Logan Reid
Rural Emergency Hospitals (REHs) are a relatively new concept, with the first policies for them being established in 2023. They are a new Medicare provider type, enacted in the Consolidated Appropriations Act of 2021. REHs provide emergency department services, observation care, and additional outpatient medical and health services. They are not permitted to provide inpatient services. As of February 2025, there are 36 REHs in the United States, with 77 hospitals considered ideal candidates for conversion. The emergence of REHs may provide important resources to maintain a rural clinician workforce and preserve jobs for healthcare workers in rural communities.
| Characteristics | Values |
|---|---|
| Number of rural emergency hospitals (REHs) in the US | 36 |
| Date of data | February 2025 |
| Number of hospitals that may consider converting to REH status | 389 |
| Number of hospitals that are "ideal candidates" for conversion | 77 |
| Number of hospitals that may consider becoming an REH | 68 |
| Number of hospitals that converted to rural emergency designation since January 2023 | 36 |
| Eligibility criteria for REH status | Critical Access Hospitals and rural acute care, tribally-operated, and Indian Health Service (IHS) hospitals with 50 or fewer beds that were open on December 27, 2020 |
| Benefits of REHs | Payment of the Outpatient Prospective Payment System (OPPS) rate plus 5% for all outpatient department services provided to Medicare patients |
| Disadvantages of REHs | Loss of certain services like surgical procedures requiring inpatient care, which may worsen access for patients |
| Opportunities provided by REHs | Preservation of core outpatient services like primary care, maternal care, and mental health; potential for expanded access to previously unavailable services like preventive screening mammography or colonoscopy; improved regional relationships and streamlined rural patient access to specialty care |
| REH enrollment policies | Refer to Chapter 10, Medicare Enrollment, of the Medicare Program Integrity Manual |
| Technical assistance for REHs | Provided by the Health Resources and Services Administration's (HRSA) Rural Emergency Hospital Technical Assistance Center |
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What You'll Learn
As of February 2025, there are 36 REHs in the US
As of February 2025, there were 36 Rural Emergency Hospitals (REHs) in the United States. The REH designation was established by Congress in December 2020, in response to the loss of healthcare services in rural areas due to hospital closures. The REH designation became effective on January 1, 2023, and since then, 36 hospitals have converted to this model.
REHs are required to provide 24-hour emergency and observation services and can elect to provide additional outpatient services, such as behavioral health, radiology, laboratory, and outpatient rehabilitation. They receive benefits such as additional monthly facility payments and a 5% increase in payments for certain outpatient services for Medicare patients.
The emergence of REHs represents a fundamental shift in rural healthcare delivery, as hospitals transition from inpatient care to exclusively outpatient and emergency services. This model aims to preserve access to healthcare in rural communities by streamlining financial resources. While this approach may improve access to care in some areas, it could also worsen access for those requiring inpatient care, as patients will need to be transferred to larger centers or take on greater travel burdens.
The financial health of rural hospitals has been a concern for policymakers, and recent policy discussions have considered options for support, including in the context of reductions in Medicaid and Medicare spending. Despite these efforts, strains on hospital finances may have implications for both access to care and local economies in rural areas.
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REHs must comply with state licensure rules
As of February 2025, there are 36 Rural Emergency Hospitals (REHs) located throughout the United States. To be eligible for REH status, hospitals must meet certain criteria, including having 50 or fewer beds and being located in a rural area. In addition to federal requirements, REHs must also comply with state licensure rules, which can vary from state to state.
The National Conference of State Legislatures (NCSL) tracks which states have proposed and enacted new laws regarding REH licensure. Some states may have existing laws and regulations that can be applied to REHs. If a state licenses REHs under the same rules as other healthcare facilities, the REH must comply with those rules. However, if a state's rules are not compatible with the Medicare REH Conditions of Participation, the facility will not be able to operate as an REH.
The process for converting to an REH typically involves completing a CMS Federal Enrollment application and a state licensure application. Facilities should complete the CMS enrollment process before submitting the state licensure application. There are no licensure fees associated with converting to an REH. However, it is important to note that the specific requirements and rules for REH licensure may differ depending on the state in which the hospital is located.
While the NCSL provides information on the legislative landscape for REHs, the National Academy of State Health Policy (NASHP) offers a guide to legislative and regulatory considerations for states interested in establishing the REH provider type. This guide can assist states in navigating the process of creating and implementing REH licensure rules. Additionally, the North Carolina Rural Health Research Program maintains a list of REHs, including their names, addresses, previous Medicare payment designations, and effective dates of REH status.
In summary, while there are federal requirements that all REHs must meet, compliance with state licensure rules is also crucial for hospitals seeking to operate as REHs. The specific rules and requirements can vary by state, and it is important for hospitals to understand and adhere to the applicable laws and regulations in their respective states. By working together with state legislatures and regulatory bodies, REHs can ensure they are providing the best possible care to their communities while adhering to the necessary legal and operational standards.
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REHs can't provide inpatient services
Rural Emergency Hospitals (REHs) are a new provider type established by the Consolidated Appropriations Act of 2021 to address the growing concern over closures of rural hospitals. They are intended to provide emergency services, observation care, and additional outpatient services to patients in rural areas. As of February 2025, there are 36 REHs located throughout the United States, with more hospitals considering conversion to REH status.
REHs are not designed to provide inpatient services and must adhere to specific guidelines regarding patient stays. Since REHs focus on outpatient care, they cannot exceed an annual average length of stay of 24 hours per patient. This timeframe begins at the patient's registration, check-in, or triage and ends upon discharge. While patients requiring inpatient psychiatric or rehabilitation services may need to stay longer if an inpatient bed is unavailable, such cases are expected to be infrequent. REHs are required to maintain documentation on attempts to transfer patients and justify extended stays.
The inability to provide inpatient services is a defining characteristic of REHs, distinguishing them from Critical Access Hospitals (CAHs) and acute care hospitals. To be eligible for REH status, acute care hospitals must have 50 or fewer beds and be located in rural areas. They can choose to offer specific outpatient services while still receiving reimbursement under their respective fee schedules. However, they cannot offer inpatient acute care services, except for skilled nursing facility services provided in a distinct part unit.
The focus on outpatient care in REHs allows them to address the immediate medical needs of patients in rural communities. While they cannot provide long-term inpatient care, they can stabilize patients, provide observation, and facilitate transfers to other facilities if needed. This model helps ensure that rural residents have access to essential healthcare services without relying on inpatient admissions.
The establishment of REHs aims to prevent the closure of rural hospitals and improve healthcare equity for rural communities. By converting to REH status, hospitals can continue providing critical services while receiving reimbursement for their outpatient services. However, the lack of inpatient services at REHs also underscores the importance of coordinating care with other healthcare providers in the region to ensure that patients can access the full range of necessary medical treatments.
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REHs can help maintain a rural clinician workforce
Rural Emergency Hospitals (REHs) are a relatively new concept, with the first policies for them being established in January 2023. As of February 2025, there are 36 REHs located throughout the United States. REHs are a type of hospital that provides emergency department services, observation care, and additional outpatient medical and health services. They are prohibited from providing inpatient services.
The emergence of REHs may provide important resources to maintain a rural clinician workforce in several ways. Firstly, by averting hospital closures, REHs preserve jobs for local healthcare workers and the broader community. This helps to maintain a rural clinician workforce by protecting the livelihoods of those already working in rural areas.
Secondly, REHs can receive increased reimbursement for outpatient services, which can help maintain and expand practices for outpatient clinicians. This may encourage clinicians to work in rural areas by providing financial stability and the opportunity to develop their practices. REHs can also support rotating specialty clinics, which can attract clinicians who value variety in their work.
Thirdly, REHs can improve the quality of care that rural patients receive. By transferring patients requiring inpatient hospital services to larger centers, patients can benefit from specialized expertise and improved access to specialty care. This can enhance the reputation of rural hospitals and make them more attractive to potential clinicians.
However, it is important to note that the elimination of inpatient care at REHs may make it more challenging to recruit and retain clinicians who provide a broad range of services needed in rural communities. For example, general surgeons who can perform common outpatient procedures may be harder to attract and retain in rural areas. Therefore, while REHs can help maintain a rural clinician workforce in some respects, they may also face challenges in recruiting and retaining clinicians who provide a comprehensive range of services.
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REHs can expand access to outpatient services
Rural Emergency Hospitals (REHs) are a relatively new concept, with the first policies for them being established as recently as January 2023. As of February 2025, there are 36 REHs across the United States. A study from February 2023 estimated that 389 rural hospitals may consider converting to REH status, with 77 hospitals deemed "ideal candidates".
Furthermore, REHs can leverage interfacility partnerships and telehealth technologies to extend specialist expertise to primary care clinicians in underserved rural areas. This collaboration between specialty and primary care clinicians can improve access to outpatient services that may not be available directly at the REH.
REHs also facilitate the transfer of patients requiring inpatient hospital services to larger centers, ensuring they receive care from dedicated experts in their respective fields. While this may lead to improved quality of care, it also means that certain inpatient services, such as surgical procedures, will no longer be available at the REH. Overall, REHs aim to strike a balance between maintaining essential services and expanding access to outpatient care in rural communities.
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Frequently asked questions
As of February 2025, there are 36 Rural Emergency Hospitals (REHs) in the United States.
A Rural Emergency Hospital is a facility that provides emergency department services, observation care, and additional outpatient medical and health services. REHs are not allowed to provide inpatient services, except in a distinct part licensed as a skilled nursing facility to provide post-hospital extended care services.
Rural Emergency Hospitals can help to maintain an adequate rural clinician workforce and preserve jobs for local healthcare workers. They can also provide important resources and access to essential services in rural areas, such as primary care, maternal care, and mental health services.
One challenge of Rural Emergency Hospitals is the potential worsening of access to certain services, particularly inpatient care. This may result in longer travel times for patients requiring hospital admission. Additionally, recruiting and retaining rural clinicians may become more difficult with the elimination of inpatient care.
