D. Removal of Employment Requirements for Services Furnished “Incident to” Rural Health
Clinics (RHC) and Federally Qualified Health Center (FQHC) Visits
1. Background
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) furnish physicians’ services; services and supplies incident to the services of physicians; nurse practitioner (NP), physician assistant (PA), certified nurse-midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW) services; and services and supplies incident to the services of NPs, PAs, CNMs, CPs, and CSWs. They may also furnish diabetes self-management training and medical nutrition therapy (DSMT/MNT), transitional care management services, and in some cases, visiting nurse services furnished by a registered professional nurse or a licensed practical nurse. (For additional information on requirements for furnishing services in
RHCs and FQHCs, see Chapter 13 of the CMS Benefit Policy Manual.)
In the May 2, 2014 final rule with comment period (79 FR 25436) entitled “Prospective
Payment System for Federally Qualified Health Centers; Changes to Contracting Policies for
Rural Health Clinics; and Changes to Clinical Laboratory Improvement Amendments of 1988
Enforcement Actions for Proficiency Testing Referral,” we removed the regulatory requirements
that NPs, PAs, CNMs, CSWs, and CPs furnishing services in a RHC must be employees of the
RHC. RHCs are now allowed to contract with NPs, PAs, CNMs, CSWs, and CPs, as long as at
least one NP or PA is employed by the RHC, as required under section 1861(aa)(2)(iii) of the
Act.
Services furnished in RHCs and FQHCs by nurses, medical assistants, and other auxiliary personnel are considered “incident to” a RHC or FQHC visit furnished by a RHC or FQHC practitioner. The regulations at §405.2413(a)(6), §405.2415(a)(6), and §405.2452(a)(6) state that services furnished incident to an RHC or FQHC visit must be furnished by an employee of the RHC or FQHC. Since there is no separate benefit under Medicare law that specifically authorizes payment to nurses, medical assistants, and other auxiliary personnel for their professional services, they cannot bill the program directly and receive payment for their services, and can only be remunerated when furnishing services to Medicare patients in an “incident to” capacity.
2. Provisions of Proposed Rule
To provide RHCs and FQHCs with as much flexibility as possible to meet their staffing needs, we are proposing to revise §405.2413(a)(5), §405.2415(a)(5) and §405.2452(a)(5) anddelete §405.2413(a)(6), §405.2415(a)(6) and §405.2452(a)(6) to remove the requirement that services furnished incident to an RHC or FQHC visit must be furnished by an employee of the RHC or FQHC to allow nurses, medical assistants, and other auxiliary personnel to furnish incident to services under contract in RHCs and FQHCs. We believe that removing the requirements will provide RHCs and FQHCs with additional flexibility without adversely impacting the quality or continuity of care.
