What a Rural Emergency Hospital does
Congress created Rural Emergency Hospitals in the Consolidated Appropriations Act, 2021, signed December 27, 2020, to respond to rural hospital closures. CMS's rules took effect January 1, 2023. Under 42 CFR Part 485, Subpart E, an REH:
- provides emergency department services, observation care and other outpatient services;
- keeps an annual average length of stay of 24 hours or less per patient;
- doesn't provide inpatient care, except in a separately licensed skilled nursing unit;
- must be licensed by the state as an REH or meet the state's licensing standards (42 CFR 485.508).
Medicare pays an REH a monthly facility payment plus 5% above the standard outpatient rate. Your Part B copayment is figured without that 5% (42 CFR 419.92), so you don't pay extra for the hospital's status.
The picture in North Carolina
CMS's Hospital General Information file, released November 12, 2026, lists no Rural Emergency Hospitals in North Carolina, out of 49 nationwide. The state has prepared for them, though. North Carolina's hospital licensing law counts a CMS-designated REH as a hospital (G.S. 131E-76), and G.S. 131E-78.3, added in 2023, requires a hospital that applies for federal REH designation to:
- Notify the state and county. Tell NCDHHS and the board of county commissioners when it applies.
- Submit a plan. Give the county commissioners an assessment of the county's current and future health care needs and how the REH would meet them.
- Hold a public hearing in the county, with notice in a local newspaper at least 15 days ahead, where anyone interested can be heard.
The conversion isn't subject to North Carolina's certificate-of-need review. If a hospital near you plans to convert, you'll have a chance to speak.
Meanwhile, rural North Carolina relies on its 20 Critical Access Hospitals.
| Critical Access Hospital | Rural Emergency Hospital | |
|---|---|---|
| Inpatient beds | Up to 25 | None |
| 24-hour emergency department | Yes | Yes |
| Average length-of-stay limit | 96 hours | 24 hours |
| Number in North Carolina (CMS, Nov. 2026) | 20 | 0 |
What it means for you
If your local hospital ever converts, your Medicare still covers emergency and outpatient care there. If you need to be admitted, you would be transferred. If you have Medicare Advantage, check that the hospital you'd be transferred to is in your plan's network; emergency care is covered in or out of network. More in Medicare in rural and mountain North Carolina, or request a call from a licensed insurance agent.
Related questions
What is a Critical Access Hospital?
North Carolina's 20 small rural hospitals.
Does Medicare pay for air ambulance?
Transfers to larger hospitals.
Medicare options in the NC mountains
Plans and networks in the west.
Sources
- CMS — Rural Emergency Hospitals
- eCFR — 42 CFR Part 485, Subpart E, Rural Emergency Hospitals
- eCFR — 42 CFR 419.92, payment to Rural Emergency Hospitals
- North Carolina General Statutes — G.S. 131E-78.3, Rural emergency hospital
- North Carolina General Statutes — G.S. 131E-76, Definitions
- CMS — Hospital General Information (released November 12, 2026)
More questions in this guide
- Does Medicare cover telehealth in rural North Carolina?
- Does Medicare pay for air ambulance in North Carolina?
- What is a Critical Access Hospital in North Carolina?
- What Medicare options are there in the North Carolina mountains?
Part of the guide: Medicare in Rural and Mountain North Carolina · All questions
Frequently asked questions
What's the difference between a Rural Emergency Hospital and a Critical Access Hospital?
A Critical Access Hospital keeps up to 25 inpatient beds for short stays. A Rural Emergency Hospital has no inpatient beds (except a separately licensed skilled nursing unit) and transfers patients who need to be admitted.
Do I pay more at a Rural Emergency Hospital?
No. Under 42 CFR 419.92, Medicare pays an REH 5% more than the standard hospital outpatient rate, but your copayment is based on the standard rate, without that increase.
Which North Carolina hospitals could become Rural Emergency Hospitals?
Under 42 CFR 485.506, only facilities that on December 27, 2020, were Critical Access Hospitals or rural hospitals with 50 or fewer beds can convert.
Medicare in your North Carolina county
Plans, local agents and help, county by county: Wake · Mecklenburg · Guilford · Forsyth · Durham · Cumberland · Buncombe · Union · Johnston · Cabarrus · New Hanover · Gaston · Onslow · Iredell · Alamance · Pitt · Davidson · Brunswick · Catawba · Rowan · All 100 counties →
