Medicare began including telehealth as a benefit nearly 20 years ago, but has used it only on a limited basis. This was in large part because of statutory restrictions that limited coverage to rural beneficiaries who received care by certain practitioners in designated sites, which did not include the beneficiary’s home.
Now, in the wake of the COVID-19 outbreak, policymakers are looking to telehealth as critical to ensuring that Medicare beneficiaries can still access care while reducing the risk of coronavirus transmission.
These broad Medicare telehealth flexibilities are unprecedented, but temporary, pursuant to the ongoing public health emergency. However, some advocates hope that this time will serve as a bridge to expanding access beyond the pandemic.
Stimulus Bills: Statutory Restrictions on Telehealth Lifted Temporarily
Congress passed three stimulus packages in response to COVID-19. This legislation, coupled with the administration’s section 1135 waiver authority, significantly modified telehealth rules to increase access for Medicare beneficiaries.
Legislation |
Description of telehealth changes |
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The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (P.L. 116-123) |
The first stimulus bill authorized the Centers for Medicare and Medicaid Services (CMS) to temporarily lift the existing geographic and originating site restrictions for furnishing telehealth services to Medicare beneficiaries. Prior to the legislation, this meant that Medicare beneficiaries residing in nonrural regions could not access telehealth services, nor could they typically receive such care in their homes. However, under the new legislation, all Medicare beneficiaries will temporarily be able to access telehealth services during a national emergency. This is true regardless of geographic region and site of care, which may include the beneficiary’s home. Moreover, this is true for any service included on the approved Medicare fee-for-service telehealth list, meaning that beneficiaries can receive care for several non-COVID-19 related reasons. |
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The Families First Coronavirus Response Act (P.L. 116-127) |
The second legislative package made clarifying changes to the first package to ensure all Medicare beneficiaries have access. |
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The Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136) |
The most recent legislation added additional telehealth flexibilities. Specifically, the law temporarily removed the requirement that a beneficiary have a preexisting relationship with a provider to be eligible for services. It also allows HHS to waive the requirement that providers furnish telehealth services through audiovisual platforms. This allows beneficiaries to access providers solely through their telephones. Last, it adds broad authority for CMS to waive additional statutory telehealth restrictions. |
Complementary Regulatory Actions
CMS also released guidance and accompanying FAQs further clarifying the new telehealth flexibilities. CMS noted that providers may reduce or waive cost-sharing for telehealth services and reiterated that a prior relationship between the beneficiary and provider is not necessary to qualify for reimbursement.
Following passage of the CARES Act, CMS released an interim final rule with comment period that included additional temporary telehealth modifications, including allowing providers to furnish certain evaluation and management services over the phone; expanding the list of approved telehealth services; adjusting telehealth payments to reflect the full amount providers would have received if the visit had been in-person; and, expanding the use of telehealth in certain settings (e.g., home health and hospice care).
The U.S. Department of Health and Human Services (HHS) also relaxed Health Insurance Portability and Accountability (HIPAA) requirements around the types of technology providers can use. During the national emergency, providers will not be penalized for communicating with patients via technologies that are not compliant with HIPAA rules, including FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype.
Finally, CMS released a series of toolkits with additional guidance to providers, tailored to general practitioners, dialysis providers, and long-term-care nursing home providers.
Medicare Advantage
Under the Bipartisan Budget Act of 2018, Medicare Advantage (MA) plans have more flexibility to cover telehealth services for all beneficiaries regardless of geographic location or facility type. They also can offer services not on the approved list for Medicare fee-for-service. Following the COVID-19 outbreak, CMS announced it would allow MA plans to implement additional telehealth benefits at any point prior to CMS approval of the updated benefit package. Doing so will permit plans to adjust their benefit packages to respond to the changing needs of enrollees.
What’s Missing
The federal government has massively increased Medicare beneficiaries’ access to telehealth services, largely overnight. But more may be needed. Here are some additional changes policymakers could consider:
- The current list of approved provider types may become a limiting factor to leveraging telehealth visits as the outbreak spreads. Policymakers should consider changing provider scope of practice rules.
- CMS could consider continuing to expand the list of covered telehealth services to more closely resemble what MA plans offer, if providing such services proves to encourage greater numbers of beneficiaries to remain at home.
- Recent guidance waives the audiovisual requirement for certain evaluation and management services via telehealth. Providers may benefit from more expansive waivers that remove these requirements for additional services.
- Beneficiaries in rural locations are limited in their ability to access telehealth if broadband infrastructure is insufficient. Similarly, some providers do not have robust telehealth platforms in place, though a new initiative from the Federal Communications Commission to distribute $200 million to providers for new telehealth systems may alleviate this.
The Future of Telehealth
The limiting factor for telehealth in Medicare fee-for-service has always been couched in potential cost ramifications. This has kept the geographic and originating site restrictions in place. Now, however, the case for telehealth is focused on disease control and prevention, with former cost-related considerations temporarily falling to the wayside.
The looming question is whether the government will allow all or some of these telehealth flexibilities to remain permanently in place. Much of this will depend on the duration and severity of the outbreak. If the consequences become even more grave, it is plausible Congress may act to permanently expand access to telehealth for Medicare beneficiaries, especially if practice standards largely shift in that direction.
This temporary expansion creates a de facto demonstration of broadened access to telehealth. Policymakers can study the effects on utilization and health and can decide whether and how to expand access moving forward. To yield a more robust evaluation, policymakers also may opt to finalize legislation that has yet to have become law: the Telehealth Innovation and Improvement Act. This bill would require the CMS Innovation Center to test broader use of telehealth services in existing demonstrations and require CMS to reimburse for telehealth services that demonstrate cost savings and quality improvement.
Increased public demand for these services in the wake of COVID-19 may necessitate swift action. A potential Phase IV stimulus bill, along with the new November 30 statutory deadline to reauthorize funding for many key public health programs (i.e., health care extenders), may serve as additional legislative vehicles to advance further reforms.
