Rule2024-00415
Promoting Telehealth in Rural America
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
January 11, 2024
Effective
February 12, 2024
Issuing agencies
Federal Communications Commission
Abstract
In this document, the Federal Communications Commission (Commission) seeks to provide vital support to assist rural health care providers with the costs of broadband and other eligible services. By offering discounted rates for these services, the Rural Health Care (RHC) Program enables health care providers to better treat patients in rural areas that often have fewer medical resources and higher service rates than in urban areas.
Full Text
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<title>Federal Register, Volume 89 Issue 8 (Thursday, January 11, 2024)</title>
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[Federal Register Volume 89, Number 8 (Thursday, January 11, 2024)]
[Rules and Regulations]
[Pages 1834-1846]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2024-00415]
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FEDERAL COMMUNICATIONS COMMISSION
47 CFR Part 54
[WC Docket No. 17-310; FCC No. 23-110; FR ID 195910]
Promoting Telehealth in Rural America
AGENCY: Federal Communications Commission.
ACTION: Final rule.
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SUMMARY: In this document, the Federal Communications Commission
(Commission) seeks to provide vital support to assist rural health care
providers with the costs of broadband and other eligible services. By
offering discounted rates for these services, the Rural Health Care
(RHC) Program enables health care providers to better treat patients in
rural areas that often have fewer medical resources and higher service
rates than in urban areas.
DATES: Effective February 12, 2024, except for Sec. Sec. 54.601(b) and
(c) (amendatory instruction 2) and 54.622(e)(1)(i) through (ii) and
(i)(3)(iv) (amendatory instruction 4), which are delayed indefinitely.
The Commission will publish a document in the Federal Register
announcing the effective date for those rule sections.
FOR FURTHER INFORMATION CONTACT: Philip A. Bonomo,
<a href="/cdn-cgi/l/email-protection#ca9aa2a3a6a3bae488a5a4a5a7a58aaca9a9e4ada5bc"><span class="__cf_email__" data-cfemail="d282babbbebba2fc90bdbcbdbfbd92b4b1b1fcb5bda4">[email protected]</span></a>, Wireline Competition Bureau, 202-418-7400 or
TTY: 202-418-0484. Requests for accommodations should be made as soon
as possible in order to allow the agency to satisfy such requests
whenever possible. Send an email to <a href="/cdn-cgi/l/email-protection#23454040161317634540400d444c55"><span class="__cf_email__" data-cfemail="e2848181d7d2d6a2848181cc858d94">[email protected]</span></a> or call the Consumer
and Governmental Affairs Bureau at (202) 418-0530 (voice), 202-418-0432
(TTY).
SUPPLEMENTARY INFORMATION: This is a synopsis of the Commission's Third
Report and (Third R&O) in WC Docket No. 17-310; FCC No. 23-110, adopted
on December 13, 2023, and released on December 14, 2023.The full text
of this document is available for public inspection during regular
business hours at Commission's headquarters 45 L Street NE, Washington,
DC 20554 or at the following internet address: <a href="https://docs.fcc.gov/public/attachments/FCC-23-110A1.pdf">https://docs.fcc.gov/public/attachments/FCC-23-110A1.pdf</a>.
I. Introduction
1. In the Third R&O, the Commission continues its efforts to
improve the effectiveness and efficiency of the Rural Health Care (RHC)
Program. The RHC Program offers discounted rates for broadband and
other communications services to health care providers who use these
increasingly essential services to better treat patients in rural areas
that may have limited resources, fewer medical professionals, and
higher rates for these services than in urban areas. Broadband-enabled
telehealth and telemedicine services in particular have proven to be
critical tools for the effective delivery of health care to millions of
patients in rural areas, as demonstrated by the heightened dependency
on these services during the COVID-19 pandemic. Telemedicine and
telehealth make the provision of high-quality health care a reality for
patients regardless of location or ability to travel. The measures
adopted will enhance the provision of these vital services through the
RHC Program.
2. The Commission adopts four revisions to the RHC Program as
proposed in the Second Further Notice of Proposed Rulemaking, 88 FR
17495, March 23, 2023 (Second FNPRM) (FCC 23-6), aimed at facilitating
participation in and improving the administration of the Program.
First, the Commission revises the RHC Program rules to permit
conditional approval of eligibility for health care providers that
expect to be eligible in the near future to allow them to initiate
competitive bidding and request funding. Second, to give participants
more flexibility with deadlines, the Commission revises its rules to
move back the RHC Program's Service Provider Identification Number
(SPIN) change deadline to align with the invoice deadline. Third, the
Commission simplifies the rules for determining urban rates by
eliminating the seldom-used ``standard urban distance'' component of
the urban rate rules. Fourth, in a separate action to provide more
flexibility with deadlines, the Commission revises the RHC Program
rules to permit health care providers to request changes to the dates
of their evergreen contracts following a funding commitment.
3. In addition to these revisions, the Commission also on its own
motion makes two programmatic improvements to the administration of the
RHC Program and Universal Service Fund. To reduce burdens and promote
efficiency, the Commission harmonizes the RHC Program eligibility
determination process by shifting to the use of a single universal
eligibility form for all program participants. Finally, to free up for
other uses unclaimed RHC Program support, the Commission establishes a
deadline by which health care providers must submit invoices for any
undisbursed funding commitments from funding year 2019 and prior that
do not currently have an applicable invoice deadline.
[[Page 1835]]
II. Discussion
4. In the Third R&O, the Commission continues to improve the RHC
Program by facilitating health care provider participation in and
improving the administration of the Program. Specifically, the
Commission revises the RHC Program rules to permit conditional
eligibility for health care providers and eliminate the seldom-used
``standard urban distance'' component of the urban rate rule. The
Commission also makes two changes relating to RHC Program
administrative deadlines by aligning the SPIN change deadline with the
existing invoice deadline and permitting health care providers to
request a change to evergreen contract dates. The Commission then
amends the rules to shift to the use of the same form when determining
Telecom and Healthcare Connect Fund (HCF) Program eligibility. Finally,
the Commission establishes a deadline by which invoices must be
submitted for undisbursed funding commitments from before funding year
2020.
5. Conditional Approval of Eligibility for Future Eligible Health
Care Providers. The Commission first adopts amendments to the RHC
Program rules to allow conditional approval of eligibility consistent
with what the Commission proposed in the Second FNPRM. The amendments
enable entities that do not meet all eligibility requirements at the
time they seek eligibility determinations to obtain conditional
approval of eligibility, conduct competitive bidding, and request
funding prior to receiving formal approval of eligibility. With this
change, entities granted such conditional approval may conduct
competitive bidding and request funding before they receive formal
eligibility approval, ensuring that they are able to participate in the
RHC Program for the funding year in which they expect to receive a
formal eligibility approval. However, entities with conditional
approval will not receive funding commitments until they meet all
eligibility requirements. The substantive standard used to determine
full eligibility remains unchanged. This change ensures that health
care providers that are not yet eligible during the application window,
but expect to become eligible in the near future, are not locked out of
much needed funding. All commenters who addressed this proposal
supported it, and no commenters opposed this change. This change will
be effective for funding year 2025, the competitive bidding process for
which begins in mid-2024.
6. Eligible health care providers, as defined in section
254(h)(7)(B) of the Communications Act and implemented in the
Commission's rules, are limited to the following categories: (1) post-
secondary educational institutions offering health care instruction,
teaching hospitals, and medical schools; (2) community health centers
or health centers providing health care to migrants; (3) local health
departments or agencies; (4) community mental health centers; (5) not-
for-profit hospitals; (6) rural health clinics; (7) skilled nursing
facilities; and (8) consortia of health care providers consisting of
one or more entities falling into the first seven categories. In
addition, eligible health care providers must be non-profit or public.
In the Telecom Program, only eligible health care providers located in
a ``rural area'' defined in Sec. 54.600(e) of the Commission's rules
can receive support. The HCF Program, on the other hand, permits rural
eligible health care providers as well as non-rural eligible health
care providers participating in a majority-rural consortium to receive
support.
7. To allow health care providers to receive RHC Program funding as
soon as they become eligible, the Commission amends Sec. 54.601 of its
rules to permit entities that expect to meet all eligibility
requirements before the end of a given upcoming funding year to request
and receive a conditional approval of eligibility. The Commission also
amends Sec. 54.622(e)(1) of its rules to allow those entities to make
the required certifications when filing a Request for Services to
initiate competitive bidding. The amendments adopted will enable
entities that receive conditional approval of program eligibility to
conduct competitive bidding and submit funding requests prior to
receiving formal approval of eligibility. However, the substantive
standard used to determine eligibility remains unchanged. Entities that
receive conditional approval of eligibility will not receive funding
commitments until they actually become eligible and receive the formal
approval of eligibility under the existing substantive standard. No RHC
funding shall be committed or disbursed to an entity for any time
period that is prior to the date the entity is formally approved as
eligible. The Commission directs the Universal Service Administrative
Company (Administrator or USAC), upon approval from the Wireline
Competition Bureau (Bureau), to implement the conditional approval of
eligibility mechanism.
8. This change is warranted given the change to a fixed application
filing window in the RHC Program. Before funding year 2016, after an
initial application filing window, the Administrator accepted
applications on a rolling basis until the last day of the funding year.
Since funding year 2017, no applications have been accepted following
the close of the initial application window. Beginning in funding year
2021, the Commission's rules require the Administrator to open an
initial filing window period with an end date no later than April 1
prior to the start of the funding year.
9. In 2016, when applications were still accepted on a rolling
basis and there were two application windows, the Bureau issued the
Hope Community Order, DA 16-855, rel. July 29, 2016 (Hope Order), which
held that that if an entity had not demonstrated its eligibility at the
time of its eligibility determination form submission for a funding
year, it would be ineligible to receive RHC Telecommunications Program
support for that funding year. The change the Commission makes
eliminates this limitation and allows health care providers to seek
conditional eligibility approval so they can participate in the program
in the year in which they expect to become fully eligible, even if they
receive their full eligibility approval after the initial application
window closes. Based on experience administering the program, the
Commission finds it appropriate to eliminate the Hope Order's
requirement that a site be eligible for RHC Program support, which
requires that it qualifies as one of the eligible health care providers
defined by section 254(h)(7)(B) of the Communications Act, at the time
of its request for eligibility determination. In funding year 2013, the
funding year at issue in the Hope Order, the Administrator accepted
applications on a rolling basis throughout the funding year, which
permitted a health care provider to begin receiving funding for RHC
Program supported services within a few months after it became an
eligible entity under section 254(h)(7)(B) of the Communications Act.
Shortly after meeting eligibility requirements, the health care
provider could receive its eligibility determination, engage in
competitive bidding, file a Request for Funding during the rolling
application window, and start to receive funding.
10. Absent this change with the current use of a fixed filing
window, a health care provider might have to wait more than one year
after becoming an eligible health care provider to receive RHC Program
funding. For example, if a new medical provider is in the process of
opening and expects to become eligible under section 254(h)(7)(B) of
the
[[Page 1836]]
Communications Act on July 1, 2025, which is after the initial
application filing window, it may not be able to receive RHC Program
support for funding year 2025 because it could not have been approved
as eligible until after the provider's July 1, 2025 opening date.
Permitting conditional approvals of eligibility will allow health care
providers that are not yet eligible but expect to become an eligible
health care provider in a given upcoming funding year to complete
competitive bidding and file Requests for Funding so they are able to
receive RHC Program funding as soon as they are fully designated as an
eligible health care provider under the Commission's rules.
11. To protect the integrity and success of the RHC program and
ensure that no RHC Program funding is disbursed for entities that are
not yet fully approved as eligible, the Commission adopts the following
safeguards for conditional approvals of eligibility. First, to request
conditional approval of eligibility, an applicant must submit an
eligibility determination form and supporting documentation to the
Administrator, which will include the estimated date that it expects to
meet all eligibility requirements. The documentation must show that the
entity is or reasonably expects to qualify as a public or non-profit
health care provider defined in Sec. 54.600(b) of the Commission's
rules by the estimated eligibility date. Additionally, if applying for
the Telecom Program or if applying as an individual applicant in the
HCF Program, the entity must be located or reasonably expect to be
located in a rural area defined in Sec. 54.600(e) of the Commission's
rules by the estimated eligibility date, or, if not located in such a
rural area, for purposes of applying for the HCF Program, be or plan to
be a member of a majority-rural HCF Program consortium that satisfies
the eligible rural health care provider composition requirement set
forth in Sec. 54.607(b) of the Commission's rules by the estimated
eligibility date.
12. Once the Administrator approves an applicant's conditional
eligibility, the applicant can proceed to conduct competitive bidding
for the conditionally-approved site(s). In order to provide notice of
the applicant's conditional eligibility to potential bidders and
service providers, an applicant engaging in competitive bidding with
conditional eligibility must provide a written indication with its
competitive bidding form indicating (1) that the eligibility is
conditional, and (2) when the estimated expected eligibility date is.
After conducting competitive bidding and signing a service contract,
the applicant can submit a funding request during the application
filing window for a given funding year, provided that the applicant's
estimated expected eligibility date is no later than the end of that
funding year. To ensure that no funding is committed or disbursed for
health care providers that are conditionally eligible under section
254(h)(7)(B) of the Communications Act or the RHC Program rules,
entities with conditional approval of eligibility will not be able to
receive funding commitments or disbursements until they meet all
eligibility requirements and are granted a formal approval of
eligibility. This restriction is consistent with the Commission rule
that RHC Program funding is provided to eligible health care providers
for services for health care purposes.
13. An applicant with conditional approval of eligibility is
expected to notify the Administrator within 30 calendar days of its
actual eligibility date and provide documentation confirming that it is
actually eligible. If the Administrator determines that the entity
meets the requirements for a public or non-profit health care provider
defined in Sec. 54.600(b) Commission's rules and the requirements for
rural location or majority-rural HCF consortium membership set forth in
the Commission's rules, the Administrator shall formally approve the
applicant's eligibility and designate the applicant as an eligible
health care provider. The Administrator will then review the
applicant's funding request and issue a funding commitment or denial in
a timely manner. The funding commitment shall cover only a time period
that starts no earlier than the applicant's actual approved eligibility
date and that is within the funding year for which support was
requested. No funding shall be committed to ineligible entities or
entities with only conditional approval and any support erroneously
disbursed to ineligible entities or entities with only conditional
approval must be recovered. The Commission directs the Administrator to
implement these requirements in its procedures and delegate authority
to the Bureau to issue further direction consistent with the Third R&O
as necessary.
14. Alignment of the Service Provider Identification Number Change
Deadline with Invoice Deadline. The Commissions next amends its rules
to move back the Service Provider Identification Number (SPIN) change
filing deadline to align with the invoice filing deadline, rather than
the service delivery deadline. A SPIN is a unique number that the
Administrator assigns to an eligible service provider seeking to
participate in the universal service support programs. An applicant
under the HCF Program or Telecom Program may request either a
``corrective SPIN change'' (in cases not involving a change in the
service provider associated with the applicant's funding request
number) or an ``operational SPIN change'' (in cases involving a change
to the service provider associated with the applicant's funding request
number). The current filing deadline to submit a SPIN change request is
no later than the service delivery deadline, which, with limited
exceptions, is June 30 of the funding year for which program support is
sought. The invoice deadline is 120 days after the later of the service
delivery deadline or the date of a revised funding commitment letter.
In the Second FNPRM, the Commission proposed to align the SPIN change
deadline with the invoice deadline and commenters supported this
change.
15. The Commission moves back the deadline for requesting SPIN
changes effective funding year 2023 in response to program participant
requests asserting that the nature of corrective SPIN changes creates a
``recurring hardship for applicants'' unable to meet the deadline,
which, in turn, results in deadline waiver requests filed with the
Commission. According to these participant comments, two commonly
recurring situations support a change to the corrective SPIN change
deadline: (1) mergers and acquisitions that can occur at any time
during the funding year and (2) a service provider that assigns one of
its multiple SPINs to a funding request without advising the healthcare
provider as to the correct SPIN before invoicing begins, a situation
that, in many instances, occurs after the service delivery deadline has
passed. These commenters maintain that changing the deadline to request
a corrective SPIN change to match the invoice deadline will provide the
Administrator with sufficient time to process the change request
without the need for applicants to request deadline waivers from the
Commission. The Commission agrees with these commenters that the
current deadline for requesting corrective SPIN changes imposes
unnecessary burdens and challenges for program participants that a
later-in-time deadline will largely eliminate.
16. The Commission moves back the SPIN change deadline to align
with the invoice deadline, which, in most cases is 120 days after the
close of the funding year, to reduce the need for applicants to seek,
and for the Commission to address, waivers of the current
[[Page 1837]]
corrective SPIN change deadline. This change facilitates participation
in and the administration of the program, while still maintaining an
administratively reasonable date by which such change requests must be
made. Aligning the SPIN change deadline with the invoice deadline will
not cause Program participants to miss the invoice deadline because a
SPIN change results in a revised commitment letter, which will create a
new invoice deadline 120 days from the issuance of the revised
commitment letter.
17. Simplifying Urban Rate Calculations. In this section, the
Commission simplifies the rules for calculating urban rates for the
Telecom Program by eliminating the rarely-invoked ``standard urban
distance'' provision from its rules. In the Order on Reconsideration,
88 FR 17379, March 23, 2023 (Order on Recon) (FCC 23-6), the Commission
eliminated the Rates Database and reinstated the long-standing rules
for calculating urban rates. These rules provide that the urban rate
for an eligible service shall be a rate no higher than the highest
tariffed or publicly-available rate charged to a commercial customer
for a functionally similar service in any city with a population of
50,000 or more in that state. If, however, the service is provided over
a distance greater than the standard urban distance, which is the
average of the longest diameters of all cities with a population of
50,000 or more within a state, the urban rate is the rate no higher
than the highest tariffed or publicly-available rate provided over the
standard urban distance. In the Second FNPRM, the Commission proposed
to simplify program rules by eliminating the distinction between
services provided over and within the standard urban distance and
proposed to base all urban rates calculations on rates provided in a
city, rather than over the standard urban distance. It also sought
comment on the extent to which health care providers rely on the
standard urban distance distinction to calculate urban rates.
18. Based on the record, the Commission finds that adopting its
proposal to eliminate the standard urban distance provision from the
urban rate rules will help simplify the calculation of urban rates in
the Telecom Program. Eliminating it will make clearer the process for
determining urban rates and there is no evidence that it will adversely
impact health care providers because few, if any, Telecom Program
participants calculate urban rates using this distinction. No
commenters opined on the extent to which health care providers rely on
the standard urban distance provision to calculate urban rates, which
suggests that standard urban distance was not commonly invoked to
calculate urban rates. The only commenter that addressed this proposal,
the Schools, Health & Libraries Broadband (SHLB) Coalition, supported
this change. Therefore, the Commission adopts the proposal to base all
urban rates calculations on rates provided in a city rather than over
the standard urban distance. This change shall be applicable for
funding year 2025.
19. Change of Evergreen Contract Dates. The Commission next amends
the RHC Program rules to permit health care providers to request a
change in the evergreen contract dates following a funding commitment.
Upon approving such a change, the Administrator will issue a revised
funding commitment letter. This change will provide health care
providers with the benefits of evergreen contract designation across
the full length of the contract's term while also reducing the need for
health care providers to seek relief from the Administrator in cases
where a post-commitment evergreen contract date change is necessary.
This new rule will become effective for funding year 2024.
20. Evergreen contracts are multi-year agreements under which
covered services are exempt from the competitive bidding requirements
for the term of the contract, which may be extended by up to an
aggregate of five years. When the Administrator issues a funding
commitment letter, it sets the period for an evergreen contract based
on the estimated service start and end dates provided by the health
care provider on the Request for Funding. However, as the Commission
explained in the Second FNPRM, services sometimes start after the
estimated service start date, which means that the evergreen status of
the contract expires before it would have if the evergreen designation
period was based on the actual service start date. In the Second FNPRM,
the Commission sought comments on whether there should be a process for
health care providers to change evergreen contract dates after a
funding commitment has been made. The Commission also requested
comments on how such a process could be accomplished.
21. SHLB and New England Telehealth Consortium (NETC) support, and
no party opposes, allowing health care providers to request changes to
their evergreen contract dates in cases when the contract supports
those changes. SHLB maintains that such requests should always be
deemed timely and not precluded by expiration of the 60-day window for
an appeal of the original funding commitment. SHLB also suggests that
the Commission clarify that the Administrator should defer to the
parties' interpretation of a contract's start and end date unless it is
``obviously inconsistent'' with the language of the contract.
22. The Commission agrees with SHLB and NETC that health care
providers should be permitted to request evergreen contract changes
following a funding commitment provided the contract supports a change.
Aligning a contract's actual service start date with the start date
that determines the duration of the evergreen contract period will
exempt health care providers from the competitive bidding process for
the full length of the contract, thereby providing certainty to RHC
Program participants. This change will not alter rules or processes for
multi-year commitments or other competitive bidding exemptions.
Accordingly, the Commission amends the RHC Program rules to allow
health care providers to request changes to evergreen contract dates,
subject to the following two requirements.
23. First, the Commission requires that the terms of the evergreen
contract support any requested date change. For example, an evergreen
contract that specifies a start date effective upon signature of the
contracting parties would not be eligible for a contract date change
because the start date is a date established by the contract
independent of the service start date. By contrast, an evergreen
contract with terms specifying a start date tied to the commencement of
services yet to be delivered would be eligible for a date change
regardless of the date of signature. The Commission makes clear that
any changes to the dates of the evergreen contract must be supported by
the contract, and declines to adopt SHLB's suggestion that the
Administrator defer to the contracting parties' interpretation on the
contract timing. As in the case of ``verification of discounts,
offsets, or support amounts'' as a general matter under Sec. 54.707 of
the Commission's rules, it will be incumbent upon applicants to ensure
that the available evidence sufficiently justifies a given date change.
24. Second, the Commission requires that health care providers
request an evergreen contract change within 60 days of the date service
commences. This 60-day window should provide health care providers with
ample time to request a date change without having to resort to
appealing the original funding commitment, which addresses the timing
concern raised by SHLB and
[[Page 1838]]
NETC. The Commission declines, however, to adopt SHLB's approach that
all requests for evergreen contract changes be deemed timely. Such an
open-ended option would provide no incentive to health care providers
to promptly notify the Administrator of evergreen contract date
changes. To memorialize the changed evergreen contract dates, the
Commission directs the Administrator to issue a revised funding
commitment letter to the health care provider reflecting the changed
dates. If the Administrator denies a requested change, the Commission
directs it to issue a letter to the health care provider explaining the
basis for the denial. Finally, the Commission directs the Administrator
to develop procedures subject to prior Bureau approval for accepting
changes to evergreen contract dates consistent with the amended
Commission's rules Sec. 54.622(i)(3), and to publicize instructions on
requesting changes to evergreen contract dates with the stakeholder
community.
25. Single Eligibility Form. To reduce burdens on Telecom Program
applicants and improve the efficiency and operation of the RHC Program,
the Commission next harmonizes the RHC Program eligibility
determination process by establishing a single eligibility
determination form for both the Telecom Program and the HCF Program
that is required to be filed only once. Applicants must first be
determined eligible under section 254(h)(7)(B) of the Communications
Act and RHC Program rules to receive support from the RHC Program. The
Telecom Program and the HCF Program currently have different procedures
for eligibility determinations. In the Telecom Program, applicants
seeking eligibility determinations use the FCC Form 465 (Description of
Services Requested and Certification Form), which is the same form used
to initiate competitive bidding. Thus, even though most Telecom Program
applicants' eligibilities are very unlikely to change from year to
year, they are required to provide, and the Administrator is required
to review, information regarding their eligibility statuses every time
there is a new competitive bidding process, which is generally every
year.
26. In contrast, when the HCF Program was established in 2012, the
Commission instituted a more efficient process for eligibility
determinations by separating the process for eligibility determination
from the process for competitive bidding. In the HCF Program,
applicants file an FCC Form 460 (Eligibility and Registration Form) to
seek a one-time eligibility determination that remains in place unless
there is a material change in the entity's eligibility. After receiving
this eligibility determination, the applicant may file an FCC Form 461
(Request for Services Form) to initiate competitive bidding. Thus,
applicants are able to know whether they are eligible before they spend
time and resources planning competitive bidding. Because the FCC Form
460 is filed only once, the eligibility determination process in the
HCF Program improves efficiency and reduces costs and time for both
health care providers and the Administrator.
27. Therefore, beginning funding year 2025, the FCC Form 460 will
be used for eligibility determinations in the Telecom Program and the
eligibility determination portion will be eliminated from the FCC Form
465. As a result of this change, starting for funding year 2025, the
FCC Form 465 will be used solely for competitive bidding in the Telecom
Program while the FCC Form 461 will continue to be used for competitive
bidding in the HCF Program. Because there are certain differences in
eligibility requirements between the Telecom Program and the HCF
Program, applicants who are determined eligible in one program are not
necessarily eligible in the other program even though one eligibility
determination form is used for both programs. For example, non-rural
public or non-profit health care providers who are members of majority-
rural consortia are eligible to receive support under the HCF Program,
but not under the Telecom Program. Thus, in this example, applicants
whose FCC Form 460s are submitted specifically for the HCF Program and
approved on that basis are not automatically eligible for support in
the Telecom Program and must seek eligibility determinations in the
Telecom Program if they subsequently wish to demonstrate their
eligibility for that program. The Commission directs the Bureau to
amend the FCC Form 460 for eligibility determinations for both the
Telecom Program and the HCF Program and direct the Administrator to
track whether a health care provider is eligible for the Telecom
Program, the HCF Program, or both.
28. As part of adopting the FCC Form 460 for the Telecom Program,
the Commission also amends Sec. 54.601(b) of its rules to extend it to
the Telecom Program effective for funding year 2025. Section 54.601(b)
of the Commission's rules addresses the timing requirements for
eligibility determinations in the HCF Program and requires health care
providers to notify the Administrator of changes to their name,
location, contact information, or eligible entity type. It was adopted
when the Commission established the HCF Program in 2012 as a procedural
rule for specifying the process for determining health care provider
eligibility in the HCF Program. There are no corresponding rules for
the eligibility determination process in the Telecom Program where
applicants previously had to make a new eligibility showing every year
they wished to seek support. Since a single eligibility determination
form will be used for both programs, and thus now in the Telecom
Program, like the HCF Program, applicants will be required to file
separate forms for eligibility determination and request for services,
and findings of eligibility will remain in place absent a material
change in circumstances, it is reasonable to amend Sec. 54.601(b) of
the Commission's rules to make it apply to both programs to provide
greater clarity to program participants.
29. To further reduce unnecessary burdens and ease the
implementation of this change, the Commission directs the Administrator
to deem presumptively eligible for funding year 2025 and beyond any
health care provider with an existing eligibility approval in the
Telecom Program. Because the eligibility status of health care
providers rarely changes, an additional up-front eligibility
determination for funding year 2025 is unnecessary. This direction is
consistent with the eligibility determination process in the HCF
Program. The Commission reminds any health care providers with changes
to conditions that might impact their eligibility status of the
requirement to update the Administrator within 30 days of the change.
As before, health care providers in both the Telecom and HCF Programs
are required to certify their eligibility when filing a Request for
Services to initiate competitive bidding.
30. The Commission emphasizes that its actions do not change the
substantive requirements for determining eligibility in the RHC
Program. It is the RHC Program applicants' obligation to submit
accurate information and certifications regarding their eligibility,
including the obligation to notify the Administrator within 30 days of
a material change in their eligibility information. Because health care
provider eligibility is limited by the Act, the Commission does not
have discretion to waive eligibility requirements, and must recover any
support erroneously disbursed to ineligible entities.
31. De-Obligation of Undisbursed, Un-Invoiced Commitments. The
Commission establishes a deadline of July 1, 2024, for Telecom Program
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participants to submit invoices for funding years 2019 and earlier, the
period during which there was no invoice deadline in the Telecom
Program. After that date, funding commitments from funding year 2019
and earlier that have not yet been invoiced will be de-obligated and
will not be able to be invoiced. The Commission established an invoice
deadline for the Telecom Program effective funding year 2020 in the
Promoting Telehealth Report and Order, 84 FR 54952, Oct. 11, 2019. The
Commission explained that this deadline of 120 days from the service
delivery deadline supported the ``harmonization of the invoice deadline
for RHC programs'' and provided ``applicants with sufficient time to
submit their invoices and seek reimbursements from the Administrator,''
while being ``necessary for the efficient administration of the RHC
program.''
32. There is currently $22.2 million in undisbursed, un-invoiced
commitments from funding year 2019 and earlier, when there was no
invoice submission deadline. Establishing an invoice submission
deadline of July 1, 2024, for Telecom Program funding requests from
funding year 2019 and earlier and de-obligating unused funding is
appropriate for several reasons. It is highly unlikely, given the
significant lapse of time, that a significant portion of this funding
will ever be invoiced, and some of these commitments may be for
services that were ultimately never used. At this point, the
Administrator receives very few invoices for services from prior to
funding year 2019. Further, this deadline provides ample time for
Program participants to assess whether they have undisbursed
commitments requiring invoicing and to complete the invoicing process
for those funding requests. Any funding de-obligated as a result of
this change can be used for more useful purposes.
33. Therefore, all existing Telecom Program commitments from
funding year 2019 and earlier must be invoiced by July 1, 2024. This
decision does not affect the invoice deadline for Telecom Program
funding requests for funding year 2020 and later, which are subject to
the invoice deadlines established in Sec. 54.627 of the Commission's
rules. In the event that the Administrator issues a funding commitment
in the future for a funding request for funding year 2019 or earlier,
invoices for that funding commitment must be submitted within 120 days
of the issuance of a commitment letter.
III. Procedural Matters
A. Paperwork Reduction Act Analysis
34. This document contains new and modified information collection
requirements subject to the Paperwork Reduction Act of 1995 (PRA),
Public Law 104-13. All such requirements will be submitted to the
Office of Management and Budget (OMB) for review under section 3507(d)
of the PRA. OMB, the general public, and other federal agencies will be
invited to comment on any new or modified information collection
requirements contained in this proceeding. The Commission will publish
a separate document in the Federal Register at a later date seeking
these comments. In addition, its noted that, pursuant to the Small
Business Paperwork Relief Act of 2002, Public Law 107-198, see 44
U.S.C. 3506(c)(4), the Commission previously sought specific comment on
how it might further reduce the information collection burden for small
business concerns with fewer than 25 employees.
35. In this present document, the Commission has assessed the
effects of allowing conditional approvals of eligibility, allowing
changes to evergreen contract dates, and adopting for the entire RHC
Program eligibility form filing requirements that previously existed
only in the HCF Program and finds that the additional funding and
administrative conveniences these changes give health care providers
justify these changes.
B. Congressional Review Act
36. The Commission has determined and the Administrator of the
Office of Information and Regulatory Affairs, Office of Management and
Budget, concurs that the rules are non-major under the Congressional
Review Act, 5 U.S.C. 804(2). The Commission will send a copy of the
Third R&O to Congress and the Government Accountability Office pursuant
to Congressional Review Act, see 5 U.S.C. 801(a)(1)(A).
37. In addition, the Commission will send a copy of the Third R&O,
including the Final Regulatory Flexibility Analysis (FRFA), to the
Chief Counsel for Advocacy of the Small Business Administration
pursuant to the Small Business Regulatory Enforcement Fairness Act of
1996.
C. Final Regulatory Flexibility Analysis
38. The Regulatory Flexibility Act of 1980, as amended (RFA),
requires that an agency prepare a regulatory flexibility analysis for
notice-and-comment rulemaking proceedings, unless the agency certifies
that ``the rule will not, if promulgated, have a significant economic
impact on a substantial number of small entities.'' Accordingly, the
Commission has prepared an FRFA concerning the potential impact of the
rule and policy changes adopted in the Third R&O.
39. As required by the RFA, an Initial Regulatory Flexibility
Analysis (IRFA) was incorporated into the Second FNPRM, FCC 23-6, rel.
January 27, 2023. The Commission sought written public comment on the
proposals in the Second FNPRM, including comment on the IRFA. No
comments were filed addressing the IRFA. This FRFA conforms to the RFA.
i. Need for, and Objectives of, the Third R&O
40. In the Third R&O, the Commission seeks to further improve the
Rural Health Care (RHC) Program's capacity to distribute
telecommunications and broadband support to health care providers--
especially small, rural healthcare providers (HCPs)--in the most
equitable and efficient manner possible. Over the years, telehealth has
become an increasingly vital component of healthcare delivery to rural
Americans. Rural healthcare facilities are typically limited by the
equipment and supplies they have and the scope of services they can
offer, which ultimately can have an impact on the availability of high-
quality health care. Therefore, the RHC Program plays a critical role
in overcoming some of the obstacles healthcare providers face in
delivering their services to rural communities. Considering the
significance of RHC Program support, the Commission implements several
measures to most effectively meet HCPs' needs while responsibly
distributing the RHC Program's limited funds.
41. Additionally, the Third R&O adopts proposals from the Second
FNPRM that allow conditional approvals of eligibility to allow soon-to-
be eligible providers to engage in competitive bidding, align the
Service Provider Identification Number (SPIN) change deadline with the
invoice deadline, simplify urban rate calculations, and allow health
care providers to change evergreen contract dates. The Commission also
harmonizes the RHC Program eligibility determination process by
establishing a single eligibility determination form for the Telecom
Program and RHC program and announce a new deadline for the de-
obligation of undisbursed, un-invoiced commitments.
[[Page 1840]]
ii. Summary of Significant Issues Raised by Public Comments in Response
to the IRFA
42. There were no comments filed that specifically address the
rules and policies proposed in the IRFA.
iii. Response to Comments by the Chief Counsel for Advocacy of the
Small Business Administration
43. Pursuant to the Small Business Jobs Act of 2010, which amended
the RFA, the Commission is required to respond to any comments filed by
the Chief Counsel of the Small Business Administration (SBA), and to
provide a detailed statement of any change made to the proposed rule(s)
as a result of those comments. The Chief Counsel did not file any
comments in response to the proposed rules in this proceeding.
iv. Description and Estimate of the Number of Small Entities to Which
the Rules Will Apply
44. The RFA directs agencies to provide a description of and, where
feasible, an estimate of the number of small entities that may be
affected by the rules adopted herein. The RFA generally defines the
term ``small entity'' as having the same meaning as the terms ``small
business,'' ``small organization,'' and ``small governmental
jurisdiction.'' In addition, the term ``small business'' has the same
meaning as the term ``small business concern'' under the Small Business
Act. A ``small business concern'' is one that: (1) is independently
owned and operated; (2) is not dominant in its field of operation; and
(3) satisfies any additional criteria established by SBA.
45. Small Businesses, Small Organizations, Small Governmental
Jurisdictions. The Commission's actions, over time, may affect small
entities that are not easily categorized at present. The Commission
therefore describes, at the outset, three broad groups of small
entities that could be directly affected herein. First, while there are
industry specific size standards for small businesses that are used in
the regulatory flexibility analysis, according to data from SBA's
Office of Advocacy, in general a small business is an independent
business having fewer than 500 employees. These types of small
businesses represent 99.9% of all businesses in the United States,
which translates to 33.2 million businesses.
46. Next, the type of small entity described as a ``small
organization'' is generally ``any not-for-profit enterprise which is
independently owned and operated and is not dominant in its field.''
The Internal Revenue Service (IRS) uses a revenue benchmark of $50,000
or less to delineate its annual electronic filing requirements for
small exempt organizations. Nationwide, for tax year 2020, there were
approximately 447,689 small exempt organizations in the U.S. reporting
revenues of $50,000 or less according to the registration and tax data
for exempt organizations available from the IRS.
47. Finally, the small entity described as a ``small governmental
jurisdiction'' is defined generally as ``governments of cities,
counties, towns, townships, villages, school districts, or special
districts, with a population of less than fifty thousand.'' U.S. Census
Bureau data from the 2017 Census of Governments indicate there were
90,075 local governmental jurisdictions consisting of general purpose
governments and special purpose governments in the United States. Of
this number, there were 36,931 general purpose governments (county,
municipal, and town or township) with populations of less than 50,000
and 12,040 special purpose governments--independent school districts
with enrollment populations of less than 50,000. Accordingly, based on
the 2017 U.S. Census of Governments data, the Commission estimates that
at least 48,971 entities fall into the category of ``small governmental
jurisdictions.''
a. Healthcare Providers
48. Offices of Physicians (except Mental Health Specialists). This
industry comprises establishments of health practitioners having the
degree of M.D. (Doctor of Medicine) or D.O. (Doctor of Osteopathy)
primarily engaged in the independent practice of general or specialized
medicine (except psychiatry or psychoanalysis) or surgery. These
practitioners operate private or group practices in their own offices
(e.g., centers, clinics) or in the facilities of others, such as
hospitals or health maintenance organization (HMO) medical centers. The
SBA small business size standard for this industry classifies a
business having annual receipts of $14 million or less as small. The
2017 Economic Census indicates that 137,366 firms operated in this
industry for the entire year. Of this number, 126,098 firms had revenue
of less than $10 million. Based on this data, the Commission concludes
that a majority of firms operating in this industry are small under the
SBA size standard.
49. Offices of Dentists. This industry comprises establishments of
health practitioners having the degree of D.M.D. (Doctor of Dental
Medicine), D.D.S. (Doctor of Dental Surgery), or D.D.Sc. (Doctor of
Dental Science) primarily engaged in the independent practice of
general or specialized dentistry or dental surgery. These practitioners
operate private or group practices in their own offices (e.g., centers,
clinics) or in the facilities of others, such as hospitals or HMO
medical centers. They can provide either comprehensive preventive,
cosmetic, or emergency care, or specialize in a single field of
dentistry. The SBA small business size standard for this industry
classifies a business having annual receipts of $8 million or less as
small. The 2017 Economic Census indicates that 113,795 firms operated
in this industry for the entire year. Of that number, 112,332 firms had
revenue of less than $5 million. Based on this data, the Commission
concludes that a majority of dental businesses are small entities.
50. Offices of Chiropractors. This industry comprises
establishments of health practitioners having the degree of DC (Doctor
of Chiropractic) primarily engaged in the independent practice of
chiropractic. These practitioners provide diagnostic and therapeutic
treatment of neuromusculoskeletal and related disorders through the
manipulation and adjustment of the spinal column and extremities, and
operate private or group practices in their own offices (e.g., centers,
clinics) or in the facilities of others, such as hospitals or HMO
medical centers. The SBA small business size standard for this industry
classifies a business having annual receipts of $8 million or less as
small. The 2017 Economic Census indicates that 34,414 firms operated in
this industry for the entire year. Of that number, 34,366 firms
operated with revenue of less than $5 million per year. Based on this
data, the Commission concludes that a majority of chiropractors are
small.
51. Offices of Optometrists. This industry comprises establishments
of health practitioners having the degree of O.D. (Doctor of Optometry)
primarily engaged in the independent practice of optometry. These
practitioners examine, diagnose, treat, and manage diseases and
disorders of the visual system, the eye and associated structures as
well as diagnose related systemic conditions. Offices of optometrists
prescribe and/or provide eyeglasses, contact lenses, low vision aids,
and vision therapy. They operate private or group practices in their
own offices (e.g., centers, clinics) or in the facilities of others,
such as hospitals or HMO medical centers, and may also provide the same
services as opticians, such as selling and fitting prescription
eyeglasses and contact
[[Page 1841]]
lenses. The SBA small business size standard for this industry
classifies a business having annual receipts of $8 million or less as
small. The 2017 Economic Census indicates that 17,879 firms operated in
this industry for the entire year. Of this number, 16,792 firms had
revenue of less than $5 million. Based on this data, the Commission
concludes that a majority of firms in this industry are small.
52. Offices of Mental Health Practitioners (except Physicians).
This industry comprises establishments of independent mental health
practitioners (except physicians) primarily engaged in (1) the
diagnosis and treatment of mental, emotional, and behavioral disorders
and/or (2) the diagnosis and treatment of individual or group social
dysfunction brought about by such causes as mental illness, alcohol and
substance abuse, physical and emotional trauma, or stress. These
practitioners operate private or group practices in their own offices
(e.g., centers, clinics) or in the facilities of others, such as
hospitals or HMO medical centers. The SBA small business size standard
for this industry classifies a business having annual receipts of $8
million or less as small. The 2017 Economic Census indicates that
19,316 firms operated in this industry for the entire year. Of that
number, 13,318 firms had revenue of less than $5 million. Based on this
data, the Commission concludes that a majority of mental health
practitioners who do not employ physicians are small.
53. Offices of Physical, Occupational and Speech Therapists and
Audiologists. This industry comprises establishments of independent
health practitioners primarily engaged in one of the following: (1)
providing physical therapy services to patients who have impairments,
functional limitations, disabilities, or changes in physical functions
and health status resulting from injury, disease or other causes, or
who require prevention, wellness or fitness services; (2) planning and
administering educational, recreational, and social activities designed
to help patients or individuals with disabilities, regain physical or
mental functioning or to adapt to their disabilities; and (3)
diagnosing and treating speech, language, or hearing problems. These
practitioners operate private or group practices in their own offices
(e.g., centers, clinics) or in the facilities of others, such as
hospitals or HMO medical centers. The SBA small business size standard
for this industry classifies a business having annual receipts of $11
million or less as small. The 2017 Economic Census indicates that
22,402 firms in this industry operated for the entire year. Of that
number, 21,712 firms had revenue of less than $5 million. Based on this
data, the Commission concludes that a majority of businesses in this
industry are small.
54. Offices of Podiatrists. This industry comprises establishments
of health practitioners having the degree of D.P.M. (Doctor of
Podiatric Medicine) primarily engaged in the independent practice of
podiatry. These practitioners diagnose and treat diseases and
deformities of the foot and operate private or group practices in their
own offices (e.g., centers, clinics) or in the facilities of others,
such as hospitals or HMO medical centers. The SBA small business size
standard for this industry classifies a business having annual receipts
of $8 million or less as small. The 2017 Economic Census indicates that
6,673 firms operated in this industry for the entire year. Of that
number, 6,235 firms had revenue of less than $5 million. Based on this
data, the Commission concludes that a majority of firms in this
industry are small.
55. Offices of All Other Miscellaneous Health Practitioners. This
industry comprises establishments of independent health practitioners
(except physicians; dentists; chiropractors; optometrists; mental
health specialists; physical, occupational, and speech therapists;
audiologists; and podiatrists). These practitioners operate private or
group practices in their own offices (e.g., centers, clinics) or in the
facilities of others, such as hospitals or HMO medical centers. The SBA
small business size standard for this industry classifies firms having
annual receipts of $9 million or less as small. The 2017 Economic
Census indicates that 14,194 firms in this industry operated the entire
year. Of that number, 10,874 firms had revenue of less than $5 million.
Based on this data, the Commission concludes the majority of firms in
this industry are small.
56. Family Planning Centers. This industry comprises establishments
with medical staff primarily engaged in providing a range of family
planning services on an outpatient basis, such as contraceptive
services, genetic and prenatal counseling, voluntary sterilization, and
therapeutic and medically induced termination of pregnancy. The SBA
small business size standard for this industry classifies firms having
annual receipts of $16.5 million or less as small. The 2017 Economic
Census indicates that 1,339 firms in this industry operated for the
entire year. Of that number, 1,014 firms had revenue of less than $10
million. Based on this data, the Commission concludes that the majority
of firms in this industry is small.
57. Outpatient Mental Health and Substance Abuse Centers. This
industry comprises establishments with medical staff primarily engaged
in providing outpatient services related to the diagnosis and treatment
of mental health disorders and alcohol and other substance abuse. These
establishments generally treat patients who do not require inpatient
treatment. They may provide a counseling staff and information
regarding a wide range of mental health and substance abuse issues and/
or refer patients to more extensive treatment programs, if necessary.
The SBA small business size standard for this industry classifies a
firm as small if it has $16.5 million or less in annual receipts. The
2017 Economic Census indicates that 5,637 firms operated for the entire
year. Of this number, 4,534 firms had of less than $10 million. Based
on this data, the Commission concludes that a majority of firms in this
industry are small.
58. HMO Medical Centers. This industry comprises establishments
with physicians and other medical staff primarily engaged in providing
a range of outpatient medical services to the HMO subscribers with a
focus generally on primary health care. These establishments are owned
by the HMO. HMO establishments that both provide health care services
and underwrite health and medical insurance policies are also included
in this industry. The SBA small business size standard for this
industry classifies firms having $39 million or less in annual receipts
as small. The 2017 U.S. Economic Census indicates that 17 firms in this
industry operated for the entire year. However, the 2017 Economic
Census does not provide disaggregated financial information for this
industry, therefore the Commission cannot determine how many of the
firms in this industry are small under the SBA small business size
standard.
59. Freestanding Ambulatory Surgical and Emergency Centers. This
industry comprises establishments with physicians and other medical
staff primarily engaged in (1) providing surgical services (e.g.,
orthoscopic and cataract surgery) on an outpatient basis or (2)
providing emergency care services (e.g., setting broken bones, treating
lacerations, or tending to patients suffering injuries as a result of
accidents, trauma, or medical conditions necessitating immediate
medical care) on an outpatient basis.
[[Page 1842]]
Outpatient surgical establishments have specialized facilities, such as
operating and recovery rooms, and specialized equipment, such as
anesthetic or X-ray equipment. The SBA small business size standard for
this industry classifies firms having annual receipts of $16.5 million
or less as small. The 2017 U.S. Economic Census indicates that 3,888
firms in this industry operated for the entire year. Of that number,
3,132 firms had revenue of less than $10 million. Based on this data,
the Commission concludes that a majority of firms in this industry are
small.
60. All Other Outpatient Care Centers. This industry comprises
establishments with medical staff primarily engaged in providing
general or specialized outpatient care (except family planning centers,
outpatient mental health and substance abuse centers, HMO medical
centers, kidney dialysis centers, and freestanding ambulatory surgical
and emergency centers). Centers or clinics of health practitioners with
different degrees from more than one industry practicing within the
same establishment (i.e., Doctor of Medicine and Doctor of Dental
Medicine) are included in this industry. The SBA small business size
standard for this industry classifies a business with annual receipts
of $22.5 million or less as small. The 2017 U.S. Economic Census
indicates that 5,524 firms operated in this industry for the entire
year. Of this number, 4,584 firms had revenue of less than $10 million.
Based on this data, the Commission concludes that a majority of firms
in this industry are small.
61. Blood and Organ Banks. This industry comprises establishments
primarily engaged in collecting, storing, and distributing blood and
blood products and storing and distributing body organs. The SBA small
business size standard for this industry classifies firms having annual
receipts of $35 million or less as small. The 2017 U.S. Census Bureau
data indicate that 293 firms operated in this industry for the entire
year. Of that number, 219 firms operated with revenue of less than $25
million. Based on this data, the Commission concludes the major of
firms that operate in this industry are small.
62. All Other Miscellaneous Ambulatory Health Care Services. This
U.S. industry comprises establishments primarily engaged in providing
ambulatory health care services (except offices of physicians,
dentists, and other health practitioners; outpatient care centers;
medical and diagnostic laboratories; home health care providers;
ambulances; and blood and organ banks). The SBA small business size
standard for this industry classifies businesses having annual receipts
of $18 million or less as small. 2017 U.S. Bureau Census data show that
2,968 firms operated in this industry for the entire year. Of that
number, 2,810 firms had revenue of less than $10 million. Based on this
data, the Commission concludes that a majority of the firms in this
industry are small. This industry comprises establishments known as
medical laboratories primarily engaged in providing analytic or
diagnostic services, including body fluid analysis, generally to the
medical profession or to the patient on referral from a health
practitioner. The SBA small business size standard for this industry
classifies a business as small if it has annual receipts of $36.5
million or less. 2017 U.S. Census Bureau data indicate that 2,799 firms
operated in this industry for the entire year. Of this number, 2,640
firms had revenue of less than $25 million. Based on this data, the
Commission concludes that a majority of firms that operate in this
industry are small.
63. Medical Laboratories. This industry comprises establishments
known as medical laboratories primarily engaged in providing analytic
or diagnostic services, including body fluid analysis, generally to the
medical profession or to the patient on referral from a health
practitioner. The SBA small business size standard for this industry
classifies a business as small if it has annual receipts of $36.5
million or less. 2017 U.S. Census Bureau data indicate that 2,799 firms
operated in this industry for the entire year. Of this number, 2,640
firms had revenue of less than $25 million. Based on this data, the
Commission concludes that a majority of firms that operate in this
industry are small.
64. Diagnostic Imaging Centers. This U.S. industry comprises
establishments known as diagnostic imaging centers primarily engaged in
producing images of the patient generally on referral from a health
practitioner. The SBA small business size standard for this industry
classifies firms having annual receipts of $16.5 million or less as
small. The 2017 U.S. Economic Census indicates that 3,556 firms
operated in this industry for the entire year. Of that number, 3,233
firms had revenue of less than $10 million. Based on this data, the
Commission concludes that a majority of firms that operate in this
industry are small.
65. Home Health Care Services. This industry comprises
establishments primarily engaged in providing skilled nursing services
in the home, along with a range of the following: personal care
services; homemaker and companion services; physical therapy; medical
social services; medications; medical equipment and supplies;
counseling; 24-hour home care; occupation and vocational therapy;
dietary and nutritional services; speech therapy; audiology; and high-
tech care, such as intravenous therapy. The SBA small business size
standard for this industry classifies a firm having annual receipts of
$16.5 million or less as small. The 2017 Economic Census indicates that
19,414 firms operated in this industry for the entire year. Of that
number, 18,291 firms had revenue of less than $10 million. Based on
this data, the Commission concludes that a majority of firms that
operate in this industry are small.
66. Ambulance Services. This industry comprises establishments
primarily engaged in providing transportation of patients by ground or
air, along with medical care. These services are often provided during
a medical emergency but are not restricted to emergencies. The vehicles
are equipped with lifesaving equipment operated by medically trained
personnel. The SBA small business size standard for this industry
classifies businesses having annual receipts of $20 million or less as
small. The 2017 U.S. Economic Census indicates that 2,744 firms
operated in this industry for the entire year. Of that number, 2,539
firms had revenue of less than $10 million. Based on this data, the
Commission concludes that a majority of firms in this industry is
small.
67. Kidney Dialysis Centers. This industry comprises establishments
with medical staff primarily engaged in providing outpatient kidney or
renal dialysis services. The SBA small business size standard for this
industry classifies firms having annual receipts of $41.5 million or
less as small. The 2017 U.S. Economic Census indicates that 378 firms
operated in this industry for the entire year. Of that number, 271
firms had revenue of less than $25 million. Based on this data, the
Commission concludes that a majority of firms in this industry are
small.
68. General Medical and Surgical Hospitals. This industry comprises
``establishments known and licensed as general medical and surgical
hospitals primarily engaged in providing diagnostic and medical
treatment (both surgical and nonsurgical) to inpatients with any of a
wide variety of medical conditions. These establishments maintain
inpatient beds and provide patients with food services that meet their
nutritional requirements. The
[[Page 1843]]
hospitals have an organized staff of physicians and other medical staff
to provide patient care services and usually provide other services,
such as outpatient services, anatomical pathology services, diagnostic
X-ray services, clinical laboratory services, operating room services
for a variety of procedures, and pharmacy services. The SBA small
business size standard for this industry classifies firms having annual
receipts of $41.5 million or less as small. The 2017 U.S. Economic
Census indicates that 2,948 firms operated in this industry for the
entire year. Of that number, 705 firms had revenue of less than $25
million, while 709 firms had revenue between $25 million and
$99,999,999 and 1,072 firms had revenue greater than $100,000,000.
Based on this data, the Commission concludes that approximately one-
quarter of firms in this industry are small.
69. Psychiatric and Substance Abuse Hospitals. This industry
comprises establishments known and licensed as psychiatric and
substance abuse hospitals primarily engaged in providing diagnostic,
medical treatment, and monitoring services for inpatients who suffer
from mental illness or substance abuse disorders. The treatment often
requires an extended stay in the hospital. These establishments
maintain inpatient beds and provide patients with food services that
meet their nutritional requirements. They have an organized staff of
physicians and other medical staff to provide patient care services.
Psychiatric, psychological, and social work services are available at
the facility. These hospitals usually provide other services, such as
outpatient services, clinical laboratory services, diagnostic X-ray
services, and electroencephalograph services. The SBA small business
size standard for this industry classifies a business having annual
receipts of $41.5 million or less as small. 2017 U.S. Census Bureau
data indicate that 414 firms operated in this industry for the entire
year. Of this number, 174 firms had revenue of less than $25 million.
The Commission notes that 195 firms had revenue between $25 million and
$99,999,999 but are unable to determine the number of firms in this
group that have revenue of $41.5 million or less. Thus, based on the
available data, under the SBA size standard slightly more than one-
third of the businesses in this industry are small.
70. Specialty (Except Psychiatric and Substance Abuse) Hospitals.
This industry consists of ``establishments known and licensed as
specialty hospitals primarily engaged in providing diagnostic, and
medical treatment to inpatients with a specific type of disease or
medical condition (except psychiatric or substance abuse).'' Hospitals
providing long-term care for the chronically ill and hospitals
providing rehabilitation, restorative, and adjustive services to
physically challenged or disabled people are included in this industry.
These establishments maintain inpatient beds and provide patients with
food services that meet their nutritional requirements. They have an
organized staff of physicians and other medical staff to provide
patient care services. These hospitals may provide other services, such
as outpatient services, diagnostic X-ray services, clinical laboratory
services, operating room services, physical therapy services,
educational and vocational services, and psychological and social work
services. The SBA small business size standard for this industry
classifies businesses having annual receipts of $41.5 million or less
as small. 2017 U.S. Census Bureau data indicate that 346 firms operated
in this industry for the entire year. Of that number, 119 firms had
revenue of less than $25 million, while 169 firms had revenue of $25
million or more. Based on this data, the Commission concludes the less
than half of the firms in this industry are small.
71. Emergency and Other Relief Services. This industry comprises
establishments primarily engaged in providing food, shelter, clothing,
medical relief, resettlement, and counseling to victims of domestic or
international disasters or conflicts (e.g., wars). The SBA small
business size standard for this industry classifies firms having annual
receipts of $36.5 million or less as small. The 2017 U.S. Economic
Census indicates that 499 firms operated in this industry for the
entire year. Of that number, 413 firms had revenue of less than $25
million. Based on this data, the Commission concludes that a majority
of firms in this industry are small.
b. Providers of Telecommunications and Other Services
(i) Telecommunications Service Providers
72. The small entities that may be affected are Wireline Providers,
Wireless Carriers and Service Providers, and Internet Service
Providers.
(ii) Vendors and Equipment Manufacturers
73. Vendors of Infrastructure Development or ``Network Buildout.''
The Commission nor the SBA have developed a small business size
standard specifically directed toward manufacturers of network
facilities. There are two applicable industries in which manufacturers
of network facilities could fall and each have different SBA business
size standards. The applicable industries are ``Radio and Television
Broadcasting and Wireless Communications Equipment'' with a SBA small
business size standard of 1,250 employees or less, and ``Other
Communications Equipment Manufacturing'' with a SBA small business size
standard of 750 employees or less.'' U.S. Census Bureau data for 2017
show that for Radio and Television Broadcasting and Wireless
Communications Equipment there were 656 firms in this industry that
operated for the entire year. Of this number, 624 firms had fewer than
250 employees. For Other Communications Equipment Manufacturing, U.S.
Census Bureau data for 2017 show that there were 321 firms in this
industry that operated for the entire year. Of that number, 310 firms
operated with fewer than 250 employees. Based on this data, the
Commission concludes that the majority of firms in this industry are
small.
74. Telephone Apparatus Manufacturing. This industry comprises
establishments primarily engaged in manufacturing wire telephone and
data communications equipment. These products may be stand-alone or
board-level components of a larger system. Examples of products made by
these establishments are central office switching equipment, cordless
and wire telephones (except cellular), private branch exchange (PBX)
equipment, telephone answering machines, local area network (LAN)
modems, multi-user modems, and other data communications equipment,
such as bridges, routers, and gateways. The SBA small business size
standard for Telephone Apparatus Manufacturing classifies businesses
having 1,250 or fewer employees as small. U.S. Census Bureau data for
2017 show that there were 189 firms in this industry that operated for
the entire year. Of this number, 177 firms operated with fewer than 250
employees. Thus, under the SBA size standard, the majority of firms in
this industry can be considered small.
75. Radio and Television Broadcasting and Wireless Communications
Equipment
[[Page 1844]]
Manufacturing. This industry comprises establishments primarily engaged
in manufacturing radio and television broadcast and wireless
communications equipment. Examples of products made by these
establishments are: transmitting and receiving antennas, cable
television equipment, global positioning system (GPS) equipment,
pagers, cellular phones, mobile communications equipment, and radio and
television studio and broadcasting equipment. The SBA small business
size standard for this industry classifies businesses having 1,250
employees or less as small. U.S. Census Bureau data for 2017 show that
there were 656 firms in this industry that operated for the entire
year. Of this number, 624 firms had fewer than 250 employees. Thus,
under the SBA size standard, the majority of firms in this industry can
be considered small.
76. Other Communications Equipment Manufacturing. This industry
comprises establishments primarily engaged in manufacturing
communications equipment (except telephone apparatus, and radio and
television broadcast, and wireless communications equipment). Examples
of such manufacturing include fire detection and alarm systems
manufacturing, Intercom systems and equipment manufacturing, and
signals (e.g., highway, pedestrian, railway, traffic) manufacturing.
The SBA small business size standard for this industry classifies firms
having 750 or fewer employees as small. U.S. Census Bureau data for
2017 show that 321 firms in this industry operated for the entire year.
Of this number, 310 firms operated with fewer than 250 employees. Based
on this data, the Commission concludes that the majority of firms in
this industry are small.
v. Description of Projected Reporting, Recordkeeping, and Other
Compliance Requirements for Small Entities
77. The rules adopted in the Third R&O will result in modified
reporting, recordkeeping, or other compliance requirements for small
and other entities. Applicants that request conditional approval for
eligibility must submit an eligibility determination and supporting
documentation, along with an estimated date to meet all eligibility
requirements. They must also be located in a rural area as defined in
Sec. 54.600(e) of the Commission's rules by the estimated eligibility
date, or plan to be a member of a majority-rural Healthcare Connect
Fund (HCF) Program consortium that satisfies the eligible rural health
care provider composition requirement set forth in Sec. 54.607(b) of
the Commission's rules by the estimated eligibility date. An applicant
with conditional eligibility that plans to engage in competitive
bidding must indicate that the eligibility is conditional, and state
the estimated date of eligibility on its competitive bidding form.
Applicants with conditional approval of eligibility must also notify
the Universal Service Administrative Company (Administrator) within 30
calendar days of its actual eligibility date and provide documentation
confirming eligibility. Beginning funding year 2025, a single
eligibility determination form for the RHC Program for both the Telecom
Program and the HCF Program, FCC Form 469, will be required to be filed
once. Applicants will use the FCC Form 460 for eligibility
determinations in the Telecom Program and the eligibility determination
portion will be eliminated from the FCC Form 465. The Commission also
amends Sec. 54.601(b) of the Commission's rules to require health care
providers in both programs to notify the Administrator of changes to
their name, location, contact information, or eligible entity type.
Telecom Program providers with invoices for funding years 2019 and
earlier, must submit invoices by July 1, 2024, after which, any funding
commitments for 2019 and earlier will be de-obligated and providers
will not be able to invoice for services.
78. The Commission expects the actions taken in the Third R&O will
achieve the goals of improving the effectiveness and efficiency of the
RHC Program without placing significant additional costs and burdens on
small entities. At present, there is not sufficient information on the
record to quantify the cost of compliance for small entities, however,
the Commission anticipates that the compliance obligations for small
providers will be outweighed by the benefits of improving the RHC
Program's capacity to distribute telecommunications and broadband
support to rural health care providers.
vi. Steps Taken To Minimize the Significant Economic Impact on Small
Entities, and Significant Alternatives Considered
79. The RFA requires an agency to provide ``a description of the
steps the agency has taken to minimize the significant economic impact
on small entities . . . including a statement of the factual, policy,
and legal reasons for selecting the alternative adopted in the final
rule and why each one of the other significant alternatives to the rule
considered by the agency which affect the impact on small entities was
rejected.''
80. In the Third R&O, the Commission takes steps to minimize the
economic impact on small entities with the rule changes that are
adopted. For example, conditional approval of eligibility for RHC
Program funding will allow soon-to-be eligible providers to begin
competitive bidding and request funding so that they may receive
support as soon as they become eligible. The Commission aligns the SPIN
change deadline with the invoice filing deadline to give small entities
more time to complete SPIN changes. The Commission simplifies urban
rate calculations by eliminating the standard urban distance provision,
which will ease administrative burdens on small entities. The
Commission changes evergreen contract dates to provide small entities
with the benefits of evergreen contract designation across the full
length of the contract's term. As a part of the reforms to use the same
form for eligibility determinations in the Telecom and HCF Program, the
Commission allows small entities to continue using their existing
eligibility determinations. Finally, in establishing an invoice
deadline for funding year 2019 and earlier, the Commission provides
ample time for small providers and other entities to meet that
deadline. These actions will promote efficiency and promote the goals
of these programs, while strengthening protections against waste, fraud
and abuse.
vii. Report to Congress
81. The Commission will send a copy of the Third R&O, including the
FRFA, in a report to Congress pursuant to the Congressional Review Act.
In addition, the Commission will send a copy of the Third R&O,
including the FRFA, to the Chief Counsel for Advocacy of the SBA. A
copy of the Third R&O and FRFA (or summaries thereof) will also be
published in the Federal Register.
IV. Ordering Clauses
82. Accordingly, it is ordered, pursuant to the authority contained
in sections 1, 4(j), 214, and 254 of the Communications Act of 1934, as
amended, 47 U.S.C. 151, 154(j), 214, and 254 and Sec. 1.429 of the
Commission's rules, 47 CFR 1.429, that the Third R&O is adopted.
83. It is further ordered, that pursuant to Sec. 1.103 of the
Commission's rules, the provisions of the Third R&O will become
effective February 12, 2024, unless indicated otherwise herein.
84. It is further ordered, that pursuant to the authority contained
in sections 1-
[[Page 1845]]
4, 201 through 205, 254, 303(r), and 403 of the Communications Act of
1934, as amended, 47 U.S.C. 151-154, 201-205, 254, 303(r), and 403, and
section 706 of the Telecommunications Act of 1996, 47 U.S.C. 1302, part
54 of the Commission's rules, 47 CFR part 54, is amended, and such rule
amendments shall be effective February 12, 2024, except for Sec. Sec.
54.601(b) and (c) and 54.622(e)(1)(i) through (ii) and (i)(3)(iv),
which may contain new or modified information collection requirements,
will not become effective until the Office of Management and Budget
completes any required review under the Paperwork Reduction Act. The
Commission directs the Wireline Competition Bureau to publish a
document in the Federal Register announcing completion of such reviews
and the relevant effective dates.
List of Subjects in 47 CFR Part 54
Communications common carriers, Health facilities, Infants and
children, Internet, Puerto Rico, Reporting and recordkeeping
requirements, Telecommunications, Telephone, Virgin Islands.
Federal Communications Commission.
Marlene Dortch,
Secretary.
Final Rules
For the reasons discussed in the preamble, the Federal
Communications Commission amends 47 CFR part 54 as follows:
PART 54--UNIVERSAL SERVICE
0
1. The authority citation for part 54 continues to read as follows:
Authority: 47 U.S.C. 151, 154(i), 155, 201, 205, 214, 219, 220,
229, 254, 303(r), 403, 1004, 1302, 1601-1609, and 1752, unless
otherwise noted.
0
2. Delayed indefinitely, amend Sec. 54.601 by revising paragraph (b)
and adding paragraph (c) to read as follows:
Sec. 54.601 Health care provider eligibility.
* * * * *
(b) Determination of health care provider eligibility for the Rural
Health Care Program. (1) Before funding year 2025, health care
providers in the Healthcare Connect Fund Program may certify to the
eligibility of particular sites at any time prior to, or concurrently
with, filing a request for services to initiate competitive bidding for
the site. Applicants who utilize a competitive bidding exemption must
provide eligibility information for the site to the Administrator prior
to, or concurrently with, filing a request for funding for the site.
Health care providers must also notify the Administrator within 30 days
of a change in the health care provider's name, site location, contact
information, or eligible entity type.
(2) Effective for funding year 2025, applicants in the Rural Health
Care Program may certify to the eligibility of particular sites prior
to, or concurrently with, filing a request for services to initiate
competitive bidding for the site. Applicants who utilize a competitive
bidding exemption must provide eligibility information for the site to
the Administrator prior to, or concurrently with, filing a Request for
Funding for the site. Health care providers must notify the
Administrator within 30 days of a change in the health care provider's
name, site location, contact information, or eligible entity type.
(c) Conditional approval of eligibility. Effective for funding year
2025:
(1) An entity that does not yet meet all eligibility requirements
under the Rural Health Care Program may request and receive a
conditional approval of eligibility from the Administrator if the
entity provides documentation showing that it satisfies the following
requirements:
(i) The entity is or reasonably expects to qualify as a public or
non-profit health care provider as defined in Sec. 54.600(b) by an
estimated eligibility date;
(ii) The entity is or reasonably expects to be physically located
in a rural area defined in Sec. 54.600(e) by the estimated eligibility
date or, for the Healthcare Connect Fund Program only, is not located
in a rural area but is or plans to be a member of a majority-rural
Healthcare Connect Fund Program consortium that satisfies the eligible
rural health care provider composition requirement set forth in Sec.
54.607(b) by the estimated eligibility date; and
(iii) The estimated eligibility date is in the same funding year as
or in the next funding year of the date that the entity requests the
conditional approval of eligibility.
(2) An entity that receives conditional approval of eligibility may
conduct competitive bidding for the site. An entity engaging in
competitive bidding with conditional approval of eligibility must
provide a written notification to potential bidders that the entity's
eligibility is conditional and specify the estimated eligibility date.
(3) An entity that receives conditional approval of eligibility may
file a request for funding for the site during an application filing
window opened for a funding year that ends after the estimated
eligibility date. The Administrator shall not issue any funding
commitments to applicants that have received conditional approval of
eligibility only. Funding commitments may be issued only after such
applicants receive formal approval of eligibility as described in
paragraph (c)(4) of this section.
(4) An entity that receives conditional approval of eligibility is
expected to notify the Administrator, along with supporting
documentation for the eligibility, within 30 days of its actual
eligibility date. The actual eligibility date is the date that the
entity qualifies as a public or non-profit health care provider as
defined in Sec. 54.600(b) and meets the requirements under paragraph
(c)(1)(ii) of this section. The actual eligibility date may be a
different date from the estimated eligibility date. The Administrator
shall formally approve the entity's eligibility if the entity meets the
requirements for a public or non-profit health care provider defined in
Sec. 54.600(b) and the requirements under paragraph (c)(1)(ii) of this
section. Upon the entity receiving a formal approval of eligibility,
the Administrator may issue funding commitments covering a time period
that starts no earlier than the entity's actual eligibility date and
that is within the funding year for which support was requested.
0
3. Revise Sec. 54.604 to read as follows:
Sec. 54.604 Determining the urban rate.
(a) Effective funding year 2024:
(1) If a rural health care provider requests support for an
eligible service to be funded from the Telecommunications Program that
is to be provided over a distance that is less than or equal to the
``standard urban distance,'' as defined in paragraph (a)(3) of this
section, for the state in which it is located, the ``urban rate'' for
that service shall be a rate no higher than the highest tariffed or
publicly-available rate charged to a commercial customer for a
functionally similar service in any city with a population of 50,000 or
more in that state, calculated as if it were provided between two
points within the city.
(2) If a rural health care provider requests an eligible service to
be provided over a distance that is greater than the ``standard urban
distance,'' as defined in paragraph (a)(3) of this section, for the
state in which it is located, the urban rate for that service shall be
a rate no higher than the highest tariffed or publicly-available rate
charged to a commercial customer for a functionally similar service
provided over the standard urban distance in any city with a population
of 50,000 or more in that state, calculated as if the service
[[Page 1846]]
were provided between two points within the city.
(3) The ``standard urban distance'' for a state is the average of
the longest diameters of all cities with a population of 50,000 or more
within the state.
(4) The Administrator shall calculate the ``standard urban
distance'' and shall post the ``standard urban distance'' and the
maximum supported distance for each state on its website.
(b) As of funding year 2025, if a rural health care provider
requests support for an eligible service to be funded from the
Telecommunications Program the ``urban rate'' for that service shall be
a rate no higher than the highest tariffed or publicly-available rate
charged to a commercial customer for a functionally similar service in
any city with a population of 50,000 or more in that state, calculated
as if it were provided between two points within the city.
0
4. Delayed indefinitely, amend Sec. 54.622 by revising paragraphs
(e)(1)(i) and (ii) and adding paragraph (i)(3)(iv) to read as follows:
Sec. 54.622 Competitive bidding requirements and exemptions.
* * * * *
(e) * * *
(1) * * *
(i) The entity seeking supported services is a public or nonprofit
health care provider that falls within one of the categories set forth
in the definition of health care provider listed in Sec. 54.600, or
expects to be such a public or nonprofit health care provider before
the end of the funding year for which the supported services are
requested provided that the entity has received a conditional approval
of eligibility pursuant to Sec. 54.601(c);
(ii) The health care provider seeking supported services is
physically located in a rural area as defined in Sec. 54.600 or is a
member of a Healthcare Connect Fund Program consortium which satisfies
the rural health care provider composition requirements set forth in
Sec. 54.607(b). If an entity seeks supported services under a
conditional approval of eligibility set forth in Sec. 54.601(c), the
entity expects to be located in a rural area defined in Sec. 54.600
before the end of the funding year for which the supported services are
requested, or plans to be a member of a Healthcare Connect Fund Program
consortium which satisfies the rural health care provider composition
requirements set forth in Sec. 54.607(b) before the end of the funding
year for which the supported services are requested;
* * * * *
(i) * * *
(3) * * *
(iv) As of funding year 2024, if the date that services start under
an evergreen contract differs from the date services were estimated to
start, participants may request a change of the start date and end date
of their evergreen contract within 60 days of the actual service start
date provided the terms of the evergreen contract support such a
change. Upon approving a requested change, the Administrator will issue
a revised funding commitment letter to the health care provider
reflecting the changed dates. If the Administrator denies a requested
change, it will issue a letter to the health care provider explaining
the basis for the denial.
* * * * *
0
5. Amend Sec. 54.625 by revising paragraph (c) to read as follows:
Sec. 54.625 Service Provider Identification Number (SPIN) changes.
* * * * *
(c) Filing deadline. An applicant must file its request for a
corrective or operational SPIN change with the Administrator no later
than the invoice filing deadline as defined by Sec. 54.627.
[FR Doc. 2024-00415 Filed 1-10-24; 8:45 am]
BILLING CODE 6712-01-P
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