Telehealth, policy develops much more slowly than the rapidly advancing technology. Incremental changes are taking place to further develop telehealth legislation. In 2017, 210 telehealth related bills were active across thirty states. One of the most common pieces of legislation relate to Medicaid and private payer reimbursement.
1. Chronic Care Management And Remote Monitoring
In January 2015, CMS created a new chronic care management (CCM) code, which provides for non-face-to-face consultation. This has opened up the possibility of receiving reimbursement for virtual remote monitoring of chronic conditions. Since then, CMS has released several instructional documents on billing the CCM codes and added reimbursement for complex CCM as well as two add-on codes. Additionally, in the final calendar year 2018 Physician Fee Schedule, CMS unbundled code 99091 allowing providers to get reimbursed separately for time spent on collection and interpretation of health data generated remotely. By not defining these codes as a “telehealth” service, these services are not subject to the restrictions other telehealth services currently face, such as geographic and location limitations.
Medicare advantage plans will start being able to provide coverage for additional telehealth benefits (beyond those already covered under Medicare Part B) beginning in plan year 2020. Those benefits would include services available under part B, but ineligible for payment due to the restrictions around telehealth currently in Medicare and those that are identified as clinically appropriate. The Secretary is required to solicit comments on the types of telehealth services that should be considered additional telehealth benefits by Nov. 30, 2018, and once implemented enrollees will have discretion as to whether or not to receive those services through an in-person visit or telehealth.
3. Accountable Care Organization
Beginning Jan. 1, 2020 all Accountable Care Organizations (ACOs) tested or expanded under the Center for Medicare and Medicaid Innovation with a two-sided model with Medicare fee-for-service beneficiaries will have the ability to expand telehealth services to include the home as an eligible originating site and would not be subject to Medicare’s current telehealth originating site geographic requirements. Some ACOs, designed to reduce fragmentation of care, have already been given additional flexibility in their use of telehealth to treat eligible beneficiaries.
In Medicare specifically, some of the current telehealth requirements in the Social Security Act are waived in both the Next Generation ACO model as well as the Comprehensive Care for Joint Replacement model, which tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements.
CMS gives states the ability to determine their own policies related to telehealth. The official policy indicates that states may reimburse for telehealth under Medicaid as long as the service satisfies federal requirements of “efficiency, economy, and quality of care”. This policy enables states to have unique standards for what services they deem appropriate for reimbursement, which causes gaps in the system due to a massive lack of uniformity between states and results in differing reimbursement policies. Recently, CMS has further clarified states’ flexibility to define their telehealth policy without filing a State Plan Amendment (SPA), stating that “States are not required to submit a (separate) SPA for coverage or reimbursement of telemedicine services, if they decide to reimburse for telemedicine services the same way/amount that they pay for face-to-face services/visits/consultations.”
Remote patient monitoring is reimbursed in 21 states, and also often is confined to specific circumstances, such as it only be reimbursed when delivered by a home health agency, or for specific conditions (such as COPD or diabetes). In addition to reimbursement to the distant site, many state Medicaid programs, like Medicare, provide a facility fee, and in addition, sometimes allow for a transmission fee to cover the cost of connecting the patient to the distant site provider.
5. Private Payors
There is no unique set of standards that pertains to insurance companies throughout the country. As of October 2017, 36 jurisdictions (including DC) have enacted (or will enact at a later date) laws that govern private payer telehealth reimbursement. In most cases, these laws offer coverage parity, requiring insurers to cover the same services delivered through telehealth, as are covered in-person, as long as it meets the same standard of care.
For example, as of last October, the state of New York’s parity law forbids private payers to “exclude from coverage a service that is otherwise covered under a policy that provides comprehensive coverage … because the service is delivered via telehealth […].” But, it does not state that private payers must reimburse telehealth services equally as in-person services, prompting one insurer in New York to reimburse telehealth delivered services at a 50% reduced rate. Thus, a few states (including New York) have begun to introduce payment parity legislation that requires private payers to cover telehealth services “at the same rate” as when the service is provided in-person. Many states also make their telehealth parity laws “subject to the terms and conditions of the contract.” This phrasing may set up certain conditions where an insurer has the flexibility to restrict telehealth reimbursement within their contract.