Telehealth parity, coverage, access debated in New Hampshire, South Dakota; CMS issues corrections to RPM in 2021 Medicare PFS rules

Two US states are taking opposite tacks on the permanence of payment parity, telehealth coverage, and access recently broadened during the COVID pandemic

  • New Hampshire’s legislature is debating a bill (HB 602) that would eliminate the payment parity requirement for all telehealth consults, as well as eliminate coverage for telephonic (audio) consults and faxes. Parity was first permitted on an emergency basis at the start of the COVID pandemic in 2020, then passed through the legislature and signed into law by Governor Sununu in July. Parity requires provider reimbursement at the same rate as in-person visits for state Medicaid and private plans.  mHealthIntelligence
  • South Dakota’s Governor Noem, however, is proposing to make permanent the emergency telehealth expansions directed in two 2020 executive orders in two bills she’s submitted to the legislature:
    • Eliminate the in-person exam requirement before a care provider begins telehealth treatment with a new patient
    • Enable providers to prescribe certain medications via telehealth
    • Eliminated the requirement for telehealth on an audio-visual platform, thus enabling providers to conduct telephonic consults for some services
    • In the second bill, South Dakota could recognize medical licenses from states included in the Uniform Emergency Management Assistance Compact (EMAC), a mutual aid agreement that allows states to share resources during natural and man-made emergencies. mHealthIntelligence

Both payment parity and coverage access are hot topics in physician reimbursement and patient services. The argument in favor of parity is to incentivize usage among physicians. Opposing this is the notion that telehealth has a lower value than in-person visits and that payers should be able to negotiate coverage and rate with care providers. In New Hampshire, a rural state but adjacent to Massachusetts, there is sparse availability of many healthcare services, especially for mental health and substance abuse services. The same is true in South Dakota, a state 8.5 times geographically larger than New Hampshire and truly ‘big sky’ country. Here parity is not an issue but ‘existing patient’ requirements, prescribing, telephonic, and licensing are. Telephonic consults in rural areas with spotty broadband are also considered to be a vital inclusion.

CMS also did some revising on the 2021 Medicare Physician Fee Schedule (PFS) to clarify and correct coding plus other information around remote patient monitoring (RPM) effective 1 January:

  • 20 minutes of time includes, but is not limited to, “Interactive Communication” with patient
  • RPM billing by one practitioner, per patient per period
  • Many codes can be used for billing RPM, including codes for collecting and monitoring the data, and treatment/management services of the conditions monitored with the data. (In the US, certified billing and coding professionals are the most frequent ‘brain benders’ on these issues. It is that complex.)

The Foley & Lardner blog has a concise summary, but you can enjoy the CMS-corrected document in the Federal Register here

CMS expands telehealth, RPM in 2021 Physician Fee Schedule, creates post-pandemic temporary category (updated)

On 1 December, the Center for Medicare & Medicaid Services (CMS) announced its all-important 2021 Physician Fee Schedule (PFS), which sets out the fees and rules for physicians providing services to Medicare fee-for-service beneficiaries and generally serves as a guideline to commercial payers. If one only reads the release headline, one would assume that the national telehealth payment expansion that was approved when the public health emergency (PHE) was declared in March would be largely retained permanently in the 2021 PFS after the earnestly desired end of the PHE, extended to 20 January 2021,

Interpreting CMS-speak is always a task, and so it is here. Your Editor will do her best to unpack it. 

Paragraph 5 is the sobering note for the telehealth ‘bulls’. Telehealth expansion, on a permanent basis, applies to Rural Health, Federally Qualified Health Centers (FQHC), and certain Medicare program models (e.g. two-sided Medicare Shared Savings Program ACOs, ESRD, Episode Payment models, and Medicare Advantage), and with a limited number of new codes. From the release:

“This final rule delivers on the President’s recent Executive Order on Improving Rural Health and Telehealth Access by adding more than 60 services to the Medicare telehealth list that will continue to be covered beyond the end of the PHE….These additions allow beneficiaries in rural areas who are in a medical facility (like a nursing home) to continue to have access to telehealth services such as certain types of emergency department visits, therapy services, and critical care services.”

The release then goes on to explain the kicker: “Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside of rural areas or, with certain exceptions, allow beneficiaries to receive telehealth in their home.” (Editor’s emphases) 

What seems like a pullback in the PFS is a reversion to status quo ante in geographic and model restrictions, which can’t be changed except by Congress. What CMS can do is expand, and create, new Categories for covered codes.

  • CMS expanded Category 1 which is the basic list of telehealth covered codes (CPTs and HCPCS). If you are in a rural area or a covered model, the expansion is real but limited: the number of new codes in Category 1 is nine codes of the 60 stated in the release. 60 is also far less than the 144 service codes added since the start of the PHE.
  • The remaining telehealth codes of the 60 quoted are in a new, temporary Category 3, which will extend through the calendar year the PHE ends–which is, as of today, 31 December 2021. (If the PHE goes into 2022, unless the rule is changed, 31 December 2022.)
    • Category 3 includes over 50 telehealth service codes for the PHE that are not in Category 1–thus the count of 60 the CMS press release trumpeted. 
    • What is not spelled out in CMS’ press release or public Fact Sheet is if statutory geographic (rural) and model restrictions will apply to this category after the PHE ends. Given the above, this Editor’s interpretation is that statutory restrictions will apply unless there’s a Federal change.
  • The Fact Sheet also clarifies certain frequency limitations, who can deliver telehealth services in a practice, telephone-only interactions with a new HCPCS code, and direct practitioner supervision.  Fact Sheet–Final Policy, Payment, and Quality Provisions Changes

For remote patient monitoring (remote physiologic monitoring) services which were modified during the PHE, there are important clarifications and two finalizations of modifications to RPM services made during the PHE, also in the Fact Sheet. 

The exception to the above is apparently the Medicare Diabetes Prevention Program (MDPP). Virtual delivery of certain services, such as educational classes which shifted from in-person to virtual and weight measurement, will not continue past the end of the PHE. CMS MDPP release. Also mHealth Intelligence.

What this all really means. CMS has Kicked The Telehealth Can Down The Road for 2021. They have retained many of the changes that the pandemic forced, but the geographic and model restrictions remain. But practices have made serious procedural modifications to incorporate remote and telephonic visits. Many patients in the Medicare age group are still self-isolating to a significant degree, and depending on the path of COVID-19 (and the flu) have good reason to limit in-office visits. This year’s use of telehealth in this group, according to CMS, was astounding: between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries received at least one of those 144 Medicare telemedicine services. What remains unclear is if Category 3, after the PHS, could continue to apply nationally through Congressional action, as there are several bills before this soon-to-close Congress.

Certainly this, plus post-COVID usage, will influence the 2022 PFS and perhaps stimulate Congress to allow CMS to permit payment for telehealth services nationally.

Editor’s note: References in addition to above are Center for Connected Health Policy’s Telehealth and Medicare page, the proposed CY 21 PFS Fact Sheet (PDF), and COVID-19 Telehealth Coverage Policies. Hat tip to former colleague Madeline Short, COO of Wilems Resource Group.

Update 3 December: The American Telemedicine Association published its comments on 2 December, agreeing with CMS Administrator Seema Verma’s comments on making telehealth permanent outside of geography, itemizing the present bills languishing in Congress, and also lamenting the short shrift that the final rule gave to remote patient monitoring. Also, Healthcare IT News includes additional comments from ATA chief Ann Mond Johnson. Some states like Texas and Wisconsin are pushing for updated parity rules applying to state-regulated plans, which would include commercial plans and Medicaid. Hat tip to reader Paul Costello for the heads-up.

The wind may finally be at the back of telehealth distribution and payment (US)

Medicare Advantage may lead, but Medicaid and regular Medicare are not far behind. The Centers for Medicare & Medicaid Services (CMS) has announced in two proposed rules changes expansion of telehealth access for both privately issued Medicare Advantage (MA) plans (26 Oct) and state-run Medicaid and CHIP (Children’s Health Insurance Plan) (14 Nov) plan members. This may mean greater acceptance by providers because they will be paid for these services.

For MA, the proposal would, starting in 2020 as part of government funded basic benefits, eliminate geographic restrictions (rural telehealth) and allow members in urban areas to access telehealth services. It would also broaden present location restrictions, allowing MA members to receive telehealth from home versus traveling to a health care facility. The most intriguing wording is here: “Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries.” which very well could mean remote patient monitoring in conjunction with visits. MA plans have always had more latitude to offer telehealth benefits to members, which are about 1/3 of Medicare-eligibles (over 65). Over 11 percent growth is forecast and it is highly competitive though dominated by United Healthcare and Aetna–over 600 new plans are entering the market next year. Enrollments close on 7 Dec for 2019. CMS.gov release, mHealth Intelligence, Healthcare Finance News.

For Medicaid and CHIP, which states use to extend insurance to low-income individuals and families via private plans, states would be able to, under an approved rule, to more flexibly determine what criteria determine telehealth access. Currently, states use proximity factors–distance from provider and time. The proposed criteria under 10. Network Adequacy (pages 15-16) recommends that time and distance be deleted and instead “adding a more flexible requirement that states set a quantitative minimum access standard (later listed) for specified health care providers and LTSS (long term services and supports) providers”. The reasons why are the limited supply of providers and the functional limitations of the LTSS population. Also notable was language in section 8 discussing access to provider directories via smartphone, as 64 percent of the population with incomes less than $30,000 own a smartphone and use it to access health information.  CMS proposed rule, POLITICO Morning eHealth

This adds to the momentum of the Medicare Physician Fee Schedule published on 1 Nov that added even more:

  • Virtual brief patient checkins and evaluation of patient-recorded photos and video to payments
  • CMS is also finalizing separate payments for three new codes covering chronic care remote physiologic monitoring that unbundle 99091 (CPT codes 99453, 99454, and 99457) and interprofessional internet consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449).
  • Two new codes covering telehealth for prolonged preventive services
  • Finalizing the addition of renal dialysis facilities and the homes of ESRD beneficiaries receiving home dialysis as originating sites
  • After 1 July, the home will be permitted as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder. CMS.gov fact sheet 

The importance of this is that more digital health covered by Medicare and government payments in public/private programs such as Medicaid and MA lead private insurers to pay doctors for these services, who will then be willing to pay vendors for providing them. For the telehealth and telemedicine companies that have weathered the storms and lean times of the past decade, there may be light at the end of the tunnel that is not an oncoming train.