It is not a coincidence that two symbolic healthcare policy events took place this week.

I’m talking about the Senate’s confirmation of Chiquita Brooks-LaSure as administrator of the Centers for Medicare & Medicaid Services and the introduction of H.R. 3447, the Permanency for Audio-Only Telehealth Act. The latter would allow for Medicare coverage of audio-only telehealth services after the COVID-19 public health emergency.

Brooks-LaSure is stepping into CMS at a time when Congress and regulators are making key decisions about healthcare in the post-pandemic world. She will help lead home care and other providers through this major period of transition.

Among those big decisions are how to handle telehealth, which perhaps literally and figuratively saved lives during the period of lockdown. Just last week the House introduced H.R. 3371, the Home Health Emergency Access to Telehealth Act (HEAT), which would provide reimbursement for telehealth services in the Medicare Home Health benefit during an emergency period.

Brooks-LaSure also will preside over an agency that will be navigating the likely growth of hospital-at-home, a major CMS initiative that, like telehealth, flourished thanks to the pandemic. There is no question that pressure is building on lawmakers to extend the Hospitals Without Walls program, as the executive director of Moving Health Home told McKnight’s Home Care Daily this week.

Of course, other issues hang in the balance. These include a possible expansion of Medicaid home- and community-based services, the growth of the Home Health Value-Based Purchasing Model, and the possibility of Medicare-covered skilled nursing facility-level care at home. Legislation regarding the latter may be introduced in the coming days.

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The home health industry hasn’t given up on securing telehealth reimbursement during the public health emergency. Their tenacity is being rewarded with recent legislative movement on Capitol Hill.

A group of bipartisan Senators on Thursday introduced S. 1309, the new version of the Home Health Emergency Access to Telehealth (HEAT) Act under the current Congress. The HEAT Act was previously introduced in both the House and Senate last October.

“The COVID-19 pandemic has firmly demonstrated the value of telehealth as a tool in meeting the clinical needs of home health patients,” National Association for Home Care & Hospice President William A. Dombi told Home Health Care News. “However, with the absence of any reimbursement for telehealth, home health agencies have not had the ability to make full use of it.”

Progress on in-home telehealth reimbursement has been a top legislative priority for the Washington, D.C.-based NAHC since last fall.

The advocacy organization described the current lack of telehealth reimbursement in home health care as a “glaring shortcoming in the era of the coronavirus pandemic.”

Similar to last year’s version, the new HEAT Act gives CMS the authority to issue a waiver that would allow for telehealth visits to count towards in-person visits as included on the plan of care only during a public health emergency. The COVID-19 public health emergency is expected to last throughout 2021, so such an action could be a huge difference-maker for home health agencies.

If enacted, the HEAT Act would help providers meet rising demand for home health services as a time when the supply of nurses and other in-home care professionals is at a premium. The bill’s potential passage would also allow agencies to conserve personal protective equipment (PPE) and minimize person-to-person contact during future outbreaks in any given area.

Senators Susan Collins (R-Maine) and Ben Cardin (D-Md.) introduced the original HEAT Act in 2020. 

They teamed up again this year, with backing from Senators Roger Marshall (R-Ky.) and Jeanne Shaheen (D-N.H.).

“The HEAT Act is a big step forward in modernizing the Medicare home health benefit,” Dombi said. “We thank the senators for their bipartisan sponsorship of the bill and look forward to an early passage.”

While the HEAT Act has overwhelming support in the home health industry, some skeptics have raised concerns about the overuse of virtual care when in-person visits are needed.

The new version of the legislation has a built-in mechanism to prevent that scenario, according to NAHC.

“During the drafting, concerns were raised of the need for patient protections to ensure for protection against fraudulent and improper behavior,” a NAHC analysis states. “To assuage these concerns, guardrails were added that would require for patient consent for telehealth services, as well as a requirement that telehealth visits can [account for] no more than half of all visits.”

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The Medicare home health benefit does not currently permit the inclusion of telehealth services as a reimbursable service as part of the plan of care. Despite this, many home health agencies (HHAs) have found great value for their patients in including telehealth as part of care delivery and do so despite the lack of reimbursement.

In 2019, as part of its annual rulemaking, the Centers for Medicare & Medicaid Services (CMS) permitted HHAs to include telehealth-related expenses on their cost reports. This was an important step that will help CMS and Congress understand the value and cost of telehealth in home health, although advocates said it fell short of meaningful action towards providing reimbursement for those services.

The COVID-19 pandemic has accelerated the need for telehealth use in the home. In late October, Sens. Ben Cardin (D-Maryland) and Susan Collins (R-Maine) introduced the Home Health Emergency Access to Telehealth (HEAT) Act to provide a path to reimbursement for telehealth in the home. A similar bill was introduced in the House.

LEGISLATION

This bill would:

• Allow CMS to issue a waiver providing for reimbursement of telehealth services in Medicare home health in the event of a public health emergency,
• Provide CMS the discretion to determine equivalency between an in-person visit and telehealth visit for purposes of reimbursement.
• Provide patient protections, including consent to telehealth services, limitation that no more than 50% of visits can be done virtually, and requirement of a pre-existing relationship with the attending physician ordering services.

The beneficiary must consent to telehealth services in order for the HHA to receive reimbursement.

TELEHEALTH STATS YOU SHOULD KNOW

Telehealth visits were up 43% in April after the announcement of the public health emergency.

• In 2019, 22% of practitioners used telemedicine to examine patients, versus only 5% in 2015.
• As a result of the pandemic, up to $250 billion of U.S. health care spending could come from virtual medicine.
• Telehealth technologies are projected to save the U.S. health care industry $305 billion annually.
• Some 89% of clinicians report that telemedicine is at least a satisfactory method of follow-up care for patients.
• Virtual health care visits were regarded by 62.6% of patients and 59% of clinicians to be just as effective as in-office care.

WHAT NEXT?

The National Association for Home Care & Hospice projected at press time that the bill likely won’t be considered until early December, when a new federal budget package goes up for a vote. This bill’s best hope for passage lies in becoming a rider to that budget package.

Track this bill at congress.gov.

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As COVID-19 infection rates continue to rise in areas of the country, telehealth continues to play an important role in the delivery of healthcare, especially to those most vulnerable to the virus.  The Public Health Emergency has officially been extended through January 23, 2021, which means that the majority of the telehealth waivers on the federal and state level will remain in place into the new year. 

In addition to the many CMS waivers that we previously covered, new proposed legislation aims to increase the availability of telehealth services provided by home health agencies.  Late last month, Senators Susan Collins and Ben Cardin introduced the bi-partisan Home Health Emergency Access to Telehealth Act (the “HEAT Act”).  U.S. Representatives Roger Marshall, Terri Sewell, Jodey Arrington, and Mike Thompson introduced companion legislation in the House. 

Existing CMS waivers allow home health agencies the flexibility to provide more services via telehealth, including conducting the required face-to-face encounter via 2-way audio-video telecommunications technology, but currently only in-person visits can be reported on a home health claim.  Under the proposed HEAT Act, home health agencies will be permitted to bill Medicare for audio and video telehealth services furnished during the Public Health Emergency, if the following requirements are met:

1. The telehealth services are furnished pursuant to a 1135 waiver;
2. The telehealth services constitute no more than 50% of the number of billable visits billed during the 30-day period of care;
3. The telehealth services are furnished under a plan of care established by a physician or other practitioner with whom the beneficiary has an existing care relationship, and the plan of care includes home health services to be furnished via video or audio-only telecommunication; and
4. The beneficiary consents to receiving home health services via video or audio-only telecommunication. 

If the HEAT Act is passed, reimbursement for the applicable telehealth services will be made under the home health prospective payment system.  The Secretary of Health and Human Services will be required to issue regulations including standards for orders, patient consents, documentation, billing units, program integrity, and the nature and level of resources utilized in the provision of telehealth services for the purpose of determining equivalency with in-person visits.  Such regulations would be required no later than 60 days after the date of the enactment of the HEAT Act.

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The bipartisan Home Health Emergency Access to Telehealth (HEAT) Act, introduced by Sens. Susan Collins (R-ME) and Ben Cardin (D-MD), if passed, would provide Medicare reimbursement for audio and video telehealth services furnished by home health agencies during the COVID-19 emergency and future public health emergencies. Companion legislation also was introduced in the House of Representatives.

“The COVID-19 emergency has further underscored the critical importance of home health services and highlighted how these agencies are able to use telehealth to provide skilled care to their patients,” said Collins, the chairman of the Senate Special Committee on Aging. “This bipartisan bill would ensure that seniors retain access to remote home health services during the COVID-19 emergency and future public health emergencies.” 

The services would not be reimbursed unless the beneficiary consented to receiving the services via telehealth. Further, to ensure that the Medicare home health benefit does not become a telehealth-only benefit, Medicare reimbursement would be provided only if the telehealth services constituted no more than half of the billable visits made during the 30-day payment period.

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Bills introduced in both the Senate and House last week call for Medicare coverage for home health care services provided via telehealth during a public health emergency.

By Eric Wicklund

October 26, 2020 – A new bill before Congress aims to improve Medicare coverage for home health services delivered via telehealth during a public health emergency.

The Home Health Emergency Access to Telehealth (HEAT) Act, introduced in both the Senate and House last week, aims at improving care management at home by allowing home healthcare programs to use connected health platforms. Home healthcare groups have long lobbied the Centers for Medicare & Medicaid Services for more access to and coverage of telehealth, with mixed results.

“The COVID-19 pandemic has challenged home health providers’ ability to provide care to patients in their homes,” Senator Ben Cardin (D-MD), a member of the Senate Finance Health Care Subcommittee and co-sponsor of the Senate bill with Susan Collins (R-ME), said in a press release. “Home health providers have been able to overcome these challenges by utilizing telehealth to deliver some services to Medicare beneficiaries. This legislation allows home health services to be provided via telehealth during a public health emergency in order to ensure patients receive needed care.”

“Home health serves a vital role in helping our nation’s seniors avoid more costly hospital visits and nursing home stays,” added Collins, who chairs the Senate’s Aging Committee. ”The COVID-19 emergency has further underscored the critical importance of home health services and highlighted how these agencies are able to use telehealth to provide skilled care to their patients.”

The bill would expand telehealth coverage during a public health emergency for home health services via “visual or audio telecommunication systems.” The use of telehealth must be deemed appropriate, must be approved by the beneficiary prior to use, and would be reimbursed only if those telehealth visits don’t make up more than half of all billable visits during a 30-day payment period.

While the bill would improve telehealth adoption during a crisis, it doesn’t address issues raised by the industry in improving adoption beyond an emergency.

CMS currently does not recognize the home health care provider as a telehealth provider – instead, it allows primary care providers to prescribe telehealth services in the home, and manages the services provided by home health care companies. In other words, doctors and other practitioners can prescribe and bill for telehealth services furnished, but home health care providers can’t.

In addition, telehealth visits do not count toward a home health care providers’ low-utilization payment adjustment (LUPA) threshold, which sets a minimum number of in-person visits that a care provider must complete.

The hope among many is that home health care programs can show enough success using telehealth during the emergency to prompt changes to long-term coverage, either via CMS or a Congressional action.

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Washington, D.C. — U.S. Senators Susan Collins (R-ME) and Ben Cardin (D-MD) introduced the Home Health Emergency Access to Telehealth (HEAT) Act, a bipartisan bill to provide Medicare reimbursement for audio and video telehealth services furnished by home health agencies during the COVID-19 emergency and future public health emergencies.  U.S. Representatives Roger Marshall (R-KS), Terri Sewell (D-AL), Jodey Arrington (R-TX), and Mike Thompson (D-CA) introduced companion legislation in the House of Representatives.

“Home health serves a vital role in helping our nation’s seniors avoid more costly hospital visits and nursing home stays.  The COVID-19 emergency has further underscored the critical importance of home health services and highlighted how these agencies are able to use telehealth to provide skilled care to their patients,” said Senator Collins, the Chairman of the Aging Committee.  “This bipartisan bill would ensure that seniors in Maine and across the country retain access to remote home health services during the COVID-19 emergency and future public health emergencies.”

“The COVID-19 pandemic has challenged home health providers’ ability to provide care to patients in their homes. Home health providers have been able to overcome these challenges by utilizing telehealth to deliver some services to Medicare beneficiaries,” said Senator Cardin, a member of the Senate Finance Health Care Subcommittee. “This legislation allows home health services to be provided via telehealth during a public health emergency in order to ensure patients receive needed care.”

The Home Health Emergency Access to Telehealth (HEAT) Act would authorize Medicare reimbursement for home health services provided through telehealth during a public health emergency where telehealth can be used appropriately.  The services would not be reimbursed unless the beneficiary consents to receiving the services via telehealth.  To ensure that the Medicare home health benefit does not become a telehealth-only benefit, Medicare reimbursement would only be provided if the telehealth services constitute no more than half of the billable visits made during the 30-day payment period.  

The bipartisan bill has been endorsed by several home health organizations and agencies, including Northern Light Health, MaineHealth Care at Home, LeadingAge, the Visiting Nurse Associations of America, the National Association for Home Care & Hospice (NAHC), and the Partnership for Quality Home Healthcare.

“On behalf of Northern Light Home Care clinicians and patients in our care, I want to thank Senator Susan Collins for her outstanding leadership in sponsoring legislation to require Medicare to cover home care services provided by visual or audio telehealth communication during an emergency period.  During the COVID-19 pandemic our nurses and therapists cared for patients throughout the State of Maine providing telehealth care allowing the patient to stay at home and receive essential clinical services. Access to telehealth care in the home avoided hospital or emergency room care for thousands of patients including children, older adults and individuals living in shelters,” said Lisa Harvey-McPherson RN, Northern Light Health Vice President Government Relations.

“We are grateful to Senator Collins for sponsoring this important legislation that will provide critical support for telehealth services during times of public health emergency.  Though telehealth has proven to be a highly efficient and effective means of providing needed care, particularly for our seniors, Medicare reimbursement continues to present a barrier to realizing its full potential. This bill takes an important step to expand access to needed telehealth services that have proven to improve health outcomes while reducing total costs for patients with chronic health care conditions,” said Donna Deblois, President of MaineHealth Care at Home.

“Many of our home health members have been providing critical services without reimbursement during the pandemic. The HEAT Act would resolve this inequity and put our home health members on par with all other providers with regards to flexibility during this and future public health emergencies. LeadingAge and our partners VNAA/ElevatingHOME thank the sponsors, Senators Collins and Cardin and Representatives Sewell, Marshall, Arrington, and Thompson, for all of their work on this important legislation,” said Katie Smith Sloan, President/CEO of LeadingAge and Acting President/CEO of the Visiting Nurse Associations of America/ElevatingHOME.

“From the early onset of the COVID-19 pandemic it has been well known that limiting person-to-person contact is key in reducing transmission and infection rates,” said Bill Dombi, President of NAHC.  “Enabling home health agencies to incorporate telehealth visits into the plan of care, with reimbursement, will unlock new means of safe care delivery bringing peace of mind to Medicare beneficiaries. This bill, the Home Health Emergency Access to Telehealth (HEAT) Act, will ensure that home health providers are able to utilize the full array of tools at their fingertips to reduce the risk of virus transmission, protecting patients in their homes, and health care professionals on the frontlines. NAHC thanks Senators Collins and Cardin, and Representatives Marshall, Sewell, Arrington and Thompson for their continued leadership in enabling patients to safely receive care in the home.”

“The Partnership applauds Senators Collins and Cardin for their introduction of this important legislation, which supports the provision of telehealth to Medicare home health patients. We thank the Senators for their ongoing and steadfast support for home health. It’s especially important during the COVID19 pandemic, as home health is an even more important lifeline for America’s disabled and elderly community,” said Joanne Cunningham, Executive Director, Partnership for Quality Home Healthcare.

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