Proposed CMS Rules Will Govern How MA Plans Structure Telehealth Benefits

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On Friday, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule regarding Medicare Part C and Part D benefits. The proposal is the next step in the implementation of the Bipartisan Budget Act which authorized Medicare Advantage (MA) plans to offer, as part of the basic benefit package, additional telehealth benefits beyond what is currently allowable in original Medicare.

After years of trying to convince CMS that telehealth services should not be considered separate clinical services, and that telehealth will not drive unnecessary utilization, the rule contains major progress for the telehealth community. However, in addition to these wins, there are a couple of areas we hope that CMS will consider modifications.

Telehealth Wins

Win 1: The biggest win is more of an existential one. For years, telehealth stakeholders have been bringing evidence to CMS to demonstrate that the use of telehealth will produce savings for Medicare. This evidence included avoided care in higher cost settings during acute situations, as well as use of telehealth for secondary prevention of chronic disease including post-acute care and medication management.

On Friday, CMS finally formally acknowledged this evidence. The CMS impact analysis of the proposed rule “assumes replacement of some face-to-face provider visits, and no additional increase in overall provider visits.” They also said that “increased coverage of the additional telehealth benefits will generally result in an aggregate reduction in use of emergency room visits and inpatient admissions because the relative increased ease of receiving healthcare services should improve health outcomes and reduce avoidable utilization that results in untreated conditions exacerbating illness.” They even acknowledged the value of telehealth in reducing patient travel time to the tune of $60-100 million.

Win 2: CMS’s proposal to allow MA plans to build their telehealth benefits “in a manner consistent with professionally recognized standards of health care” is consistent with the way MA plans treat other services. By declining to set up a prescriptive system to determine what is “clinically appropriate,” CMS implicitly recognized that telehealth is simply health care delivery by another modality. It’s not a separate service, and doesn’t need to be treated separately.

Win 3: CMS currently allows MA plans to engage in differential cost sharing for original Medicare benefits. This flexibility would be extended to additional telehealth benefits, meaning that MA plans could offer telehealth services for free should they so choose. This flexibility is crucial for enrollees and plans alike. Making telehealth services available with little or no co-pay facilitates it’s use.

Win 4: The proposed rule notes that CMS recognizes “the potential for additional telehealth benefits to support coordinated health care and increase access to care in both rural and urban areas.” This is exciting because in the past some have posited that telehealth may make care more disjointed. CMS sees the value that telehealth can bring to coordinating care.

Issues to Watch

Issue to Watch 1: MA plans want to offer telehealth services to increase access to care. CMS acknowledges this will happen. However, we need to ensure that telehealth services can be offered alongside in-person care without having to be classified as supplemental to in-person visits. In other words, we shouldn’t have exactly the same number of in-person providers as telehealth providers after network adequacy standards are met. MA plans should be able to add as many telehealth providers as they want after they have met their network adequacy standards.

Issue to Watch 2: The definition of technology in the rule is very broad. It’s good to have flexibility to allow for future technology innovation, but just like in the proposed Physician Fee Schedule rule, allowing secure messaging and phone to count as telehealth may simply mean paying for services that doctors already provide. We should have the same definition for telehealth in both original Medicare and fee-for-service for consistency. The fee-for-service definition is sufficiently broad to allow for technological innovation.

Overall, this proposed rule represents major progress for telehealth in Medicare, and will surely give seniors more access to care through technology.