Federal Advocacy

The Alliance advocates to remove barriers and restriction for the use of telehealth. See below for a few of our top federal priorities. See here for a full list.

History of Medicare Telehealth

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).

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.”

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.

As a result of the COVID-19 pandemic, CMS has made permanent certain telehealth changes for Medicare:

• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can serve as a distant site provider for behavioral/mental telehealth services
• Medicare patients can receive telehealth services for behavioral/mental health care in their home
• There are no geographic restrictions for originating site for behavioral/mental telehealth services
• Behavioral/mental telehealth services can be delivered using audio-only communication platforms
• Rural Emergency Hospitals (REHs) are eligible originating sites for telehealth