CMS SOM App. G, Tag J-0082

(1) . . . Rural health clinic staffs must also include one or more physician’s assistants

or nurse practitioners.

(3) The physician assistant, nurse practitioner, . . . may be the owner or an employee

of the clinic . . ., or may furnish services under contract to the clinic . . . In the case

of a clinic, at least one physician assistant or nurse practitioner must be an employee

of the clinic.

§491.2 Definitions. As used in this subpart, unless the context indicates

otherwise:

Nurse practitioner means a person who meets the applicable State requirements

governing the qualifications of nurse practitioners, and who meets at least one of the

following conditions:

(1) Is certified as a nurse practitioner by a recognized national certifying body that

has established standards for nurse practitioners and possesses a master’s or doctoral

degree in nursing practice; or

(2) Has satisfactorily completed a formal 1 academic year educational program

that:

(i) Prepares registered nurses to perform an expanded role in the delivery of

primary care;

(ii) Includes at least 4 months (in the aggregate) of classroom instruction and a

component of supervised clinical practice; and

(iii) Awards a degree, diploma, or certificate to persons who successfully complete

the program; or

(3) Has successfully completed a formal educational program (for preparing

registered nurses to perform an expanded role in the delivery of primary care) that

does not meet the requirements of paragraph (2) of this definition, and has been

performing an expanded role in the delivery of primary care for a total of 12

months during the 18-month period immediately preceding the effective date of this

subpart.

Physician assistant means a person who meets the applicable State requirements

governing the qualifications for assistants to primary care physicians, and who

meets at least one of the following conditions:

(1) Is currently certified by the National Commission on Certification of Physician

Assistants to assist primary care physicians; or

(2) Has satisfactorily completed a program for preparing physician's assistants that:

(i) Was at least 1 academic year in length;

(ii) Consisted of supervised clinical practice and at least 4 months (in the aggregate)

of classroom instruction directed toward preparing students to deliver health care;

and

(iii) Was accredited by the American Medical Association's Committee on Allied

Health Education and Accreditation; or

(3) Has satisfactorily completed a formal educational program (for preparing

physician assistants) that does not meet the requirements of paragraph (2) of this

definition and assisted primary care physicians for a total of 12 months during the

18-month period that ended on December 31, 1986.

Interpretative Guidelines § 491.8(a)(1) & (3)

In addition to having a physician on staff, the RHC’s health care staff must also include

one or more nurse practitioner(s) (NP) or physician assistant(s) (PA), as defined at §

491.2. The RHC’s NP and/or PA must meet the Medicare definition of an NP or PA and

be licensed in accordance with the law of the State in which the RHC is located and

practicing within their permitted State scope of practice.

At least one NP or PA must be an employee of the RHC (note that a clinic’s owner may

also be an employee; this is at the owner’s discretion). CMS interprets an “employee” to

mean an individual to whom the clinic issues an IRS Form W-2, Wage and Tax

Statement. (See 79 FR 25462, May 2, 2014). However, once the clinic has employed at

least one NP or PA, the other practitioners may furnish services under contract to the

clinic instead of being employees. These other NPs or PAs may contract directly with the

clinic or may have an arrangement with a third party that contracts with the clinic to

furnish the practitioner’s services.

In all cases the RHC must have sufficient practitioners, both physician and non-physician, to furnish the volume of RHC services it provides to its patients, consistent

with accepted standards of practice.

• As provided by § 1861(aa)(7) of the Act, and implemented in Section 2248 of the

SOM, an existing RHC may request a waiver of the requirement to employ a NP or

PA. The mid-level staffing waiver is applicable to Medicare-participating RHCs

only. Initial applicants to participate in Medicare as an RHC are not eligible for

staffing waivers. CMS grants a currently certified RHC a one-year waiver of the

requirement to employ a NP or PA if:

• The RHC submits the written request for a waiver to the appropriate SA;

• The RHC demonstrates that it has been unable, despite reasonable efforts, to hire a

NP or PA in the previous 90-day period; and

• The RHC’s request is submitted six months or more after the date of the expiration of

any previous such waiver for the RHC.

The SA is responsible for reviewing the evidence the RHC provides regarding its efforts

to hire an NP or PA in the previous 90 days and recommending approval or disapproval

of the requested waiver to the RO. The SA must complete its review and

recommendation within 30 calendar days of receiving the written waiver request from the

RHC.

The waiver is deemed to have been granted, unless the waiver request is denied by the

RO within

60 calendar days after the date the SA received the RHC’s waiver request. In cases

where the waiver request is deemed to have been approved, the effective date of the 1-year waiver is the 61st day after the date the request was received by the SA.

See Section 2248 for more details on the waiver process and the expectations for RHCs

and SAs

Survey Procedures § 491.8(a)(1) & (3)

• Determine that the clinic has at the time of the survey at least one NP or PA who is an

employee of the clinic, as evidenced by the clinic issuing a W-2.

• If the clinic already participates in Medicare as an RHC and does not employ a NP or

PA, check whether there is a valid waiver in effect.