CMS Finalizes 2024 Regulatory Updates

Provides MHC and MFT Coverage Details, Adds Remote Patient Monitoring and other services to G0511, Among Other Key Provisions for RHCs

Sarah Hohman, Director of Government Affairs


On November 2nd, the Centers for Medicare and Medicaid Services (CMS) issued the CY 2024 Medicare Physician Fee Schedule (MPFS) Final Rule and the CY 2024 Medicare Outpatient Prospective Payment System (OPPS) Final Rule, finalizing several Rural Health Clinic (RHC) specific policy proposals that NARHC first outlined in July.

In September, NARHC submitted comments as to how CMS proposals may impact the RHC community, and suggested various changes to ensure that safety net providers are able to take full advantage of the expanded benefits. Much of our advocacy was successful, particularly in conveying to CMS that RHCs should be able to bill the general care management code, G0511, more than once per patient per month to capture the full benefits of expanded Remote Patient Monitoring (RPM) flexibilities and other benefits. 

“The 2024 Final Rules are a mixed bag,” said Nathan Baugh, Executive Director of the National Association of Rural Health Clinics. “The addition of MFTs and MHCs to the suite of RHC practitioners is an excellent step forward, as is the ability to bill for remote physiologic monitoring. However, we will need more explicit guidance on some of the care management policies and we disagree with CMS’ policy to only allow telehealth during RHC hours of operation.”

We encourage you to join our Washington, D.C. team for a webinar on December 11th, 2023, where we will discuss the final rule and answer your questions about implementation of these various policy proposals. Please register for the webinar here.

Unless otherwise noted, the below, finalized proposals will go into effect on January 1, 2024. Highlights include:

  • Medicare Coverage of Marriage and Family Therapists and Mental Health Counselor
  • Intensive Outpatient Program (IOP) Services Billable in RHC Under Special Payment Rule
  • Remote Physiologic Monitoring, Remote Therapeutic Monitoring, Community Health Integration, and Principal Illness Navigation Services Billable in RHC as G0511
  • Definition Change to Nurse Practitioner

For a detailed summary of the RHC-relevant provisions of the 2024 MPFS and OPPS final rules please see below:


Medicare telehealth policy has shifted dramatically for the entire healthcare industry in response to COVID-19.

Beginning January 2022 on a permanent basis, RHCs can bill and be reimbursed for mental health services provided via telehealth, as they would an in-person behavioral health visit and receive their RHC’s All-Inclusive Rate (AIR).

Regarding medical telehealth services, in December 2022 Congress passed the Consolidated Appropriations Act of 2023 to extend current RHC telehealth policy (billing G2025 for any of these allowable telehealth services with a flat reimbursement) through December 31, 2024.

What CMS Proposed
In this year’s final rule, CMS made necessary technical changes in the regulation to implement this law including:

  • 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.
    • 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.

NARHC Comments
NARHC commented in support of the continued telehealth flexibilities granted by Congress and for the technical changes made by CMS to reflect these policies.

While we continue to advocate to Congress on changing telehealth reimbursement and making RHC distant site flexibilities permanent, NARHC also implored CMS to consider their authority to implement normal coding within the “special payment rule” (G2025) authorized by Congress. NARHC argued to CMS that the special payment can be indicated through a modifier code (95) in order to better facilitate data collection of RHC services performed via telehealth, including proper counting of Annual Wellness Visits and other preventive services.

Finally, NARHC requested guidance from CMS to clarify for the RHC community if distant site telehealth services may be provided outside the RHC’s hours of operations. NARHC believes that RHCs should not be limited to only offering telehealth during the hours of operation of the physical RHC as such a policy would only limit access to care for safety-net patients.

What CMS Finalized
CMS finalized its telehealth technical changes as proposed. CMS stated the following in response to our additional comments:

Regarding Normal Coding
We agree that transparency in the services furnished can improve data collection and inform payment policies and can explore options that may provide RHCs and FQHCs the ability to report the HCPCS code that describes the service furnished instead reporting G2025. If we were to implement such changes in the claims processing systems, we do not believe that it would change the payment policy, that is, overall payment would be the same. Therefore, changes in the way RHCs and FQHCs would report these services and how CMS pays would be effectuated through sub-regulatory guidance.

Regarding Telehealth Hours
Currently, RHCs and FQHCs are required to furnish services during their hours of operation and if services are furnished at times other than the RHC’s or FQHC’s posted hours of operation, they may not be billed to Medicare Part B if the practitioner’s compensation for these services is included in the RHC/FQHC cost report. This policy is discussed in Pub. 100- 02 Medicare Benefit Policy Manual, Chapter 13, section 40.2 “Hours of Operation.” We appreciate the commenter bringing this concern to our attention and we can consider for future rulemaking.

We will continue to engage with CMS on these telehealth provisions.

New Billable RHC Providers: Marriage and Family Therapists and Mental Health Counselors

The Consolidated Appropriations Act of 2023 included provisions allowing RHCs to bill for Marriage and Family Therapists (MFTs) and Mental Health Counselors (MHCs) beginning January 1, 2024.

What CMS Proposed
CMS proposed to add MFTs and MHCs as qualified RHC providers meaning that they can generate a Medicare encounter, reimbursable at the RHC’s All-Inclusive Rate (AIR). Further, MFTs and MHCs will be subject to the same policies and supervision requirements as a PA, NP, CNM, CP, and CSW. Addiction counselors that meet the applicable supervision, licensure, and certification requirements are also eligible to enroll with Medicare as MHCs. Marriage and Family Therapists and Mental Health Counselors will also be eligible to bill G0511 for general behavioral health integration services.

NARHC Comments
NARHC commented in support of these proposed regulatory changes to implement new Medicare coverage of these providers consistent with the statute in order to maximize the available behavioral health workforce. NARHC also requested confirmation from CMS that MFTs and MHCs will not be subject to a productivity standard in the RHC.

What CMS Finalized
CMS broadly finalized these policies as proposed. RHCs can review the definitions of MFTs and MHCs, as well as what will be considered MFT/MHC services here. CMS recognizes that the specific titles of mental health practitioners often vary by state and clarify that “mental health practitioners who meet all of the applicable statutory qualifications for the mental health counselor benefit category but are licensed by their State under a different title, are eligible to enroll in Medicare under the Part B “Mental Health Counselor” statutory benefit category.” Finally, CMS clarified that these practitioners will not be subject to a productivity standard in RHCs.

CMS added MFTs and MHCs to the regulation at 491.8(a)(3) and 481.8(a)(6), meaning that these provider types may serve as the RHC owner or an employee, or be under contract. Additionally, MFTs and MHCs can fulfill the requirement that a provider must be available to furnish care at all times the clinic is open. Various RHC guidance documents such as State Operations Manual Appendix G and Medicare Benefit Policy Manual Chapter 13 will need to also be updated to reflect these new billable provider types.

Now that the final rule has been published, MFTs and MHCs can begin the Medicare enrollment process. CMS published FAQs on the newly covered provider types here.

RHC Care Management Services Expansion

Since 2016, RHCs have been able to bill for Chronic Care Management (CCM) services through this consolidated care management code. G0511 pays a consolidated fee schedule amount, $77.24 in 2023, which is the average of the Physician Fee Schedule (PFS) rates for CCM and principal care management (PCM) services, as well as codes newly added in 2023: Chronic Pain Management and General Behavioral Health Integration.

For several years, NARHC has been advocating for CMS to extend Remote Patient Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) billing privileges to RHCs.

What CMS Proposed
In the 2024 MPFS proposed rule, CMS extended RPM and RTM billing opportunities to RHCs and FQHCs under the general care management code of G0511. CMS also proposed entirely new care management codes for Community Health Integration (CHI) and Principal Illness Navigation (PIN) services, all through the G0511 code.

Additional details on the specific codes and services in the RPM, RTM, CHI, and PIN categories can be found here.

Currently, G0511 reimburses at the average of the PFS rates for all services captured (and equally weighted) in the consolidated code. Beginning in 2024, CMS is proposing to use a weighted average of the services billable under G0511. However, because RHCs bill using a consolidated code, there is no utilization data on the various CCM services provided in RHCs. Therefore, in their proposed weighted average, CMS uses utilization data from non-RHC physician offices.

Under the proposed methodology, the 2024 G0511 reimbursement amount would be $72.98. While this is a decrease from the 2023 reimbursement rate, it is not as significant as the decrease would have been simply using the true average methodology.

NARHC Comments
NARHC commended CMS for creating a mechanism for RHCs to provide and bill for RPM/RTM services that would not fit our traditional definition of a reimbursable encounter. Additionally, we appreciate the creation of the new CHI and PIN codes in acknowledgment of the care and social services provided by auxiliary members of a care team, such as Community Health Workers and Peer Specialists.

However, NARHC pointed out that Medicare Claims Processing Manual Chapter 9 states “HCPCS code G0511 or G0512 can only be billed once per month per beneficiary and cannot be billed if other care management services are billed for the same time period.” Therefore, if an RHC patient is already enrolled in a clinic’s CCM program, regardless of whether they may benefit from additional services like RPM, CHI, etc.; the RHC will only be eligible for one G0511 reimbursement for that patient each month. This differs from fee-for-service flexibilities, in that FFS providers can bill RPM, CCM, CHI, and PIN all for the same patient, in the same month, so long as time and services are not duplicative.

NARHC asked CMS to change their policy to allow multiple G0511 services per month, or consider a different approach overall, to ensure that safety-net providers and their patients are not disadvantages by this special payment rule. We provided three different solutions to the issue, including potential pros and cons for each, such as:

  1. Allowing for multiple G0511 payments per month distinguished by modifiers;
  2. Creating several sets of G-codes to represent distinct care management services;
  3. Allowing RHCs to bill the full suite of care management codes similar to how traditional fee-for-service providers bill for such services.

Regarding the proposed payment methodology revision, NARHC agreed with a weighted average methodology revision. NARHC emphasized that CMS must consider other care management reimbursement structures altogether to ensure that RHCs are not limited to one billable care management service per patient per month while traditional fee for service offices can bill many different care management services together.

What CMS Finalized

CMS finalized their proposal to add the suite of RPM and RTM services, as well as two new codes for each CHI and PIN (G0019, G0022, G0023, and G0024, respectively) all to G0511. Most importantly, they clarified that an RHC may bill G0511 multiple times in a calendar month so long as they are: “medically reasonable and necessary, meet all requirements, and not be duplicative of services paid to RHCs and FQHCs under the general care management code for an episode of care in a given calendar month.”

NARHC is very pleased by this clarification and look forward to seeing RHCs expand their care management services to expand these services to eligible patients.

While certainly a positive step forward, we still have many questions as to the details of expanded G0511 implementation. In response to our suggested options listed above, CMS stated: “We appreciate the commenter’s recommendations on how to operationalize and track HCPCS code G0511 when billed multiple times in a calendar month. We did not propose these options in the CY 2024 PFS proposed rule; however, we will take these options into consideration for future rulemaking.”

Based on our interpretation of the various services, especially complex patients may theoretically benefit, without double counting of services/minutes, from CCM, RPM, CHI, and PIN in a single month. However, given that these will all be billed as G0511 without the requirement for any sort of modifier, determining the “reasonableness” of these multiple G0511 claims may be challenging. Other questions include whether multiple of the five distinct codes in the RPM service list (i.e., device set-up and collection and interpretation of the data) can also be billed concurrently by the RHC. Based on the language in this final rule, it is unclear to us what exactly the parameters are regarding multiple G0511 codes per patient per month.

We believe that CMS will need to revise various guidance documents and provide clear direction to the Medicare Administrative Contractors (MACs) in order to ensure that the policy is implemented uniformly and that claims with multiple G0511s are not unnecessarily denied.

Finally, CMS finalized the proposal to change the G0511 payment methodology to the weighted average of all included codes. This is estimated to be approximately $73.00 in 2024, however CMS will post the final 2024 payment rate soon.

Intensive Outpatient Program Services

What CMS Proposed
In the OPPS proposed rule, CMS proposed to implement various provisions from the Consolidated Appropriations Act of 2023 regarding the new treatment category Intensive Outpatient Program (IOP) services.

As directed by Congress, RHCs, as well as hospital outpatient departments, community mental health centers, and FQHCs, can begin billing for these services on January 1, 2024, and RHCs will be reimbursed under a special payment rule.

Intensive Outpatient Program (IOP) services are behavioral health services provided through an outpatient setting, i.e., not an inpatient or residential setting, nor the patient’s home, that provides less than 24-hour per day care. The psychiatric services provided through IOP are for those individuals with an acute mental illness such as substance use disorders, depression, schizophrenia, and others. IOP is a distinct program from partial hospitalization programs (PHPs) and is understood to be less intensive than PHP; however, IOP is for patients requiring a higher level of care than isolated outpatient visits with a behavioral health provider.

CMS specifies that the services eligible to be provided under the IOP benefit include:

  • Individual and group therapy with physicians, psychologists, and other mental health professionals as authorized by state law
  • Occupational therapy
  • Furnishing of drugs and biologics for therapeutic purposes that are not self-administered
  • Family counseling (as part of treatment of the patient’s condition)
  • Patient training and education
  • Individualized activity therapies
  • Diagnostic services
  • Other related services for diagnosis and active treatment intended to improve or maintain the patient’s condition and function

In order for a patient to qualify for IOP services, a physician must certify that a patient needs behavioral health services for at least 9, but no more than 19 hours per week. The certification of eligibility must be done by the physician at least once every other month. The patient’s plan of care must adequately demonstrate that the individual:

  • Requires at least 9 hours of therapeutic services per week
  • Is likely to benefit from these coordinated services more than they would individual sessions of outpatient treatment
  • Does not need 24-hour care
  • Has a separate support system outside of the IOP
  • Has received a mental health diagnosis
  • Is not a danger to themselves or others
  • Has the cognitive and emotional ability to tolerate the IOP

IOP services are at a level above isolated behavioral health encounters between qualified practitioners and patients. Therefore, these services are not to be billed as RHC encounters. Instead, as CMS has done with other services including care management, telehealth, etc. RHCs are eligible for reimbursement under a special payment rule.

RHCs will receive a flat payment per day which CMS is proposing as $284 in 2024. This corresponds to an anticipated 3 separate qualifying services per day. CMS is proposing to require that RHCs report condition code 92 to identify IOP services.

The 3 services per day would be any of those found in Table 43: Proposed HCPCS Applicable for PHP and IOP (page 364 of the HOPPS Proposed Rule). In order to qualify for payment, at least one of the three services must be from Table 44 Proposed Partial Hospitalization and Intensive Outpatient Primary Services (page 367).

In its proposal, CMS sought comment as to whether the $284.00 payment rate should be adjusted by geographic area and also if RHCs should be eligible to bill for the equivalent of “4-service days,” reimbursable in the hospital-based provision of IOP services at $368.18 per day, as opposed to just the “3-service days” reimbursement of $284.00.

As these services are mental health services, an IOP service and a separate mental health encounter would not be eligible for same day billing (RHC All-Inclusive Rate reimbursement plus $284). However, RHCs could bill for IOP services and a separate medical visit for the same patient on the same day. Finally, costs associated with IOP services will need to be carved out of an RHC’s cost report as to not impact the All-Inclusive Rate.

NARHC Comments

We expressed our support for the codified changes to the RHC scope of benefits and services, certification, and plan of care requirements. Broadly, we also shared support for the special payment rule established for RHCs to offer these services outside the scope of an RHC encounter.

However, we believe that RHCs should have the same opportunities as hospital based IOPs to bill, and be adequately reimbursed for, the furnishing of 4-service days as well as 3- service days, depending on the number of services appropriate for their patients. Given that IOP is an entirely new benefit and that there is no data on its utilization or cost, NARHC implored CMS to grant broad flexibilities to all providers eligible for the benefit so it can be used as necessary for patients. We believe that based on the number of qualified services (3 or 4) RHCs should be eligible to receive the associated payment, $284.00 or $368.18, respectively, similar to how the program will be structured for hospital based IOPs.

NARHC also expressed support for a geographic adjustment to the payment rate given that RHCs may need to recruit and retain additional providers and staff or make additional investments in their clinics with associated expenses that may be higher due to their rural locations.

CMS proposes that for hospital-based IOPs, and Community Mental Health Centers (CMHCs) the 3- service payment rate would also be utilized for days with three or fewer services, “to accommodate occasional instances when a patient is unable to complete a full day of IOP,” in order to “not discourage treatment” when a patient enrolled in IOP cannot complete 3-service day. While this is expected to be infrequently used for such a scenario, NARHC asked for these flexibilities to be extended to RHCs as well. Finally, we requested that CMS provide MACs with explicit instruction on this newly billable service and provide oversight to ensure that it is implemented uniformly, so that RHCs offering these services do not face barriers to receiving reimbursement for such services.

What CMS Finalized

Broadly, CMS finalized the IOP details (certification, plan of care, patient eligibility, IOP services, and payment etc.) as proposed.

Regarding payment, CMS elected to not grant RHCs offering IOP services the flexibility to provide 3-or 4-service days, in part citing the RHC statute that says RHCs may not be “primarily engaged in the treatment of mental diseases.” Given this arbitrary barrier to full integration of behavioral health services in RHCs, CMS expects that uptake of this new benefit will be slower and that the 3-service day only is appropriate.

CMS also did not implement a geographic adjustment but said they may take the comments into account for future rulemaking.

We look forward to seeing the ways that RHCs will engage in offering these services to their patients and appreciate CMS’ willingness to revisit such regulations, within their authority, dependent on rural provider experiences and potentially unforeseen limitations over the next few years of implementing IOP.

Nurse Practitioner Definition Change


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. However, CMS acknowledged that there are various other national certifying organizations with standards for Nurse Practitioners that more fully represent available certifications available for NPs.

What CMS Proposed

They proposed 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;


“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 listed 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.

CMS also sought comments on whether NPs working in RHCs should be required to be certified in “primary care” or if that specificity should be removed from 491.2.

NARHC Comments

NARHC commented in support of these changes to expand the breadth of allowable certifying entities that will better capture the full suite of NPs adequately trained to provide care in RHCs, and to increase the flexibility of RHCs to utilize the providers best equipped to join its care team, without limitations that such a “primary care” specification may require.

What CMS Finalized

CMS finalized both definition changes as proposed.

Other Proposals Not Included

In our 2024 MPFS comments NARHC continued to advocate for changes to the Annual Wellness Visit limitations in the RHC setting. Specifically, we asked CMS to amend the definition of an RHC medical visit to allow for Annual Wellness Visits (other than IPPEs) to be eligible for same day billing and to allow Registered Nurses (RNs) to perform AWVs as they are eligible to do in Medicare fee-for-service settings.

While not included in this year’s final rule, CMS stated that the recommendation “has been informative and we will take it into consideration for possible future rulemaking”

As CMS will immediately begin crafting the RHC provisions to be included in the 2025 proposed rules released next summer, NARHC maintains a running list of regulatory changes that would benefit the RHC community and will convey these in upcoming meetings with the CMS RHC payment and CMS RHC survey & certification teams.

Please contact Sarah Hohman, NARHC Director of Government Affairs at with any questions or other feedback, and don’t forget to register for NARHC’s December 11th webinar on these finalized rules here.