COVID-19 Telehealth Program; Promoting Telehealth for Low-Income Consumers, 18459-18475 [2021-07370]

Agencies

• FEDERAL COMMUNICATIONS COMMISSION

[Federal Register Volume 86, Number 67 (Friday, April 9, 2021)]
[Rules and Regulations]
[Pages 18459-18475]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-07370]


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FEDERAL COMMUNICATIONS COMMISSION

47 CFR Chapter I

[WC Docket Nos. 20-89, 18-213; FCC 21-39; FR ID 20341]


COVID-19 Telehealth Program; Promoting Telehealth for Low-Income 
Consumers

AGENCY: Federal Communications Commission.

ACTION: Final rule; denial of petition for partial reconsideration.

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SUMMARY: In this document, the Federal Communications Commission 
(Commission) establishes rules and processes to further distribute 
funding through the COVID-19 Telehealth Program to health care 
providers, in response to the COVID-19 pandemic, to build on Round 1 of 
the Program, and implement Congress's direction under the Consolidated 
Appropriations Act, 2021 (CAA) for additional relief. The CAA funding 
is distributed through the Program to the health care providers who 
need it most, as determined by objective metrics.

DATES: Effective April 9, 2021.

FOR FURTHER INFORMATION CONTACT: Stephanie Minnock, Wireline 
Competition Bureau, (202) 418-7400 or by email at 
[email protected]. We ask that requests for accommodations 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.

SUPPLEMENTARY INFORMATION: This is a synopsis of the Commission's 
Report and Order (RO) and Order on Reconsideration (Recon) in WC Docket 
Nos. 20-89 and 18-213; FCC 21-39, adopted March 29, 2021 and released 
March 30, 2021. Due to the COVID-19 pandemic, the Commission's 
headquarters will be closed to the general public until further notice. 
The full text of this document is available at the following internet 
address: https://docs.fcc.gov/public/attachments/FCC-21-39A1.pdf.

I. Introduction

    1. The RO, builds upon the success of the Commission's Coronavirus 
Disease 2019 (COVID-19) Telehealth Program (Program), established 
pursuant to the Coronavirus Aid, Relief, and Economic Security (CARES) 
Act. The Commission adopts additional requirements and processes to 
further fund telehealth and connected care services as required by 
Congress in the CAA. Over the course of the last year, in response to 
the COVID-19 pandemic, people across the country have migrated more 
aspects of their daily lives online, including health care visits and 
treatment, to slow the spread of the COVID-19 virus. As a result, the 
use of telehealth has exploded and has become an increasingly vital 
tool for health care providers, enabling them to minimize the risk of 
exposure to COVID-19 while still providing patient care.
    2. On April 2, 2020, the Commission established the Program to 
administer $200 million in funding appropriated by Congress in the 
CARES Act. Congress directed the Commission ``to support efforts of 
health care providers to address coronavirus by providing 
telecommunications services, information services, and devices 
necessary to enable the provision of telehealth services'' during the 
COVID-19 pandemic. For the initial round of funding (Round 1), the 
Commission geared the Program toward providing immediate assistance to 
eligible health care providers to provide telehealth and connected care 
services to patients at their homes or mobile locations. The Commission 
directed the Wireline Competition Bureau (Bureau) to evaluate 
applications on a rolling basis and to prioritize applications that 
targeted the areas hit hardest by COVID-19 and where the Program's 
support would have the most impact on addressing health care needs. The 
Commission fully obligated the $200 million by issuing awards for 539 
applications from April 16, 2020 through July 8, 2020.
    3. Subsequently, in December 2020, as part of the CAA, Congress 
appropriated $249.95 million in additional funding for the Program. In 
January 2021, as required by the CAA, the Bureau sought comment on 
application evaluation metrics to ensure the equitable distribution of 
these additional funds, including proposing and seeking comment on 
improvements to the initial application process. Then, in February 
2021, the Commission adopted a Report and Order, FCC 21-24, expanding 
the responsibilities of the Universal Service Administration Company 
(USAC) to include the administration of the COVID-19 Telehealth 
Program. The Commission establishes requirements, processes, and 
procedures for the second round of Program funding appropriated under 
the CAA (Round 2). The Commission directs USAC to administer the 
Program and the Bureau and the Office of Managing Director (OMD) to 
provide oversight over USAC's activities consistent with the RO.
    4. Telehealth refers to a ``broad range of health care-related 
applications that depend upon broadband connectivity,'' and can 
include, ``telemedicine; exchange of electronic health records; 
collection of data through Health Information Exchanges and other 
entities; exchange of large image files (e.g., X-ray, MRIs, and CAT 
scans); and the use of real-time and delayed video conferencing for a 
wide range of telemedicine, consultation, training, and other health 
care purposes.'' This definition does not preclude health care 
providers from using telecommunications services to provide

[[Page 18460]]

telehealth in response to COVID-19, as telecommunications services are 
eligible for funding for Round 2 of the Program. The Commission has 
previously observed that health care providers use telehealth to 
respond to health challenges as varied as diabetes, pediatric heart 
disease, opioid dependency, strokes, high-risk pregnancies, cancer, and 
mental health treatment, and to provide such benefits as specialist 
consultations and ongoing patient monitoring. In addition to improving 
health outcomes for patients, telehealth technologies have the 
potential to significantly reduce health care costs. In the First 
COVID-19 Report and Order, FCC 20-44, 85FR70150, November 4, 2020 (C19-
RO), the Commission defined ``connected care services'' as a subset of 
telehealth that ``uses broadband internet access service-enabled 
technologies to deliver remote medical, diagnostic, patient-centered, 
and treatment-related services directly to patients outside of 
traditional brick and mortar medical facilities--including specifically 
to patients at their mobile location or residence.'' While the use of 
telehealth and connected care services are not new methods of providing 
health care, the deployment of these services has accelerated in 
response to the transmission risks of the coronavirus.
    5. The first reported cases of COVID-19 were identified in the 
United States over one year ago. While development and distribution of 
effective vaccines has provided hope, a quick emergence from the spread 
of the virus is not a certainty and the needs of the health care 
community are still great. As Congress recognized in the CAA, providing 
health care providers the funds they need to deploy telehealth 
solutions for their patients thus remains as important as ever during 
this public emergency.
    6. On December 27, 2020, the CAA was signed into law, providing an 
additional $249.95 million to the Commission to support the COVID-19 
Telehealth Program. This additional funding will allow the Commission 
to continue its efforts to expand telehealth and connected care 
services throughout the country and enable patients to access necessary 
health care services while helping slow the spread of the disease. In 
addition to appropriating $249.95 million in new funds for the Program, 
the CAA requires the Commission to consider several changes to the 
Program and to make several others. First, it directs the Commission to 
seek comment on the ``metrics the Commission should use to evaluate 
applications for funding'' and ``how the Commission should treat 
applications filed during the funding rounds for awards from the 
[Program] using amounts appropriated under the CARES Act . . . .'' 
Second, it instructs the Commission, to the extent feasible, to ensure 
that at least one applicant from all 50 states and the District of 
Columbia is awarded funds during either of the Program's funding 
rounds. Third, the CAA directs the Commission to allow applicants from 
Round 1 the opportunity to update or amend their applications. Fourth, 
it directs the Commission, to the extent feasible, to provide 
applicants, upon request, information on the status of their 
application and a rationale for the final funding decision. And 
finally, it requires that the Commission ``issue notice to the 
applicant of the intent of the Commission to deny the application and 
the grounds for that decision'' and ``provide the applicant with 10 
days to submit any supplementary information that the applicant 
determines relevant,'' which must be taken into account for the final 
funding decisions.
    7. On January 6, 2021, the Bureau released a Public Notice that 
sought comment, as required by the CAA, on improvements to the Program 
and lessons learned from Round 1. In the C19-RO, the Commission 
determined that additional notice and comment was not necessary for two 
independent reasons: Additional notice and comment procedures would be 
impracticable and contrary to the public interest under the 
Administrative Procedure Act's ``good cause'' exception, and all or 
nearly all of the COVID-19 Telehealth Program was a logical outgrowth 
of the agency's Connected Care Notice, FCC 18-112. See C19-RO, 35 FCC 
Rcd at 3383, paras. 35-36 (citing, inter alia, 5 U.S.C. 553(b)). The 
Commission reachs a similar determination here. First, the Commission 
finds that the decision today is a logical outgrowth of the Connected 
Care Notice. Indeed, the Commission's decision constitutes a second 
round of the very same program for which the FCC properly proceeded to 
an Order in April 2020, FCC 20-44. Second, the Commission also finds 
that the APA's good cause exception to notice and comment is satisfied. 
In reaching this conclusion, the Commission notes that the CAA 
specified that the Commission ``shall issue a Public Notice seeking 
comment within ten days of enactment.'' CAA 903(c)(1)(A). The 
Commission satisfied this directive when it sought comment through a 
Bureau-level Public Notice in January 2021, DA 21-14, 86FR8356, 
February 5, 2021. In any event, the Commission finds that there was 
good cause to seek comment through a Bureau-level Public Notice because 
of the unprecedented nature of this pandemic and the need for immediate 
action, and the fact that issuing a Commission-level Public Notice 
would have necessitated a delay in committing funds to providers who 
are addressing the COVID-19 pandemic. Indeed, issuing a Notice of 
Proposed Rulemaking in these circumstances would be unnecessary and 
therefore not required under the ``good cause'' exception of U.S.C. 
553(b)(B). See 5 U.S.C. 553(b)(B) (permitting deviation from formal 
rulemaking procedures where the agency ``for good cause'' finds that 
they are ``impracticable, unnecessary, or contrary to the public 
interest.''). The Bureau first sought comment on which evaluation 
metrics to use during Round 2, and whether the Commission should 
continue to target funding to areas that were ``hardest hit'' by COVID-
19 and where applicants were working under pre-existing strain. The 
Bureau also asked whether the Commission should maintain the $1 million 
cap per applicant on funding awards and proposed establishing an 
application filing window rather than continuing to accept and evaluate 
applications on a rolling basis. Next, the Bureau sought comment on how 
the Commission should treat remaining, unfunded applications from Round 
1, and proposed requiring Round 1 applicants to update and resubmit 
their applications to be considered for Round 2. The Bureau further 
sought comment on additional improvements to the Program and proposed 
using USAC to assist in administering the remaining work necessary to 
complete Round 1, as well as Round 2 application review, invoice 
review, and outreach. Finally, the Bureau requested comment on how to 
improve the eligibility review processes for Round 2, both with respect 
to the eligibility of health care provider applicants and their 
requests for services and connected devices.
    8. On February 2, 2021, the Commission acted on the Public Notice, 
DA 21-14 and decided to use USAC to administer the remainder of Round 1 
and to administer all of Round 2 of the Program. On February 4, 2021, 
the Commission entered into an MOU with USAC in support of the Program. 
As with its role in administering the Universal Service Fund (USF) 
Programs, USAC will be limited to program administration and will not 
have the authority to make policy decisions.

[[Page 18461]]

II. Discussion

    9. In the RO, the Commission adopts changes to the Program to 
implement the CAA's requirements, improve the administration of the 
Program, and to establish the process by which USAC, with oversight 
from the Bureau, will award the additional appropriated funds to 
eligible health care providers. First, the Commission establishes an 
application filing window to provide a level playing field to all 
applicants, regardless of size or resource level. Second, the 
Commission explains the application filing process for Round 2, 
including the process used to determine an applicant's eligibility. 
Third, the Commission details the application evaluation process, 
including the specific metrics USAC will use to prioritize and evaluate 
the Round 2 applications and provide additional information on the 
process to confirm the eligibility of requested items. Fourth, the 
Commission explains the funding commitment process. Last, the 
Commission directs USAC to conduct educational outreach efforts to 
explain the application process for Round 2, and to use the same 
reimbursement structure for Round 2 of the Program that was used for 
Round 1.
    10. Through the RO, the Commission takes steps to improve the 
COVID-19 Telehealth Program in accordance with Congressional guidance 
while building upon the lessons learned during Round 1. The Commission 
modifies some Program requirements but keep unchanged many others, 
including requirements regarding the eligibility of health care 
providers, funding limitations, procurement, compliance audits, and 
post-program feedback reports. The Commission cautions applicants to 
carefully review the Program requirements and guidance. Applicants are 
ultimately responsible for compliance with Program requirements, 
including all deadlines and eligibility requirements.
    11. Establishing an Application Filing Window. To facilitate a more 
efficient and equitable application review process, the Commission 
first establishes an application filing window after which USAC, with 
oversight from the Bureau, will review all applications from eligible 
applicants based on the pre-defined evaluation metrics the Commission 
discusses in more detail. The Commission's C19-RO established an 
application process for the first round of the COVID-19 Telehealth 
Program applicants that permitted applicants to file requests at any 
time after the start of the Program and required Commission staff to 
review, approve, and grant funding to applicants ``as rapidly as 
possible on a rolling basis . . . until it ha[d] committed all COVID-19 
Telehealth Program funding . . . .''
    12. During Round 1 of the Program, applications were submitted 
starting on April 13, 2020; the Bureau announced that it would no 
longer accept new applications on June 25, 2020. At the same time, 
Commission staff reviewed and awarded funding on a rolling basis until 
all appropriated funding had been committed. While this process allowed 
funding to be committed immediately after the Program began, 
applications submitted later in the Program were not reviewed because 
the available funds had already been committed. There is also a concern 
that some smaller providers with more limited resources may have faced 
difficulties quickly completing their applications. In the Public 
Notice, DA 21-14 the Bureau proposed establishing an application filing 
window and awarding funding based on pre-defined evaluation metrics 
instead of reviewing applications and awarding funding on a rolling 
basis. Commenters overwhelmingly supported this approach, and the 
Commission agrees. Establishing a filing window is consistent with the 
plain language of the CAA, is more equitable, and will allow USAC to 
review all applications before selecting the best-qualified applicants.
    13. The Commission also finds that the CAA effectively compels the 
opening of a filing window that treats all applications received during 
the window as timely and requires the review in full of all such 
applications. Were the Commission to accept applications on a rolling 
basis and commit funding once an application was received and reviewed, 
it would be impossible to compare all applications against each other 
and use an objective set of evaluation metrics. Instead, the earliest-
filed applications that met a quality threshold would be awarded 
funding, while later-filed applications that scored higher based on a 
set of objective metrics could be denied the same funding.
    14. The CAA also directs the Commission to ensure that, to the 
extent feasible, at least one applicant in each state and the District 
of Columbia receives Program funding. Adopting a filing window and 
objective evaluation metrics allows the Commission to fulfill this the 
statutory directive by comparing all applicants against each other, and 
committing funding to the top-scoring applicant in each state. It would 
not be possible to follow this statutory directive if the Commission 
accepted applications on a rolling basis, as the Commission would risk 
exhausting all funding before an acceptable application from a certain 
state was received. By adopting a filing window, the Commission is able 
to ensure that funding will be committed to applicants in each state 
and territory, as discussed in more detail in the following.
    15. A filing window also enables the Commission to more easily 
implement other new procedures required by Congress in Round 2. 
Congress provided that if the Commission intends to deny any Round 2 
applications, it is required to issue notice to the applicant, provide 
the grounds for the denial, and give the applicant 10 days to submit 
any supplementary information. Congress also instructed the Commission 
to provide, to the extent feasible, applicants with information about 
the status of their application and the rationale for a final funding 
decision. If applications were accepted on a rolling basis, compliance 
with these statutory directives would not be feasible, as commitments 
would be awarded as soon as an application was approved and likely 
would be exhausted by the time unsuccessful applicants were able to 
supplement their applications. In short, awarding commitments on a 
rolling basis would completely undermine the requirement that the 
Commission provides applications to be denied the ability to submit new 
information. Instead, the Commission adopts an application filing 
window and a series of simple, transparent metrics to evaluate 
applications. This approach will allow all properly filed applications 
to be reviewed, and it will also allow for advance notice of an 
applicant's potential denial to be provided.
    16. Commenters overwhelmingly supported a filing window. Commenters 
argued that accepting applications on a rolling basis disadvantaged 
smaller providers who lacked the resources to quickly complete 
applications, and that awarding funding on a ``first-come, first-
served'' basis meant that many applications would not be evaluated. 
While a few commenters supported awarding Round 2 funding on a rolling 
basis because it would allow for funding to be awarded more quickly, 
the Commission believes the CAA requires a funding window and also, 
based on the experience administering Round 1, all applications should 
be reviewed first, before funding decisions are made, to ensure that 
funding is awarded to the most deserving applicants. A filing window 
will therefore enable the Commission to accomplish Congress's 
objectives. At the same time, and to address in part concerns about the

[[Page 18462]]

ability to quickly commit funding, the Commission establishes an 
abbreviated application filing window of seven calendar days for Round 
2 of the Program. Commenters also requested additional guidance, 
including technical webinars, for Round 2 of the COVID-19 Telehealth 
Program. See, e.g., Hudson Headwaters Health Comments, WC Docket No. 
20-89, at 4. As the Commission discusses in more detail in the 
following, see infra Round 2 Outreach, the Commission instructs USAC to 
conduct outreach and education for a period of at least three weeks 
before the filing window opens to prepare potential applicants for the 
application filing window
    17. Given the short duration of the Round 2 application filing 
window, the Commission directs the Bureau to publicly provide notice of 
the opening of the Round 2 application filing window at least two weeks 
before it opens. The Commission believes this two-week notice period, 
along with outreach associated with the Program, will provide potential 
applicants enough time to ready applications for filing during the 
window. The Commission also expects that the Round 2 application filing 
window will open within 30 days of release of the RO. Accordingly, the 
Commission directs the Bureau to issue a Public Notice announcing the 
opening and closing dates for the Round 2 application filing window as 
soon as possible, consistent with the effective date of this Program.
    18. Application Filing Process. In the Public Notice, DA 21-14 the 
Bureau sought comment on a number of application-related issues, 
including whether Round 1 applicants would be required to resubmit 
their applications for Round 2, whether Round 1 applicants that 
received funding awards (funding awardees) should be eligible to 
participate in Round 2, and whether applicants should be required to 
complete the FCC Form 460. As the Commission discusses in more detail 
in the following, Round 1 applicants that did not receive funding 
during the initial round are required to submit a new application for 
Round 2; Round 1 funding awardees are eligible to apply for Round 2 of 
the Program, subject to a $1 million cap per applicant for Round 2; and 
all Round 2 applicants without an approved eligibility determination 
through the FCC Form 460 process will be required to submit FCC Forms 
460.
    19. Round 1 Applicants' Eligibility. Congress made it clear that at 
least some applicants who had applied for funding in Round 1 were to be 
eligible for Round 2 of the Program, and it instructed the Commission 
to seek comment on how to treat Round 1 applicants during Round 2. To 
fulfill Congress's directives, the Public Notice, DA 21-14 sought 
comment on specific issues, and proposed requiring Round 1 applicants 
who wished to participate in Round 2 to update and resubmit their 
applications to be considered for Round 2 funding. Commenters 
overwhelmingly supported the Bureau's proposal that Round 1 applicants 
should be able to update and resubmit their applications to receive 
Round 2 funding, and the Commission adopts this requirement. Many 
commenters agreed that applications filed during Round 1 contain stale, 
outdated information, and therefore require updating. While some 
commenters suggested that it should be optional for Round 1 applicants 
to resubmit their applications, and others suggested a more streamlined 
application or review process for Round 1 applicants, including a 
priority review process for such applications, the Commission disagrees 
with these suggestions. By requiring Round 1 applicants to resubmit 
their applications for Round 2, the Commission can ensure that funding 
is not awarded based on outdated, incorrect information, and ensure 
equitable review of all Round 2 applications. Finally, as discussed 
later, Round 1 applicants that were not awarded funding will also 
receive an increase in points in Round 2 which are not available to 
other Round 2 applicants.
    20. The Public Notice, DA 21-14 also specifically sought comment on 
whether Round 1 participants that were awarded $1 million in Round 1 
should be eligible to participate in Round 2, and whether the 
Commission should continue the approach of not awarding more than $1 
million per applicant. The Commission concludes to maintain the 
commitment to not award more than $1 million total per applicant in 
Round 2 to distribute funding to more applicants. While the record was 
mixed on limiting support to $1 million across both rounds, the 
Commission concludes that the limitation should only apply to Round 2. 
Thus, all eligible Round 2 applicants may qualify for the full 
commitment amount per application. The Commission believes that many 
applicants, even those receiving Round 1 funding, continue to need 
program support given the passage of time between last year's 
commitments and Round 2, and that the application evaluation metrics 
the Commission adopts will sufficiently ensure equitable, nationwide 
distribution of funding, and a blanket prohibition on applicants who 
received $1 million in Round 1 could lead to providers who badly need 
funding being unable to receive it.
    21. Eligibility and Application Requirements. Health Care Provider 
Eligibility. The Commission will also continue to use the Rural Health 
Care (RHC) program's statutory categories to determine the eligibility 
of health care providers for Round 2 of the Program, including non-
profit and public health care providers, as defined in section 
254(h)(7)(B) of the Communications Act. Accordingly, the Commission 
directs USAC, with oversight from the Bureau and OMD, to only award 
funding to applications from eligible health care providers. The 
Commission reminds health care providers interested in applying for 
Round 2 of the Program that for-profit entities are not eligible for 
funding. With the limited exception of dedicated emergency departments 
of rural for-profit hospitals that participate in Medicare, which are 
also eligible to participate in the RHC program, and were therefore 
eligible for Round 1 funding. See Rural Health Care Support Mechanism, 
Report and Order, Order on Reconsideration, and Further Notice of 
Proposed Rulemaking, 18 FCC Rcd 24546, 24553-54, para. 13 (2003), 68 FR 
74492, December 24, 2003. The Program remains open to eligible health 
care providers regardless of whether they are located in a rural or 
non-rural location. Based on its extensive experience administering the 
RHC Program, the Commission concluded that instituting the same 
eligibility criteria for Round 1 would facilitate the administration of 
the COVID-19 Telehealth Program. The Commission finds that this 
conclusion was correct.
    22. Several commenters recommended expanding the eligibility for 
Round 2 to include other health care providers, such as physician-
office-based practices. The Commission disagrees. As the Commission 
explains in more detail in the following, Program participation is 
limited to the providers enumerated in section 254(h)(7)(B) of the 
Communications Act to maintain consistent eligibility with Round 1 and 
to provide clarity to program participants. Keeping Program eligibility 
requirements the same across both Rounds will result in more efficient 
review of applications. Maintaining the same eligibility rules will 
also ensure that funding is targeted to health care providers that are 
likely to need it most to respond to this pandemic while allowing the 
Commission to ensure that funding is used for its intended purposes. 
Accordingly, Round 2 funding should only be provided to

[[Page 18463]]

non-profit and public eligible health care providers that fall within 
the categories of health care providers in section 254(h)(7)(B) of the 
Communications Act. The statutory categories of health care providers 
include: (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; or (8) consortia of health 
care providers consisting of one or more entities falling into the 
first seven categories. For purposes of the COVID-19 Telehealth 
Program, which is authorized by the CARES Act, and not the 1996 
Telecommunications Act, both rural and non-rural health clinics are 
eligible to receive funding.
    23. Round 2 Application Requirements. During Round 1, the 
Commission required any health care provider interested in 
participating in the Program that did not already have an eligibility 
determination for the RHC Program to file an FCC Form 460 to receive an 
eligibility determination and an HCP number for each site included on 
its application. While the Commission retains the previously adopted 
eligibility rules for applicants in Round 2, the Commission modifies 
the previous requirement that applicants obtain an eligibility 
determination for each site listed on its application by filling out an 
FCC Form 460 for each site. Instead, the Commission will only require 
applicants to obtain an approved eligibility determination for the lead 
health care provider listed on the application. The Commission expects 
the lead health care provider site listed on each application to ensure 
that it has an approved eligibility determination from USAC. If it does 
not already have an approved eligibility determination, the lead health 
care provider should file an FCC Form 460 with USAC. Applicants 
requesting funding for multiple eligible health care provider sites in 
a single application do not need to receive eligibility determinations 
for every site that will receive funding during Round 2 of the Program, 
but instead will be required only to certify under penalty of perjury 
that all other health care sites that would receive Program funding are 
eligible for Program funding. Additionally, although applicants may 
still file their applications while their FCC Forms 460 are pending 
USAC's review, during Round 2 all applicants must have a health care 
provider number (HCP Number) assigned to them by USAC at the beginning 
of the FCC Form 460 application process before they can submit their 
application. Health care providers submitting FCC Forms 460 in 
anticipation of participation in Round 2 of the Program should indicate 
on their FCC Forms 460 that they are applying for the COVID-19 
Telehealth Program to expedite the review of their FCC Forms 460.
    24. While requiring applicants to submit FCC Forms 460 for each 
site in their applications during Round 1 assisted with funding 
eligible locations, it also delayed review of many applications, 
particularly for applications with a large number of sites, each of 
which required its own eligibility determination. This requirement also 
imposed a substantial burden on applicants with multiple sites. In the 
Public Notice, DA 21-14 the Commission sought comment on ways to 
streamline the application process, including directing USAC to include 
eligibility review as part of the application process and potentially 
ending the requirement that applicants submit FCC Forms 460. In 
conjunction with seeking comment on ending the requirement that 
applicants submit the FCC Form 460, the Commission sought comment on 
other methods of determining an applicant's eligibility for the 
Program.
    25. After a careful review of the record, the Commission retains 
the requirement that each new applicant submit an FCC Form 460. The 
Commission note's that Round 1 applicants who submitted an FCC Form 460 
and were deemed eligible do not need to submit a new Form; if any 
applicant's FCC Form 460 is no longer accurate, however, they must 
update the Form's information. While some commenters argued that filing 
an FCC Form 460 is a burdensome and unnecessary process, the Commission 
concludes that the FCC Form 460 remains a necessary tool that will 
enable USAC to quickly and efficiently determine an applicant's 
eligibility, and the Commission strongly encourages prospective 
applicants that have not already obtained an eligibility determination 
to file an FCC Form 460 as soon as possible.
    26. The Commission concludes that the FCC Form 460 remains 
necessary because the information contained on the form is essential 
for determining an applicant's eligibility for the Program. As a 
threshold matter, the FCC Form 460 was designed specifically to capture 
the relevant information to determine an applicant's eligibility for 
the RHC Program. Because the RHC Program and the COVID-19 Telehealth 
Program have nearly identical eligibility criteria, the Commission 
believes that the FCC Form 460 is similarly essential for determining 
the eligibility of a Program applicant. The FCC Form 460 requires an 
applicant to provide its contact and location information, along with 
its basis for qualifying for the Program. All of this information is 
essential to determining an applicant's eligibility; requiring that 
information to be provided via some medium other than the FCC Form 460 
would be less efficient than simply using the FCC Form 460, which was 
designed to make eligibility determination as efficient as possible for 
both applicants and reviewers.
    27. The Commission also concludes that requiring the lead applicant 
to submit an FCC Form 460 is an important Program safeguard because it 
allows for reviewers to ensure that only eligible health care providers 
receive funding. This conclusion is supported by the experience in 
Round 1 when many ineligible applicants filed the FCC Forms 460 and 
incorrectly certified their eligibility. Ineligible applicants also 
contributed to the FCC Forms 460 processing backlog that many 
commenters noted. The Commission is confident that with more extensive 
outreach and education before the filing window opens, fewer ineligible 
applicants will submit the FCC Form 460. While some commenters 
suggested applicant certifications combined with post-disbursement 
audits would be sufficient to ensure program integrity, the Commission 
disagrees. Even if disbursements to ineligible applicants were 
discovered during audits and the improper payments were recouped, this 
approach would still thwart Congress's clear intent of quickly 
distributing funding to the eligible health care providers who need it 
the most. Such a delay, in the midst of a pandemic, would harm the 
public interest. The Commission concludes that eligibility reviews must 
be conducted before funds are awarded to make sure that funds go to 
those eligible providers who need them the most.
    28. The Commission's review of the record also convinces that a 
better alternative to the FCC Form 460 is not available. Many 
commenters opined that filing the FCC Form 460 was an unnecessary 
burden, yet none identified an adequate alternative to verify an 
applicant's eligibility for purposes of this Program. While some 
commenters suggested using an applicant's Tax ID number or National 
Provider Identifier

[[Page 18464]]

(NPI) number, the Commission does not believe that either identifier, 
standing alone, would be sufficient to determine an applicant's 
eligibility because an NPI number does not provide information needed 
to determine an applicant's Program eligibility, such as an applicant's 
non-profit status. Other commenters suggested using an applicant's HCP 
number. The Commission notes that a health care provider that already 
has an HCP number and an approved eligibility determination, whether 
obtained from USAC for this Program or the RHC program after filling 
out an FCC Form 460, does not need to file an additional FCC Form 460 
application. Additionally, the Commission agrees with those commenters 
who noted that Round 1 applicants are already familiar with the 
Program's application procedures, and new eligibility determination 
procedures for Round 2 would lead to confusion for applicants.
    29. At the same time, the Commission recognizes that requiring a 
separate FCC Form 460 for each site in an application created a 
significant burden on both applicants and reviewers. To streamline 
application review for this round of the Program while still retaining 
the protections that the FCC Form 460 provides, the Commission will no 
longer require applicants whose applications contain multiple sites to 
submit a separate FCC Form 460 for each site. Instead, applicants will 
only be required to submit the form for the application's lead health 
care provider. In instances where the applicant is not a health care 
provider, applicants are required to receive an eligibility 
determination for the lead health care provider. The Commission 
concludes that requiring only one FCC Form 460 per applicant will 
significantly reduce the burdens on applicants and on reviewers. This 
decision is similar to the approach used in the Rural Health Care Pilot 
Program, when the Commission allowed applicants to submit only one FCC 
Form 465 for all sites and briefly explain why each health care 
provider listed on an application was eligible for the program. At the 
time, the Commission concluded that ``[r]equiring the filing of a 
separate FCC Form 465 for each health care provider location would 
result in thousands of FCC Forms 465 being filed with USAC, creating a 
substantial administrative burden for both USAC and the selected 
participants. By contrast, in permitting selected participants to file 
a single FCC Form 465 per application with an attachment detailing all 
participating health care providers, the Commission intends to ease the 
administrative burden on both USAC and selected participants.'' After 
reviewing the record, the Commission concludes that given the limited, 
emergency nature of the Program, similar administrative burden concerns 
justify the different eligibility determination approach that the 
Commission adopts solely for purposes of the COVID-19 Telehealth 
Program.
    30. To further expedite the FCC Form 460 review process, the 
Commission expects health care providers undergoing the FCC Form 460 
review process for Round 2 of the Program to respond to any questions 
from USAC about their FCC Form 460 on an accelerated timetable. 
Accordingly, the Commission directs USAC to only require health care 
providers seeking eligibility determinations for Round 2 of the Program 
to respond to written information requests from USAC, such as requests 
for clarification about an applicant's responses on their FCC Form 460, 
within two business days. USAC can provide an extension of two 
additional business days upon request, but may deny an FCC Form 460 if 
the health care provider does not timely respond to written information 
requests. If an FCC Form 460 request is rejected because the applicant 
did not timely respond to these written information requests, the 
applicant may file a new FCC Form 460. The Commission establishes this 
deadline to set expectations for health care providers and to allow 
USAC to more quickly review and process the FCC Forms 460 filed in 
anticipation of Round 2 of the Program.
    31. Required Application Information. To provide applicants with 
additional assistance, the Commission attached, as Appendix C to the 
RO, an application process guidance document which sets forth the 
complete list of information that should be included in each 
application. Similar to the application requirements in Round 1, Round 
2 applications must contain, at a minimum, the following information:
     The name, physical address, county, and the HCP number, 
for the lead health care provider seeking funding from the COVID-19 
Telehealth Program application. USAC assigns a health care provider 
number when an applicant files an FCC Form 460. As discussed in more 
detail in the following, an HCP number, and approved eligibility 
determination, is only required for an application's lead health care 
provider site.
     Contact information for the individual who will be 
responsible for the application (telephone number, mailing address, and 
email address), as well as the contact information for the project 
manager.
     A list of the telecommunications services, information 
services, or connected ``devices necessary to enable the provision of 
telehealth services'' requested, the cost for each service or connected 
device, and the total amount of funding requested.
     Supporting documentation for the costs indicated in the 
application, such as a vendor or service provider quote, invoice, or 
similar information.
    32. SAM Registration. All entities that intend to apply to the 
Program must also register with the System for Award Management (SAM). 
SAM is a web-based, government-wide application that collects, 
validates, stores, and disseminates business information about the 
federal government's partners in support of federal awards, grants, and 
electronic payment processes. Registration in SAM provides the 
Commission with an authoritative source for information necessary to 
provide funding to applicants and to ensure accurate reporting pursuant 
to the Federal Funding Accountability and Transparency Act of 2006, as 
amended by the Digital Accountability and Transparency Act of 2014 
(collectively the Transparency Act or FFATA/DATA Act). In August 2020, 
the Office of Management and Budget updated the rules governing 
compliance with the Transparency Act as part of wider ranging revisions 
to title 2 of the Code of Federal Regulations. 85 FR 49506 (published 
Aug. 13, 2020) (including revisions to 2 CFR parts 25, 170, 183, and 
200). OMB explained that the SAM registration requirements were 
expanded ``beyond grants and cooperative agreements to include other 
types of financial assistance'' to ensure compliance with FFATA. 85 FR 
49506, 49517. Only those entities registered in SAM will be able to 
receive reimbursement from the Program. Potential applicants that are 
already registered with SAM do not need to re-register with that 
system. Active SAM registration, however, is required for an awardee to 
receive a payment from the Treasury. To register with the system, go to 
https://www.sam.gov/SAM/ and provide the requested information. 
Furthermore, Program awardees may be subject to further FFATA/DATA Act 
reporting requirements to the extent that awardees subaward the 
payments they receive from the Program, as defined by FFATA/DATA Act 
regulations. Awardees may be required to submit data on those 
subawards.
    33. Do Not Pay. Pursuant to the requirements of the Payment 
Integrity

[[Page 18465]]

Information Act of 2019 (PIIA), the Commission is required to ensure 
that a thorough review of available databases with relevant information 
on eligibility occurs to determine program or award eligibility and 
prevent improper payments before the release of any federal funds. To 
meet this requirement, the Commission and USAC will make full use of 
the Do Not Pay system administered by the Treasury's Bureau of the 
Fiscal Service. If a check of the Do Not Pay system results in a 
finding that a Program awardee should not be paid, the Commission will 
withhold issuing commitments and payments. USAC may work with the 
Program awardee to give it an opportunity to resolve its listing in the 
Do Not Pay system if the awardee can produce evidence that its listing 
in the Do Not Pay system should be removed. However, the awardee will 
be responsible for working with the relevant agency to correct its 
information before a reimbursement payment will be issued by the 
Treasury.
    34. Application Evaluation Process. Application Evaluation Metrics. 
The CAA directs the Commission to seek public comment on ``the metrics 
the Commission should use to evaluate applications for funding'' as 
well as ``how the Commission should treat applications filed during'' 
Round 1 that did not receive CARES Act funding, should those applicants 
wish to apply for funding during Round 2. The CAA also requires the 
Commission to provide notice to Congress of what metrics the Commission 
intends to use to evaluate applications.
    35. The Public Notice, DA 21-14 sought comments on how to evaluate 
and prioritize applications during Round 2; whether the Commission 
``should continue to target funding to health care providers in areas 
`hardest hit' by COVID-19,'' particularly given the broader infection 
rate across the nation; and whether there are ``any other metrics [the 
Commission] should use to prioritize applications during the evaluation 
process.'' It also sought comment on prioritizing applications from 
providers who treat ``specific at-risk populations, such as Tribal, 
low-income, or rural communities,'' and sought comment on defining the 
populations that each metric represents.
    36. In response, stakeholders recommended that the Commission use a 
variety of factors to evaluate Round 2 applications, including: 
Application quality, treatment of specific types of patients, 
underserved and at-risk communities, treatment of low-income and 
impoverished patients (regardless of rural or urban location), mental 
and behavioral health facilities, large percentage of COVID-19 
patients, institutions with telehealth experience, and teaching 
hospitals. Commenters were generally supportive of prioritizing 
applicants who serve at-risk populations. Other commenters stressed 
that Round 1 funding was disproportionately awarded to urban areas.
    37. The Commission agrees with commenters who supported using a set 
of evaluation metrics, and the Commission establishes an objective and 
transparent application evaluation process for Round 2. After reviewing 
the record and considering the lessons learned during the Round 1 
application review process, the Commission concludes that Round 2 
application evaluation metrics should prioritize the overall 
performance goals of the Program to fund: (1) Eligible health care 
providers that will benefit most from telehealth funding; (2) as many 
eligible health care providers as possible; (3) Tribal, rural, and low-
income communities to ensure that this additional support will be 
directed to communities where the funding would have the most impact; 
and (4) hardest hit areas to make sure that funding continues to 
support health care providers in areas most impacted by the COVID-19 
pandemic. Each metric is assigned its own objective scoring mechanism, 
which will allow USAC to score applications. The Commission 
acknowledges that some of the metrics overlap and applications could 
receive points under multiple metrics for the same factor (e.g., 
serving a low-income population), which could make certain applications 
more likely to receive funding. This result is reasonable because it 
ensures that the providers who need funding the most will be 
prioritized. Finally, to enhance transparency, the Commission selects 
application evaluation metrics that can be verified using publicly 
available information. To reduce the administrative burden during the 
review process, the Commission adopts application evaluation metrics 
that will be simple to quantify and evaluate. The Commission directs 
USAC to apply these evaluation metrics during the Round 2 application 
review process.
    38. Round 2 Evaluation Metrics. The Commission directs USAC to 
prioritize applications from eligible health care providers that 
demonstrate that they qualify for the following evaluation metrics: 
Hardest Hit Area; Low-Income Area; Round 1 Unfunded Applicant; Tribal 
Community; Critical Access Hospital; Federally Qualified Health Center, 
Federally Qualified Health Center Look-Alike, or Disproportionate Share 
Hospital; Healthcare Provider Shortage Area; Round 2 New Applicant; and 
Rural County. The Commission finds that these objective metrics will 
allow the Commission to award funding to the providers that need it 
most without imposing an undue burden on applicants. To provide 
stakeholders with clarity regarding the Round 2 application evaluation 
process, the Commission provides a list of both the metrics and the 
prioritization points for those metrics in the following table.

                                           Round 2 Evaluation Metrics
----------------------------------------------------------------------------------------------------------------
               Factor                               Information required                         Points
----------------------------------------------------------------------------------------------------------------
Hardest Hit Area....................  Applicants must provide health care provider      Up to 15.
                                       county.
Low-Income Area.....................  Applicants must provide health care provider      Up to 15.
                                       physical address and county.
Round 1 Unfunded Applicant..........  Applicants must provide unique application        15.
                                       number from Round 1. For applicants that
                                       applied during Round 1, the application number
                                       started with ``GRA'' followed by seven numbers
                                       (e.g., GRA0000123). Some applications submitted
                                       via e-mail during Round 1 did not receive a GRA
                                       number. If the applicant did not receive an
                                       application number, USAC may accept proof of an
                                       email submission in lieu of the application
                                       number.
Tribal Community....................  Applicants must provide physical address and/or   15.
                                       provide supporting documentation to verify
                                       Indian Health Service or Tribal affiliation.
Critical Access Hospital............  Applicants must provide proof of Critical Access  10.
                                       Hospital certification.
Federally Qualified Health Center/    Applicants must (1) provide proof of Federally    10.
 Federally Qualified Health Center     Qualified Health Center certification, or (2)
 Look-Alike/Disproportionate Share     demonstrate qualification as a Federally
 Hospital.                             Qualified Health Center Look-Alike, or (3)
                                       demonstrate qualification as a Disproportionate
                                       Share Hospital.

[[Page 18466]]

 
Healthcare Provider Shortage Area...  Applicants must provide Healthcare Provider       Up to 10.
                                       Shortage Area ID number or health care provider
                                       county.
Round 2 New Applicant...............  Applicants must certify, under penalty of         5.
                                       perjury, that the applicant has not previously
                                       applied for Program funding.
Rural County........................  Applicants must provide health care provider      5.
                                       county.
----------------------------------------------------------------------------------------------------------------

    39. Hardest Hit Area. In response to the Public Notice, DA 21-14 
several commenters supported using the ``hardest hit'' factor to 
prioritize applications during Round 2. The Commission agrees, as this 
metric ensures that Program funding is prioritized to health care 
providers responding directly to the COVID-19 pandemic. While some 
commenters expressed concern that prioritizing applications based on 
areas that are ``hardest hit'' may favor large, urban institutions, and 
others argued that ``hardest hit'' is no longer a useful metric because 
the virus has spread exponentially since last April and most locations 
could be considered ``hardest hit,'' the Commission finds it 
appropriate to continue to prioritize funding to eligible health care 
providers located in areas that are most-impacted by the COVID-19 
pandemic. To limit support only to those areas most affected by the 
COVID-19 pandemic, the Commission defines ``hardest hit'' as areas 
designated as either a ``sustained hotspot,'' or a ``hotspot,'' on the 
COVID-19 Community Profile Report, Area of Concern Continuum by County 
dataset provided by the U.S. Department of Health and Human Services 
(HHS). The Commission directs USAC to use the county tab of the report 
generated on the date of the close of the application filing window for 
this prioritization factor. A ``sustained hotspot'' is defined by HHS 
as a community that has ``a high sustained case burden and may be 
higher risk for experiencing health care limitations.'' Hotspots are 
defined by HHS as ``communities that have reached a threshold of 
disease activity considered as being of high burden.'' For Round 2, the 
Commission directs USAC to rely on publicly available COVID-19 
infection rates from the day the application filing window closes, 
specifically using the U.S. Department of Health and Human Services 
dataset identified in the preceding, which breaks down different levels 
of community spread of COVID-19, and award prioritization points to 
applications in which an eligible health care provider is located in a 
county defined as a ``sustained hotspot'' or a ``hotspot.'' The 
Commission also finds that this factor warrants a generous point 
assignment because it is the only metric directly linked to the 
geographic area of the applicant as it relates to the spread of the 
virus. Accordingly, the Commission directs USAC to award seven (7) 
points to applications that demonstrate that an eligible health care 
provider is located in a ``hotspot'' and 15 points to applications that 
demonstrate that an eligible health care provider is located in a 
``sustained hotspot.''
    40. Low-Income Area. In response to the Public Notice, DA 21-14 
many commenters recommended prioritizing applications from health care 
providers that are located in low-income areas. The Commission finds 
using this evaluation metric is sufficient to target funding to low-
income areas, and decline to also use Qualified Opportunity Zones as an 
additional evaluation metric to target funding to low-income areas 
because the Commission believes that the U.S. Census Bureau, Small Area 
Income and Poverty Estimates dataset more accurately represents a 
location's economic reality, and using both low-income areas and 
Qualified Opportunity Zones as evaluation metrics would be redundant. 
The Commission agrees that health care providers located in low-income 
areas should be prioritized because such areas contain underserved and 
at-risk populations. Poverty rates serve as useful benchmarks to 
identify these low-income areas. Accordingly, the Commission directs 
USAC to use Census Bureau data to determine which health care providers 
are located in low-income areas. County-level median and 75th 
percentile poverty rates are calculated from the Small Area Income and 
Poverty Estimates data, and census tract rates are calculated from the 
American Community Survey data. These resulting levels vary because the 
Small Area Income and Poverty Estimates include additional information 
related to participation in the Supplemental Nutrition Assistance 
Program and individual income tax return data, and because the 
distributions of rates among each geographic area are different. The 
Commission directs USAC to use both county and census tract poverty 
data because county data alone may not sufficiently capture highly 
concentrated low-income communities in urban areas or the poverty level 
of communities within counties where there are large income gaps. An 
average poverty rate in a county may fail to reveal substantially 
higher poverty rates in smaller geographic areas within a county. For 
example, Cook County, Illinois has a county-level poverty rate of 13%; 
however, over 53% of the census tracts within the county have poverty 
rates greater than the tract-level nationwide median rate of 11.5% and 
approximately 31% of the tracts have tract-level poverty rates greater 
than the 75th percentile rate of 19.8%. If only county-level poverty 
data were used, eligible health care providers in those low-income 
census tracts would be ineligible for any low-income prioritization 
points. Similar differences in county and census tract poverty rates 
occur in other counties across the United States, e.g., Los Angeles 
County, California; Allegheny County, Pennsylvania; Mecklenburg County, 
North Carolina; Erie County, New York. In such areas, considering both 
county and census tract poverty rates provides greater flexibility and 
will identify low-income communities that may otherwise be obscured in 
county-level data. The median poverty rate for a county is 13.4%, and 
the 75th percentile poverty rate for a county is 17.5%. For census 
tracts, the median poverty rate is 11.5%, and the 75th percentile 
poverty rate is 19.8%. The Small Area Income and Poverty Estimates do 
not include estimates for U.S. territories. For consistency, the 
Commission excludes Puerto Rico from the American Community Survey 
census tract poverty rates. To the extent information for U.S. 
territories and protectorates is not available in these datasets, the 
Commission directs USAC to rely on other U.S. Census Bureau data sets 
or other publicly available information to estimate poverty rates. The 
Commission directs USAC to determine the poverty rate of both the 
county and the census tract for the eligible health care provider site 
the applicant has designated for this metric. The Commission also 
directs

[[Page 18467]]

USAC to determine the relevant census tract for a health care provider 
by geocoding the applicant-submitted physical address using standard 
Geographic Information Systems processes. The census tract where an 
eligible health care provider is located is geographically limited and 
may not reflect the provider's complete service area. The Commission 
therefore directs USAC to develop a methodology to consider poverty 
rates in adjacent census tracts in awarding points for this metric. If 
an application would be eligible for more points using the census tract 
poverty rate than using the county-level poverty rate (or vice versa), 
the Commission directs USAC to award the application the higher points 
available between the two. The Commission further directs USAC to award 
7 points to applications that demonstrate that an eligible health care 
provider is located in a county or census tract where the poverty rate 
is equal to or greater than the median poverty rate and less than the 
75th percentile for poverty for that geographic area, and 15 points to 
applications that demonstrate that an eligible health care provider is 
located in a county or census tract where the poverty rate is in the 
75th percentile or greater for that geographic area.
    41. Round 1 Unfunded Applicants. During Round 1, the Commission 
received thousands of applications from health care providers 
nationwide. The Commission awarded funding commitments to 539 
applications during Round 1, which left a substantial number of Round 1 
applications unfunded. Notably, only about 2,500 of these are from 
institutions that may be eligible for Program funding. Many 
applications were received from for-profit or otherwise ineligible 
providers. In response to the high number of applications that did not 
receive funding, and the CAA, the Public Notice, DA 21-14 sought 
comment on prioritizing the applications of eligible health care 
providers who applied for, but did not receive, Round 1 funding. The 
majority of commenters supported prioritizing these applicants. While 
some commenters did not believe that these applicants should be 
prioritized, the Commission concludes that it is appropriate to 
prioritize eligible applicants who applied for but did not receive 
Round 1 funding. The Commission believes that equitable distribution of 
Program funds is essential, and thus find that prioritizing eligible 
health care providers that did not receive funding during Round 1 over 
eligible health care providers that did receive Round 1 funding is 
consistent with the goal of distributing funding as widely as possible. 
Accordingly, the Commission directs USAC to prioritize eligible health 
care providers that applied for Round 1 funding but did not receive it, 
and award 15 points to applications that demonstrate they applied for, 
but did not receive, Round 1 funding. Furthermore, the Commission also 
assigns a sizable points allocation to this metric to reflect the 
importance of encouraging unfunded Round 1 applicants to file in Round 
2 and the statutory requirement that Round 1 applicants are able to 
file in Round 2.
    42. Tribal Community. The Commission next prioritizes applications 
to serve sites located in Tribal areas because those areas are 
generally most in need of support to enhance broadband connectivity. 
While broadband in urban areas is nearly ubiquitous, as of the end of 
2019, ``approximately 17% of Americans in rural areas and 21% of 
Americans in Tribal lands lack coverage from fixed terrestrial 25/3 
broadband.'' The absence of broadband availability in these areas also 
makes it more difficult for telehealth to be provided, and the 
Commission concludes that prioritizing these factors will help to 
address this discrepancy. Additionally, the Commission has previously 
recognized that ``there are significant health care shortages in rural 
areas and Tribal lands,'' and seek to address this issue by 
prioritizing Tribal participation in this Program. Accordingly, the 
Commission's decisions to prioritize applicants located on Tribal lands 
is rooted in both commenters' support and the ``significant obstacles 
to broadband deployment'' that Tribal lands still face. While broadband 
deployment is nearly ubiquitous in urban areas, broadband deployment 
``on certain Tribal lands, particularly rural Tribal lands, lags behind 
deployment in other, non-Tribal areas.'' Additionally, Tribal 
populations face a significantly higher risk from the COVID-19 
pandemic, and facilitating a more robust telehealth infrastructure 
could help to address this disparity. For Round 2, the Commission 
adopts the definition of Tribal lands provided in the Commission's 
Lifeline program rules, and direct Program applicants to use USAC's 
Tribal PDF map or the reference shapefile to determine whether they are 
located on Tribal lands. The Commission also includes the Eastern 
Navajo Agency lands that have previously been designated as eligible 
for Lifeline and are included in the shapefile and map posted on USAC's 
website. Consistent with the eligibility determinations made using the 
FCC Form 460, the Commission directs USAC to award 15 points to 
applications that demonstrate that an eligible health care provider 
site is either located on Tribal lands or is operated by the Indian 
Health Service or is otherwise affiliated with a Tribe. The Commission 
directs applicants that are otherwise affiliated with a Tribe to 
provide supporting documentation sufficient to verify their Tribal 
affiliation. Finally, in recognition of the importance of funding 
applicants on Tribal lands, the Commission assigns the largest point 
allocation to these applications.
    43. Critical Access Hospital. Critical Access Hospitals are located 
in states that have established a State Medicare Rural Hospital 
Flexibility Program. Applicants should review their state's department 
of health websites for additional information, and must include some 
identifier or proof of CAH certification in their application. In 
response to the Public Notice, DA 21-14 several commenters suggested 
considering whether an applicant is a Critical Access Hospital (CAH). A 
CAH designation is given to eligible rural hospitals in participating 
states by the Centers for Medicare and Medicaid Services. As defined by 
statute, a CAH is a hospital that is located in a rural area and that: 
(1) Has 25 or fewer acute care inpatient beds; (2) is located more than 
35 miles from another hospital (although exceptions to this requirement 
apply); (3) maintains an annual average length of stay of 96 hours or 
less for acute care patients; and (4) provides 24/7 emergency care 
services. Small health care providers like CAHs frequently struggle to 
access the resources and capacity to set up their own telehealth 
infrastructure. The Commission finds that these characteristics place 
CAHs among the health care providers that need funding from the 
Program, as they would benefit from telehealth and are frequently the 
only health care institutions in their nearby vicinities. Accordingly, 
the Commission directs USAC to award 10 points to applications that 
demonstrate an eligible health care provider qualifies as a Critical 
Access Hospital. The Commission awards these entities points to reflect 
the importance of these facilities, but the Commission assigns a modest 
allocation of points because the Commission anticipates that this 
metric will overlap with other metrics.
    44. Federally Qualified Health Center, Federally Qualified Health 
Center Look-Alike, or Disproportionate Share Hospital. Applicants shall 
verify whether they qualify for this metric by

[[Page 18468]]

providing either their Federally Qualified Health Center ID number or 
BHCMISID/UDS numbers. In response to the Public Notice, DA 21-14 
commenters recommended prioritizing applications that include health 
care providers that qualify as a Federally Qualified Health Center 
(FQHC), a FQHC Look-Alike, or a Disproportionate Share Hospital (DSH). 
Applicants can verify their eligibility as a Look-Alike on the Health 
Resources and Services Administration website. A Federally Qualified 
Health Center is a community-based health care provider that receives 
funds from the Health Resources and Services Administration (HRSA) 
Health Center Program to provide primary care services in underserved 
areas. They are also referred to as the ``backbone of the nation's 
health care safety net.'' These entities must: (1) Offer services to 
all, regardless of the person's ability to pay; (2) establish a sliding 
fee discount program; (3) be a nonprofit or public organization; (4) be 
community-based, with the majority of its governing board of directors 
composed of patients; (5) serve a Medically Underserved Area or 
Population; (6) provide comprehensive primary care services; and (7) 
have an ongoing quality assurance program. Federally Qualified Health 
Centers provide health care services to at-risk and vulnerable patients 
supporting low-income and underserved communities in both urban and 
rural areas. FQHC Look-Alikes meet the same HRSA Health Center Program 
qualifications required of FQHCs, and they provide primary care 
services in underserved areas (like traditional FQHCs), provide care on 
a sliding fee scale based on ability to pay, and operate under a 
governing board that includes patients. A DSH must serve a 
significantly disproportionate number of low-income patients and 
receive payments from the Centers for Medicaid and Medicare Services to 
cover the costs of providing care to uninsured patients. After careful 
review of the record, the Commission finds that directing Program 
funding to FQHCs, FQHC Look-Alikes, and DSHs will meet the preceding 
stated objectives of directing Program funding to entities that target 
funding to at-risk and low-income communities and would most benefit 
from telehealth services. Accordingly, the Commission directs USAC to 
award 10 points to applications that demonstrate that an eligible 
health care provider qualifies as (1) an FQHC, (2) an FQHC Look-Alike, 
or (3) a DSH.
    45. Healthcare Provider Shortage Area. Applicants should use the 
HPSA score for primary care, which is publicly available on the Health 
Resources and Services Administration website. In response to the 
Public Notice, DA 21-14 some commenters suggested prioritizing health 
care providers located in a Healthcare Provider Shortage Area (HPSA). 
HPSAs do not have enough health care providers to adequately serve 
their community. Support for telehealth and connected care services is 
especially needed in these areas to help health care providers serve 
more patients at a greater distance. The Commission directs applicants 
and USAC to the Health Resources and Services Administration (HRSA), 
which is an agency that provides health care to people who are 
geographically isolated, and economically or medically vulnerable. HRSA 
uses a health care provider's geographic area and the medical services 
it provides to award an HPSA score that ranges from 1 to 25. Applicants 
should use the HRSA website to find their HPSA score under the 
``primary care'' category, and to provide on their application either 
the county information or the HPSA ID number for the eligible health 
care provider site for this prioritization factor. The Commission 
directs USAC to award 5 points to applications that include this 
information on their application and qualify for this factor with an 
HPSA score of 1-12; and to award 10 prioritization points to 
applications that include this information on their application and 
qualify for this factor with an HPSA score of 13-25.
    46. Round 2 New Applicants. Because the Commission concludes that 
equitable and widespread distribution of Program funds is essential, 
the Commission also directs USAC to prioritize applicants that are new 
to the Program over applicants who were awarded funding in Round 1. New 
applicants, however, will receive a smaller point allocation than Round 
1 applicants who did not receive any funding. There was support in the 
record for this idea, given the time and effort that these applicants 
devoted in submitting applications in both Rounds of the Program. 
Moreover, this approach acknowledges that because of the high demand, 
``[a] lot of organizations [in Round 1] who did not receive funding 
have great ideas to which this funding could be used in meaningful 
ways,'' and will help distribute funding to as many providers as 
possible. Accordingly, the Commission directs USAC to award 5 points to 
applicants who did not apply for Round 1 funding.
    47. Rural County. The Commission also prioritizes applicants that 
are located in rural areas, as defined by the Rural Healthcare Program. 
Although other application evaluation metrics, such as whether an 
applicant is a Critical Access Hospital, already take into 
consideration the rurality of health care providers for Round 2 
funding, the Commission directs USAC to consider this evaluation metric 
independently as well to ensure that applications representing health 
care providers in rural areas are prioritized. Given that multiple 
other evaluation metrics also target funding to rural areas, however, 
the Commission attaches fewer prioritization points to the Rural Area 
metric to account for the expected overlap between evaluation metrics. 
Applicants should use USAC's Eligible Rural Areas Search tool to 
determine if an eligible health care provider is located in a rural 
area, and provide the physical address of the qualifying health care 
provider in their application. To the extent information for U.S. 
territories and protectorates is not available in this dataset, the 
Commission directs USAC to rely on other publicly available 
information, e.g., urbanization codes, to confirm that the health care 
provider is located in a rural area. The Commission directs USAC to 
award 5 points to applications that demonstrate that an eligible health 
care provider site is located in a rural area.
    48. Ensuring Equitable Nationwide Distribution of COVID-19 
Telehealth Program Funding. The CAA directs the Commission, to the 
extent feasible, to ensure ``that not less than 1 applicant in each of 
the 50 States and the District of Columbia has received funding'' from 
the Program since the Program's inception, ``unless there is no such 
applicant eligible for assistance in a State or in the District of 
Columbia.'' The Public Notice, DA 21-14 sought comment on different 
ways to accomplish this directive, and proposed adopting an application 
filing window, which would allow for applications from states, the 
District of Columbia, or territories where a lead applicant did not 
receive Round 1 funding to be prioritized. The Commission also sought 
comments on ways to ensure that lead applicants from each state and the 
District of Columbia would receive Round 2 funding. The Commission now 
adopts these proposals and seeks to ensure that at least two 
applications with lead health care providers from every state, 
territory, and the District of Columbia receive Program funding, if 
such applications exist. After applications are scored, the Commission 
directs USAC, with Bureau and OMD oversight, to first commit funding to 
the

[[Page 18469]]

top-scoring Round 2 application with an eligible lead health care 
provider located in a state or territory that did not have a lead 
health care provider receive funding during Round 1, if feasible. Those 
states are Alaska, Hawaii, and Montana, and the territories are 
American Samoa, the Northern Mariana Islands, Puerto Rico, and the U.S. 
Virgin Islands. The Commission then directs USAC, with Bureau and OMD 
oversight, to commit funding to the top-scoring Round 2 application in 
the states and territories where an application with a lead health care 
provider was awarded Round 1 funding, and to award funding to the 
second-ranked application in the states where no lead health care 
provider received Round 1 funding. If there is more than one 
application with the same highest or second-highest total score in a 
location, then the application with the highest score for only the four 
most valuable metrics, each of which is worth 15 points, will receive 
the equitable distribution commitment. Those metrics are Hardest Hit, 
Low-Income Area, Round 1 Unfunded Applicant, and Tribal Area. 
Applications may have a maximum of 60 points across those four metrics, 
and the tiebreaker between applications is which application scores 
higher considering only those four metrics. Making this the first 
tiebreaker reflects the Commission's view that the most important 
factors should determine the commitment in the event of identical 
scores for applications in the same geographic location. If two or more 
applications remain tied after considering only the four most valuable 
metrics, then the application with the highest score only for the next 
most valuable metrics, each worth 10 points: Critical Access Hospital; 
Federally Qualified Health Center, Federally Qualified Health Center 
Look-Alike, or Disproportionate Share Hospital; and Healthcare Provider 
Shortage Area, will receive the equitable distribution commitment. 
Applications may get a total of 30 points from those three metrics, and 
the next tiebreaker between applications is which application scores 
higher among those three metrics. This will result in funding for at 
least two applications with lead health care providers in each state, 
territory, or the District of Columbia across both rounds of the 
Program, if such applications exist.
    49. The Commission believes that committing funding to the top-
scoring application in states and territories where a lead health care 
provider was not awarded Round 1 funding is dictated by the statute's 
unambiguous language. Because the Commission has already committed to 
using an application filing window, it is feasible to ensure that the 
highest-scoring applicant with a lead health care provider in the 
states and territories where a lead health care provider was not 
awarded Round 1 funding will receive funding in Round 2. The Commission 
also believes that guaranteeing each state, territory, and the District 
of Columbia Round 2 funding is consistent with the statutory goal of 
nationwide equitable distribution of Program funding. The Commission 
declines to adopt SHLB's proposal to use a ``proportional allocation of 
funds based on state and territory population.'' SHLB Comments, WC 
Docket No. 20-89, at 4. The application process adopted in the RO 
provides a simpler solution, and satisfies the CAA requirement. The 
Commission also declines to adopt UAB Hospital's suggestion that the 
Commission set aside $250,000 for each state. UAB Hospital Comments, WC 
Docket No. 20-89, at 2-3. Establishing an application filing window 
will allow USAC to commit funds to applicants of each state without the 
Commission separately setting aside funds for this purpose. Finally, 
the Commission declines to adopt Northern Light Health's proposal that 
the Commission commits a minimum of three awards to applicants in each 
state where an applicant did not receive funding during Round 1. 
Northern Light Health Comments, WC Docket No. 20-89, at 2. While this 
decision could result in some lower-scoring applications receiving 
funding commitments at the outset of the Program, the Commission notes 
that applications with lead health care providers in 47 states, the 
District of Columbia, and Guam received Round 1 funding without 
separate prioritization, and the Commission anticipates a similar 
geographic distribution of Round 2 applications.
    50. Pre-Existing Strain. In the Public Notice, DA 21-14 the 
Commission sought comments on whether to prioritize health care 
providers that are experiencing pre-existing strain, which, the 
Commission said, could include ``providing care for a large underserved 
or low-income patient population, facing health care provider 
shortages, or dealing with rural hospital closures.'' While some 
commenters supported using the metric, most disagreed, and pointed out 
that the COVID-19 pandemic has placed many health care providers under 
significant strain. After careful consideration of the record, the 
Commission declines to use pre-existing strain as an application 
evaluation metric because that factor, as described in the C19-RO, is 
difficult to verify. Instead, the Commission adopts metrics that the 
Commission previously identified as factors that contribute to pre-
existing strain, e.g., areas with low-income patient population and 
health care provider shortages to target the communities where funding 
is most needed.
    51. Applicants are required to use the publicly available resources 
specified in the `Round 2 Evaluation Metrics' table to determine 
whether they qualify for points in any of the application evaluation 
metrics, and should also include any information that is necessary to 
verify these factors on their applications. Applicants must also 
certify, under penalty of perjury, to the accuracy of their 
applications, and the Commission directs USAC to verify these 
qualifications during the application review process using the same 
publicly available datasets. The Commission anticipates that, just as 
in Round 1, many applications will include multiple health care 
provider sites, and an eligible health care provider may only appear on 
one application. Applications may only receive the associated 
prioritization points once for each factor. In instances in which the 
application requests funding for multiple eligible health care provider 
sites, and the health care provider site that qualifies for one or more 
factors is not the lead health care provider on the application, the 
applicant must provide the information of the qualifying health care 
provider site, in addition to the lead health care provider's 
information, to receive points for that evaluation metric. The 
Commission directs USAC not to award points to applicants that do not 
include sufficient information on their application.
    52. Confirming Eligibility of Requested Services and Devices. 
Consistent with the review process established in Round 1, the 
Commission directs USAC to conduct an eligibility review of the 
services and devices applicants request on their applications. This 
review is an important safeguard and allows the Commission to ensure 
that funding awards are based on the cost of eligible services and 
devices, which in turn ensures funding is available to as many health 
care providers as possible. Moreover, as supported by the record, the 
Commission continues to allow applicants who are awarded funds the 
flexibility to purchase, in the course of implementing their telehealth 
and connected care programs, any necessary

[[Page 18470]]

eligible services and connected devices, and do not limit them to 
receiving funding for only the eligible services and connected devices 
listed in their applications. Finally, to provide applicants with 
additional clarity regarding the eligibility of various products and 
services, and to enhance the transparency of the application review 
process, the Commission provides applicants with a list of eligible and 
ineligible services, attached as Appendix B in the RO.
    53. Maintaining Flexibility. In the Public Notice, DA 21-14 the 
Bureau sought comments on whether the Commission should continue 
providing applicants that receive funding commitments the flexibility 
to respond to changing circumstances by not limiting them to the 
vendors, eligible services, and eligible devices identified in their 
applications, as long as the total amount sought for reimbursement does 
not exceed the commitment amount. Commenters unanimously supported the 
Bureau's suggestion. Many commenters noted that this flexibility 
provided significant help to funding recipients in Round 1. Other 
commenters explained that this policy was still necessary because the 
COVID-19 pandemic continued to present a rapidly changing and evolving 
situation for health care providers to manage, and still other 
commenters specified that they expect to continue facing equipment 
shortages. The Commission maintains this policy from Round 1 because 
the Commission believes that providing funding recipients this 
flexibility will allow them to best provide care for their patients in 
response to the COVID-19 pandemic. However, consistent with the 
Commission's process in Round 1, the Commission directs USAC, subject 
to Bureau oversight, to review the eligibility of each service or 
connected device that a funding awardee proposes to substitute at the 
reimbursement request stage to ensure that Program funds are used only 
for authorized purposes. As part of this review, the Commission permits 
USAC to request a brief explanation from a funding awardee about the 
reason for the substitution and/or an explanation on how the 
substituted items are eligible.
    54. Funding Request Review. The Bureau also sought comment in the 
Public Notice, DA 21-14 on whether, if the Commission maintained this 
flexibility for applicants, the Commission should also streamline the 
application process by eliminating the requirement that applicants 
submit supporting documentation on the eligibility of connected devices 
and services in their applications. During the Round 1 application 
process, applicants were required to answer several questions about the 
anticipated uses and eligibility of their requested services and 
devices, and they were required to submit documentation supporting the 
estimated costs for their funding requests. As a result of this 
process, efforts by Commission staff to review each application to 
determine the eligibility of the services and devices requested were 
often hampered by the lack of adequate information in the application. 
Because applicants commonly did not include enough information on their 
applications about each of their requested services and connected 
devices, reviewers conducted substantial outreach to determine what 
items were being requested and whether those items were eligible for 
funding. Commission staff also completed a second eligibility review 
after Round 1 funding awardees filed their reimbursement requests.
    55. The record was mixed in response to the Bureau's suggestion to 
only require applicants to demonstrate the eligibility of services and 
connected devices during the reimbursement phase. The Commission 
concludes, however, that conducting this eligibility review during the 
invoicing review process, including requiring applicants to provide 
supporting documentation with their applications, is in the public 
interest. Therefore, to promote the integrity of each funding award and 
to ensure that COVID-19 Telehealth Program funds are distributed in a 
fiscally responsible manner, Round 2 applicants are still required to 
submit information about the telecommunications services, information 
services, and connected devices that they anticipate purchasing using 
Program funds, along with documentation supporting the estimated costs 
for their requests with their applications. However, the Commission 
directs USAC to work with the Bureau, to the extent feasible, to 
improve the process by which reviewers determine the eligibility of the 
services and connected devices requested. The Commission believes the 
process will be improved by requiring applicants to provide itemized 
lists of products and services, specifying quantity and cost for each, 
on their application. As part of this effort, the Commission also 
directs USAC to include in its outreach program guidance on the 
eligible services and connected devices and tutorials on filling out 
the application.
    56. Eligible Services List. In the Public Notice, DA 21-14 the 
Bureau also sought comments on whether the Commission should ``publish 
a list of eligible and ineligible equipment and services to provide 
applicants with specific guidance on what may be requested for 
reimbursement.'' Commenters largely supported this idea. The Commission 
agrees, because an eligible services list will help address the 
concerns of commenters that advocated for the Commission to develop 
``guidance on eligible expenses'' more generally, and will help 
applicants prepare better applications with this knowledge, which in 
turn will facilitate USAC's application review. Commenters that opposed 
the Commission publishing an eligible services list argued that it may 
unintentionally exclude services or connected devices, that COVID-19 
still presents too rapidly evolving of a situation for there to be a 
fixed list of eligible and ineligible services, and finally that the 
Commission should only publish an ineligible services list to provide 
applicants needed flexibility in their applications.
    57. To address these concerns, the Commission used the experience 
from Round 1 to develop an eligible services list, attached as Appendix 
B in the RO, that is broad enough to provide illustrative guidance on 
eligible telecommunications services, information services, and 
connected devices applicants may include in their applications. This 
approach provides stakeholders with the flexibility needed to respond 
to rapidly evolving situations. The eligible services list also 
includes guidance on ineligible services. Moreover, the Commission will 
continue to allow applicants to substitute eligible services and 
connected devices prior to seeking reimbursement, which provides 
adequate flexibility to account for the challenging conditions that the 
COVID-19 pandemic has created.
    58. The Commission makes no additional changes to the types of 
services and connected devices eligible under the Program. A number of 
commenters requested the Commission make additional services or devices 
eligible for funds, such as administrative costs or indirect costs. The 
Commission notes that the CARES Act directs Program funding to 
``telecommunications services, information services, and devices 
necessary to enable the provision of telehealth services'' during the 
pendency of the COVID-19 pandemic, and, thus, the Commission is 
prohibited from expanding the services and equipment that are eligible 
for Program funding during Round 2.

[[Page 18471]]

    59. The Commission directs USAC, subject to Bureau oversight, to 
review the services and equipment listed on each application, and award 
only as much funding as is supported by the application and associated 
documentation. The CAA appropriated additional funding to the Program, 
but is silent regarding the eligibility of services and devices 
eligible for the additional funding. Under the CARES Act, the Program 
awards funds to eligible health care providers to support the purchase 
of ``telecommunications services, information services, and devices 
necessary'' to provide telehealth and connected care in response to the 
COVID-19 pandemic. Because the Program is a ``Federal subsidy made 
available through a program administered by the Commission,'' program 
funding may not be used to ``purchase, rent, lease, or otherwise obtain 
any communications equipment or service . . . identified and published 
on the Covered List.'' See Protecting Against National Security Threats 
to the Communications Supply Chain Through FCC Programs, WC Docket No. 
18-89, Second Report and Order, 35 FCC Rcd 14284, 14326, paras. 94-95 
(2020); see also 47 CFR 54.10; Public Safety and Homeland Security 
Bureau Announces Publication of the List of Equipment and Services 
Covered by Section 2 of the Secure Networks Act, WC Docket No. 18-89, 
Public Notice, DA 21-309 (PSHSB Mar. 12, 2021, 86 FR 2904, January 13, 
2021). Consistent with Round 1, the Commission interprets this language 
to include only connected devices (e.g., Bluetooth-enabled pulse-
oximeters or remote blood pressure monitoring devices). Personnel 
costs, marketing costs, administrative expenses, or training costs 
continue to be ineligible for Program funding. Program funding may be 
used to support connected care services and devices, but may not be 
used to support the development of new websites, systems, or platforms. 
Applicants may apply to receive retroactive funding for eligible 
services and devices purchased on or after March 13, 2020, so long as 
they did not receive Round 1 funding for those eligible services and 
devices. Any services must have been purchased in response to the 
COVID-19 pandemic, but can include pandemic-related upgrades to 
existing services.
    60. The Commission next addresses how long applicants may receive 
funding for eligible recurring services. During Round 1, having 
uncertainty as to how long the pandemic would last, the Commission 
allowed applicants to request reimbursement for up to six months of 
eligible recurring services, but allowed applicants to request 
reimbursement for annual license agreements because of the one-time, 
up-front nature of those costs. The Commission now anticipates that 
health care providers will likely continue to rely on telehealth and 
connected care services as a critical means of addressing the COVID-19 
pandemic through at least a good portion of 2022. Accordingly, for 
Round 2, applicants may receive Program funding to support up to 12 
months of eligible recurring services as well as eligible annual 
license agreements (only one one-year term will be funded). This change 
will also provide more certainty to applicants and reduce confusion 
about the funding period.
    61. Funding Commitment Process. Funding for Round 2 of the Program 
will be awarded in two phases in order to satisfy the statutory 
requirement that applicants be given an opportunity to provide 
additional information if their application is going to be denied, and 
in recognition that funding commitments must be awarded as soon as 
possible. In the initial commitment phase, at least $150 million will 
be awarded to the highest-scoring applicants. Once the initial group of 
awardees is identified, applications outside that group will be 
provided a ten-day period to supplement their application. After that 
ten-day period, USAC will re-rank the remaining applications and award 
the remaining funding in the final commitment window. Bifurcating the 
funding awards allows the Commission to expeditiously commit funding to 
the highest-scoring applicants while simultaneously complying with the 
statutory language requiring the Commission to provide applicants an 
opportunity to supplement their applications.
    62. Initial Commitments. The Commission directs USAC, subject to 
Bureau and OMD oversight, to award at least $150 million during the 
initial commitment phase. After the application filing window closes, 
USAC will score each application using the metrics the Commission 
adopts in the preceding. After the applications are scored, USAC will 
rank all of the applications in descending order by the score assigned 
to each application. The initial funding commitments will then be made 
in two steps: The first equitable distribution step, as required by the 
CAA, will ensure that applications with lead health care providers in 
every state, territory, and the District of Columbia are awarded 
funding commitments. The second step will award funding to the highest-
scoring applications regardless of geographic location of the lead 
health care provider.
    63. Equitable Distribution. USAC will first, as discussed in the 
preceding, commit funding to the highest-scoring application with a 
lead health care provider in a state or territory that did not have an 
application with a lead health care provider from that state or 
territory receive Round 1 funding. Next, USAC will commit funding to 
the highest scoring application from each state, territory, and the 
District of Columbia, in which a lead health care provider applicant 
from that geographic location did receive Round 1 funding. Finally, 
USAC will commit funding to the second-highest-scoring application with 
a lead health care provider in a state or territory that did not have 
an application with a lead health care provider from that state or 
territory receive Round 1 funding.
    64. Highest-Scoring Applications. After ensuring that funding is 
committed across all states, territories, and the District of Columbia, 
USAC, with oversight from the Bureau and OMD, will then begin to commit 
funding to the highest-scoring applications, in descending order, until 
at least $150 million has been committed in the initial commitment 
window. As an example, if $10 million was awarded during the equitable 
distribution step of the initial commitment window, when funding 
commitments are awarded in each state, territory, and the District of 
Columbia, there would be at least $140 million available for the 
highest-scoring applications. Once $150 million in funding has been 
committed, any applications with the same score as the last application 
to receive a funding commitment will also receive a funding commitment, 
and the remaining appropriated funds will be rolled over into the final 
commitment window. Once the initial commitment awardees have been 
determined, the Commission directs the Bureau to issue a Public Notice 
announcing those awardees, the amount of their awards, and the 
remaining funding available for the final commitment window.
    65. Notifications of Intent to Deny and Opportunity to Supplement. 
Upon the Bureau's release of the Public Notice identifying the eligible 
health care providers awarded funding during the initial commitment 
phase, the Commission directs USAC, with oversight from the Bureau, to 
issue notices of intent to deny to all Round 2 applications that did 
not receive funding awards during the initial commitment phase. In the 
CAA, Congress directs the Commission to

[[Page 18472]]

``issue notice to the applicant of the intent of the Commission to deny 
the application and the grounds for that decision'' for any application 
the Commission chooses to deny and to ``provide the applicant with 10 
days to submit any supplementary information that the applicant 
determines relevant,'' which must be taken into account for the final 
funding decisions. Accordingly, each notice will include a denial 
justification so that the applicant may know why its application was 
not funded during the initial commitment phase. The Commission notes, 
that while required by statute to send every applicant that does not 
receive funding during the initial window a notice of the Commission's 
intent to deny their application, some of those applicants will 
ultimately receive funding. The Commission directs the Bureau to 
provide guidance on how applicants may supplement their applications in 
the Public Notice announcing the winners from the initial commitment 
phase. As provided in the statute, applicants will have ten days from 
the date that this Public Notice is issued to supplement their 
applications. The Commission directs USAC to consider the supplemental 
information before issuing the remaining funding awards.
    66. The Commission stresses, however, that it is important for 
applicants to accurately fill out their applications at the time of 
initial submission, before they have an opportunity to supplement them. 
If an applicant supplements its application and receives a score that 
would have qualified it for funding during the initial funding window, 
the initial funding commitments will not change and that application 
will only be eligible to receive funding during the final commitment 
window to the extent there are remaining funds. If an applicant 
determines that they made an error on their application and this has 
resulted in an incorrectly high prioritization score, however, they are 
responsible for notifying the Commission as soon as they discover the 
error, and the funding that was awarded to that applicant may be made 
available during the final commitment phase, or at a later point.
    67. Final Commitment. After the 10-day period during which unfunded 
Round 2 applicants may supplement their applications, the Commission 
directs USAC, subject to Bureau oversight, to review any supplemental 
information submitted during the 10-day period for each applicant, make 
changes to prioritization scores as necessary, and re-rank the unfunded 
Round 2 applications according to the same prioritization scoring 
metrics used during the initial commitment phase. This process will 
include an evaluation of all remaining unfunded Round 2 applications, 
regardless of whether an applicant has chosen to supplement its 
application. After the applications are re-scored, the Commission 
directs USAC, with oversight from the Bureau and OMD, to document the 
commitment of the remaining Round 2 funding to the highest scoring 
eligible applications with eligible funding requests, in descending 
order by score, until there is insufficient funding available.
    68. If there are insufficient remaining funds to award the final 
eligible, qualifying application with the highest remaining 
prioritization score the entirety of its funding request, the 
application will receive the remaining funds in the Program. In the 
event there is more than one eligible, qualifying application with the 
same highest remaining prioritization score, the remaining funds will 
be split proportionally among each application in this final scoring 
tier. The Commission believes that this is the fairest approach to 
distributing the remaining funds to these applicants. Because this will 
result in the remaining applicants each receiving a partial award of 
funds, the Commission expects the Bureau to work with affected 
applicants to determine if the proposed commitment meets the needs of 
the applicant and if the applicant is still interested in receiving a 
portion of the requested Program support.
    69. Finally, the Commission directs the Bureau and OMD to release a 
second Public Notice announcing the final list of awardees and funding 
commitments from both phases. Additionally, the Commission directs 
USAC, with oversight from the Bureau, to issue final denials to each 
unfunded Round 2 applicant providing the justification for the denial 
of its application.
    70. Round 2 Outreach. The Commission remains committed to helping 
health care providers address the COVID-19 pandemic as demand for 
telehealth and connected care services increases, and the Commission 
believes that coordination and outreach with health care providers 
before the application filing window opens will improve the overall 
efficacy of Round 2 of the Program. Upon release of the RO, to ensure 
that health care providers are aware of the available funding under the 
Round 2 of the Program, the Commission directs USAC to coordinate with 
the FCC's Connect2Health Task Force, as necessary, to promote and 
announce Round 2 to interested stakeholders, including service 
providers and health care providers. The Commission directs USAC to 
respond to any questions from health care providers regarding Round 2, 
including, but not limited to, questions about the eligibility and 
application processes, application status, funding awards, and request 
for reimbursement process.
    71. Outreach to Tribal Communities. American Indians and Alaska 
Natives (AI/AN) are among the racial and ethnic minority groups at 
highest risk from COVID-19. The CDC found that in 23 selected states, 
the cumulative incidence of laboratory-confirmed COVID-19 cases among 
cases among AI/AN was 3.5 times that of non-Hispanic whites. To address 
these issues, the Commission directs USAC to also focus its outreach 
efforts on Tribal communities and health care providers in those areas.
    72. The Commission also directs USAC to coordinate with the 
Commission's Consumer and Governmental Affairs Bureau and its Office of 
Native Affairs and Policy, as necessary, to promote and announce Round 
2 of the Program throughout Tribal health care communities. The 
Commission directs USAC to use its Tribal Liaison to assist with 
Tribal-specific outreach, training, and assistance for Round 2. The 
Tribal Liaison should provide direct communication with Tribal health 
care providers throughout the application and invoicing processes, help 
conduct and coordinate Tribal-specific trainings and training 
materials, and field questions from Tribal health care providers. By 
directing USAC to leverage the existing connections of its Tribal 
Liaison, the Commission helps ensure that Tribal health care providers 
can fully participate and effectively access funding during Round 2.
    73. Round 2 Invoicing and Dibursements. Invoicing and 
Disbursements. The Commission directs USAC, with Bureau and OMD 
oversight, to use the same reimbursement structure for Round 2 as was 
used for Round 1. The Commission concludes that using the same 
reimbursement structure will allow the use of the existing invoicing 
systems, processes, and procedures already in use for Round 1. The 
current system is effective, and it would be impractical to expend 
limited resources to develop an entirely new invoicing system, 
processes, and procedures solely for Round 2. Accordingly, Round 2 
funding recipients must submit their requests for reimbursement, and 
any necessary subsequent filings (to include any information necessary 
to satisfy the Commission's oversight responsibilities and/or agency-
specific/government-

[[Page 18473]]

wide reporting obligations associated with the appropriation by 
Congress) through the Invoice Processing Platform (IPP), which is part 
of the U.S. Department of the Treasury's Bureau of Fiscal Services. 
Funding recipients must first pay the vendor or service provider for 
the costs of the eligible services and/or connected devices received 
before requesting reimbursement for those costs from the COVID-19 
Telehealth Program. The Commission declines to adopt the suggestion 
that the Commission allows applicants to access committed funds prior 
to first purchasing the eligible services and connected devices and 
request reimbursement. See Elite Program Comments, WC Docket No. 20-89, 
at 4; Mount Sinai Comments, WC Docket No. 20-89, at 4; SHLB Comments, 
WC Docket No. 20-89, at 9. The Commission also declines to adopt the 
suggestion to use ``a two-phased approach, wherein a smaller amount of 
initial seed funding is provided with continued support predicated on 
meeting performance goals or other milestones.'' Hudson Headwaters 
Health Comments, WC Docket No. 20-89, at 4. The Commission is mindful 
of the responsibility to prevent waste, fraud, and abuse of Program 
funding, and the Commission believes that verifying each applicant's 
purchase of eligible services and connected devices prior to 
reimbursement is an important part of this responsibility. The COVID-19 
Telehealth Program will not directly pay a health care provider's 
service providers or vendors.
    74. Upon receipt of services and/or connected devices and 
subsequent payment by the health care provider(s) of the costs of the 
eligible services and/or connected devices to the service provider or 
vendor, a funding recipient shall submit its requests for reimbursement 
and supporting documentation to receive reimbursement for the cost of 
the eligible services and/or devices they have received from their 
applicable service providers or vendors under the Program. Applicants 
that distribute Program funding to other health care provider sites 
must submit Letter(s) of Authorization with their request for 
reimbursement form to demonstrate that the lead health care provider 
has been given permission to distribute the requested funding to the 
other health care provider sites listed on its application. The 
Commission emphasizes that Program funds shall only be used for 
services and devices eligible under the CARES Act. The cost of 
ineligible items must not be included in the reimbursement requests for 
the Program. To guard against potential waste, fraud, and abuse, the 
Commission reiterates that participating health care providers are 
prohibited from selling, reselling, or transferring services or devices 
funded through the Program in consideration for money or any other 
things of value. Moreover, the Commission reminds applicants that they 
shall not use Program funding to pay for the non-discount share of 
services purchased under the Rural Healthcare Program. Finally, the 
Commission reminds applicants that they must certify, under penalty of 
perjury, that they have not received and may not receive duplicative 
funding for the same services from state, local, or federal sources 
twice. For example, applicants may not receive funding from both the 
Program and the Connected Care Pilot Program for the same services or 
connected devices. Applicants must agree to withdraw their Round 2 
application if they receive duplicative funding from another source.
    75. In reviewing requests for reimbursement, USAC shall ensure that 
funding is only awarded after receiving documentation that demonstrates 
the eligibility of the requested items and substantiates the cost of 
those items. USAC will review the request for reimbursement forms along 
with all supporting documentation, and approve requests for 
reimbursement for eligible items that are supported by invoice 
documentation. The Commission directs USAC not to accept requests for 
reimbursement that do not contain the required certifications as part 
of the Request for Reimbursement Form to ensure that Program funds are 
used for their intended purpose. The Commission delegates to the 
Bureau, in coordination with OMD, the authority to make changes to the 
Request for Reimbursement Form that was used in COVID-19 Telehealth 
Program Round 1 to facilitate Program administration and to better 
track expenditures under the COVID-19 Telehealth Program. Pursuant to 
section 903(e) of the CAA, the collection of information sponsored or 
conducted under the regulations promulgated in the RO is deemed not to 
constitute a collection of information for the purposes of the 
Paperwork Reduction Act, 44 U.S.C. 3501-3521. Accordingly, any changes 
made to the Request for Reimbursement Form for Round 2 do not require 
PRA approval.
    76. Red Light Rule. Additionally, the Commission finds that it 
remains in the public interest, and good cause still exists, to waive 
the Commission's ``red light'' rule with respect to applications to the 
Program. As part of the collection and disbursement rules associated 
with the Debt Collection Improvement Act, the Commission may withhold 
action on applications and requests made by any entity found to be 
delinquent in its debt to the Commission until full payment or 
resolution of such debt. This is commonly referred to as the 
Commission's ``red light'' rule. For Round 1 of the Program, OMD and 
the Bureau found that it was in the public interest and good cause 
existed to waive the ``red light'' rule because of the extremely 
unusual circumstances the COVID-19 pandemic presented for health care 
providers. The Commission finds that this reasoning remains true today; 
therefore, the Commission continues the waiver of the Commission's 
``red light'' rule for Round 2 applicants. As with Round 1, the 
Commission do not expect there to be a large number of applicants to 
the Program that are delinquent in their debt to the Commission, and 
the Commission reiterates that this waiver is limited to COVID-19 
Telehealth Program applicants. This waiver does not affect the 
Commission's right or obligation to collect any debt owed by an 
applicant by any other means available to the Commission, including by 
referral to the U.S. Treasury for collection.
    77. Post-Program Reporting and Feedback. Throughout the RO, the 
Commission reviewed stakeholder comments as guideposts for the 
decisions related to the telecommunications services, information 
services, and connected devices needs of eligible health care providers 
and their ability to obtain those services to assist their patients 
throughout this pandemic. The Commission adopts reporting obligations 
for USAC and for COVID-19 Telehealth Program Round 2 participants that 
will enable the Commission to measure the funding impact. While the 
Commission identifies specific reporting obligations, the Commission 
delegates authority to the Bureau, in coordination with OMD, to 
finalize the format of those reporting obligations. In doing so, OMD 
and the Bureau will ensure that such reporting satisfies the CARES Act 
oversight provisions incorporated by Congress by reference in the CAA.
    78. The Commission further directs USAC to collect, within six 
months after the conclusion of the COVID-19 Telehealth Program Round 2, 
feedback on the Program from Round 2 funding awardees. This deadline 
will be calculated from the invoice filing deadline for Round 2. The 
Commission directs the Bureau to issue a Public

[[Page 18474]]

Notice announcing the post-program feedback report deadline and to 
provide a reporting template and instructions on how to submit the 
final reports for Round 2 funding. After collecting this feedback, USAC 
shall provide a report to the Commission in a format to be approved by 
the Bureau on the effectiveness of the COVID-19 Telehealth Program 
funding on health outcomes, patient treatment, health care facility 
administration, benefits from services and connected devices on 
patients treatments and outcomes, administration, and health care 
providers overall expanded telehealth programs, and any other relevant 
aspects of the COVID-19 pandemic. Such information could include: 
Feedback on the application and invoicing processes; a description of 
how funding was helpful in providing or expanding telehealth services, 
including anonymized patient accounts; a description of how funding 
promoted innovation and improved health outcomes; and other areas for 
improvement. The Commission delegates authority to the Bureau to update 
the Post-Program Feedback Report Template based on its experience with 
Round 1 Post-Program Feedback Reports. The Commission directs the 
Bureau to provide specific information about how to provide feedback, 
and associated deadlines, to Round 2 funding recipients. This 
information will assist Commission efforts to respond to pandemics and 
other national emergencies in the future. Pursuant to section 903(e) of 
the CAA, the collection of information sponsored or conducted under the 
regulations promulgated in the RO is deemed not to constitute a 
collection of information for the purposes of the Paperwork Reduction 
Act, 44 U.S.C. 3501-3521. Accordingly, any changes made to the Post-
Program Feedback Report for Round 2 do not require PRA approval.
    79. Audits. While the Commission seeks to ease the burdens upon 
applicants and service providers, the Commission is mindful of the 
commitment to ensure the Program's integrity by protecting against 
waste, fraud, and abuse. The Commission believes that proper 
documentation is crucial for demonstrating health care providers' 
compliance with the COVID-19 Telehealth Program rules, and for 
uncovering waste, fraud, and abuse in the Program, whether through 
compliance audits or investigations. The Commission's Office of 
Inspector General was allocated Program funds to provide oversight, and 
the Commission will provide further guidance about audit procedures at 
a later date. In addition, the Section 903 appropriation, like all 
other Division N appropriations, is subject to the same oversight 
provisions included in the CARES Act, Consolidated Appropriations Act, 
2021, H.R. 133, div. O, tit. VIII--Pandemic Response Accountability 
Committee Amendments Section 801, Amendment to the Pandemic Response 
Accountability Committee (2020). OMB guidance on such provisions also 
continues to apply. In this regard, the Commission notes that in Round 
1 the Commission leveraged audits conducted under the Single Audit Act 
to oversee the program.
    80. To that end, the Commission delegates authority to OMD to 
develop and implement an audit process of participating health care 
providers that complies with the requirements and procedures of the 
COVID-19 Telehealth Program. OMD may obtain the assistance of third 
parties, including but not limited to USAC, in carrying out this 
effort. Consistent with the experience with the Universal Service Fund, 
the Commission finds that audits are the most effective way to ensure 
compliance with the rule requirements. Funding recipients are required 
to maintain documentation sufficient to demonstrate their compliance 
with program rules for six years after the last date of delivery of 
services or connected devices supported through the COVID-19 Telehealth 
Program. Upon request, COVID-19 Telehealth Program participants must 
submit documents sufficient to demonstrate compliance with Program 
rules, including, at a minimum, applications, contracts, communications 
related to Program services, invoices, delivery records, and purchase 
and receipt records. Additionally, certain health care providers 
participating in the COVID-19 Telehealth Program that meet the 
thresholds for being audited under the Single Audit Act are subject to 
a single audit that contains the FCC compliance supplement for the 
COVID-19 Telehealth Program. For health care providers subject to a 
single audit, the CFDA number for the COVID-19 Telehealth Program is 
32.006. The Single Audit Act is codified, as amended, at 31 U.S.C. 
7501-06, and implementing Office of Management and Budget (OMB) 
guidance is reprinted in 2 CFR part 200 (2020). Federal award 
recipients that expend $750,000 or more in federal awards in a fiscal 
year are required to undergo a single audit, which is an audit of an 
entity's financial statements and federal awards, or a program-specific 
audit, for the fiscal year. 31 U.S.C. 7502; 31 CFR 200.501 (2020).
    81. Administrative Procedure Act Exception. The Administrative 
Procedure Act (APA) provides that with a showing of ``good cause,'' an 
agency is permitted to make rules effective before 30 days after 
publication in the Federal Register. ``In determining whether good 
cause exists, an agency should `balance the necessity for immediate 
implementation against principles of fundamental fairness which require 
that all affected persons be afforded a reasonable amount of time to 
prepare for the effective date of its ruling.' '' As a general matter, 
the Commission believes that the APA requirements are an essential 
component of the rulemaking process. In this case, however, because of 
the unprecedented nature of this pandemic and the need for immediate 
action, the Commission finds there is good cause to make the Program 
rules effective April 9, 2021. In light of the continued spread of 
COVID-19 and the increasing need to address this public health crisis, 
any further delay in the use of these funds to assist health care 
providers in meeting the health care needs of their patients could 
impede efforts to mitigate the spread of the disease. Waiting an 
additional 30 days to make this relief available ``would undermine the 
public interest by delaying'' much needed expansion of telemedicine 
resources.

III. Order on Reconsideration

    82. On April 9, 2020, the American Hospital Association (AHA) filed 
a Petition for Partial Reconsideration of the Commission's C19-RO. 
AHA's petition was limited to the Commission's decision to limit 
eligibility in the Program to the statutorily enumerated providers who 
are eligible for the Rural Health Care Program. More specifically, 
AHA's petition sought to extend Program eligibility to ``all types of 
hospitals and other direct patient care facilities regardless of their 
size, location or for-profit or not-for-profit status.'' Several 
commenters filed responses in support of the petition.
    83. The Commission concludes that granting the petition for 
reconsideration would be contrary to the public interest and that the 
decision here is consistent with Congressional intent. Accordingly, the 
Commission denies the petition. In the CARES Act, Congress gave the 
Commission the authority to rely on its already-existing rules to 
administer Round 1 of the Program, and, consistent with that authority, 
the Commission adopted the definition of ``health care provider'' as 
set out in the

[[Page 18475]]

Communications Act and the Commission's rules. The Commission reached 
this conclusion because it was consistent with both the Communications 
Act and the CARES Act, and because it would help to ``ensure that 
funding is targeted to health care providers that are likely to be most 
in need of funding to respond to this pandemic while helping us ensure 
that funding is used for its intended purposes.'' The Commission 
reaches the same conclusion, and conclude that directing Program 
funding away from non-profit providers would be contrary to the public 
interest.
    84. In limiting eligibility of health care providers under the 
Universal Service Fund (USF) to certain categories of health care 
providers, Congress effectively expressed its view that these providers 
were those most in need of USF support. Accordingly, the Commission has 
limited RHC Program support to these entities. Similarly, during this 
pandemic, the Commission has no reason to conclude that these providers 
are not also the most in need of support for telehealth. Particularly 
where the demand for these COVID-19 telehealth funds is much greater 
than availability, as it was in Round 1, the Commission reiterates the 
conclusion that it is in the public interest to limit eligibility to 
those entities listed by Congress in section 254(h)(7)(B) of the 
Communications Act, as amended, including the limitation to not-for-
profit hospitals.
    85. This conclusion is bolstered by recent Congressional action 
through the CAA, when Congress appropriated additional funding for a 
second round of the Program. By directing these funds to ``the COVID-19 
Telehealth Program established by the Commission'' under the authority 
of the CARES Act, without modifying the eligibility requirements, 
Congress indicated that it saw no need to change these requirements, 
especially in light of the fact that Congress chose to mandate a number 
of other changes to the Program.
    86. AHA argues that the COVID-19 pandemic has financially impacted 
all health care providers, and that many smaller hospitals operate as 
part of a larger health care system, which could also render these 
hospitals ineligible for the Program. Additionally, AHA argues that 
because the Commission has previously ``determined that emergency 
departments of for-profit hospitals that participate in Medicare should 
be deemed `public' health care providers within the meaning of section 
254(h)(7)(B) of the Communications Act,'' it has previously 
acknowledged the importance of for-profit hospitals, and that those 
providers are ``public'' by nature of their obligation to treat all 
emergency patients. The Commission finds these arguments unpersuasive. 
The Commission's previous conclusion that emergency departments of for-
profit hospitals that participate in Medicare can participate in the 
Rural Health Care Program reflected a careful balance of multiple 
considerations, and those same emergency departments remain eligible 
for the Program as well. Similarly, while the Commission acknowledges 
the important role played by smaller hospitals who operate as part of a 
larger health care system, the Commission notes that by definition 
these smaller hospitals have available to them the resources of a 
larger, for-profit health care system. Finally, Congress has had 
occasion as recently as 2016 to revisit the health care providers who 
should be eligible for the Rural Health Care program, and to date it 
has not included for-profit hospitals as eligible. While the Commission 
does not dispute that all health care providers have been impacted by 
the COVID-19 pandemic, that does not alter the conclusion that limited 
funding is best directed towards those entities listed by Congress in 
section 254(h)(7)(B) of the Communications Act of 1934 as amended.

IV. Procedural Matters

A. Paperwork Reduction Act Analysis

    87. Pursuant to section 903(e) of the Consolidated Appropriations 
Act, the collection of information sponsored or conducted under the 
regulations promulgated in this Report and Order is deemed not to 
constitute a collection of information for the purposes of the 
Paperwork Reduction Act, 44 U.S.C. 3501-3521.

B. Congressional Review Act

    88. The Commission has determined, and the Administrator of the 
Office of Information and Regulatory Affairs, Office of Management 
Budget (OMB), concurs that the rules implementing the COVID-19 
Telehealth Program are ``major'' under the Congressional Review Act, 5 
U.S.C. 804(2). Because the Commission finds good cause that compliance 
with the notice and public procedure requirements of the Administrative 
Procedure Act on the rules adopted herein is impracticable, 
unnecessary, or contrary to the public interest, the Report and Order 
and Order on Reconsideration will become effective April 9, 2021 
pursuant to 5 U.S.C. 808(2). The Commission will send a copy of the the 
Report and Order and Order on Reconsideration to Congress and the 
Government Accountability Office pursuant to 801(a)(1)(A).

V. Ordering Clauses

    89. Accordingly, it is ordered that, pursuant to the authority 
contained in sections 201, 254, 303(r), and 403 of the Communications 
Act of 1934, as amended, 47 U.S.C. 201, 254, 303(r), and 403, DIVISION 
B of the Coronavirus Aid, Relief, and Economic Security Act, Public Law 
116-136, 134 Stat. 281, and DIVISION N of the Consolidated 
Appropriations Act, 2021, Public Law 116-260, 134 Stat. 1182, the 
Report and Order and Order on Reconsideration is adopted.
    90. It is further ordered that, pursuant to the authority contained 
in section 808(2) of the Congressional Review Act, 5 U.S.C. 808(2), and 
5 U.S.C. 553(d), the Report and Order and Order on Reconsideration 
shall become effective April 9, 2021.
    91. It is further ordered that the Commission shall send a copy of 
the Report and Order to the appropriate Congressional Committees 
identified in the Consolidation Appropriations Act to provide notice of 
the application evaluation metrics.
    92. It is further ordered that the Commission shall send a copy of 
the Report and Order to Congress and the Government Accountability 
Office pursuant to the Congressional Review Act, see 5 U.S.C. 
801(a)(1)(A).
    93. It is further ordered that, pursuant to sections 4(i) and 405 
of the Communications Act of 1934, as amended, 47 U.S.C. 154(i), 405, 
and Sec.  1.429 of the Commission's rules, 47 CFR 1.429, the Petition 
for Partial Reconsideration filed by the American Hospital Association 
is denied.

Federal Communications Commission.
Marlene Dortch,
Secretary.
[FR Doc. 2021-07370 Filed 4-8-21; 8:45 am]
BILLING CODE 6712-01-P