A rural health clinic (RHC) is a clinic located in a rural, medically under-served area in the United States that has a separate reimbursement structure from the standard medical office under the Medicare and Medicaid programs. RHCs were established by the Rural Health Clinic Services Act of 1977 (P.L. 95-210), (Section 1905 of the Social Security Act). The RHC program increases access to health care in rural areas by creating special reimbursement mechanisms that allow clinicians to practice in rural, under-served areas increasing utilization of physician assistants (PA) and nurse practitioners (NP) As of 2018, there were approximately 4,300 RHCs across 44 states in the U.S. RHCs facilitate 35.7 million visits per year and provide services for millions of people, including 8 million Medicare beneficiaries. As primary care facilities, RHCs are essential to the health care safety net in rural America. Unlike FQHCs, RHCs are not legally mandated to provide care to patients who cannot pay but many of their patients are uninsured. Recent evidence shows that the presence of RHCs enables greater appointment availability for Medicaid patients. Requirements for certification Location At the time of creation of an RHC, the clinic must be located in an area that has the following characteristics:[6] defined as a non-urbanized area (fewer than 50,000 inhabitants) by the United States Census Bureau defined as medically under-served by one of the following characteristics: Primary Care Geographic Health Professional Shortage Area (HPSA) under Section 332(a)(1)(A) of the Public Health Service Act (PHS Act); Primary Care Population-Based HPSA under Section 332(a)(1)(B) of the PHS Act; Medically Underserved Area under Section 330(b)(3) of the PHS Act; or Governor-designated and Secretary-certified shortage area under Section 6213(c) of the Omnibus Budget Reconciliation Act of 1989. Staffing In addition, a RHC must employ a nurse practitioner (NP) or a physician assistant (PA) and have a NP, PA, or certified-nurse midwife (CNM) available at least 50 percent of the time the RHC operates. Services At least 50% of services furnished in an RHC must be services typically performed in an outpatient setting and RHCs are prohibited from primary providing behavioral health services. Survey and recertification RHCs must be certified through a survey process by a State Survey Agency and meet Medicare's Conditions for Certification. RHCs must undergo an annual program evaluation to ensure quality of care. Payment design Rural Americans face a number of challenges in accessing healthcare, namely a lack of