[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 [www.gpo.gov]
[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, 
[email protected], 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 [email protected] 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: https://docs.fcc.gov/public/attachments/FCC-23-110A1.pdf.

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

[[Page 1839]]

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