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Through several recently published rules, the Centers for Medicare & Medicaid Services (CMS) is making it possible for Medicare beneficiaries to have greater access to health care services provided remotely through telehealth or “telehealth-like” methods and to implement telehealth provisions included in the Bipartisan Budget Act of 2018 (BBA). The recently posted Medicare physician fee schedule (PFS) and home health prospective payment system (HH PPS) final rules and the Medicare Advantage and Prescription Drug Benefit proposed rule all included provisions that establish or would establish new rules concerning telehealth or related services. Viewed together, this demonstrates CMS’ belief that telehealth and related communication technology-based services can provide expanded access to high-quality and cost-effective health services and that CMS will be providing more flexibility to encourage the use of these services. These changes recognize growing beneficiary and health care professional comfort with the use of communication technology in the provision of health services. The changes also implicitly acknowledge the growing demand for the convenience of telehealth services. It remains to be seen whether these Medicare program developments will result in expanded coverage of telehealth services under any state Medicaid programs.

Medicare physician fee schedule final rule

On November 1, CMS posted the Medicare physician fee schedule final rule. Because the Medicare statute limits payment for telehealth services to beneficiaries in certain geographic  areas (primarily rural) and limits the “originating sites” where beneficiaries can get access to telehealth services, CMS has used its rule-making authority to bypass these restrictions by identifying and paying for certain telehealth-like services described below as “communication technology-based services” outside the telehealth benefit. CMS also is paying for new remote monitoring services, as described below. Medicare will begin paying separately for all of these new services in January 2019. CMS has expressed interest in recognizing innovations in the use of new communication technologies. CMS also noted that several of these new services are aimed at avoiding the scheduling of office visits that may not be necessary by providing a lower level payment for a separate service. The rates for these new services are provided in a chart below.

Virtual check-in (HCPCS code G2012)

Under Healthcare Common Procedure Coding System (HCPCS) code G2012, Medicare will pay separately for “brief communication technology-based services,” also referred to as a “virtual check-in,” provided certain conditions are met. This five to 10-minute non-face-to-face telephone or computer-based interaction can be provided only to established patients in order to assess whether the patient’s condition warrants an office visit. If the visit is in follow-up to a related evaluation and management (E/M) service provided within the past seven days, or if it results in an office visit within the next 24 hours or the soonest available appointment, then CMS will consider it to be bundled into those visits and it will not be separately reimbursed. The payment will be lower than the rate for the lowest level E/M in-person service, and because these “visits” will be subject to Medicare coinsurance, the patient’s verbal consent (oral consent, as opposed to written or electronic consent) must be obtained and noted in the medical record. CMS has said it will monitor utilization of this code to determine whether frequency limits are warranted.

Remote evaluation of prerecorded patient information (HCPCS code G2010)

Similar to the virtual check-in, Medicare also will pay separately for professional evaluation of prerecorded images or video transmitted by established patients for the purpose of determining whether an office visit is warranted. After reviewing the images or video sent by patients, the clinician must follow up with the patient within 24 business hours by phone, email, text message, or other mode of communication. As with the virtual check-in, if this remote evaluation originates from a related E/M service within the past seven days or results in an office visit within the next 24 hours or the next available appointment, the service will be considered bundled and not separately payable. Beneficiary consent (oral, written, or electronic) to the service must be documented because the service would be subject to coinsurance.

Interprofessional internet consultation (CPT®1 codes 99446-49 and 99451-52)

CMS also finalized its proposal to pay separately for four existing and two new Current Procedural Terminology (CPT®) codes describing consultations between physicians or other qualified health professionals when they are for the benefit of a specific patient. These consultations occur when a treating physician seeks the opinion and/or treatment advice of a consulting physician or other health professional with specific expertise, and CMS noted that the current lack of reimbursement for these interactions often leads to the scheduling of an office visit for the patient even though the patient’s presence is not necessary and a telephone or internet consultation between health care professionals would be sufficient. CMS views its recognition of these services as part of the movement away from a strictly fee-for-service-based system and toward a more care management-based approach to providing quality care to beneficiaries with multiple complex conditions. CMS is requiring documentation of beneficiary consent to receive these services because they will be subject to coinsurance, and it will monitor use of the consultations and consider refinements in documentation and billing policies if warranted.

Remote patient monitoring (HCPCS codes 99453, 99454, and 99457)

Having already established payment for chronic care management services in 2016, which are non-face-to-face, in 2019 CMS will establish payment for three codes to report “Chronic Care Remote Physiologic Monitoring.” These include a code for the initial setup and patient education regarding use of remote monitoring of physiologic parameters such as weight, blood pressure, pulse oximetry, and respiratory flow rate, and another code that can be billed monthly for the costs associated with the supplies and transmission of data. A separate code can be reported for 20 minutes or more of a physician or other health care professional’s time on treatment management during the month, but this service cannot be provided by auxiliary personnel and billed “incident to” a professional’s service. CMS will be issuing further guidance on the specific kinds of technology and scope of services covered under these codes.

Medicare telehealth services (HCPCS codes G0513 and G0514)

In addition to the new types of services described above, CMS annually updates the list of approved Medicare telehealth services, and this year added two codes for reporting “prolonged preventive services.” These codes, which are similar to existing E/M codes, are for reporting preventive services that require direct patient contact beyond the typical service time.

1 CPT Copyright 2018 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Use of telehealth in treatment of substance use disorders

The physician fee schedule final rule also implements provisions in the recently passed Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which is focused on addressing the opioid crisis, expanding the use of telehealth for treatment of substance use. Effective July 1, 2019, the geographic restrictions applicable to most telehealth services will not apply to use of telehealth for the treatment of diagnosed substance use disorders or co-occurring mental health disorders. The patient’s home will also be an acceptable originating site, although no facility fee will be paid. Implementation of this SUPPORT for Patients and Communities Act provision was issued as an interim final rule with a 60-day comment period, and CMS solicits comments on this provision.

Medicare home health prospective payment system final rule

On October 31, CMS posted the HH PPS final rule, which will allow home health agencies to include the costs of remote patient monitoring as an allowable administrative cost (e.g., operating expense) on their cost report if the remote monitoring is used to assist in the care planning process. This will allow such expenses to be factored into the costs per visit. Commenters on the proposed rule suggested that CMS should take an even broader approach to telehealth and include payment for virtual visits. CMS declined to do so, but described the inclusion on the cost report of costs associated with remote patient monitoring as a necessary first step in determining whether the use of such technology improves outcomes for home health patients.  This suggests CMS may further expand payment for the use of telehealth in home health in the future.

Expanded coverage of telehealth by Medicare Advantage plans

In implementing the Bipartisan Budget Act of 2018, CMS also is proposing to allow Medicare Advantage (MA) plans to offer expanded coverage for “clinically appropriate additional telehealth benefits” beginning in plan year 2020. CMS would allow the plans to treat them as “basic benefits” for purposes of bid submission and payment, making it more likely that plans will offer them. Under the proposal, MA plans could offer Part B covered services as “additional telehealth benefits” outside the scope of services currently allowed under the Medicare telehealth benefit and not subject to the location restrictions applicable to telehealth services. To preserve beneficiary choice, any Part B service covered by plans as an “additional telehealth benefit” must also be available through an in-person visit and not only via telehealth. In addition, CMS is proposing to continue allowing plans to offer supplemental benefits (e.g., benefits not covered by original Medicare) via remote technologies or telemonitoring services that do not qualify as “additional telehealth benefits.”

CMS is not proposing to define which services are “clinically appropriate” to be offered as “additional telehealth benefits,” but would instead allow MA plans the flexibility to make that determination for themselves each year, consistent with professionally recognized standards of care. The MA plan would have to use contracted providers to provide these additional telehealth benefits and other MA regulations, including those regarding provider credentialing and selection would apply. Plans would be responsible for ensuring that the telehealth provider was in compliance with applicable licensing requirements and other state laws for the state in which the enrollee is located. CMS has solicited comments on its proposed approach and on the impact such telehealth providers should have on determinations of MA network adequacy.

Taken together, these recent changes by Congress and CMS indicate significant interest in making more health services available to Medicare beneficiaries via telehealth and similar technologies and to continue testing whether and when such services can be used to expand access to high-quality, cost-effective care, and to improve care coordination.

Appendix: Remote monitoring services payment rates

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The Centers for Medicare and Medicaid Services (CMS) recently published two rules designed to promote the use of telehealth and remote patient monitoring (RPM) under the Medicare program.

Telehealth Benefits under Medicare Advantage

On November 1, 2018, CMS published a proposed rule that (among other things) implements provisions of the Bipartisan Budget Act of 2018 (the BBA) authorizing reimbursement of additional telehealth services as basic benefits under Medicare Advantage (MA) plans.

Generally, MA plans are health insurance policies offered by private companies that contract with CMS to provide coverage to Medicare beneficiaries. The benefits these plans offer fall into two categories: (1) basic benefits, which are paid through a government-funded capitation rate, and (2) supplemental benefits, which are funded using rebate dollars and/or additional enrollee premiums. Currently, MA plans may cover as basic benefits only those specific telehealth services available under traditional Medicare, which must be rendered using telecommunications systems that permit real-time communication between a beneficiary and the provider and are subject to location or “originating site” limitations. Any telehealth benefits beyond those provided under traditional Medicare must be offered only as supplemental benefits.

In accordance with Section 50323 of the BBA, the proposed rule would allow MA plans to provide, starting in plan year 2020, “additional telehealth benefits” payable by CMS. Under the BBA, these “additional telehealth benefits” must be (1) for services generally available under Medicare Part B, but not payable (under traditional Medicare) as telehealth services, and (2) identified by the MA plan in the applicable year’s Evidence of Coverage document as clinically appropriate to furnish via telecommunications technology. MA plans may continue to cover telehealth services that do not meet these requirements as supplemental benefits.

Importantly, in order to protect patient choice, the proposed rule provides that any service that is covered by a MA plan as a telehealth benefit must also be covered if provided in a face-to-face encounter. Additionally, as required by the BBA, the rule prohibits payment for any capital and/or infrastructure costs relating to the additional telehealth benefits. Comments on the proposed rule are due by 5:00 p.m. on December 31, 2018.

RPM in Home Health

On October 31, 2018, CMS issued a final rule allowing home health agencies to include the costs of RPM among their reimbursable administrative expenses beginning in calendar year 2019. This rule defines RPM for purposes of the Medicare home health benefit as “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the HHA.” Although the Social Security Act prohibits payment for services furnished via a telecommunications system if such services are substituted for in-person home health services required under a patient’s plan of care, CMS concludes in its discussion of the rule that this prohibition does not apply to RPM because RPM does not involve any direct interaction between patient and provider. Accordingly, RPM does not replace in-person services required under the plan of care, but rather may be used by an HHA to more quickly identify changes in a patient’s condition and appropriately update the plan of care.

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Recently, the Centers for Medicare & Medicaid Services (CMS) released their Contract Year (CY) 2020 Medicare Advantage and Part D proposed rule, a wide-ranging proposal that expands access to telehealth in Medicare Advantage, updates the methodology for calculating Medicare Advantage Star Ratings, and makes policy updates to address program integrity.

In the proposed rule, CMS included an assortment of proposals that impact Medicare Advantage and Medicare Part D plans in CY2020. However, what was missing from the proposed rule was any action on President Trump’s plan for lower drug prices. Instead, it was addressed with a brief statement, “CMS plans to release a proposed Medicare rule in the near future to further the President’s agenda of reducing drug costs.” Stay tuned to Policy & Medicine for that portion, as it was released just a few days after the main CY2020 proposal.

Telehealth Expansion

Included in the proposal were looser restrictions on telehealth benefits in the Medicare Advantage plan. The proposal implements the part of the Bipartisan Budget Act of 2018 that permits telehealth benefits to be treated as basic benefits when Medicare Advantage plans submit bids to CMS and also places the plans in the position to determine which benefits are clinically appropriate for telehealth service. It would also allow plans to offer telehealth benefits to enrollees regardless of geography and would remove requirements that enrollees access telehealth services at a healthcare facility. The proposal would retain plans’ abilities to offer additional telehealth services not as part of the basic benefit package. CMS is specifically soliciting comments on how to implement the requirement that services offered as telehealth options be accessible by in-person means as well.

While Medicare Advantage plans have always been able to offer more telehealth services than are currently payable under original Medicare through supplemental benefits, this change in how such additional telehealth benefits are financed (that is, accounted for in payments to plans) makes it more likely that Medicare Advantage plans will offer them and that more enrollees will be able to use the benefits.

Dual Eligible Special Needs Plans (D-SNPs)

Under the proposed rule, which mirrors requirements found in the Bipartisan Budget Act, D-SNPs would be required to integrate with Medicaid long-term services and supports (LTSS), behavioral health services, or both by having the relevant state Medicaid agency make a capitated payment to the plan or by complying with a minimum set of requirements for LTSS. The rule would also require that one organization be responsible for grievances and appeals for D-SNPs rather than bifurcating the process between Medicare and Medicaid.

Part D Plan Access to Claims Data

As required by the Bipartisan Budget Act of 2018, the proposed rule would allow Part D plans to request that the Secretary provide in an electronic format on a periodic basis standardized extracts of Medicare claims data about its plan enrollees. Such extracts would contain a subset of Medicare Parts A and B claims data, any may be used for: (1) optimizing therapeutic outcomes through improved medication use; (2) improving care coordination; and (3) other purposes as determined appropriate by the Secretary.

“President Trump is committed to strengthening Medicare, and an increasing number of seniors are voting with their feet and choosing to receive their Medicare benefits through private plans in Medicare Advantage. Today’s proposed changes would give Medicare Advantage plans more flexibility to innovate in response to patients’ needs,” said CMS Administrator Seema Verma. “I am especially excited about proposed changes to allow additional telehealth benefits, which will promote access to care in a more convenient and cost-effective manner for patients.”

CMS will accept comments through December 31, 2018. Comments may be submitted electronically through the e-Regulation website here.

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In Depth

The Centers for Medicare & Medicaid Services (CMS) released a Notice of Proposed Rulemaking on Friday, October 26, 2018 (the Proposed Rule) addressing expanded telehealth coverage in Medicare Advantage (MA), extrapolation of Risk Adjustment Data Validation (RADV) audit results, and updates to the MA and Part D Quality Star Ratings program, among othertopics. Some of these changes implement provisions of the Bipartisan Budget Act of 2018, which was passed by Congress earlier this year, and other changes reflect CMS’s new use of notice and comment rulemaking in areas that were previously governed primarily by subregulatory guidance.

If finalized, the regulations set forth in the Proposed Rule would impact notonly MA and Part D plan sponsors (Plan Sponsors) but also a broad range of providers and health care companies, particularly those involved in the provision or delivery of telehealth services.

Extrapolation of RADV Audit Results without Fee-for-Service Adjuster

CMS proposes significant changes to its RADV audit methodology. Notably, CMS proposes to extrapolate the findings of RADV audits without applying a Fee-for-Service Adjuster to the audit findings to reflect the error rate inherent in diagnosis coding in the Medicare Fee-for-Service program. This proposal is a significant change from CMS’s previously announced RADV audit methodology, issued in 2012, in which CMS announced it would apply a Fee-for-Service Adjuster. CMS proposes to implement its proposal retroactively, beginning with payment year 2011. CMS estimates that, if finalized, the RADV proposal could result in the recovery of $4.5 billion from MAOs over the next ten years, including $1 billion in 2020 alone.

Expansion of MA Telehealth Benefits

The Proposed Rule includes provisions implementing the additional MA telehealth benefit added by the Bipartisan Budget Act of 2018. MAOs were previously limited in the telehealth services they could include in their basic benefit package because they could only cover the telehealth services available under the Fee-for-Service Medicare program. MAOs were permitted to offer more expansive benefits as supplemental benefits, but there are financial limitations on the ability of many MAOs to offer a wide range of additional benefits. Under the Bipartisan Budget Act of 2018 and the Proposed Rule, MAOs would be able to include in their basic benefit packages any Part B benefit that the plan identifies as “clinically appropriate” to be furnished electronically by a remote physician or practitioner. These additional telehealth benefits and any applicable limitations would need to be described in the plan’s Evidence of Coverage document.

There are a few notable limitations applicable to the expanded telehealth coverage under the Proposed Rule. First, MAOs will only be permitted to provide additional telehealth benefits through contracted providers that meet plan selection and credentialing standards. Contracts with telehealth providers must require compliance with applicable licensure laws imposed by the state in which the member is located and receiving the service. Pursuant to a statutory requirement, MAOs will also be prohibited from including any capital or infrastructure costs related to the additional telehealth benefits in their bids.

Updates to Quality Star Ratings

In the first rulemaking since the Quality Star Ratings (Star Ratings) were codified into regulation earlier this year, CMS proposes a number of updates to the Star Ratings program for MA and Part D contracts. Among other changes, CMS proposes to revise the methodology for determining cut points, codify its adjustments for contracts facing extreme and uncontrollable circumstances, and update the specifications of several individual Star Ratings measures.

• Cut point methodology. CMS proposes two significant revisions to the way in which cut points for non-CAHPS measures are calculated. In CMS’s words, these changes would balance how to accurately measure true performance with providing more predictable and stable cut points. First, CMS proposes to perform mean resampling, under which CMS would calculate the cut point 10 times (each time leaving out a different random sample of scores) and then take the average of each of the 10 cut points. CMS suggests in the preamble to the Proposed Rule that this would reduce the impact of outliers and increase the stability of the cut points over time. Second, CMS proposes to impose a 5 percent bi-directional cap on the change in a cut point from the prior year, noting that this would increase the predictability of cut points. CMS notes that there are various ways such a cap could be implemented and indicates that the agency is considering alternatives, including whether the cap should be 3 percent. Plan Sponsors should consider whether a 5 percent cap would provide the increased predictability CMS apparently seeks, as scores on many measures may not move significantly from year to year.

• Adjustment for extreme and uncontrollable circumstances. CMS also proposes to codify its policy (originally implemented for the 2019 Star Ratings though the CY 2019 Final Call Letter) of adjusting the Star Ratings for contracts that are affected by “extreme and uncontrollable conditions” such as natural disasters. The proposed methodology would compare the Star Ratings of a qualifying contract from the current year and the previous year and apply the higher of the two. Although this policy will likely affect only a handful of contracts in any given year, the impact of this adjustment on some Plan Sponsors may be significant.

• Changes to individual measures. In the past, CMS has proposed and finalized changes to individual Star Ratings measures through subregulatory guidance. As these updates are now implemented through formal notice and comment rulemaking, the Proposed Rule reflects individual measure-level changes that CMS proposes for performance periods beginning on or after January 1, 2020 and/or January 1, 2021 (depending on the measure). In particular, CMS proposes changes to the following measures: Controlling High Blood Pressure (Part C), Medicare Price Finder (MPF) Price Accuracy (Part D), Plan All-Cause Readmissions (Part C), and the Improvement Measures (Parts C and D). Perhaps most notably, as forecast in the CY 2019 Final Call Letter, CMS proposes revising the MPF Price Accuracy measure to take into account both the frequency of differences in prices listed on MPF and those paid at the point-of-sale and the magnitude of those differences. This change may help alleviate concerns that Plan Sponsors are penalized for very minimal differences in the display price and the paid price.

Preclusion List Clarifications

Finally, CMS proposes several changes and clarifications to its recently adopted preclusion list standards. Under the existing preclusion list framework, Plan Sponsors will be prohibited from paying for Part D drugs and MA services prescribed or furnished by a provider on the preclusion list. There have been ongoing questions about the implementation of this new screening mechanism, which becomes effective in 2019. The Proposed Rule includes new requirements and clarifications regarding:

• The process for a provider to appeal preclusion list status;
• How long a provider will remain on the preclusion list;
• The obligation to notify members whose providers are added to the preclusion list; and
• Hold harmless protections for members that receive services from in-network precluded providers.

CMS is accepting comments on the Proposed Rule through December 31, 2018.

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The Bipartisan Budget Act of 2018 was recently signed into law. Within the number of provisions is the use of telehealth and reimbursement for Part B Medicare beneficiaries using CPT code 99091.

February 14, 2018 by Cafe Staff

If 2017 ended on a high for telehealth and remote patient monitoring, the start of 2018 also did not disappoint. Indeed, on Feb 9, the Bipartisan Budget Act of 2018 was signed into law. This bill, which provides a budget agreement for 2018-2019, also includes a number of policy provisions in support of telehealth, also opening the door to remote patient monitoring (RPM). This budget deal expands the use of telehealth for patients undergoing home dialysis by allowing Medicare beneficiaries to elect to receive monthly related clinical assessments through telehealth, and to those having suffered a stroke, it expands the possible locations where patients may receive a telehealth consultation. The use of telehealth was also expanded for Medicare Advantage (MA) plans and accountable care organizations (ACOs).

We are advancing to a new “personal health” paradigm.

Beginning in plan year 2020, a MA plan may provide additional telehealth benefits to its enrollees. The bill defines additional telehealth services as those “for which benefits are available under Medicare part B…” and “that are identified for such year as clinically appropriate to furnish using electronic information and telecommunications technology when a physician… or practitioner… providing the service is not at the same location as the plan enrollee.” I had mentioned above that the door was opened for RPM. And, as I reported before, the Centers for Medicare & Medicaid Services (CMS) started reimbursing RPM (code 99091 is now reimbursed in Part B Medicare), as such so that it is “available under Part B” (note the underlined text above) and therefore reimbursable as part of MA. Or, at least, this is our interpretation. In fact, CMS should issue a clarification in this respect to ensure plans start covering RPM.

As to the expansion of telehealth use by ACOs, the bill removes the restrictions (subject to some conditions) set by 1834(m) of the Social Security Act to a Medicare fee-for-service beneficiary of the ACO whereby the home of the beneficiary can be treated as an originating site (similar to the changes presented above for the treatment of stroke patients), and geographic limitations are lifted.

Intel has long believed that the old “mainframe health” paradigm (i.e., centralized, hospital-centric, expert driven, reactive, costly) is giving way to a new “personal health” paradigm (i.e., distributed, data rich, preventive, home- and consumer- centric, and efficiency-driven). An ingredient of this transformation is Intel’s Health Application Platform for remote healthcare. This application software platform enables a variety of remote care usage models. When coupled with an Intel architecture-based design specification, it can enable healthcare solution providers to securely deliver distributed services.

With the passing of this legislation, the US Congress showed bipartisan support for the expansion of technologies that support Medicare’s modernization. Patients will have more choices to access healthcare services, hopefully improving clinical outcomes, which is another step in the right direction for a more nimble, patient centric healthcare framework. Intel lauds this bipartisan agreement and the support for the expansion of telehealth. We will be now looking to CMS’ next steps to bring to fruition the possibilities opened by this legislation.

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