 11, which will end several waivers specific to rural health clinics (RHCs). While some waivers and flexibilities have been made permanent or given a separate phase-out timeline from the PHE end date, many will end alongside the PHE.

Because the PHE was renewed every 90 days since January 27, 2020, it may take some time to adjust to reverting to requirements that haven’t been followed in three years. Familiarize yourself with the soon-to-be reinstated requirements below and learn more about which waivers and flexibilities will remain in effect past the May 11th deadline thanks to the passing of the CARES Act.

Key Takeaways:

  • The COVID-19 Public Health Emergency (PHE) will come to an end on May 11, 2023, as announced by the Biden Administration 
  • Several waivers surrounding staffing requirements, bed counts and temporary expansion locations for rural health clinics (RHCs) will end as a result 
  • Other waivers, such as requirements for physicians to provide medical direction for RHC-based nurse practitioners, may be made permanent through ongoing legislative efforts 
  • COVID-19 products, such as tests and vaccines, will transition into commercial products, but there are special exemptions for their use by RHCs

Staffing Requirements for NPs, PAs and CNMs 

While the PHE was active, the Centers for Medicare and Medicaid Services (CMS) waived the requirement of 42 CFR 491.8(a)(6), which required that a certified nurse midwife (CNM), physician assistant (PA) or nurse practitioner (NP) be available at least 50% of the time an RHC is operating to provide patient care services. As of May 11, this requirement will go back into effect. 

Return to Physician Supervision of NPs 

CMS waived the requirement of 42 CFR 491.8(b)(1) for the duration of the PHE, which required physicians to provide medical direction for the RHCs’ nurse practitioners, as allowed by state law. The waived requirement could become permanent for NPs and PAs through the RHC Burden Reduction Act which was recently introduced in the Senate.  

RHC Temporary Expansion Locations 

Requirement of 42 CFR §491.5(a)(3)(iii) was waived during the PHE, which allowed RHCs to no longer be separately considered for Medicare survey and certification if its services were expanded into more than one permanent location, which includes areas that wouldn’t typically meet RHC location requirements. Once the PHE period ends, the relevant expanded locations will once again be subject to location requirements and need a separate survey and certification.  

Home Nursing Visits 

Before the PHE was enacted, RHCs in an area without an ongoing home health shortage required a written request and justification to provide home nursing services. This requirement was waived during the PHE and will resume at the conclusion of the PHE.  

Bed Count for Provider-Based RHCs 

Provider-based RHCs, subject to their clinic-specific, grandfathered upper-payment limit, were permitted during the PHE to increase their hospital bed count over 50 without the loss of their grandfathered status. Once the PHE ends, grandfathered RHCs are required to lower their bed count to 50 or less to prevent losing their grandfathered payment status.  


One of the first telehealth flexibilities granted to RHCs during COVID allowed for online digital evaluation and management services (99421, 99422 and 99423) to be reimbursed under G0071. Once the PHE comes to a conclusion, G0071 should only be used for G2012 and G2010. The passage of the CARES Act allowed more telehealth services to be performed through the PHE and past it. RHCs may still serve as distant site providers through December 31, 2024. This waiver was originally linked to the PHE but it and other Medicare telehealth flexibilities, will remain in place beyond the May 11 PHE end date.  

The enforcement discretion allowing telehealth services to be performed via non-HIPPA-secure communications technology will end immediately upon the PHE’s termination. Audio-only telehealth services can still be covered by providers and will not be prevented by the HIPPA privacy rule. Mental health services delivered via telehealth are permanently covered and paid at the RHC All-Inclusive Rate. The occasional in-person requirement has been delayed through December 31, 2024. Medical telehealth services should continue to be billed in 2023 using G2025 and will be reimbursed at $98.27.  

COVID-19 Treatment and Product Commercialization 

A number of other waivers are slated to end once the PHE stops, including the 20% hospital payment increase for treating patients who have contracted COVID-19. Other blanket waivers, including Stark Law waivers, will also come to an end. 

The end of the PHE also means the end of insurer requirements to cover COVID-19 testing, vaccines and treatment without cost-sharing. Vaccines, tests, and certain other materials will begin transitioning to commercial products after the federal government’s purchased supply has been exhausted. COVID-19 vaccines and their administration will continue to be paid at 100% of reasonable cost for RHCs via the cost report.  

Monoclonal antibody products and their administration will also be paid at reasonable cost through the RHC cost report, but only through December 3, 2023. The HRSA RHC COVID-19 Supply Programs, which offer free and direct access to COVID-19 vaccines, therapeutics and testing supplies are not tied to the PHE. The COVID-19 Health Care Staff Vaccination mandate will remain in place after the PHE ends and CMS has not announced planned changes or a sunset date for the mandate as of publishing time.  

Anders Health Care Advisors collaborate with RHCs and other health care organizations to ensure compliance, discover improvements to your revenue cycle management. For more information related to our services, contact Anders below.

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