Medicare Telehealth Coverage During the Public Health Emergency and Beyond

Remy Kerr, MPH, AMRPA Health Policy and Research Manager

Prior to the COVID-19 pandemic, Medicare beneficiaries had limited access to telehealth services due to Medicare coverage and payment rules. In response to the public health emergency (PHE), the Centers for Medicare and Medicaid Services (CMS) implemented temporary waivers and flexibilities to allow for increased access to telehealth services. Before the PHE, AMRPA was on record advocating for select telehealth expansion within the Medicare program on both the legislative and regulatory front. AMRPA urged the CMS to take steps to expand use of telehealth within the Medicare program in its calendar year (CY) 2018 Physician Fee Schedule proposed rule response. The association also engaged with the Congressional Telehealth Caucus and formally endorsed the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019 (S. 2741) sponsored by Senator Brian Schatz (D-HI) – described in detail below. AMRPA’s advocacy for expanded telehealth continued in response to the COVID-19 PHE, with the association requesting flexibilities and waivers – such as recognizing therapists as telehealth-eligible providers in the Medicare program and expanding the types of platforms that could be used to furnish telehealth. AMRPA intends to consider ongoing advocacy to permanently reform certain telehealth rules within the Medicare program, following the telehealth expansion that was provided IRFs throughout the pandemic. Telehealth coverage prior and during the PHE, and policy considerations for expansion beyond the PHE, and AMRPA’s efforts are detailed below.

Pre-Pandemic Telehealth Prior to the COVID-19 pandemic, Medicare beneficiaries were required to be from rural areas in order to qualify for telehealth services. Additionally, patients often had to travel to an originating site.1 Originating sites included medical offices, hospitals, rural health clinics, federally qualified health centers and skilled nursing facilities, and others. In addition, providers were required to be located in a Medicare-eligible facility (known as the distant site), such as a medical office or hospital, to provide telehealth services and be licensed within the state where they were providing services and where the beneficiary was located. Further, only select types of providers were permitted to offer telehealth services.2 Telehealth was also limited to a select number of services with already established patients. Medicare beneficiaries were also subject to cost-sharing for telehealth.

1 Originating site - “The location where a Medicare beneficiary gets physician or practitioner medical services through a telecommunications system.” – The Centers for Medicare and Medicaid Services (CMS) 2 Distant site practitioners as defined by CMS include physicians, nurse practitioners, physician assistants, nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists and clinical social workers, registered dietitians and nutrition professionals.

AMRPA’s advocacy efforts prior to the pandemic focused primarily on: 1) recommending CMS establish a demonstration program to evaluate certain types of therapy provided via telehealth to Medicare beneficiaries; 2) ensuring all specialties, including rehabilitation physicians and therapists, are incentivized to utilize remote patient monitoring; and 3) removal of geographic restrictions for critical services. Specifically, the association formally supported the aforementioned CONNECT for Health Act of 2019, with provisions including: authorization for a demonstration model to test allowing additional clinicians to furnish telehealth services; removal of geographic restrictions and allowing the home to serve as an originating site for critical services (e.g., behavioral health services); and encouraging CMMI to test additional telehealth models.

Pandemic Telehealth In response to the COVID-19 PHE, CMS issued telehealth-related flexibilities for the Medicare program under the Section 1135 waiver and the CARES Act3 – many of which AMRPA advocated for. These flexibilities remain in effect and include recognizing any provider eligible to bill for Medicare services – including physical therapists, occupational therapists and speech-language pathologists – as distant site telehealth providers, expanding the list of telehealth-approved services to include therapy services, allowing rehabilitation physicians to utilize telehealth to meet weekly face-to-face visit requirements, and waiving cost-sharing requirements at the discretion of the provider. In addition, providers are currently able to offer telehealth services through technology that is non-HIPAA-compliant and can provide audioonly telehealth services. Lastly, providers are currently able to provide telehealth to both new and established patients, and do not have to be licensed in the state where the patient is located.4

While many of these flexibilities are tied to the PHE-declaration and could be rescinded at CMS’ discretion, CMS has taken steps to expand some telehealth services on a longer-term basis. In the CY 2021 Physician Fee Schedule (PFS) final rule, CMS added several new services as eligible telehealth services through the end of the CY in which the PHE ends. In alignment with AMRPA’s comments, CMS included commonly billed occupational, physical and speech-language therapy services to this list. The services, however, will be restricted to being billed as “incident to” physician services due to CMS’ lack of authority to add therapists to the list of distant site telehealth providers without legislative action. CMS also opted to create a temporary reimbursement code to allow billing by physicians when providing audio-only services. CMS did not include use of this code beyond the end of the PHE but asserted it will continue to evaluate the code and consider permanent implementation in the future. Lastly, CMS added emergency department visits, observation status visits and observation discharge day management, inpatient discharge day management, critical care services and SNF discharge day management to the list of temporary telehealth services. The Future of Telehealth In addition to the telehealth provisions included on a temporary basis in the CY 2021 PFS final rule, CMS also included some permanent telehealth provisions. In line with AMRPA’s comments, CMS clarified that non-physician practitioners and therapists can bill for virtual check-ins and other remote services on a permanent basis. Other services added to the eligible telehealth services list on a permanent basis include: psychological and neurological testing, established patient home visits, cognitive assessment and care planning and add-on codes for complex and prolonged patient visits. CMS also finalized permitting SNFs to utilize telehealth for physician visits every 14 days (prior to the PHE, SNFs were limited to every 30 days).

AMRPA continues to advocate for continued expansion of telehealth in the Medicare program on a permanent basis. The association’s most recent advocacy efforts included a response to HHS’ Request for Information regarding Regulatory Relief to Support Economic Recovery and an early letter to the Biden administration. In these letters, AMRPA expressed support for permanent implementation of several telehealth-related waivers, including: 1) expanding the list of services that can be provided in the Medicare program via telehealth to include therapy services; 2) recognizing therapists as eligible telehealth providers; 3) relaxing originating site requirements in order to allow more patients to receive care in their home; 4) continuing to allow virtual team conferences as needed; 5) allowing the provision of audio-only telehealth services; and 6) eliminating state licensing restrictions.

While it is unclear what degree telehealth expansion will be permanently implemented within the Medicare program, the issue seems to be at the forefront for policymakers. MedPAC held three meetings on the topic in recent months and plans to include preliminary recommendations in their Report to Congress in March. Steps were also taken in the former 116th Congress to expand telehealth for Medicare beneficiaries, including introduction of Protecting Access to Post-COVID-19 Telehealth Act of 2020 (H.R. 7663), which AMRPA supported. Other telehealth-related bills have already been introduced in the current 117th Congress, and the association will be closely monitoring them.

AMRPA will continue to monitor telehealth developments both as they pertain to the PHE-related flexibilities and waivers, and permanent expansion within the Medicare program. If your hospital is interested in participating in AMRPA’s advocacy efforts related to telehealth, please contact Remy Kerr, AMRPA Health Policy and Research Manager.