Proposed Change to the RHC Nurse Practitioner Definition and Implementation of Various Telehealth Provisions

Sarah Hohman, Director of Government Affairs

08/04/2023

Additional provisions included in the Centers for Medicare and Medicaid Services (CMS) CY 2024 Medicare Physician Fee Schedule (MPFS) Proposed Rule relevant to RHCs includes a proposed change to the definition of a Nurse Practitioner certified for practice in a RHC, as well the implementation of various telehealth policies passed by Congress.

Proposed Changes to the RHC Conditions for Certification

  • Definition of Nurse Practitioner (NP)

Currently, only two organizations have the authority in the RHC regulations (§491.2(1)) to certify NPs to practice as primary care NPs in RHCs, the American Nurses’ Association and the National Board of Pediatric Nurse Practitioners and Associates. CMS acknowledges that there are various other national certifying organizations with standards for Nurse Practitioners that more fully represent available certifications available for NPs.

Therefore, they are proposing to change the definition of nurse practitioner at § 491.2(1)

From:

Is currently certified as a primary care nurse practitioner by the American Nurses' Association or by the National Board of Pediatric Nurse Practitioners and Associates;

To:

“Be certified as a primary care nurse practitioner at the time of provision of services by a recognized national certifying body that has established standards for nurse practitioners and possess a master’s degree in nursing or a Doctor of Nursing Practice (DNP) doctoral degree.”

CMS lists examples of other certifying boards, including the American Academy of Nurse Practitioners Certification Board (AANPCB), American Nurses Credentialing Center (ANCC) Certification Program, Pediatric Nursing Certification Board (PNCB), and the National Certification Corporation (NCC), however these would not be explicitly listed in the regulation.

We believe that expanding the breadth of allowable certifying entities will better capture the full suite of NPs adequately trained to provide care in RHCs.

Further, CMS is seeking comment as to whether the definition of nurse practitioner at § 491.2(1), shown above, should continue to require that the NP’s certification be in primary care or whether this should be removed. Other “non-primary care” specialties could include adult acute care, neonatal, and pediatric acute care. In their consideration of this change, CMS writes the following:

Primary care NPs are trained to offer comprehensive, continuous care for patients with most health needs, including chronic conditions. In contrast, acute care NPs are equipped to provide restorative care, which involves addressing rapidly changing clinical conditions in patients with unstable, chronic, and complex acute and critical conditions. The NP scope of practice allows them to provide care to patients based on the acuity of the patient’s needs, rather than the setting in which the services are administered. This implies that an acute care NP can offer their services to patients within their scope of practice in RHCs and FQHCs, and other settings. NPs increasingly provide services to Medicare b eneficiaries; however, the scope of benefits between primary care and acute care may be different. We seek comments on whether the specification of requiring NPs to be certified in primary care should remain in the definition at § 491.2.

If anyone in the RHC community has questions, concerns, or other feedback on this
“primary care” definition change, please contact NARHC.

Telehealth

The proposed rule implements the various telehealth provisions established in the Consolidated Appropriations Act of 2023, or the “omnibus” bill and makes necessary technical changes in the regulation for the following:

  • Through December 31, 2024:
    • Extends RHC medical telehealth flexibilities including reimbursement through G2025.
    • Removes originating and geographic site requirements, allowing patients to be located at any location during the telehealth service, including a patient’s home.
    • Delays the in-person requirement for mental health visits furnished via telehealth, which can now be permanently offered by RHCs.
    • Extends audio-only coverage for those denoted as billable via audio-only communications on Medicare’s telehealth list.
    • Allows for physician or practitioner “direct supervision” of incident to services to be performed via two-way, real time-audio visual technology, as opposed to immediately available in the physical space of the RHC.
      • CMS is specifically seeking comment on whether this flexibility should continue post-December 31, 2024.
    • Expands the list of telehealth distant site practitioners to include Marriage and Family Therapists and Mental Health Counselors beginning January 1, 2024.
    • Proposes the 2024 telehealth originating site facility fee as $29.92.

RHCs can always find current telehealth policy at NARHC.org.

Please contact Sarah Hohman, NARHC Director of Government Affairs at Sarah.Hohman@narhc.org with any questions or other feedback, and don’t forget to register for NARHC’s August 30th webinar on these CMS proposed rules here.