Federal Advocacy2022-08-05T16:00:12-04:00

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Background

Statutory Restrictions under Section 1834(m) of the Social Security Act

Section 1834(m) of the Social Security Act (42 U.S.C. 1395m) restricts utilization of and reimbursement for telehealth and remote patient monitoring services in the traditional Medicare fee-for-service (FFS) program by narrowly defining conditions around eligibility for coverage. As a result, the benefits offered by these advanced technologies are limited to certain groups of beneficiaries. A primary limitation is the originating site restriction, which requires the patient receiving the telehealth service to be in specific sites and geographic regions to qualify for Medicare coverage. Generally, covered telehealth services must be provided in rural areas as determined by the Department of Health and Human Services (HHS).

Telehealth provisions from the pandemic is tied to the end of the public health emergency. The latest Public Health Emergency was renewed on July 15. See below how many days left telehealth advocates has to ensure telehealth flexibilities remain permanent after the public health emergency.

Section 1834(m) of the Social Security Act

(42 U.S.C. 1395m)

Originating Site Requirements
Location of the patient when the service being delivered via a telecommunications system

  • Geographic eligibility: Eligible locations for the originating site must be identified either as:
    • A rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or within a rural census tract; or
    • A county outside of an MSA.
  • Each calendar year, the geographic eligibility of an originating site is established based on the status of the area as of December 31st of the prior calendar year.
  • Eligible facilities include:
    • Physicians’ offices; Hospitals; Critical Access Hospitals (CAH); Rural Health Clinics; Federally Qualified Health Centers; Hospital-based or CAH-based Renal Dialysis Centers (including satellites); Skilled Nursing Facilities (SNF); and Community Mental Health Centers (CMHC).

Distant Site Requirements
Location where the physician or other licensed practitioner delivering the service is located when the time the service is provided via a telecommunications system

  • Distant site cannot be the same location as the originating site.
  • Providers serving at the distant site must be licensed to provide the service under state law.
  • Eligible physician or practitioner includes:
    • Physicians; Nurse practitioners (NPs); Physicians assistants (PAs); Nurse-midwives; Clinical nurse specialists (CNS); Certified registered nurse anesthetists; Clinical psychologists (CP) and clinical social workers (CSW); or Registered dietitian or nutrition professional.
    • Does NOT include a federally qualified health center (FQHC) or rural health center (RHC).

Eligible Technologies
Eligible telecommunications systems must use interactive audio and video equipment that results in real-time communication between the provider and beneficiary. Store- and-forward technologies, such as those that allow for the electronic transmission of digital images, like pictures and x-rays, or prerecorded videos, are permitted only in federal demonstration programs conducted in Alaska and Hawaii.

Eligible Services
Eligible services include, but are not limited to, office or other outpatient visits, professional consultations, individual psychotherapy, pharmacologic management and individual and group medical nutrition therapy services.

Current Procedural Terminology (CPT) Codes and Billing

  • The specific telehealth-delivered services eligible for Medicare reimbursement are identified by Current Procedural Terminology (CPT) billing codes. Each year, the Centers for Medicare and Medicaid Services (CMS) accepts submissions from the public to add or delete CPT codes for reimbursement for telehealth-delivered services.
  • CY2015 Changes: On October 31 2014, CMS finalized a rule adding seven new telemedicine billing codes to the 2015 Medicare physician fee schedule. These new codes are for psychotherapy services, prolonged office visits, annual wellness visits, and related matters. In addition, the rule increased by 0.8 percent Medicare payments to telehealth originating sites in 2015.

Reimbursement Rates
Provider reimbursement rates for telehealth-delivered services are the same as the current Physician Fee Schedule. In addition, the originating site is eligible to receive a facility fee. Claims for reimbursement are submitted with the appropriate CPT code for the professional service provided and the telehealth modifier “GT” –“via interactive audio and video telecommunications system.”

COVID-19 Flexibilities

Active until 151-days after the end of the Public Health Emergency (PHE)

Patient Location
Health care providers may offer telehealth services to patients located in their homes and outside of designated rural areas. For the duration of the COVID-19 public health emergency, CMS will reimburse telehealth visits in lieu of many in-person appointments.

Geographic Eligibility
CMS announced a waiver allowing health care providers to furnish telehealth and other services using communications technology wherever the patient is located, including at home, even across state lines.

Safety Net Provider
Federally Qualified Health Centers and Rural Health Clinics can provide telehealth services to patients wherever they are located — including in their homes — for the duration of the COVID-19 public health emergency. This includes coverage for certain audio-only telephone evaluation and management services.

Eligible Providers
Generally, any provider who is eligible to bill Medicare for their professional services is eligible to bill for telehealth during this period.

Eligible Services
CMS significantly expanded the list of services that can be provided by telehealth during the COVID-19 PHE. Some types of telehealth services no longer require both audio and video – visits can be conducted over the telephone.

Federal Cost-sharing
Health care providers won’t face administrative sanctions for reducing or waiving cost-sharing obligations for telehealth services paid for by federal or state health care programs, such as Medicare and Medicaid.

The COVID-19 Pandemic

Secretary Azar used his authority under the Public Health Service Act to declare a public health emergency across the entire United States on January 31, 2020 giving HHS additional emergency powers to respond to the coronavirus. On March 13, 2020, President Trump declared a national emergency, unlocking additional powers, under section 1135 of the Social Security Act.

On March 5, 2020, Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act, waiving restrictions on telehealth in Medicare fee-for-service to enable more seniors to access care from the safety of their own homes during the public health emergency.

On March 21, 2020, Congress subsequently passed the Coronavirus Aid, Relief and Economic Security (CARES) Act, providing even greater flexibility for telehealth services.

HHS has used these new powers to unleash a wide array of changes aimed at increasing access to telehealth.

COVID-19 Resources

Alliance Resources

Legislation Tracker
HDHP Telehealth Advocacy
COVID-19 Resources and Guidance from Alliance Members and Partners
Taskforce on Telehealth Policy
Alliance for Connected Care Applauds the House for Advancing Telehealth Coverage for Seniors (7/27) – The Alliance for Connected Care (the Alliance) applauds U.S. House lawmakers for their commitment to protecting telehealth access through the passage of the Advancing Telehealth Beyond COVID-19 Act of 2022 (H.R. 4040). This legislation would ensure that Medicare beneficiaries continue to have access to telehealth until at least December 31, 2024.

Centers for Medicare and Medicaid Services: CMS Releases Hospital OPPS Proposed Rule (7/15) – CMS released the CY2023 Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule, which makes policy and payment updates for hospital outpatient and ambulatory surgical centers. CMS is seeking comment on several measures under consideration for the new Rural Emergency Hospital Quality Reporting Program, including rural telehealth services. CMS is also proposing behavioral health services furnished remotely by clinical staff of hospital outpatient departments, including staff of critical access hospitals (CAHs), through the use of telecommunications technology to beneficiaries in their homes, to be considered as covered outpatient services for which payment is made under the OPPS. For more information, see this general fact sheet and a fact sheet on Rural Emergency Hospitals.

Centers for Medicare and Medicaid Services: CMS Released the CY2023 Physician Fee Schedule Proposed Rule to Expand Access to High-Quality Care (7/7) – CMS issued the Calendar Year 2023 Physician Fee Schedule (PFS) proposed rule, which would significantly expand access to behavioral health services, Accountable Care Organizations (ACOs), cancer screening, and dental care — particularly in rural and underserved areas.

Office of Management and Budget: Audio-Only Telemedicine for Buprenorphine Initiation for Treatment of Opioid Use Disorder (7/5) – The Office of Management and Budget received and began to review a proposed rule entitled, “Audio-Only Telemedicine for Buprenorphine Initiation for Treatment of Opioid Use Disorder”. This rule would clarify the rights and obligations for DATA-waived registrants when prescribing buprenorphine to patients with Opioid Use Disorder pursuant to a telemedicine encounter which utilizes audio-only telecommunication systems.

House Appropriations Committee: FY 2023 House Appropriations Committee Report (6/29) – On June 29, the House Appropriations Committee released the Report for the Departments of Labor, Health and Human Services, and Related Agencies for Fiscal Year 2023 Appropriations. The report includes specific instructions with respect to the appropriated amounts. The report includes several telehealth provisions, which would ensure patients can continue to access care through this modality and that data about its usage can be adequately collected to inform future policy. The Alliance published a blog with key telehealth report language, which can be found here. The House Appropriations Committee passed this bill on June 30, and a full House vote is expected in July.

White House Office of National Drug Control Policy: ONDCP Announces Report on Improving Telehealth Services for Substance Use Disorder (6/22) – The White House Office of National Drug Control Policy (ONDCP) released the Telehealth and Substance Use Disorder Services in the Era of Covid-19: Review and Recommendations report. The report by the Legislative Analysis and Public Policy Association (LAPPA) found telehealth services can provide increased access to vulnerable individuals with substance use disorder, decrease costs, and reduce the spread of communicable diseases. The report makes several recommendations, including to expand and make consistent current state and federal telehealth policies, and for federal support of mutual recognition and reciprocity of state licenses. For additional coverage, see Bloomberg Law.

Health Resources and Services Administration (HRSA): Evaluation of the Rural Maternity and Obstetrics Management Strategies (RMOMS) Program: 2019 Cohort (6/9) – The Health Resources and Services Administration (HRSA) released the second annual report evaluating the Rural Maternity and Obstetrics Management Strategies (RMOMS) Program, the first cohort of which completed its first year of implementation last August. The program uses a network approach to coordinate and improve telehealth services to increase access to care in rural areas, among others. Program awardees laid the groundwork for expanded telehealth, which they consistently identified as a major focus area to improve maternal health access. Implementation delays have pushed such efforts into the next implementation year, however all three networks made progress on telehealth initiatives during this first implementation year.

HHS Office of the Inspector General: Spring 2022 Semiannual Report to Congress, Highlights Telehealth Use Among Medicare Beneficiaries (6/6) -The HHS Office of the Inspector General (OIG) released its Spring 2022 Semiannual Report to Congress, which highlights nearly $3 billion in expected recoveries as a result of HHS-OIG audits and investigations and provides an overview of HHS-OIG activities from October 1, 2021 through March 31, 2022. Notably, the report highlights the OIG finding that from March through December 2020, 84 percent of Medicare beneficiaries received telehealth services from providers with whom they had an established relationship, among other findings.

Government Accountability Office: National Strategy Needed to Guide Federal Efforts to Reduce Digital Divide (5/31) – The Government Accountability Office (GAO) published a report on broadband, which recommends the White House to develop and implement a national broadband strategy with clear roles, goals, objectives, and performance measures to support better management of fragmented, overlapping federal broadband programs and synchronize coordination efforts. Increased broadband access would help underserved populations virtually access essential health care services, such as telehealth. (Note that the Biden Administration announced a major broadband initiative several weeks ago that is likely not captured)

Centers for Disease Control & Prevention: National Health Statistics Report Shows Telemedicine Use in Children Age 0-17 (5/10) – The CDC found that, in the second half of 2020, only 14.1 percent of children used telehealth due to the pandemic, but use was higher among those with asthma, a developmental condition, or a disability. In total, about 12.6 million children, or 17.5 percent, used telehealth in the past 12 months, which included a period before the COVID-19 pandemic. Approximately 10.2 million children, or 14.1 percent, used telehealth due to the COVID-19 pandemic. About 23.5 percent of children with asthma used telehealth because of the pandemic compared with 13.6 percent of those without asthma. Similarly, 32.5 percent and 29.8 percent of children with a current developmental condition and a disability, respectively, used telemedicine due to the pandemic.

Health Affairs: Medicare and Telehealth – Delivering on Innovation’s Promise for Equity, Quality, Access and Sustainability (5/1) – The COVID-19 pandemic profoundly changed health care. Policy makers and health care leaders must evaluate the lessons learned from the pandemic and leverage telehealth innovations with an eye toward how such changes can advance health equity; drive high-quality, high-value, person-centered care; and promote affordability and sustainability. This report explores these topics in more detail.

HHS OIG Releases New Report on Medicare Telehealth Services During the Pandemic (3/17) – On March 17, 2022, the HHS Office of the Inspector General (OIG) released a new report examining the use of telehealth services in Medicare during the first year of the pandemic, declaring that telehealth was critical during this time period for Medicare beneficiaries. The report also looks at the growth of telehealth services, the types of telehealth services most commonly used, and the extent to which beneficiaries also used in-person services.

ASPE Report: Medicare Beneficiaries’ Use of Telehealth in 2020: Trends by Beneficiary Characteristics and Location (1/3) – Telehealth services expanded rapidly during the COVID-19 pandemic. Using data from the Census Bureau’s Household Pulse Survey (HPS) in 2021, this Issue Brief analyzes national trends in telehealth utilization across all payers and examines how use of video-enabled vs. audio-only telehealth services differ across patient populations. The study finds notable disparities by race, ethnicity, income, age, and insurance status in access to video-enabled telehealth.

Alliance Leads a Letter Supporting the Benefit Expansion for Workers Act of 2022 (6/30) – The Alliance for Connected Care led a letter with other leading telehealth groups supporting the Benefit Expansion for Workers Act of 2022, which would allow employers to provide telehealth or other remote care services to employees ineligible for an employer-sponsored group health plan.

Alliance Applauds Inclusion of Telehealth Provisions in the FY 2023 House Appropriations Committee Report (6/29) – 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.

Telehealth Resource Centers Support Letter (5/31) – On May 31, more than 80 organizations called on Congressional Appropriators to increase funding for Telehealth Resource Centers. This increase in funding would provide a critical boost to the TRCs, which have experienced a high of an 800% increase in demand for telehealth assistance during the COVID-19 pandemic across the nation, yet have been level-funded since 2006. Learn more about this request.

Patients and Practitioners Agree – Telehealth Is Important for Patient Access, Health Care Workforce (4/6) – The Alliance for Connected Care released a major survey of both healthcare patients and practitioners conducted by Morning Consult on the Alliance’s behalf. The poll asked patients and practitioners about their telehealth usage, telehealth experiences, their use of care across state lines, and the workforce implications of these developments.

Read more here.

Featured: Alliance for Connected Care Applauds the House for Advancing Telehealth Coverage for Seniors

WASHINGTON D.C. July 27, 2022 – The Alliance for Connected Care (the Alliance) applauds U.S. House lawmakers for their commitment to protecting telehealth access through the passage of the Advancing Telehealth Beyond COVID-19 Act of 2022 (H.R. 4040). This legislation would ensure that Medicare beneficiaries continue to have access to telehealth until at least December 31, 2024.

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