Rural Health Clinic (RHC) Medicare Coverage
Rural health clinics (RHCs) are federally certified clinics that provide primary care and preventive services to Medicare beneficiaries in rural areas with a shortage of doctors and other health care providers. RHCs can be public, nonprofit or for-profit organizations, but must meet certain federal requirements.
What Is a Rural Health Clinic?
Rural health clinics were created by federal law to address shortages of doctors and other health care professionals serving Medicare beneficiaries in rural areas.
RHCs were created by the Rural Health Clinic Service Act of 1977, and in addition to improving access to physicians in rural areas, it increased the number of nurse practitioners, physician assistants and certified nurse-midwives in rural areas served by RHCs.
Services Rural Health Clinics Provide
Rural health clinics typically provide outpatient primary health care and preventive health services.
- Physician services
- Nurse practitioner, physician assistant, certified nurse-midwife, clinical psychologist and clinical social worker services
- Certain care management services
- Certain laboratory services on site
- Certain virtual communication services
- Drugs covered by Medicare Part B that are integral to the services the RHC provides
- Immunization services including flu, pneumonia, hepatitis B and COVID-19 shots
- Services and supplies that are integral to the services provided the RHC’s health care professionals’ services
- Has arrangements with one or more hospitals to provide necessary medical services not available through the RHC
- Visiting nurse services to homebound Medicare beneficiaries (in areas Medicare certifies there is a shortage of home health agencies)
Medicare Reimbursements and How Much You Owe for RHC Visits
Medicare beneficiaries can use local rural health clinics and Medicare will reimburse the RHC for Medicare-approved costs. But you may still have out-of-pocket costs.
Once you’ve hit your deductible, Medicare pays 80 percent of the Medicare-approved costs.
But the deductible and coinsurance are waived on certain preventive services, including the initial preventive physical examination and annual wellness visit. Medicare pays 100 percent of preventive services’ costs.
Medicare pays RHCs an all-inclusive rate (AIR) for face-to-face primary health care Medicare considers “medically necessary.” The AIR also covers qualified preventive health services provided by one of the RHC’s health practitioners.
What Qualifies as a Rural Health Clinic?
To qualify as an RHC, a clinic has to meet certain requirements and be certified by Medicare.
RHCs must be in a nonurbanized area as defined by the U.S. Census Bureau and in an area currently designated under federal law as one of four types of places that have limited access to health care in the previous four years.
The Department of Health and Human Services and the National Organization of State Offices of Rural Health maintain searchable databases and contact information to help you find a rural health clinic in your area.
- Primary Care Geographic Health Professional Shortage Area (HPSA)
- HPSAs are geographic areas, populations or facilities that have a shortage of primary care, dental or mental health care providers. You can use the federal government’s HPSA find tool to see if your area qualifies.
- Primary Care Population Group
- This is specific to population groups — such as low-income people, homeless people, Native Americans and migrant farm workers — that are experiencing a shortage of health care providers. The federal government’s HPSA find tool can also tell you if your area qualifies.
- Medically Underserved Area (MUA)
- MUAs are areas — including a whole county and groups of neighboring counties — with a lack of access to primary care services, high poverty, high infant mortality rates and/or a large elderly population. You can find out if your area qualifies by using the federal government’s MUA Find tool.
- Governor-Designated and Secretary-Certified Shortage Areas
- Areas declared by a state’s governor and certified by the U.S. Secretary of Health and Human Services as having a shortage of health care services. Contact your state Office of Rural Health to see if you live in one of these areas.
Rural health clinics can be public, nonprofit or for-profit health care facilities. But to receive certification, they must be in underserved, rural areas and must use a team approach of doctors and nonphysician health care professionals working together to provide services.
All rural health clinics must have at least one nurse practitioner (NP) or physician assistant (PA) on staff. They must have either an NP, PA or a certified nurse-midwife (CNM) on-site at least 50 percent of the time the clinic is open.
In addition, a physician must supervise each NP, PA or CNM as required by the law of the state where the rural health clinic is located.
7 Cited Research Articles
- U.S. Medicare & Medicaid Services. (2020, April 14). Rural Health Clinics Center. Retrieved from https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center
- U.S. Medicare & Medicaid Services. (2019, May). Rural Health Clinic. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/RuralHlthClinfctsht.pdf
- Kaiser Family Foundation. (2020). Number of Medicare Certified Rural Health Clinics. Retrieved from https://www.kff.org/other/state-indicator/total-rural-health-clinics/
- Rural Health Research Gateway. (2019, November 14). Rural Health Clinic Costs and Medicare Reimbursement. Retrieved from https://www.ruralhealthresearch.org/alerts/307
- Rural Health Information Hub. (2019, October 16). Rural Health Clinics (RHCs). Retrieved from https://www.ruralhealthinfo.org/topics/rural-health-clinics
- Kaiser Family Foundation. (n.d.). Providers & Service Use Indicators; Rural Health Clinics. Retrieved from https://www.kff.org/state-category/providers-service-use/rural-health-clinics/
- U.S. Medicare & Medicaid Services. (n.d.). Rural Health Clinic Services. Retrieved from https://www.medicare.gov/coverage/rural-health-clinic-services