Timeline of Temporary Telehealth Policy Changes
March 6: Coronavirus Preparedness and Response Supplemental Appropriations (CARES) Act
- First COVID-19 supplemental funding bill lets HHS temporarily waive Medicare telehealth restrictions.
- Adds “telehealth service” to what HHS can temporarily waive or modify.
- Applies to rural and originating site restrictions.
- Authority only exists during declared COVID-19 public health emergency.
- Limited to providers with a previous relationship with a patient:*
- Furnished services to the patient in previous three years.
- The provider is in same TIN as someone with an established relationship through Medicare.
March 10: CMS Medicare Advantage Guidance
- May waive/reduce cost-pays for COVID-19 tests, telehealth and other services if done for all enrollees.
- May provide Part B services via telehealth in any area and from many places, including homes.
- May waive prior authorization that otherwise applies to COVID-19 tests or services at any time.
- May provide smartphone/tablet as supplemental benefit.
March 17: CMS FFS Guidance
- Medicare covers office, hospital and other telehealth visits nationwide and in homes as of March 6.
- Telehealth waiver applies to all treatment during the Public Health Emergency, not just COVID-19.
- Providers already authorized in statute (1834(m)) get telemedicine pay, including NPs, MDs, PAs.
- Interactive audio-visual telecommunications system that permits real-time communication.
- Allows the use of telephones with audio and visual capabilities – smart phones permissible.
- HHS is waiving HIPAA enforcement for provision of services in good faith via FaceTime and Skype.
- CMS not enforcing statute’s Established Relationship language.
- The IG grants flexibility for providers to waive co-pays.
- Did not change e-visit codes.
- Controlled substance prescribing rules waived
March 17: CMS Medicaid Guidance
- Flexibility to incent greater use of telehealth through 1135 waivers.
- Allows providers to use non-HIPAA compliant telehealth modes from platforms.
- Flexibility to make it easier for providers to care for people at home:
- To allow telehealth and virtual/telephonic communications for covered State plan benefits
- Waiver of face-to-face encounters for FQHCs and Rural Health Clinics
- Reimbursement of virtual communication and e-consults for certain providers
- Flexibility so Medicaid and Managed care enrollees could use telephones to receive care.
- Flexibility to let Medicaid pay for the same telehealth services Medicare now can.
March 17: Department of Health and Human Services, Office of Civil Rights
- Announces enforcement discretion to waive HIPAA penalties for good faith telehealth during COVID.
- Drug Enforcement Administration – Effective March 31
- Allows controlled substance prescribing by telehealth if:
- For legitimate medical purpose by practitioner acting in the usual course of professional practice
- Done via an audio-visual, real-time, two-way interactive communication system.
- In accordance with applicable federal and state law.
March 27: Congressional Action: 3rd Package—Coronavirus Aid, Relief and Economic Security Act
- Amends Telehealth Network and Telehealth Resource Centers grant program to support evidence-based projects, extend grant period funding from 4 years to 5 years and ensures that 50% of funds go to rural projects ($29M for each of FY21-25).
- Allows plans or employers to provide pre-deductible telehealth coverage for people with HSA-eligible HDPs, either discounted or fully covered. Amends Safe Harbor language and Disregard list.
- Eliminates requirement that clinicians must have treated patients in the past three years.
- Allows FQHCs and Rural Health Clinics to furnish telehealth in home or other setting, with composite reimbursement similar to comparable Medicare Physician Fee Schedule for telehealth.
- Eliminates the requirement that nephrologists conduct periodic home dialysis evaluations face-to-face.
- Allows hospice providers to use telehealth for face-to-face eligibility recertification encounter.
- Provides HHS flexibility to consider ways to encourage home health use of telecommunications and other communications or monitoring, consistent with the individual’s care plan.
April 2: Federal Communications Commission
- Establishes the $200M COVID-19 Telehealth Program to help providers connect to patients per the CARES Act.
Effective April 6 – CMS Interim Final Rule
- Adds 80 services that can be furnished via telehealth.
- Adds payment codes for prolonged audio-only E&M services between the practitioner and patient:
- Removes the preexisting relationship requirement on virtual check-ins.
- Additional codes for licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists and speech language pathologists. Distant site restrictions remain for some.
- Allows virtual required physician supervision via real-time audio/video technology.
April 10: Medicare Advantage Memo
- Allows risk adjustment for diagnoses via interactive audio-visual communication.
- Health risk assessment codes – 96160 and 96161- are “add-on” codes.
April 30 – CMS Second Interim Final Rule
- Along with 1135 waiver, removes remaining limitations on who can furnish telehealth including physical therapists, occupational therapists and speech language pathologist.
- Along with an 1135 waiver, waives the video requirement for certain telephone E&M services, and adds them to the list of Medicare telehealth services.
- Allows hospitals to bill for services furnished remotely by hospital-based practitioners to registered outpatients, including at home, when it is a temporary, provider-based hospital department.
- Allows hospitals to bill the originating site (facility fees) for telehealth furnished by hospital-based practitioners to registered outpatients, including when the patient is at home.
- Expansion of codes approved for audio-only telehealth visits using the 1135 waiver: E&M, behavioral, SUD, educational services and annual wellness visits at same pay as an office visit.
- Medicare covers telehealth services provided by rural health clinics and FQHCs as per the CARES Act.
- New additions will be made on a sub-regulatory basis to speed the process.
- Waived licensure laws, to varying extents to facilitate cross-border care (50).
- Pay at same rate as in-person care (32).
- Expand services (44), providers (32), phone (44), text/email (11), home as originating site (26).
Taskforce on Telehealth Policy (TTP) Overarching and Subgroup Questions
To help guide the TTPs work, conveners crafted a set of questions, some overarching about telehealth and several specific to its three subgroups:
- Patient Safety and Program Integrity.
- Telehealth’s Effect on Total Cost of Care.
- Data Flow, Care Coordination and Quality Measurement.
There naturally is overlap among these topics. Patient safety is essential for quality as is cost, by avoiding costly patient harm. Program integrity to prevent and fight fraud, waste and abuse is integral to cost, and quality and safety, because delivering unnecessary care diminishes quality and can harm patients. Data flow and care integration are necessary to optimize patient safety and prevent costly unnecessary care. Quality measurement to assess whether people get appropriate also affects cost, safety and integrity. The overlap quickly emerged in subgroup discussions and helped bring about consensus in the final recommendations.
- What criteria should be for which emergency regulatory changes to keep vs. default to pre-COVID rules?
- What role can federal and state policy play in giving patients and providers tools and technical assistance to meet telehealth needs?
- What have we learned during the pandemic that can be applied to a policy on access, quality, safety, cost effectiveness, and outcomes?
Patient Safety and Program Integrity
Patient safety concerns drove some pre-COVID telehealth restrictions.
- What do data tell us about program integrity with telehealth vs. in-person care?
- How can telehealth/virtual care technologies be used to enhance program integrity?
- How does your organization address program integrity with telehealth/virtual care and does it differ from in-person care?
- What best practices should payers implement to optimize program integrity to prevent fraud and abuse?
- What do data tell us about patient safety with telehealth vs. in-person care?
- Are there opportunities for greater levels of patient safety in telehealth?
- What controls are needed to prevent diversion of controlled substances prescribed via telehealth?
- How can we best protect patient privacy while ensuring interoperable telehealth access that enables effective payer-provider collaboration?
Data Flow, Care Coordination and Quality Measurement
Telehealth was often seen as separate rather than part of core care.
- How do we fully leverage telehealth capabilities throughout the care and quality ecosystems?
- What are barriers to a more integrated quality measurement system, data sharing and patient-centered care for remote services?
- What are the best ways to assess the impact of telehealth expansion on quality and patient experience?
- How do we adapt the quality infrastructure to incorporate and support telehealth expansion and strengthen its infrastructure?
- What has your experience been with consumer telehealth satisfaction? Would they accept virtual care in an integrated care system?
- How might policies encourage patients and providers to view telehealth as another kind of care vs. a different care modality?
Telehealth Effect on Total Cost of Care
Before COVID, policymakers often assumed that expanding telehealth would increase costs.
- What have we learned about telehealth utilization during the pandemic?
- How should federal budgeting models adapt to reflect expanded telehealth access?
- What is needed to determine the effect of telehealth expansion on prevention, urgent care, post-acute care, and so on?
- What principles should inform telehealth pay vs. in-person care and do these vary by service/mode of telehealth?
Taskforce on Telehealth Policy Members
- Peter Antall, MD, Chief Medical Officer and President, Amwell Medical Group
- Kate Berry, Senior Vice President of Clinical Innovation, America’s Health Insurance Plans
- Regina Benjamin, MD, Founder, BayouClinic/Gulf States Health Policy Center, former U.S. Surgeon General
- Sean Cavanaugh, Chief Administrative Officer, Aledade
- Krista Drobac, Executive Director, Alliance for Connected Care
- Yul Ejnes, MD, Clinical Associate Professor of Medicine, Brown University, Board of Regents Chair-Emeritus, American College of Physicians
- Rebekah Gee, MD, Chief Executive Officer, Louisiana State University Health System
- Nancy Gin, MD, Executive Vice President and Chief Quality Officer, The Permanente Federation
- Kate Goodrich, MD, Senior Vice President Trend and Analytics, Humana
- Ann Mond Johnson, Chief Executive Officer, American Telemedicine Association
- Chuck Ingoglia, President & Chief Executive Officer, National Council for Behavioral Health
- Megan Mahoney, MD, Chief of Staff, Stanford Health Care, Clinical Professor, Division of Primary Care and Population Health, Stanford University
- Chris Meyer, Director of Virtual Care, Marshfield Clinic
- Ricardo Munoz, MD, Chief, Division of Cardiac Critical Care Medicine, Executive Director, Telemedicine, Children’s National Health System, Co-director, Children’s National Heart Institute, Professor of Pediatrics, The George Washington University School of Medicine
- Peggy O’Kane, President, National Committee for Quality Assurance
- Kerry Palakanis, DNP, APRN, Executive Director, Connected Care Operations, Intermountain Healthcare
- Michelle Schreiber, MD, Federal Liaison (non-voting), Centers for Medicare & Medicaid Services
- Dorothy Siemon, JD, Senior Vice President for Policy Development, AARP
- Julia Skapik, MD, MPH, Medical Director, Informatics, National Association of Community Health Centers
- Jason Tibbels, MD, Chief Quality Officer, Teladoc
- Nicholas Uehlecke, Federal Liaison (non-voting), Department of Health & Human Services
- Andrew Watson, MD, MLitt, Surgeon, Vice-President University of Pennsylvania Medical Center, Past President ATA
- Cynthia Zelis, MD, MBA, Chief Medical Officer, MD Live