Major announcements and news related to program, state, or policy changes

Texas Wins the 2021 MBQIP Spirit Award!
July 30th, 2021

Rural Resilience for Healthier Communities

On July 30th, 2021, Texas Agriculture Commissioner Sid Miller announced that the Texas Department of Agriculture’s (TDA) State Office of Rural Health has won national recognition for its effort to expand and improve delivery of first class health care in rural Texas during the 2021 Flex Program Virtual Reverse Site Visit conference. The Texas Flex Program, a program managed by the State Office of Rural Health to support and improve Critical Access Hospitals in rural areas, was awarded the 2021 Medicare Beneficiary Quality Improvement (MBQIP) Spirit Award by the Federal Office of Rural Health Policy.

“This award is not just recognition for the job we’re doing here in the TDA State Office of Rural Health,” said Miller, “but for the tremendous job done by all the healthcare professionals at rural hospitals across the Lone Star State. The recent COVID-19 pandemic packed a wallop for rural hospitals, but this award shows that we’ve come out stronger and better, because that’s what Texans do. We don’t just survive, we thrive. I could not be more proud.”

Texas Agriculture Commissioner Sid Miller

The goal of the MBQIP Spirit Award is to recognize state programs that strive to be innovative, improve and advance the objectives of the federal project in their state. According to Natalia Vargas, Federal MBQIP Officer for Texas, the Spirit Award “underscores the incredible efforts, hard work, innovative thinking to problem solve, and the drive to truly make healthcare better for rural populations.”

Flex Coordinator Robert Shaw

Flex coordinator Robert Shaw from the State Office of Rural Health stated, "Texas is a big'ol state, and I am proud to say that we all work together— from our quality partners at the CAHs, Texas Hospital Association, and Texas A&M Rural and Community Health Institute, along with our Federal partners, to move our state forward in our quality journey. Everyone has a role to play in improving quality!"

The Medicare Beneficiary Quality Improvement Project (MBQIP) is a quality improvement activity under the Medicare Rural Hospital Flexibility (Flex) program of the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP). The goal of MBQIP is to improve the quality of care provided in critical access hospitals (CAHs), by increasing quality data reporting by CAHs and then driving quality improvement activities based on the data.

Dedicated to serving the health needs of rural Texas, the TDA State Office of Rural Health (SORH) works with local health care providers and other partners to support access to quality health care for rural Texans. SORH works to support rural health providers by providing technical assistance with finance, operations, and quality through a variety of grant programs, workshops, and one-on-one assistance. Additional resources include educational awards that are available to individual clinicians and health care institutions, information and referral, funding resources, and assistance with medical license applications.

Texas MBQIP Trending Scorecards
October 7th, 2020

The new Texas MBQIP Trending Scorecard reports containing EDTC measures are now available. Please check your email for these reports as they will be sent out following the national data reports. These reports are based on the feedback collected during the MBQIP Pilot Study conducted this summer.

Conditions of Participation Related to COVID Reporting
August 31, 2020

Dear Flex Program Colleagues,

The Centers for Medicare and Medicaid Services (CMS) posted an interim final rule (IFR) related to COVID-19 surveillance with new reporting and testing requirements for nursing homes and other providers, including hospitals and critical access hospitals (CAHs). The new rules make reporting a requirement of participation in the Medicare and Medicaid programs for both hospitals and CAHs. The IFR states: “Should a hospital or CAH fail to consistently report test results throughout the duration of the PHE for COVID-19, it will be non-compliant with the hospital and the CAH CoPs” (Conditions of Participation) “set forth at §§ 482.42(e) and 485.640(d), respectively, and subject to termination as defined at 42 CFR 489.53(a)(3).“

Hospitals and CAHs

Hospitals and CAHs will be required to report data daily, including but not limited to elements such as the number of confirmed or suspected COVID-19 positive patients, intensive care unit beds occupied, and availability of essential supplies and equipment such as ventilators and personal protective equipment (PPE). In March, Vice President Pence sent a letter to all hospitals requesting that they provide the results of COVID-19 tests performed in their in-house laboratories to help better understand and track disease patterns. CMS’ new rules require such reporting of test results in order to ensure a more complete picture in the nationwide surveillance of COVID-19, as well as a more efficient allocation of PPE and other vital supplies.

More Information

Please see the links below to a brief fact sheet about the IFR and the full IFR, that pertain not only to hospitals and CAHs, but also to labs, nursing homes, and physician and pharmacist orders for COVID-19 testing.

CMS Fact Sheet:

Interim Final Rule:

Please do not hesitate to reach out with questions.

Nicole Clement | Program Specialist

National Rural Health Resource Center

Texas Department of Agriculture
MBQIP Data Reporting Reminders
August 6, 2020

Important Notice:

Per recent announcements from the Federal Office of Rural Health Policy and the Centers for Medicare & Medicaid, due to the COVID-19 pandemic, quality reporting is optional for data collected during Quarter 1 and Quarter 2 of 2020. Hospitals that can report for these quarters are strongly encouraged to do so. Please review the information below carefully. For more information, please see the Quality Reporting Updates Due to COVID-19 Pandemic article in the April 2020 MBQIP Monthly.

August 15, 2020
CMS Inpatient Measures
  • Patients seen Q1 2020 (January, February, March)
  • CMS Hospital Inpatient Reporting Specifications Manual version 5.7
  • Submitted to the QualityNet warehouse via CART or by vendor
  • CART version 4.25
October 31, 2020
Emergency Department Transfer Communication (EDTC)
  • Patients seen Q3 2020 (July, August, September)
  • Note –there is no reporting exception for Q3 2020 submission
  • Make sure to use the revised EDTC Manual for 2020 encounters
  • Submission process directed by state Flex Program
November 1, 2020
CMS Population and Sampling (optional)
  • Patients seen Q2 2020 (April, May, June)
  • Inpatient and outpatient
  • Entered via the Secure Portal on QualityNet or HARP account
November 1, 2020
CMS Outpatient Measures
  • Patients seen Q2 2020 (April, May, June)
  • CMS Hospital Outpatient Reporting Specifications Manual version 13.0a
  • Submitted to the QualityNet warehouse via CART or by vendor
  • CART version 1.18.1

COVID-19 Update
March 31, 2020

Hello Rural Health Partners,

First off, we would like to thank you for your hard work in quality reporting and improvement efforts. Thank you for everything that you do to submit MBQIP data. As we are aware, you may be facing hardships to submit MBQIP data due to the COVID-19 pandemic. If you are unable to submit MBQIP data due to COVID-19, we understand and with guidance from the Federal Office of Rural Health Policy, you will not be penalized for not reporting. However, the State of Texas has come a long way in reporting MBQIP measures, and if you are still able, we encourage you to continue reporting, as measures will be used to inform both ours and the federal efforts about making improvements in care for rural populations.

While hospitals direct their resources toward caring for ill patients and ensuring the health and safety of their staff, we recognize that any quality measure reporting during this national emergency may not be reflective of actual performance. Alongside our Federal partners, we will continue to monitor the developing COVID-19 situation and re-assess reporting requirements as needed.

Please don’t hesitate to reach out to us if you have any questions or need anything. Stay safe and healthy!

Robert Shaw | Flex Coordinator

State Office of Rural Health

Texas Department of Agriculture