Rural Health Systems

The Washington State Office of Community Health Systems, Rural Health section helps healthcare facilities in several ways. We provide technical assistance to rural health clinics, critical access hospitals and community health centers along with other healthcare facilities located in Washington's rural areas.

Critical Access Hospitals

Critical Access Hospital (PDF) is a federal designation under the Rural Hospital Flexibility Program (Flex Program), administered by the federal Office of Rural Health Policy. The purpose of the program is to ensure people enrolled in Medicare have access to healthcare services in rural areas, particularly hospital care.

Critical Access Hospitals (CAHs) are small hospitals with fewer than 25 beds in rural areas. There are 39 CAHs in Washington (PDF). A map of CAHs in Washington is online (PDF). Most CAHs are operated by public hospital districts.

CAHs are often the central hub of health services in their communities, providing primary care, long-term care, physical and occupational therapy, cardiac rehabilitation and other services in addition to emergency and acute care. Hospital staff provide these services either directly or in partnership with other community providers.

Medicare rules and payment for CAHs are a little different from larger, urban hospitals. CAHs are paid based on reasonable costs for Medicare, rather than a set amount per diagnosis or procedure. In Washington, this is also true for Medicaid. CAHs also have some flexibility in staffing requirements and some other Medicare rules.

The Department of Health receives Flex Program funding to support CAHs and encourage the development of cooperative systems of care in rural areas, joining together CAHs, EMS providers, clinics and health practitioners to increase efficiencies and quality of care. Program priorities and activities include:

  • Quality Improvement – Improve and sustain the quality of care provided by CAHs so that rural citizens receive high-quality, appropriate care in their communities.
  • Operational and Financial Improvement – Support efforts to improve CAH financial and operational performance.
  • Health System Development and Community Engagement – Assist CAHs in developing collaborative regional or local systems of care, addressing community needs, and integrating EMS in those regional and local systems of care.

Resources for Critical Access and Rural Hospitals

For more information, contact the Critical Access Hospital Program manager at 360-236-2826.

Certificate of Need Program

The Certificate of Need (CON) program is a component of the regulated health care industry. The program ensures healthcare facilities and services are developed in Washington as needed. For example, licensed acute care hospitals and critical access hospitals may require CON approval before starting services like adding beds to an existing facility or constructing a new facility. More information about CON is on the department's Certificate of Need webpage.

Rural Health Clinics (RHC)

The Rural Health Clinics program was established by the federal government to stabilize access to outpatient primary care in underserved rural areas. Under the program, the U.S. Centers for Medicare & Medicaid Services (CMS) designate private and non-profit clinics meeting conditions for certification as Rural Health Clinics (RHCs). RHCs are eligible for enhanced Medicare and Medicaid reimbursement.

Department of Health's RHC Certification Support

The Washington State Office of Rural Health provides technical assistance to existing RHCs and clinics interested in pursuing RHC certification. A separate office at the Department of Health surveys clinics to determine whether they meet federal requirements.

Washington State's Process for Becoming a Certified RHC

**Applicants with a financial hardship or other considerations may contact the State Office of Rural Health, (360) 236-2800 for support.

  • Accrediting organization conducts survey and submits results to the applicant. Applicant forwards survey recommendation and findings to the Department.
  • Upon receipt of the survey, and Accrediting Organization recommendation letter, the department sends all certification documentation with the state's recommendation to CMS.
  • CMS notifies applicant of approval or denial.
  • Once a clinic is certified by CMS, clinic submits an application for enrollment in WA Apple Health to

Please note: Once certified, RHCs are surveyed by the Department of Health every seven years to ensure they continue to meet certification requirements.

Resources for RHCs

Payment Resources:

Medicare Benefit Policy Manual | Medicare Claims Processing Manual | Medicaid RHC Provider Guidelines

Other resources:

CMS Rural Health Clinics Center | Rural Health Information Hub | National Association of Rural Health Clinics | Rural Health Clinic Association of Washington | Find a Rural Health Center

Contact Information

For questions about RHCs

Washington State Department of Health
Phone: 360-236-2800

For questions about RHC Medicaid reimbursement:

Washington State Health Care Authority
Rural Health Clinics/Federally Qualified Health Centers programs

Rural Hospital Flexibility Grant Program

The Washington State Flex Program encourages and supports the development of cooperative systems of care in rural areas, joining together critical access hospitals (CAH), emergency medical service (EMS) providers, clinics and health practitioners to increase efficiencies and quality of care.

Program background

The Medicare Rural Hospital Flexibility (Flex) Program was established by the Balanced Budget Act (BBA) of 1997. The Federal Office of Rural Health Policy (FORHP) provides this funding to the state programs. This provides resources for the creation of rural networks, promotes regionalization of rural health services, and improves access to hospitals for rural residents.

Areas of Focus

The Flex Program is required to develop rural health plans and funds efforts to implement community-level outreach. It includes support for the following five program areas:

  • CAH Quality Improvement
  • CAH Operational and Financial Improvement
  • CAH Population Health Improvement
  • Rural EMS Improvement
  • Innovative Model Development

Services and Activities

Activities our program provides funding for include, but are not limited to:

  • Currently our program supports both rural hospital networks in the state – The Washington Rural Health Collaborative (WRHC) and The Northwest Rural Health Network (NRHN).
  • The University of Washington Tele-Antimicrobial Stewardship program
  • Institute for Healthcare Improvement Open School
  • Population Health Projects
  • Assists in planning and supporting the annual Northwest Rural Health Conference
  • Providing rural scholarships to attend the Northwest Rural Health Conference
  • Chief Financial Officer Annual Summit for rural hospitals
  • EMS Testing Vouchers for certification
  • The educational program providing funding for CAH staff to earn and maintain their CPHQ, CIC, CDE, CPPS, or CPHRM certifications
  • Charge Master Reviews
  • Volunteer Retired Provider Program
  • Leadership training


The Washington State Flex Program collaborates with state and national partners to bring our hospitals and health care facilities an abundance of resources and targeted programs. Some of these groups include:

Eligibility to Participate in Flex Funded Activities

To be eligible to participate in Flex funded programs a hospital must meet certain criteria:

  1. Be designated as a critical access hospital.
  2. Have a signed Memorandum of Understanding (MOU).
  3. Be in good standing with the MBQIP program:
    1. Report data on at least one MBQIP Core measure, for at least one quarter, in at least three of the four quality domains, by the second reporting quarter of the previous year.
    2. Complete the Notices of Participation (NOPs) for “Public Reporting” and “Quality Improvement” as well as not opt to suppress their quality data from Hospital Compare.

Rural Health Resources


For questions or technical assistance regarding the Washington State Flex Program:

  • Rural Hospital Program Manager at 360-236-2826
  • Rural Hospital Quality Improvement Manager at 360-915-5135.
Medicare Beneficiary Quality Improvement Project (MBQIP)

Medicare Beneficiary Quality Improvement Project (MBQIP) takes a proactive approach to help ensure CAHs are well-prepared to meet future quality requirements. Furthermore, it's clear that some CAHs are not only participating in national quality improvement reporting programs but are excelling across multiple rural relevant topic areas.


MBQIP is a quality Improvement activity launched in 2011 under the Flex program. The goal of the program is to improve the quality of care provided in CAHs by increasing quality data reporting and then driving quality improvement activities based on the data.

The program provides an opportunity for individual hospitals to look at their data, compare their results against other CAHs, and partner with other hospitals around quality improvement initiatives to improve outcomes and provide the highest quality care to every patient.

MBQIP measures are divided into two categories:

  • Core MBQIP Measures are those that all state Flex Programs are expected to support, and reporting on these measures contributes towards a CAH's Flex eligibility requirements.
  • Additional MBQIP Measures are those that state Flex Programs can elect to support in addition to the core measures, particularly in alignment with other partners or initiatives. While these measures are also rural relevant, they may not be as widely applicable across all CAHs.

MBQIP measures, both core and additional categories, are further divided into four domains:

  • Patient Safety/Inpatient
  • Patient Engagement
  • Care Transitions
  • Outpatient

MBQIP Reporting and Quality Improvement Resources

For questions or technical assistance regarding the Washington State Flex Program contact:

Rural Hospital Program Manager

Rural Hospital Quality Improvement Manager

Small Hospital Improvement Program

Small Rural Hospital Improvement Program (SHIP) grants provide support to small rural hospitals implementing delivery system changes. These funds help ensure that the hospitals have a strong foundation to provide quality healthcare to their communities.

Awards are available from the Office of Community Health Systems. To be eligible hospitals must be non-Federal, general acute care facilities with fewer than 50 beds and located in rural Washington.

For more information about the SHIP program, contact Critical Access Hospital Program manager at 360-236-2826.

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