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Specifically, interested parties questioned the language in the CMS State Operations Manual RHC interpretative guidance as it relates to 491.9(a)(2), which states that RHCs may not be primarily engaged in specialized services. [322] The guidance goes on to state that, in this context, primarily engaged is determined by considering the total hours of an RHC's operation and whether a majority, i.e., more than 50 percent, of those hours involve the provision of RHC services, whereas section 1861(aa)(2)(A) of the Act only reference being primarily engaged in furnishing to outpatients physician services and services furnished by a physician assistant or a nurse practitioner, clinical psychologist or by a clinical social worker, as cross-referenced by sections 1861(aa)(1)(A) and (B) of the Act