On June 29, the House Appropriations Committee released the Report for the Departments of Labor, Health and Human Services, Education, and Related Agencies for Fiscal Year 2023 Appropriations. The report includes specific instructions with respect to the appropriated amounts.

The Alliance was thrilled to see the inclusion of several telehealth provisions in this report, which ensure patients can continue to access care through this modality and data about its usage can be adequately collected to inform future policy. Below is a topline of the key telehealth provisions included in the report language.

HHS Office of the Secretary

• Telehealth Data. —The Committee recognizes that demand for telemedicine increased in 2020 in response to the COVID–19 pandemic. In addition, the Committee notes disparities in telehealth exist between and within racial and ethnic groups, rural and urban locations, and geographic regions as detailed in a December 2021 report by the Assistant Secretary for Planning and Evaluation. The Committee urges the Secretary, working with CMS and HRSA, to categorize telehealth usage data, including for audio-only services, by Health Professional Shortage Areas. The Committee further urges the Secretary to work across agencies to ensure that improvements to broadband availability are prioritized in those areas with lowest telehealth usage, highest audio-only usage, and a known health professional shortage. The Committee requests an update within 120 days of the date of enactment of this Act on this categorization and broadband availability.

Centers for Medicare and Medicaid Services (CMS)

• Telehealth and Health Care Access. —The Committee requests a report in the fiscal year 2024 Congressional Budget Justification on the impact of telehealth on health care access, utilization, cost, and outcomes, broken down by race, ethnicity, sex, age, disability status, and zip code under the Medicaid program and CHIP.

Health Resources and Services Administration (HRSA)

• Telehealth. —The Committee includes $37,050,000 for Telehealth, an increase of $2,000,000 above the fiscal year 2022 enacted level. Funds support the Office for the Advancement of Telehealth, which promotes the effective use of technologies to improve access to health services for people who are isolated from health care and to provide distance education for health professionals.
• Telehealth Provider Bridge. —The Committee includes $500,000 within the total for Telehealth for the Provider Bridge program. With funds appropriated in the Coronavirus License Portability Grant Program, HRSA established the Provider Bridge Program to empower medical professionals to safely and efficiently deliver urgently needed care to communities during public health emergencies. To date, over 400 entities and 85,000 healthcare professionals have leveraged this national tool connecting health care professionals with State agencies and health care entities to quickly verify credentials and professional background information. Specifically, the platform provides a directory of State and Federal COVID–19 resources, allows health care professionals to submit professional background information, produces official and verified digital documents of licensure and credentialing information, and provides access to a database of information for volunteer clinicians willing to provide care.
• Telehealth Centers of Excellence. —The Committee supports the continued development of Telehealth Centers of Excellence to continue to validate technologies and reimbursement mechanisms, establish training protocols, and develop comprehensive templates for States to integrate telehealth into their state health provider networks.
• Rural Telehealth Initiative. —The Committee supports the Memorandum of Understanding entered into on August 31, 2020, establishing a Rural Telehealth Initiative among HHS, the Federal Communications Commission, and the Department of Agriculture. Together, this important initiative can leverage expertise of each respective agency and improve collaboration amongst entities tasked with addressing rural telehealth access. This initiative recognizes the unique problems facing rural Americans that need access to critical care services through telehealth platforms. The Committee encourages agencies involved in this initiative to prioritize opportunities to continue the expansion of telehealth services, close the digital divide, and not leave rural communities behind.

This week, the House Appropriations Committee introduced the Consolidated Appropriations Act, 2022 (H.R. 2471), consisting of all 12 fiscal year 2022 appropriations bills and supplemental funding to support Ukraine. The House passed this bill on March 9, 2022 and the Senate passed this bill on March 10, 2022. The bill now goes to President Biden for signature.

The Alliance was thrilled to see the inclusion of several major telehealth provisions included in this package, which will continue several COVID-era telehealth policies for about five months after the public health emergency (PHE) ends. These provisions provide an opportunity for the telehealth community to continue advocating for permanent telehealth reform.

The only major legislative provision not included on a temporary basis were provisions allowing Critical Access Hospitals (CAHs) to serve as a distant site provider for telehealth and offer services the same way they do for in-person care.   Without this flexibility, we are concerned that many CAHs will cease offering telehealth at the end of the PHE.

Below is a topline of the key telehealth provisions included in the appropriations bill and corresponding report language.

Highlights from H.R. 2471

Division P – Health Provisions

Title III – Medicare, Subtitle A – Telehealth Flexibility Extensions. Unless otherwise noted, all provisions are active for the 151-day period beginning on the first day after the end of the public health emergency (bringing us through mid-December if the PHE ends in July).

• Sec. 301. Removing geographic requirements and expanding originating sites for telehealth services.
  • This section would amend the current originating site definition and expand it to mean any site in the United States at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system (without geographic restriction). Additionally, there is no facility fee.
• Sec. 302. Expanding practitioners eligible to furnish telehealth services.
  • This section temporarily adds qualified physical therapist, qualified speech-language pathologist, and qualified audiologist as eligible providers to provide telehealth services.
• Sec. 303. Extending telehealth services for federally qualified health centers and rural health clinics.
  • This section would extend the CARES Act telehealth payment structure for federally qualified health centers and rural health clinics.
• Sec. 304. Delaying the in-person requirements under Medicare for mental health services furnished through telehealth and telecommunications technology.
  • This section delays in-person requirements for mental health services until the day that is the 152 day after the end of the emergency period. In-person requirements for rural health clinics and federally qualified health centers shall not apply prior to the day that is the 152 day after the end of the PHE.
• Sec. 305. Allowing for the furnishing of audio only telehealth services.
  • This section requires the HHS Secretary to continue providing coverage and payment for audio-only telehealth services as of the date of engagement during the 151 day following the end of the PHE.
• Sec. 306. Use of telehealth to conduct face-to-face encounter prior to recertification of eligibility for hospice care during emergency period.
  • This section continues the CARES Act provision which allows virtual recertification of hospice care.
• Sec. 307. Extension of exemption for telehealth services.
  • This section renews flexibility for employers or plans using high-deductible health plans coupled with a health savings account (HDHP-HSAs) to provide first-dollar coverage for telehealth services from March 31, 2022 – January 1, 2023. Any care provided between January 1, 2022 and March 31, 2022 is not covered.
• Sec. 308. Reports on telehealth utilization.
  • This section requires a MedPAC report on utilization of telehealth services, expenditures on telehealth services, Medicare payment policy for FQHCs and RHCs, and other areas as determined appropriate by the Commission.

Title I – Public Health, Subtitle D – Maternal Health Quality Improvement

Under Chapter 2 – Rural Maternal and Obstetric Modernization of Services section, the following provision is included:

• Sec. 143. Telehealth Network and Telehealth Resource Centers Grant Program.
  • This section amends Section 330I of the Public Health Service Act (42 U.S.C. 245c-14) to add providers of prenatal, labor care, birthing, and postpartum care services, including hospitals that operate obstetric care units, to the list of eligible entities to receive a grant to provide services through a telehealth network. It will also help develop plans for, or to establish, telehealth networks that provide prenatal care, labor care, birthing care, or postpartum care.

Highlights from the Joint Explanatory Statement Report Language and House Report Language for Labor-HHS-Education

CMS –

• Telehealth and the Homeless Population — The agreement directs CMS to identify and share with States best practices regarding ways in which telehealth and remote patient monitoring can be leveraged through the Medicaid and Medicare programs for the homeless. This should include identification of barriers to mental health services via telehealth coverage, as well as ways to address those barriers.
• Audio-Only Evaluation and Management Services — The agreement requests CMS, in coordination with the Assistant Secretary for Planning and Evaluation, conduct a review of audio-only services delivered during the COVID-19 public health emergency, and provide an update on the provision of such services in the fiscal year 2023 Congressional Justification.
• Blue Button — The Committee believes that the Blue Button program can play an important patient safety and care coordination role for Medicare beneficiaries and their health care providers, particularly in relation to COVID–19 vaccination efforts and the increasing use of telehealth. Unfortunately, Blue Button has had a low participation rate. The Committee urges the Secretary to examine barriers to participation, including health and technology related inequities, and widely educate beneficiaries about Blue Button.
• Telehealth for Pediatric ESRD.—The Committee understands that due to the scarcity of pediatric nephrologists and precautions following the COVID–19 pandemic, more children are successfully receiving care for end stage renal disease at home through telehealth technology. However, persistent inequalities in access to broadband and information technology prevent many children from accessing this technology. The Committee requests that, within 120 days of enactment of this Act, the Secretary provide a report on the usage of telehealth technology for pediatric end stage renal disease patients covered by Medicare and Medicaid during the COVID–19 pandemic, including an analysis of use in HRSA-designated rural counties and designated eligible census tracts in metropolitan counties and HRSA-designated medically underserved areas.

HHS Office of the Secretary –

• Telehealth Report – The agreement directs HHS to submit a report no later than 180 days after enactment of this Act detailing the impact of the actions taken by the Secretary during the COVID- 19 public health emergency (PHE) to increase telehealth services under the Medicare, Medicaid, and Children’s Health Insurance Programs, as well as other HHS entities engaged in policy or programmatic telehealth changes during the PHE.
• Telehealth Standards.—The Committee believes that the flexibility afforded to telehealth providers has played an essential role in ensuring that Americans receive timely and quality care throughout the COVID–19 pandemic; however, quality standards remain important no matter the health care delivery method to ensure quality and safety. The Committee urges the Secretary to establish an advisory group to study issues relating to the provision of telehealth and associated quality of care. Such a study should generate recommendations regarding the applicability of telehealth modalities for various clinical scenarios. The Secretary shall assemble a technical advisory group that includes experts in the delivery of telehealth services. The advisory group shall also evaluate whether equity exists in access to appropriate telehealth modalities throughout the country, including broadband, computers, smartphones, landline telephones, and cell phones that only allow for audio-only communications. The Committee requests the Secretary deliver a report from the advisory group, no later than one year after enactment of this Act, with recommendations as to whether quality of care criteria should be applied to the specific use of any telehealth modality in different clinical scenarios.

Health Resources & Services Administration  –

• Telehealth Centers of Excellence – The agreement includes $7,500,000 for the Telehealth Centers of Excellence (COE) awarded sites, an increase of $1,000,000 above the fiscal year 2021 enacted level. Grantees examine the efficacy of telehealth services in rural and urban areas and serve as a national clearinghouse for telehealth research and resources. The Centers of Excellence serve to promote the adoption of telehealth programs across the country by validating technology, establishing training protocols, and by providing a comprehensive template for States to integrate telehealth into their State health provider network. Additional funding for the Centers of Excellence will support the development of models of care and best practices for the expansion of telemental health.
• Telehealth — The Committee includes $39,000,000 for Telehealth, an increase of $5,000,000 above the fiscal year 2021 enacted level and $2,500,000 above the fiscal year 2022 budget request. Funds support the Office for the Advancement of Telehealth, which promotes the effective use of technologies to improve access to health services for people who are isolated from health care and to provide distance education for health professionals.
• Urban Focused Telehealth Network Grant Program — The Committee believes that a fundamental element to ensuring our health care system is prepared for pandemic events is the development of robust telehealth services and integrated systems that can provide a continuum of care across State and regional lines. This is especially true in the nation’s urban areas, where a pandemic event has the potential to disproportionately impact and overwhelm the health care and delivery system. The Committee believes increased investments in urban telehealth services could have a tremendous impact on the health and well-being of the nation’s most vulnerable citizens and medically underserved populations, especially during times of national public health emergencies. The Committee encourages HRSA to establish a pilot program to expand academic health system telehealth programs aimed at addressing the health inequities of urban populations.

Substance Abuse and Mental Health Services Administration (SAMHSA) –

• Opioid Abuse in Rural Communities —The agreement encourages SAMHSA to support initiatives to advance opioid abuse prevention, treatment, and recovery objectives, including by improving access through telehealth. SAMHSA is encouraged to focus on addressing the needs of individuals with substance use disorders in rural and medically underserved areas. In addition, the agreement encourages SAMHSA to consider early interventions, such as co-prescription of overdose medications with opioids, as a way to reduce overdose deaths in rural areas.
• Substance Use Disorder Response in Rural America —The Committee is aware that response to the SUD crisis continues to pose unique challenges for rural America, which suffers from problems related to limited access to both appropriate care and health professionals critical to diagnosing and treating patients along with supporting recovery. Rural America’s unique challenges require a comprehensive approach, including training to provide care in a culturally responsive manner with an understanding of diverse populations; the use of technologies to ensure improved access to medically underserved areas through the use of telehealth; and workforce and skills development to advance data capture and analytics. The Committee encourages SAMHSA to support initiatives to advance SUD objectives in rural areas, specifically focusing on addressing the needs of individuals with SUD in rural and medically-underserved areas, and programs that stress a comprehensive community-based approach involving academic institutions, health care providers, and local criminal justice systems.

Office of the National Coordinator for Health IT (ONC) –

• Accessibility of Online Telehealth Platforms.—The Committee recognizes that the COVID–19 pandemic led to the increased use of online portals and web services for patients seeking information, scheduling, and accessing remote services. However, the Committee is concerned that many online platforms are not user-friendly, especially for less digitally literate communities, including seniors. The Committee urges the Secretary, working through ONC, to coordinate with the Agency for Healthcare Research & Quality (AHRQ), the Centers for Medicare & Medicaid Services (CMS), and Office for Civil Rights (OCR) on any Federal efforts that can be made to evaluate the accessibility of digital health platforms for Federally-supported providers, including any assessments of how seniors and persons with disabilities are included in the design and testing of the platforms. Further, the Committee directs the Secretary, working through ONC, AHRQ, CMS, and OCR, to establish best practices for healthcare providers to improve their online telehealth platforms for seniors, individuals with disabilities, and individuals with limited English proficiency.

Other Notable Provisions –

• Federal Communications Commission – $382 million for the FCC, an increase of $8 million above the FY 2021 enacted level, to support efforts to expand broadband access, improve the security of U.S. telecommunications networks, and administer billions in COVID relief programs.
• Agriculture, Rural Development, Food and Drug Administration – $550 million in the expansion of broadband service to provide economic development opportunities and improved education and health care services, including an additional $450 million for the ReConnect program.
• Office of the Assistant Secretary for Preparedness and Response (ASPR) – The agreement includes funding for the National Emergency Tele-Critical Care Network (NETCCN), which enables skilled telehealth providers to support health systems undergoing a COVID-19 surge or experiencing staff shortages to operate remotely during the COVID-19 public health emergency. This funding could be used to expand the NETCCN to meet additional COVID-19 needs or used in future public health emergencies and disaster response efforts.