COVID-19 significantly affected home-based care providers, such as home health agencies (HHAs) and hospices, whose staff had to overcome both physical and mental burdens of going into patients’ homes to deliver care, especially in the days before a COVID-19 vaccine. While these providers benefitted from a number of Medicare program regulatory flexibilities during the public health emergency (PHE), virtually all of those will sunset on May 11, 2023.

In anticipation of the PHE’s expiration, the Centers for Medicare and Medicaid Services (CMS) issued guidance for both HHAs and hospice providers that clarifies which regulatory flexibilities will continue.

Flexibilities Expiring for Both HHA and Hospice

The following HHA and hospice provider flexibilities will end in conjunction with the May 11 expiration of the PHE:

• The waiver of annual onsite supervisory visits for each aide that provides services on the agency’s behalf. All previously postponed site visits must be completed within 60 days from the end of the PHE.
• The narrowed scope of Quality Assessment and Performance Improvement (QAPI) programs, which permitted a focus on infection control and tracking adverse events more closely associated with COVID-19. Maintaining broader QAPI programs will be required upon the expiration of the PHE.
• CMS accelerated review of any pending or new provider and supplier enrollment applications.

Hospice-Specific Flexibilities That Will Sunset

The following hospice provider flexibilities will end in conjunction with the expiration of the PHE:

• Allowance for the provision of services to Medicare patients receiving routine home care through telecommunications, including remote patient monitoring, telephone calls, and two-way audio-visual technology.
• The extension permitting completion of comprehensive assessments of patients within 21 days. The comprehensive assessment will return to the 15-day completion requirement.
• The waiver exempting hospices from providing certain noncore services, such as physical therapy, occupational therapy, and speech-language pathology.

Hospice-Specific Flexibilities Being Extended

The following hospice provider flexibilities will temporarily or permanently extend beyond the expiration of the PHE:

• The exception allowing providers to conduct face-to-face encounters via telehealth for purposes of recertification to the Medicare hospice benefit is set to expire December 31, 2024.
• The waiver allowing hospices to postpone annual assessment of the skills and competency of all individuals providing care and postpone the provision of in-service training and education programs. All previously postponed assessments, trainings, and education programs must be completed prior to the end of the first full quarter after the PHE expires (September 30, 2023).
• The waiver of minimum volunteer hour requirements. Pre-PHE volunteer requirements of 5% of hospice hours will be reinstated at the end of calendar year 2023.
• Through the FY 2022 Hospice Wage Index and Payment Rate Update Final Rule (CMS-1754-F), CMS finalized the waiver allowing hospice aides to complete evaluations through use of pseudo-patients (such as roleplay participants or computer-based mannequin devices) instead of on patients themselves. Relatedly, CMS also finalized hospice aide supervision requirements to address situations of deficient practice and institute remediation.

HHA-Specific Flexibilities That Will Sunset

The following HHA flexibilities will end in conjunction with the PHE’s expiration:

• The waiver of the requirement to provide detailed information regarding discharge planning when a patient, their caregiver, or their representative is selecting a post-acute care provider.
• The extension allowing HHAs to provide patients a copy of their medical record within 10 business days instead of four business days.
• The waiver of the requirement for a nurse to conduct onsite visits every two weeks, including the requirements for aide supervision. Note that, pursuant to CY 2022 Home Health Prospective Payment System Final Rule (CMS 1747-F), CMS now permits a virtual aide supervision visit for patients receiving skilled care once per 60-day episode in rare circumstances. For patients receiving nonskilled care, a registered nurse must conduct an in-person supervisory visit every 60 days and semiannually make a supervisory direct observation visit for each patient to whom the aide provides services.
• Outcome and Assessment Information Set (OASIS) extensions that permit completion of the comprehensive assessment within 30 days instead of five days and waiver of the 30-day OASIS submissions requirement.
• The waiver allowing occupational therapists, physical therapists, and speech language pathologists to perform initial and comprehensive assessments for all patients receiving therapy services in the plan of care, instead of performing such assessments when only therapy services are ordered. Note that, pursuant to CMS 1747-F, occupational therapists alone may continue to perform assessments pursuant to this waiver after the PHE expires.

HHA-Specific Flexibilities Being Extended

The following HHA flexibilities will temporarily or permanently extend beyond the expiration of the PHE:

• The CMS allowance for face-to-face encounters via telehealth when the patient is at home. The home is only permitted to serve as an originating site through December 31, 2024.
• The delay for completion of home health aide in-service training requirements will end and be reinstated to pre-PHE requirements at the end of calendar year 2023.
• The CMS allowance for HHAs to provide services using telecommunications technology within the 30-day period of care so long as the services are included in the patient’s plan of care and do not replace necessary in-person visits. Note that home health services provided through telecommunications technology must be included on a patient’s home health claim beginning July 1, 2023.
• The CMS allowance for nurse practitioners, clinical nurse specialists, and physician assistants—in addition to physicians—to order home health services, establish and review a plan of care, and certify and recertify eligibility for Medicare claims with a “claim through date” on or after March 1, 2020.

Implications

As the regulatory flexibilities permitted during the PHE begin to expire, HHAs and hospice providers must have internal systems in place to either come into compliance with expiring waivers or maintain lasting compliance with the surviving flexibilities.

HHAs and hospices will not continue to enjoy significant use of telehealth after the PHE ends outside of supervisory and face-to-face encounters by physicians. This is perhaps unsurprising given that the nature of HHA and hospice care is centered around hands-on nursing and other care to actively treat or palliate patients’ symptoms.

As the healthcare sector continues to endure challenges, such as the nurse staffing shortage, the sunset of these regulatory flexibilities will add to the regulatory compliance burdens for HHAs and hospices. Nevertheless, while in-person services will always remain a central component of these home-based care services, HHAs and hospices can use the skills and technologies they may have developed during the PHE to enhance their in-person care and data collection.

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To a certain extent, hospices will soon be operating under pre-pandemic rules in a “post-COVID” world.

With the COVID-19 Public Health Emergency (PHE) going away on May 11, many of the temporary flexibilities that came with it are expected to end, though Congress did extend some through 2024, including hospice re-certifications via telehealth.

The flexibilities enabled hospice and palliative care providers to maintain continuity of care while reducing safety risks, according to Ben Marcantonio, COO and interim CEO of the National Hospice and Palliative Care Organization (NHPCO).

“Hospice and palliative care providers have long prepared for the end of the PHE, and we believe they will manage the transition seamlessly,” Marcantonio told Hospice News in an email. “It’s also important to remember that separate from the PHE, there are telehealth flexibilities that allow hospice patients and providers to continue to use telehealth for low-touch, face-to-face visits prior to recertification for the hospice benefit.”

The expanded availability of telehealth has become an integral part of care delivery for most hospices, even though this was introduced as a temporary exemption during the pandemic. Hospices and other providers have been furrowing their brows over the possibility that former restrictions would eventually return.

If hospices were to lose those capabilities, their workforce would come under greater strain, potentially causing some to leave the field, according to Kathleen Benton, president and CEO of Georgia-based Hospice Savannah.

“For any of us to survive financially and be able to continue to care for people, it’s going to take innovative health care and technology to help make us more efficient in care delivery,” Benton previously told Hospice News. “We should feel compelled and called to make telehealth part of our expectations because health care can’t look the same as it did prior to COVID.”

In addition to recertifications, Congress has extended flexibilities for audio-only visits, as well as some related to originating sites, eligible practitioners, rural health and mental health services. Some states also have enacted laws extending telehealth in their Medicaid programs.

The end of the PHE should not be the last word on possible extensions of additional waivers, according to Bill Dombi, president of the National Association for Home Care & Hospice (NAHC).

“[The U.S. Centers for Medicare & Medicaid Services (CMS)] needs to consider what other flexibilities that emerged with the PHE can be made permanent, particularly several administrative, supervisory parts of the Conditions of Participation,” Dombi told Hospice News.

Additionally, some waivers pertaining to telehealth, hospitals, skilled nursing facilities and other facets of the health care system are set to expire with the PHE on May 11, the Kaiser Health Foundation reported.

Soon, hospices will have to resume compliance with volunteer requirements, as well as rules for the training and assessment of aides. Also, payers — including private companies, Medicare and Medicaid — will no longer be required to offer free COVID-19 tests, vaccines and some treatments.

Hospices are now working to prevent any potential disruption from affecting patient care, the National Partnership for Hospice and Healthcare Innovation (NPHI) indicated in an email to Hospice News.

“NPHI appreciates the flexibilities and waivers that CMS was able to offer hospice providers which enabled them to sustain operations throughout the COVID-19 pandemic,” the emailed statement stated. “We look forward to working with our partners in government and our members across the country to ensure a smooth transition out of the COVID-19 public health emergency and a seamless care experience for patients and their families.”

CMS last year published a “roadmap” to help health care organizations adapt to the changing environment.

Nevertheless, the transition will be difficult, according to LeadingAge President and CEO Katie Smith Sloan.

“The declaration of a public health emergency has provided valuable flexibility and access to critical resources providers desperately need to ensure the wellbeing of older adults, who are among the most vulnerable to falling ill or worse from COVID-19, and also of the people who care for them. On May 11, many of those resources and flexibilities will be gone,” Sloan said in a statement. “While we appreciate the administration giving our mission-driven, nonprofit providers some time to plan, our members are severely overstretched and now face a new landscape of funding and rules while simply trying to survive.”

The White House Office of Management and Budget (OMB) announced the May 11 expiration date on Monday, indicating that the timeline complies with the administration’s pledge to give providers 60-day notice of the PHE’s termination.

The announcement comes as the U.S. House of Representatives mulls two pieces of legislation designed to end the PHE earlier than May 11.

Rep. Brett Guthrey (R-Ky.) has introduced H.R. 382, the “Pandemic Is Over Act,” which, if enacted, would end the PHE immediately. Also before the House is Joint Resolution 7, introduced by Rep. Paul Gosar (R-Ariz.), which would likewise end the PHE upon enactment.

“The continued maintenance of this state of affairs is inappropriate for at least two reasons. First, the country has largely returned to normal. Every day, Americans have returned to work and school with no restrictions on their activities,” House Rules Committee Chairman Tom Cole (R-Okla.) said in a recent hearing. “It is time that the government acknowledges this reality: the pandemic is over, and there is no need for these declared emergencies to continue.”

OMB said in its announcement that ending the PHE so quickly would have wide-ranging harmful effects on the health care system.

The proposed bills would not allow certain policies to phase out gradually to ensure an orderly transition, according to OMB. This would include special Medicaid rules designed to ensure continuity of coverage, as well as the Title 42 policy impacting the U.S. border.

OMB also raised concerns that earlier termination could result in reductions in state funding, as well as patients losing their insurance or telehealth services. Also, hospitals and nursing homes would have insufficient time to retrain staff and implement new billing policies, OMB contends.

“An abrupt end to the emergency declarations would create wide-ranging chaos and uncertainty throughout the health care system — for states, for hospitals and doctors’ offices, and, most importantly, for tens of millions of Americans,” OMB indicated.

As of Jan. 25, about 295,000 COVID-19 people in the United States were sick with COVID-19, according to the U.S. Centers for Disease Control & Prevention (CDC). The number of U.S. deaths that week totaled 3,756.

With or without the federally declared PHE, hospices can continue their independent COVID-prevention efforts, Craig Dresang, CEO of California-based hospice provider YoloCares, told Hospice News.

“Ending the COVID PHE in May makes sense,” he said. “We will continue to monitor for symptoms and infection rates, and implement testing and masking policies based on the data and on our own initiatives to protect patients, families, employees and the community.”

The post What Terminating the COVID PHE Means for Hospices appeared first on mTelehealth.

A fourth year into the pandemic, its effects have hospices continuing to combat against financial and operational headwinds, as well as uncertainty about the future of telehealth rules.

The COVID-19 public health emergency (PHE) is likely to endure past another extension. Currently set to expire Jan. 11, 2023, the U.S. Department of Health & Human Services (HHS) has not issued a 60-day notice that the agency indicated it would prior to the PHE’s end. This means the PHE will presumably remain in place an additional 90 days, or until April.

If next year brings a halt to the PHE, this could also mean an end to some of the telehealth flexibilities it brought, spelling operational and patient delivery issues for hospices during times of short staffing.

Telehealth impacts for hospice

The pandemic has helped illuminate areas of fragility across the nation’s health care delivery system, as well as ways that virtual care could help fill gaps, according to U.S. Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure. The agency is giving careful consideration to the future of telehealth and its long-term impacts on health care, she said.

“We’re very focused on lessons learned. Some of the big ones are virtual care, which has been a lifeline for so many people across the country,” Brooks-LaSure said at the HLTH conference in Las Vegas. “CMS has extended virtual care in Medicare in mental health to the extent of our authority, and Congress has extended a lot of the telehealth flexibilities beyond the public health emergency. One of the biggest pieces is just how much we have to engage people. It’s critical as we think about how to eventually move to the other end of the public health emergency of really making sure that we build back our health system in a much stronger way.”

The Consolidated Appropriations Act of 2022 ensured that CMS would extend telehealth waivers set in place during the PHE for an additional 151 days (or roughly five months) after it expires to allow for a transitional adjustment period.

Some of these waivers will remain permanent, such as the ability for Medicare patients to receive mental or behavioral telehealth services if they meet certain criteria.

Other flexibilities will be phased out, such as those that permitted the use of telehealth to fulfill requirements typically done in person, according to a recent CMS report. This includes recertifications by physicians, which will again require in-person visitation following the PHE’s expiration.

Doing away with some of the telehealth flexibilities will add strain to the hospice clinical workforce, creating dangerous headwinds that will be difficult for many providers to manage and weather through in the post-pandemic era, according to Kathleen Benton, president and CEO of Georgia-based Hospice Savannah.

“The health care world has been turned upside down in a new wave of people who are more acutely ill. We were already preparing for a large baby boomer aging population to rear its head, but that happening simultaneously to COVID just formed a perfect storm,” Benton told Hospice News. “For any of us to survive financially and be able to continue to care for people, it’s going to take innovative health care and technology to help make us more efficient in care delivery. We should feel compelled and called to make telehealth part of our expectations, because health care can’t look the same as it did prior to COVID.”

Telehealth has played a vital role in hospices’ ability to sustain care delivery while also easing some of their staffing strains. Hospices have been able to do more with less clinical staffing resources as demand rose in part due to expanded virtual care, Benton said.

Hospices have seen rising turnover in recent years, with clinicians leaving the industry in higher volumes during the pandemic. Hospice and home health providers saw clinical turnover rise by 16% to 20% in 2020 compared to previous years, according to a study from BerryDunn.

Other disciplines have also seen high rates of loss. Case in point, social workers left the health care field at record-high rates that exceeded pre-pandemic levels by 35%, data from the Peterson-Kaiser Family Foundation Health System Tracker reflected.

Other PHE issues eating away at hospice sustainability in year four

The labor issues have had a significant adverse impact on hospices’ finances and operations. Rising expenses are a major concern, such as rising wages, costs for personal protective equipment and supplies, gas prices, as well as slimming census volumes caused by diminished capacity. Hospices have seen disruptions to their referral mixes, and reductions in referrals from hospitals and other facility-based settings during the outbreak.

While some of these COVID disruptions have eased, the trickle down effects could continue well past the pandemic, according to Benton.

Additionally, some of the pandemic’s long-term impacts may be less visible and more pressing on hospices when the public health emergency eventually ceases – particularly when it comes to staff retention, Benton added.

“The biggest constraints are the intangibles that represent a true problem. The pandemic has put this mentality shift upon us that is rampant among health care workers right now and hasn’t gone away,” Benton told Hospice News. “We are investing tons of dollars and efforts into boosting that morale and shaping our culture. It may sound more philosophical, but retention is the toughest thing to work on a daily basis and will be for years to come after the pandemic.”

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As the COVID-19 pandemic continues across the United States, states, payers, and providers are looking for ways to expand access to telehealth services. Telehealth is an essential tool in ensuring patients are able to access the healthcare services they need in as safe a manner as possible. In order to provide our clients with quick and actionable guidance on the evolving telehealth landscape, Manatt Health has developed a federal and comprehensive 50-state tracker for policy, regulatory and legal changes related to telehealth during the COVID-19 pandemic. This summary of findings is current as of noon ET, Thursday, October 15.

Federal Actions and Legislation:

Select introduced federal legislation:

Federal Flexibilities and Reports:

Flexibilities

On Friday, October 2, the U.S. Department of Health & Human Services (HHS) announced that the Public Health Emergency (PHE) declaration for COVID‑19 will be renewed for another 90 days, beginning on October 23 (the date the PHE was previously scheduled to expire) and extending through January 20, 2021. For more information the renewed PHE, please see our Manatt Newsletter.

Reports:

On October 14, CMS released a Preliminary Medicaid and CHIP Data Snapshot to provide information on telehealth utilization during the PHE. This data shows more than 34.5 million services were delivered to Medicaid and CHIP beneficiaries via telehealth between March and June of this year—an increase of 2,600% when compared to the same period in 2019. Additionally, CMS updated its State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth, COVID-19 Version to help providers and other stakeholders understand which policies are temporary or permanent, and to communicate telehealth access and utilization strategies to providers.

On July 28, HHS released the issue brief Medicare Beneficiary Use of Telehealth Visits: Early Data from the Start of the COVID-19 Pandemic. On July 15, CMS director Seema Verma released Early Impact of CMS Expansion of Medicare Telehealth During COVID-19, a blog on Health Affairs. This article highlights CMS’s efforts to expand telehealth during COVID-19 through the addition of 135 allowable telehealth services and the expanded list of types of health care providers who can offer telehealth, and explores how various mechanisms that have allowed for the increase in telehealth utilization during the PHE may continue.

State Laws, Policy, and Guidance

In Medicaid, states have broad authority to permit coverage for telehealth services. Prior to the COVID-19 emergency, many states had implemented broad coverage for telehealth, and in recent months, all 50 states and Washington D.C. have issued guidance expanding telehealth for their Medicaid populations. Medicaid programs have the broad ability to cover telehealth services and the flexibility to rapidly scale up benefits and adjust normal cost-sharing rules, making Medicaid well positioned to quickly address the needs of its beneficiaries during states of emergency.

Select State Legislation and Executive Orders

Since the COVID-19 public health emergency was declared, states have been moving to pass legislation that would permanently expand access to telehealth. The below chart lists telehealth legislation that has been enacted since March 13, the beginning of the PHE, and executive orders that have made the temporarily waived restrictions around telemedicine permanent.

State Trends

Coordination on Telehealth: Colorado, Nevada, Oregon, and Washington announced they will work together to identify best practices around access, confidentiality, equity, standard of care, stewardship, patient choice, and payment/reimbursement. The overarching goal of this partnership is to “ensure that the nation benefits from our knowledge as changes to federal regulations are contemplated, to support continued application and availability of telehealth in our states, and to ensure that we address the inequities faced in particular by tribal communities and communities of color”.

Commercial Payment Parity: In light of the COVID-19 pandemic, states that previously did not require payment parity for telehealth services in commercial plans have begun to issue temporary guidance requiring payment parity for specific telehealth cases. Prior to COVID-19, 9 states (Arkansas, Delaware, Georgia, Hawaii, Kentucky, Minnesota, Missouri, New Mexico, and Utah) had payment parity laws for commercial payers in 2020. California, Arizona and Washington had also recently passed telehealth payment parity legislation in 2019 and early 2020 that would come into effect in January 2021, bringing the total to 12 states. The Governor of Washington recently issued an Executive Order in March which required immediate implementation of its payment parity law.

Appendix K Telehealth Flexibilities: As of October 15, CMS has approved Section 1915(c) Waiver Appendix K (Appendix K) from 47 states and Washington, D.C. Appendix K is a long-standing federal authority that helps states streamline and expedite changes to their 1915(c) home and community-based services (HCBS) waivers to prepare for and respond to emergencies. As of October 15, at least 44 of the approved Appendix K waivers included telehealth flexibilities for states. Some of these flexibilities include adding electronic methods of delivery for case management; permitting personal care services that require only verbal cueing, in-home habilitation, or monthly monitoring; temporarily modifying provider qualifications; temporarily modifying processes for level of care evaluations and re-evaluations; and temporarily modifying medication management.

Audio-Only Telehealth Services: Many state Medicaid agencies are following Medicare’s lead to expand telehealth coverage to audio-only. This includes states that are either adding coverage for telephonic evaluation and management codes or allowing providers to bill the usual service codes when the services are delivered via telephone. As of October 15, all 50 state Medicaid agencies and Washington D.C. have issued guidance to allow for a form of audio-only telehealth services.

Child Well-care and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Visits: EPSDT is a mandated benefit that provides comprehensive and preventive healthcare services for children under age 21 who are enrolled in Medicaid. Each state is responsible to provide EPSDT services to children and adolescents enrolled in its Medicaid program. The American Academy of Pediatrics has issued guidance recommending all children still receive EPSDT visits. As of October 15, only 19 states and Washington D.C. have issued telehealth guidance for Child Well-care and EPSDT visits.

Early Intervention Services: As of October 15, 16 states have issued guidance to providers to allow for telehealth or remote care delivery for early childhood intervention services. On April 5, Illinois’ Chief Bureau of Early Intervention cleared all previous Illinois Department of Healthcare and Family Services requisites in order to implement and practice Illinois’ first-ever Early Intervention Teletherapy. On April 6, the Illinois Early Intervention Program (IEIP) instituted use of Live Video Visits as a temporary measure until the Illinois state of emergency is lifted. The IEIP is now working on tip sheets for families in English and Spanish and developing resources to help families with internet fees and costs for a computer, camera, and microphone. On April 7, North Carolina (NC) Medicaid released new telehealth guidance expanding the services and provider types eligible to deliver telehealth during the COVID-19 pandemic. Special Bulletin COVID-19 #34 expands telehealth codes and guidance to services delivered through local education and children’s developmental service agencies, and services pertaining to dietary evaluation and counseling, medical lactation, research-based behavioral health treatment for autism spectrum disorder, and diabetes self-management education. NC Medicaid also published an accompanying billing code summary to equip providers with the new codes pertaining to telehealth.

The post Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19 – October 15, 2020 appeared first on mTelehealth.

As the COVID-19 pandemic continues across the United States, states, payers, and providers are looking for ways to expand access to telehealth services. Telehealth is an essential tool in ensuring patients are able to access the healthcare services they need in as safe a manner as possible. In order to provide our clients with quick and actionable guidance on the evolving telehealth landscape, Manatt Health has developed a federal and comprehensive 50-state tracker for policy, regulatory and legal changes related to telehealth during the COVID-19 pandemic. This summary of findings is current as of noon ET, Thursday, September 17.

Federal Actions and Legislation:

On September 4, 14 U.S. Senators sent a letter to the Secretary of the Department of Veteran Affairs (VA) encouraging the VA to provide coverage of comprehensive telehealth services, including audio-only and text messaging services, to Civilian Health and Medical Program of Department of Veterans Affairs (CHAMPVA) beneficiaries. CHAMPVA currently covers real-time audio-visual telehealth, but as this letter notes, many beneficiaries reside in rural areas where internet access is limited.

On August 3^rd, CMS released a proposed Physician Fee Schedule Rule which would make certain Medicare telehealth flexibilities permanent and extend others for the remainder of the year in which the public health emergency (PHE) ends. Additionally, CMS released a list of services they are seeking comment on to decide whether they should be added on a permanent or temporary basis. For a complete list of services impacted by this rule, please see the table below.

Summary of CY 2021 Proposals for Addition of Services to the Medicare Telehealth Services List

On the same day, the President issued an executive order (EO) requiring that within 60 days, the Secretary of HHS shall propose regulation to extend temporary telehealth flexibilities put in place during the PHE. The practical impact of this EO is limited given the statutory restrictions on coverage and payment for telehealth in the Medicare program and that CMS is already in the process of proposing telehealth coverage and payment changes through its typical policymaking process. It is important to note that CMS has consistently stated that extending many of the temporarily waived telehealth restrictions will require Congressional action.

Select federal legislation currently being considered includes:

Federal Flexibilities:

State Laws, Policy, and Guidance

In Medicaid, states have broad authority to permit coverage for telehealth services. Prior to the COVID-19 emergency, many states had implemented broad coverage for telehealth, and in recent months, all 50 states and Washington D.C. have issued guidance expanding telehealth for their Medicaid populations. Medicaid programs have the broad ability to cover telehealth services and the flexibility to rapidly scale up benefits and adjust normal cost-sharing rules, making Medicaid well positioned to quickly address the needs of its beneficiaries during states of emergency.

State Legislation and Executive Orders

Since the COVID-19 public health emergency was declared, states have been moving to pass legislation that would permanently expand access to telehealth. The below chart lists telehealth legislation that has been enacted since March 13, the beginning of the PHE, and executive orders that have made the temporarily waived restrictions around telemedicine permanent.

State Trends

Coordination on Telehealth: Colorado, Nevada, Oregon, and Washington announced they will work together to identify best practices around access, confidentiality, equity, standard of care, stewardship, patient choice, and payment/reimbursement. The overarching goal of this partnership is to “ensure that the nation benefits from our knowledge as changes to federal regulations are contemplated, to support continued application and availability of telehealth in our states, and to ensure that we address the inequities faced in particular by tribal communities and communities of color.”

Commercial Payment Parity: In light of the COVID-19 pandemic, states that previously did not require payment parity for telehealth services in commercial plans have begun to issue temporary guidance requiring payment parity for specific telehealth cases. Prior to COVID-19, 9 states (Arkansas, Delaware, Georgia, Hawaii, Kentucky, Minnesota, Missouri, New Mexico, and Utah) had payment parity laws for commercial payers in 2020. California, Arizona and Washington had also recently passed telehealth payment parity legislation in 2019 and early 2020 that would come into effect in January 2021, bringing the total to 12 states. The Governor of Washington recently issued an Executive Order in March which required immediate implementation of its payment parity law.

Appendix K Telehealth Flexibilities: As of July 23, CMS has approved Section 1915(c) Waiver Appendix K (Appendix K) from 47 states and Washington, D.C. Appendix K is a long-standing federal authority that helps states streamline and expedite changes to their 1915(c) home and community-based services (HCBS) waivers to prepare for and respond to emergencies. As of July 23, at least 44 of the approved Appendix K waivers included telehealth flexibilities for states. Some of these flexibilities include adding electronic methods of delivery for case management; permitting personal care services that require only verbal cueing, in-home habilitation, or monthly monitoring; temporarily modifying provider qualifications; temporarily modifying processes for level of care evaluations and re-evaluations; and temporarily modifying medication management.

Audio-Only Telehealth Services: Many state Medicaid agencies are following Medicare’s lead to expand telehealth coverage to audio-only. This includes states that are either adding coverage for telephonic evaluation and management codes or allowing providers to bill the usual service codes when the services are delivered via telephone. As of July 23, all 50 state Medicaid agencies and Washington D.C. have issued guidance to allow for a form of audio-only telehealth services.

Child Well-care and Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Visits:

EPSDT is a mandated benefit that provides comprehensive and preventive healthcare services for children under age 21 who are enrolled in Medicaid. Each state is responsible to provide EPSDT services to children and adolescents enrolled in its Medicaid program. The American Academy of Pediatrics has issued guidance recommending all children still receive EPSDT visits. As of July 23, only 15 states have issued telehealth guidance for Child Well-care and EPSDT visits.

Early Intervention Services: As of July 23, 16 states have issued guidance to providers to allow for telehealth or remote care delivery for early childhood intervention services. On April 5, Illinois’ Chief Bureau of Early Intervention cleared all previous Illinois Department of Healthcare and Family Services requisites in order to implement and practice Illinois’ first-ever Early Intervention Teletherapy. On April 6, the Illinois Early Intervention Program (IEIP) instituted use of Live Video Visits as a temporary measure until the Illinois state of emergency is lifted. The IEIP is now working on tip sheets for families in English and Spanish and developing resources to help families with internet fees and costs for a computer, camera, and microphone. On April 7, North Carolina (NC) Medicaid released new telehealth guidance expanding the services and provider types eligible to deliver telehealth during the COVID-19 pandemic. Special Bulletin COVID-19 #34 expands telehealth codes and guidance to services delivered through local education and children’s developmental service agencies, and services pertaining to dietary evaluation and counseling, medical lactation, research-based behavioral health treatment for autism spectrum disorder, and diabetes self-management education. NC Medicaid also published an accompanying billing code summary to equip providers with the new codes pertaining to telehealth.

The post Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19 – September 2020 appeared first on mTelehealth.

Like providers, patients and families are adapting to rising use of telehealth in hospice care during the COVID-19 pandemic, as apparent plans to make temporary regulatory flexibilities permanent start to move forward. If telehealth remains a growing priority among hospices, gauging patient and family satisfaction with those services will be critical, particularly as they prepare to negotiate with Medicare Advantage plans starting in 2021.

The U.S. Centers for Medicare & Medicaid Services (CMS) extended a number of flexibilities for telehealth on a temporary basis during the COVID-19 national emergency. The White House recently issued an executive order instructing the U.S. Department of Health & Human Services to review those actions to see which could be made permanent. These moves by CMS coupled with the need to maintain social distancing has caused demand for telehealth to skyrocket.

Patient and family satisfaction will be critical to maximize as hospice moves towards value-based payment models in 2021. Emerging evidence suggests that senior citizens comprise the demographic that is most eager to use telehealth for chronic care management, according to a recent consumer survey by health care company American Well (AmWell). Respondents cited chronic disease management and prescription renewals as the leading drives towards telehealth among older populations.

AmWell reported that of the 47.8 million Americans over the age of 65, 24.85 million were willing to use telehealth. Interest in telehealth among seniors was found to be driven most by faster access to care providers.

“The 65+ demographic was most interested in using telehealth to receive faster care,” read the report. “Seniors were also the demographic most interested in receiving better access to their health care professionals, which they valued almost as much as cost savings.”

Another survey from data solutions company Kyruss spanning the COVID-19 pandemic’s initial hit into the nation from February to May also showed positive patient perception of telehealth, reporting high overall satisfaction with virtual care among the responses, including those in hospice settings.

“Seniors are very receptive to [telehealth] when it is recommended by their doctors, yet the technology they use needs to be simple,” said Drew Livingston, who spoke on the evolution and innovation of telehealth at a recent 36|86 virtual health care event. “The rule of thumb for seniors, based on my experience in telehealth, is that if an individual can text, they will be able to engage with their provider through a telemedicine visit.”

Livingston is chief innovation officer of Harrow Health, Inc., and CEO of Visionology, a telemedicine company launching later this year. He previously co-founded telemedicine software solution company Doxy.me.

“Time is of the essence for health care when you are a senior,” Livingston told Hospice News following the event. “Getting quick access to a care provider via telemedicine can make all the difference. Telehealth for hospice gives patients a level of comfort knowing that care is a click away. Many seniors feel isolated and alone when they are in hospice care. Telehealth also allows a caretaker or family member to involve other loved ones through a three-way, HIPAA-compliant video call so that everyone can be part of the hospice care process without having to be in the same room physically.”

Despite positive feedback, hospice providers have faced several challenges as they work to expand their telehealth programming. With barriers such as a lack of internet access for some patients and social isolation among seniors, hospices are zeroing in more closely on social determinants of health.

According to the AmWell survey findings, providers should seek to gain a better understanding of consumer health care personas in order to tailor telehealth programming to age-specific patient needs, including those who serve older populations. Hospice providers have increasingly utilized technology, such as adoption of predictive analytic systems, to help identify patients in need of their services further upstream in their disease trajectories.

The complex needs involved around the end of life have many hospice providers concerned about their ability to adequately assess patient needs virtually. CMS reported that patient assessment topped the list of most common deficiencies found during regulatory surveys in 2019, with 42% of hospices surveyed failing to provide key content in areas such as pain assessment and updated comprehensive care plans.

“The most common objection I hear is the fear that talking about difficult issues via telehealth will be harder somehow, but the opposite is usually true,” Brian Mistler, chief operating officer of California-based palliative service provider Resolution Care, which operates a virtual palliative care program that enables clinicians to support patients and families in real time. “People often find it easier to get to the heart of the matter more quickly and to share what’s really going on within the frame of the telehealth platform when the doctor or other facilitator is an expert. There’s something about the clear boundary of telehealth that actually helps people open up and focus.”

Patient monitoring systems have aided hospices in assessing care needs remotely with the ability to analyze data collected through routine visits such as blood pressure, weight, heart rate and blood sugar and oxygen levels. Technological advances are expected to continue to unfold in the hospice industry as telehealth programming opportunities expand beyond COVID-19.

“The future for telehealth in the hospice space will have more diagnostics that work seamlessly with a telehealth visit,” said Livingston. “For example, smart bed sheets can measure blood pressure, blood oxygen, hydration and more, and they alert the hospice care provider so that a patient’s care can be escalated as needed. At the end of the day, the use of telehealth in hospice care needs to be driven by care providers and family members pushing for their loved ones to take advantage.”

While CMS may permanently enshrine the temporary COVID-19 telehealth rules, the number provisions affecting hospices remains undetermined as the agency conducts its review. Preparing for the post-pandemic landscape will involve hospices embracing the changing winds towards increased virtual care, as well as buy-in from policymakers.

“Hospice and palliative care often work with the most vulnerable populations in many ways, dealing with very difficult issues,” Mistler told Hospice News. “There is perhaps no other field where telehealth offered in a quality way is as critical and transformative as it is for hospice and palliative care patients. Individuals who may not be your traditional first adopters also have had a chance to explore technology because it keeps them safer, and they’ve found it’s also a lot more efficient and convenient. It is critical that local, state and national governments continue to prioritize broadband internet access for all communities so every individual and every health plan both can take advantage of telehealth’s convenience and cost savings across populations.”

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The U.S. Centers for Medicare & Medicaid Services (CMS) will be making permanent a number of the temporary flexibilities to expand telehealth that the agency implemented in response to the COVID-19 pandemic. The number of rules affecting hospices that would be extended remains to be seen.

President Donald Trump signed an executive order that among other provisions directed CMS to review the temporary steps taken during the pandemic to determine which could be extended and to propose a rule to that effect within 60 days. The order also contains provisions to improve the broadband networks needed to support telehealth as well as new supports for rural health care providers.

“The policy proposes to make permanent multiple regulatory flexibilities on telemedicine made available during the coronavirus pandemic and initiate the national conversation on the use of telehealth,” CMS Administrator Seema Verma said in a White House briefing. “During the pandemic to rapidly and extensively expand telehealth on Medicare beneficiaries, using emergency authorities and at the president’s direction, we were able to temporarily get rid of restrictive regulations and allow for telehealth across the country — not just in rural areas. We allow telehealth to be provided and more sites of care, including nursing homes and allow telehealth to fulfill face-to-face requirements for different health care services including inpatient rehab facilities, hospice and home health.”

During periods of national disaster, the U.S. Department of Health and Human Services has the authority to waive regulatory requirements under section 1135 of the Social Security Act, allowing the CMS to issue waivers relaxing conditions of participation (CoPs) for hospices and health care providers, including expanded use of telehealth for patient care. Telehealth visits have helped providers maintain continuity of care while limiting in-person contact that could spread the COVID-19 virus.

These actions have greatly expanded the use of telehealth nationwide. Prior to the emergency declaration, about 13,000 Medicare beneficiaries accessed telemedicine services during a typical week. As of the last week of April, that number had ballooned to almost 1.7 million people, Verma indicated. All told, more than 9 million beneficiaries have received a telehealth service between mid-March and mid-June. A number of stakeholders in the hospice space, as well as a group of U.S. senators have called on CMS to make these actions permanent.

During the pandemic, hospices have been able to provide interdisciplinary services via telemedicine or audio as long as the patient is receiving routine home care level of care and those telemedicine services which are audio-only services are capable of meeting the patient and caregiver needs.

The $2.2 trillion CARES Act, designed to help the economy and essential industries weather the impact of the pandemic, also contained provisions related to hospice telehealth, including permitting practitioners to recertify patients via telemedicine appointments rather than face-to-face encounters.

According to Verma, the forthcoming proposed rule would add 135 services to the list that CMS allows to be performed via telehealth. The scope, however, is limited by statute. Congressional action may be necessary to advance some aspects of expanded telehealth.

“One of the things that we can do is expand the number of services that can be provided via telehealth, and that’s what you’re going to see in the rule. Some of the areas that we cannot do is [change] where the services are provided,” Verma said. “One of the things that we’ve been able to do during the pandemic is allow people to receive telehealth services from their home, and it’s something that Congress would need to change. Also the types of providers that are allowed to provide telehealth services is also something that Congress would have to change, and the third area is also allowing telehealth to not just the providers in rural areas but across the entire country.”

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Tuesday, June 2, 2020

As previously reported, Congress and Department of Health and Human Services (HHS) have removed longstanding regulatory barriers to the broad deployment of telehealth for general care during the COVID-19 pandemic. In parallel, the Coronavirus Aid, Relief, and Economic Security (CARES) Act has established the Federal Communication Commission (“FCC”) COVID-19 Telehealth Program, (the “FCC Program”) to reimburse providers for expenditures in furtherance of building out telehealth programs to meet this growing demand.

The FCC Program covers many types of nonprofit and public providers and a variety of expenditures (e.g., for connected devices or telecom services). But, if you are a provider interested in seeking reimbursement through the FCC Program, you should do so quickly as $63 million of the Program’s total $200 million has already been spoken for. Once the funds have been consumed, there is no indication they will be replenished.

The FCC will support eligible health care providers responding to the COVID-19 pandemic by fully funding their telecommunications services, information services, and devices necessary to provide critical connected care services. This raises two key questions: who are “eligible health care providers” and what are “telecommunications services, information services, and devices necessary to provide critical connected care services”?

Who is eligible?

The FCC defines “eligible health care providers” as nonprofit and public eligible health care providers that fall within the categories of health care providers in section 254(h)(7)(B) of the 1996 Telecommunications Act. These include:

• post-secondary educational institutions offering health care instruction, teaching hospitals, and medical schools;
• community health centers or health centers providing health care to migrants;
• local health departments or agencies;
• community mental health centers;
• not-for-profit hospitals;
• rural health clinics;
• skilled nursing facilities; or
• consortia of health care providers consisting of one or more entities falling into the first seven categories.

What are “telecommunications services, information services, and devices necessary to provide critical connected care services”?

The FCC Program reimburses purchases of telecommunications, information services, and connected devices necessary to provide telehealth services to patients in response to the coronavirus pandemic.   The FCC has been publishing summaries of approved applications for services and connected devices that it will reimburse. The FCC recently announced its eighth set of telehealth reimbursement approvals covering about 50 providers and a variety of services and devices.  Examples of the types of services and devices the FCC has approved include:

• Telecommunications Services: Telecommunication and broadband connectivity services to remotely connect health care providers and their patients.
  • Examples of approved services include: mobile data plans, software licenses, and video-conferencing licenses.
• Information Services: Internet connectivity services for health care providers or their patients; remote patient monitoring platforms and services; patient reported outcome platforms; store and forward services, such as asynchronous transfer of patient images and data for interpretation by a physician; platforms and services to provide synchronous video consultation.
  • Examples of approved services include: network upgrades, mobile hotspots, and telehealth platforms to design, implement, and support an integrated telemedicine application.
• Connected Devices/Equipment:
  • Examples of approved devices include: laptop computers, broadband enabled blood pressure and pulse oximetry monitors, tablets, diagnostic equipment, and telemedicine carts.
  • Note: devices must be connected; The FCC will not fund unconnected devices patients can use at home and then manually report the results to their medical professional. Connected devices may include devices with Bluetooth or WiFi connectivity, including devices that connect to a consumer’s phone, for example.

In total, the FCC has approved applications for 185 providers for approximately $68 million, leaving about $130 million still available. The FCC’s application process is straightforward and has a comprehensive “FAQ” section that covers everything from eligibility to instructions for applying.© Copyright 2020 Squire Patton Boggs (US) LLP

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Hospice: CMS Flexibilities to Fight COVID-19

Since the beginning of the COVID-19 Public Health Emergency, the Trump Administration has issued an unprecedented array of temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. These temporary changes will apply immediately across the entire U.S. healthcare system for the duration of the emergency declaration. The goals of these actions are to 1) expand the healthcare system workforce by removing barriers for physicians, nurses, and other clinicians to be readily hired from the community or from other states; 2) ensure that local hospitals and health systems have the capacity to handle a potential surge of COVID-19 patients through temporary expansion sites (also known as CMS Hospital Without Walls); 3) increase access to telehealth in Medicare to ensure patients have access to physicians and other clinicians while keeping patients safe at home; 4) expand in-place testing to allow for more testing at home or in community based settings; and 5) put Patients Over Paperwork to give temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, Medicare Advantage and Part D plans, and States can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.

Medicare Telehealth and Telecommunications Technology

• Hospice providers can provide services to a Medicare patient receiving routine homecare through telecommunications technology (e.g., remote patient monitoring;telephone calls (audio only and TTY); and 2-way audio-video technology), if it is feasibleand appropriate to do so. Only in-person visits are to be recorded on the hospice claim.
• Face-to-face encounters for purposes of patient recertification for the Medicare hospicebenefit can now be conducted via telehealth (i.e., 2-way audio-videotelecommunications technology that allows for real-time interaction between thehospice physician/hospice nurse practitioner and the patient).

Workforce

• Training and Assessment of Aides: CMS is waiving the requirement at 42 CFR§418.76(h)(2) for Hospice and 42 CFR §484.80(h)(1)(iii) for HHAs, which require aregistered nurse, or in the case of an HHA a registered nurse or other appropriate skilledprofessional (physical therapist/occupational therapist, speech language pathologist) tomake an annual onsite supervisory visit (direct observation) for each aide that providesservices on behalf of the agency. In accordance with section 1135(b)(5) of the Act, weare postponing completion of these visits. All postponed onsite assessments must becompleted by these professionals no later than 60 days after the expiration of the PHE.
  • . CMS is modifying the requirement at 42 CFR §418.100(g)(3), whichrequires hospices to annually assess the skills and competence of all individuals

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furnishing care and provide in-service training and education programs where required. Pursuant to section 1135(b)(5) of the Act, we are postponing the deadline for completing this requirement throughout the COVID-19 PHE until the end of the first full quarter after the declaration of the PHE concludes. This does not alter the minimum personnel requirements at 42 CFR §418.114. Selected hospice staff must complete training and have their competency evaluated in accordance with unwaived provisions of 42 CFR Part 418.

• Quality Assurance and Performance Improvement (QAPI). CMS is modifying the requirement at 42 CFR §418.58 for Hospice and §484.65 for HHAs, which requires these providers to develop, implement, evaluate, and maintain an effective, ongoing, hospice/HHA-wide, data-driven QAPI program. Specifically, CMS is modifying the requirements at §418.58(a)–(d) and §484.65(a)–(d) to narrow the scope of the QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events. This modification decreases burden associated with the development and maintenance of a broad-based QAPI program, allowing the providers to focus efforts on aspects of care delivery most closely associated with COVID-19 and tracking adverse events during the PHE. The requirement that HHAs and hospices maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement program will remain.
• Waive requirement for hospices to use volunteers. CMS is waiving the requirement at 42 CFR §418.78(e) that hospices are required to use volunteers (including at least 5% of patient care hours). It is anticipated that hospice volunteer availability and use will be reduced related to COVID-19 surge and anticipated quarantine.
• Waived onsite visits for Hospice Aide Supervision: CMS is waiving the requirements at 42 CFR 418.76(h), which require a nurse to conduct an onsite visit every two weeks. This would include waiving the requirements for a nurse or other professional to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan, as this may not be physically possible for a period of time.

Patients Over Paperwork

• Comprehensive Assessments: CMS is waiving certain requirements for Hospice 42 CFR §418.54 related to update of the comprehensive assessments of patients. This waiver applies the timeframes for updates to the comprehensive assessment (§418.54(d)). Hospices must continue to complete the required assessments and updates, however, the timeframes for updating the assessment may be extended from 15 to 21 days.
• Waive Non-Core Services: CMS is waiving the requirement for hospices to provide certain non-core hospice services during the national emergency, including the requirements at 42 CFR §418.72 for physical therapy, occupational therapy, and speech-language pathology.

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• Accelerated/Advance Payments: In order to provide additional cash flow to healthcare providers and suppliers impacted by COVID-19, CMS expanded and streamlined the Accelerated and Advance Payments Program, which provided conditional partial payments to providers and suppliers to address disruptions in claims submission and/or claims processing subject to applicable safeguards for fraud, waste and abuse. Under this program, CMS made successful payment of over $100 billion to healthcare providers and suppliers. As of April 26, 2020, CMS is reevaluating all pending and new applications for the Accelerated Payment Program and has suspended the Advance Payment Program, in light of direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund. Distributions made through the Provider Relief Fund do not need to be repaid. For providers and suppliers who have received accelerated or advance payments related to the COVID-19 Public Health Emergency, CMS will not pursue recovery of these payments until 120 days after the date of payment issuance. Providers and suppliers with questions regarding the repayment of their accelerated or advance payment(s) should contact their appropriate Medicare Administrative Contractor (MAC).

Medicare appeals in Fee for Service, Medicare Advantage (MA) and Part D

• CMS is allowing Medicare Administrative Contractors (MACs) and Qualified Independent Contractor (QICs) in the FFS program 42 CFR 405.942 and 42 CFR 405.962 and MA and Part D plans, as well as the Part C and Part D Independent Review Entity (IREs), 42 CFR 562, 42 CFR 423.562, 42 CFR 422.582 and 42 CFR 423.582 to allow extensions to file an appeal;
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966 and the Part C and Part D IREs to waive requirements for timeliness for requests for additional information to adjudicate appeals; MA plans may extend the timeframe to adjudicate organization determinations and reconsiderations for medical items and services (but not Part B drugs) by up to 14 calendar days if: the enrollee requests the extension; the extension is justified and in the enrollee’s interest due to the need for additional medical evidence from a noncontract provider that may change an MA organization’s decision to deny an item or service; or, the extension is justified due to extraordinary, exigent, or other non-routine circumstances and is in the enrollee’s interest 42 CFR § 422.568(b)(1)(i), § 422.572(b)(1) and § 422.590(f)(1);
• CMS is allowing MACs and QICs in the FFS program 42 C.F.R 405.910 and MA and Part D plans, as well as the Part C and Part D IREs to process an appeal even with incomplete Appointment of Representation forms 42 CFR § 422.561, 42 CFR § 423.560. However, any communications will only be sent to the beneficiary;

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appeal that don’t meet the required elements using information that is available 42 CFR §422.562, 42 CFR § 423.562.

•CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966and MA and Part D plans, as well as the Part C and Part D IREs, 42 CFR 422.562, 42 CFR

423.562 to utilize all flexibilities available in the appeal process as if good cause requirements are satisfied.

• Cost Reporting. CMS is delaying the filing deadline of certain cost report due dates due to the COVID-19 outbreak. We are currently authorizing delay for the following fiscal year-end (FYE) dates. CMS will delay the filing deadline of FYE 10/31/2019 cost reports due by March 31, 2020, and FYE 11/30/2019 cost reports due by April 30, 2020. The extended cost report due dates for these October and November FYEs will be June 30, 2020. CMS will also delay the filing deadline of the FYE 12/31/2019 cost reports due by May 31, 2020. The extended cost report due date for FYE 12/31/2019 will be July 31, 2020.

Additional Guidance

• The Interim Final Rules and waivers can be found at: https://www.cms.gov/about­cms/emergency-preparedness-response-operations/current-emergencies/coronavirus­waivers .
• CMS has released guidance to describe standards of practice for infection control andprevention of COVID-19 in hospices at https://www.cms.gov/files/document/qso-20-16­hospice.pdf
• CMS has released guidance to providers related to relaxed reporting requirements forquality reporting programs at https://www.cms.gov/files/document/guidance-memo­exceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf.

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