A Rural Emergency Hospital (REH) is a Medicare provider type that furnishes emergency department services, observation care and other outpatient services, with an annual per-patient average length of stay of no more than 24 hours and no inpatient care except in a distinct-part skilled nursing unit (42 CFR 485.502). Conversion is open to critical access hospitals and small rural hospitals that held that status on December 27, 2020. Integral Healthcare Solutions (IHS) revises your hospital's policies and tracks the agreements for REH conversion; your board and clinicians own the service redesign.
Last reviewed: October 2026.
What is a Rural Emergency Hospital (REH)?
42 CFR 485.502 defines an REH as "an entity that operates for the purpose of providing emergency department services, observation care, and other outpatient medical and health services specified by the Secretary in which the annual per patient average length of stay does not exceed 24 hours." It adds: "The entity must not provide inpatient services, except those furnished in a unit that is a distinct part licensed as a skilled nursing facility to furnish post-hospital extended care services" (42 CFR Part 485, Subpart E).
The governing texts, in the versions reviewed for this page:
- 42 CFR Part 485, Subpart E, "Conditions of Participation: Rural Emergency Hospitals (REHs)" (§§ 485.500–485.546), eCFR current as of September 30, 2026 (eCFR).
- CMS QSO-24-20-REH, September 6, 2024, "REVISED: Guidance for Rural Emergency Hospital Provisions, Conversion Process and Conditions of Participation," which revises QSO-23-07-REH (January 26, 2023) and includes a Model Action Plan Template (CMS).
- CMS MLN2259384, "Rural Emergency Hospitals," December 2025 (CMS).
- The CMS Rural Emergency Hospitals page (CMS).
QSO-24-20 states: "The final interpretive guidance for REHs is pending and will be provided in a future release." We have not confirmed whether CMS has issued it since September 2024.
Who needs it and what triggers it
REH conversion readiness is for the boards and management teams of eligible rural hospitals. Eligibility is fixed by date: "CMS certifies a facility as an REH if the facility was, as of December 27, 2020— (a) A critical access hospital; or (b) A hospital as defined in section 1886(d)(1)(B) of the Act with not more than 50 beds located in a county (or equivalent unit of local government) that is considered rural" (42 CFR 485.506, eCFR).
The work usually starts when a board decides to evaluate or pursue conversion. CMS describes the filing: eligible facilities must "submit a change of information application" (Form CMS-855A) to their Medicare Administrative Contractor, along with "an action plan for starting REH services" (CMS Rural Emergency Hospitals page).
How IHS helps
IHS's process runs against the REH conditions of participation in 42 CFR 485 Subpart E and the CMS conversion guidance:
- Gap assessment. IHS compares your current hospital or critical access hospital policies to the REH conditions, using questionnaires on the services you will retain, modify, add and discontinue, on transfers and on staffing.
- Document and evidence mapping. IHS builds an implementation plan and an agreement tracker, including the transfer agreement with a level I or level II trauma center.
- Drafting. IHS drafts the policy changes, with clinical content approved by your medical staff, and drafts the action plan content on the CMS Model Action Plan Template for your administrator to sign and your hospital to submit.
- Mock readiness review. IHS reviews the revised policies and agreements against the REH conditions.
- Readiness support. IHS keeps an open-items list until the policies, agreements and action plan content are final.
What your hospital supplies: current policies, service redesign decisions, transfer agreements, financial analysis and medical staff approval.
The limit: the conversion decision and its finances belong to your board. Hospital survey depth, including life safety and the physical environment, is outside IHS's experience. CMS points converting facilities to HRSA's Rural Emergency Hospital Technical Assistance Center; IHS's work complements that center and does not replace it.
Related IHS pages: Compliance Services and Accreditation Consulting.
What to have ready
Each item below ties to 42 CFR 485 Subpart E (eCFR current as of September 30, 2026), QSO-24-20 (September 6, 2024) or the CMS REH page.
- Evidence that you were a critical access hospital, or a rural hospital of not more than 50 beds, as of December 27, 2020 (42 CFR 485.506, eCFR).
- A change of information application, Form CMS-855A, for your Medicare Administrative Contractor (CMS REH page).
- An action plan with "a detailed transition plan that lists the following: Specific services the facility will retain; Specific services the facility will modify; Specific services the facility will add; and Specific services the facility will discontinue" (QSO-24-20).
- "information regarding how the facility intends to use the additional facility payment" (QSO-24-20).
- A transfer agreement "with at least one certified hospital that is a level I or level II trauma center for the referral and transfer of patients requiring emergency medical care beyond the capabilities of the REH" (42 CFR 485.538, eCFR).
- An emergency department staffing plan covering "24 hours a day, 7 days a week" with individuals "competent in the skills needed to address emergency medical care" (42 CFR 485.528(a), eCFR).
- A plan for ending inpatient services other than a distinct-part skilled nursing unit (42 CFR 485.502, eCFR).
- Evidence of current compliance with your existing critical access hospital or hospital requirements, since converting facilities "are expected to be in full compliance with the existing CAH and hospital requirements at the time of the request for conversion" (QSO-24-20).
When these are together, the introductory call is the place to start.
How it compares
A board weighing conversion usually considers these routes and sources of help.
| Route | What the sources say | What to weigh |
|---|---|---|
| Keep the current critical access hospital or rural hospital designation | RHIhub, a secondary source, states that "REH status does not guarantee a better financial situation" (RHIhub). | Your board's own financial analysis. |
| Convert to an REH | No inpatient services except a distinct-part skilled nursing unit (42 CFR 485.502); an action plan filed with Form CMS-855A (CMS). | Which services stop, change or start, and the transfer agreement. |
| Convert, then revert later | "REHs can convert back to their prior designation of a CAH or rural hospital. At that time, the CAH or rural hospital would be considered a new CAH or rural hospital, therefore, losing any grandfathered privileges" (QSO-24-20, FAQ A7, CMS). | What grandfathered status your facility holds today. |
| HRSA-funded REH Technical Assistance Center | CMS: the Health Resources and Services Administration's Rural Emergency Hospital Technical Assistance Center "offers technical assistance for REHs" (CMS). The center's operator lists "the review of policies and procedures, education on compliance requirements" (rhrco.org). | The page we opened does not state the center's terms. |
| IHS policy revision and agreement tracking | Gap assessment, implementation plan, agreement tracker, drafted policies and action plan content, mock readiness review. | Your hospital still decides, signs and submits. |
What it costs
CMS does not publish a fee schedule for REH conversion on the pages we reviewed; fees depend on scope. QSO-24-20 notes that a facility reverting to its prior designation would complete "a new CMS-855A and payment of any applicable fees" without stating an amount (CMS). CMS does publish what it pays REHs. MLN2259384 states: "We pay an additional 5% over the payment rate of the Hospital Outpatient Prospective Payment System (OPPS) for REH services" and "The CY 2026 REH facility monthly payment amount is $295,051.54 with the sequestration amount deducted" (CMS MLN2259384). Verify current amounts with CMS. IHS scopes each engagement after a free introductory call.
What this is not
- This page is not legal or financial advice. IHS does not recommend whether to convert and does not prepare the financial analysis.
- IHS does not file Form CMS-855A or the action plan, and does not correspond with CMS, your Medicare Administrative Contractor or your state for you. Your hospital signs and submits; IHS drafts.
- IHS does not review life safety or the physical environment and does not guarantee a CMS decision.
Frequently asked questions
What is a Rural Emergency Hospital (REH) and how is it different from a critical access hospital?
Under 42 CFR 485.502, an REH provides emergency department services, observation care and other outpatient services, with an annual per-patient average length of stay of no more than 24 hours. It must not provide inpatient services except in a distinct-part unit licensed as a skilled nursing facility. A critical access hospital is one of the two facility types eligible to convert under 42 CFR 485.506.
Is our hospital eligible to convert to an REH?
42 CFR 485.506 limits REH certification to facilities that, as of December 27, 2020, were a critical access hospital, or a hospital as defined in section 1886(d)(1)(B) of the Social Security Act with not more than 50 beds in a county considered rural. Your status on that date is the test.
What does the REH conversion process involve, step by step?
The CMS REH page states that eligible facilities submit a change of information application, Form CMS-855A, to their Medicare Administrative Contractor along with an action plan for starting REH services. IHS drafts the policy changes and the action plan content; your hospital submits. The action plan must include a detailed transition plan of services to retain, modify, add and discontinue (QSO-24-20).
What has to be in the REH action plan CMS requires?
QSO-24-20 states that the action plan must include a detailed transition plan listing the services the facility will retain, modify, add and discontinue. It must also explain how the facility intends to use the additional facility payment. QSO-24-20 states that action plans will be available to the public.
Do we need an on-site survey to convert to an REH?
QSO-24-20 states that eligible facilities that self-attest to meeting the REH requirements will not require an automatic on-site initial survey. The reason given is that they are expected to be in full compliance with the existing critical access hospital and hospital requirements when they request conversion.
What services can an REH provide, and what has to stop?
42 CFR 485.502 covers emergency department services, observation care and other outpatient medical and health services specified by the Secretary. Inpatient services must stop, except those in a distinct-part unit licensed as a skilled nursing facility. Your board and medical staff decide the service redesign.
What is the REH monthly facility payment for 2026, and the 5% OPPS add-on?
CMS MLN2259384 states that CMS pays an additional 5% over the Hospital Outpatient Prospective Payment System rate for REH services. It states that the CY 2026 REH facility monthly payment amount is $295,051.54 with the sequestration amount deducted. Verify current amounts with CMS.
What transfer agreement does an REH need?
42 CFR 485.538 requires an agreement with at least one certified hospital that is a level I or level II trauma center for the referral and transfer of patients requiring emergency medical care beyond the capabilities of the REH. IHS tracks the agreement; your hospital negotiates and signs it.
Can an REH convert back to a critical access hospital later, and what do we lose?
QSO-24-20 FAQ A7 states that REHs can convert back to their prior designation of a critical access hospital or rural hospital. The facility would then be considered a new critical access hospital or rural hospital and would lose any grandfathered privileges.
Where can we get federal technical assistance for REH conversion, and what does a consultant add?
The CMS REH page states that HRSA's Rural Emergency Hospital Technical Assistance Center offers technical assistance for REHs, including help with implementing REH requirements for converting facilities. IHS adds drafted policy revisions, an agreement tracker, drafted action plan content and a mock readiness review, and works alongside that center rather than replacing it.