CMS is updating its Value-Based Insurance Design model of care to allow telehealth to replace certain in-person medical visits in Medicare Advantage plans.

By Eric Wicklund

January 18, 2019 – Healthcare providers treating patients on Medicare Advantage plans may soon be able to use telehealth in place of in-person care when appropriate.

The update was one of several unveiled Friday by the Centers for Medicare & Medicaid Services’ Value-Based Insurance Design (VBID) model of care, introduced in 2017 and overseen by CMS’ Center for Medicare and Medicaid Innovation Center (CMMI).

According to that update, beginning in calendar year 2020, MA plans will be able to use telehealth instead of in-person visits “as long as an in-person option remains, to meet a range of network requirements, including certain requirements that could not previously be fulfilled through telehealth.”

“Expanding choices for patients, aligning incentives, and providing new flexibility for insurers in Medicare Advantage and Medicare Part D will deliver better value from these programs,” Health and Human Services Secretary Alex Azar said in a press release.  “The models being announced today create new incentives for plans, patients, and providers to choose drugs with lower list prices, and new ways to meet the unique healthcare needs of specific populations, prevent disease, and expand the use of telehealth.  Today’s announcement draws on successes we have already seen in Medicare and advances our priority of using HHS programs to build a value-driven healthcare system.”

“Today’s announcements are prime examples of how CMMI can test policies to modernize CMS programs and ensure that our seniors can access the latest benefits,” added CMS Administrator Seema Verma. “These two models ignite greater competition among plans, creating pressure to improve quality and lower costs in order to attract beneficiaries.”

Other updates focus on:

  1. Allowing plans to provide reduced cost sharing and additional benefits to enrollees in a more targeted fashion than has previously been allowed, including customization based on chronic condition, socioeconomic status, or both, and even for benefits not primarily related to health care, such as transportation; and
  2. Bolstering the rewards and incentives programs that plans can offer beneficiaries to take steps to improve their health, permitting plans to offer higher value individual rewards than were previously allowed.

In addition, CMMI expects to allow MA plans to cover hospice care beginning in calendar year 2021.

CMS officials are looking to the telehealth update to measure how connected care platforms can improve or complement an MA plan’s network of providers, as well as overcoming barriers to access in underserved areas.

“Where deemed appropriate by CMS, MA plans may propose using telehealth services in lieu of in-person visits to meet network adequacy requirements,” CMS says in an accompanying fact sheet. “Organizations must ensure that enrollee choice is preserved and that enrollee access to an in-person visit, if that is the enrollee’s preference and choice, is maintained. CMS expects that this will provide MA plans with an opportunity to enter into underserved markets, including rural areas where there may be few to no MA plan choices.”

Among those offering comments on the update was the American Telemedicine Association.

“Telehealth can and should be leveraged as a way to increase access to needed providers and services that patients and consumers may not otherwise have ready access to,” Ann Mond Johnson, the organization’s CEO, said. “The ATA applauds the Centers for Medicare and Medicaid Services (CMS) for recognizing that need in their new guidance allowing Medicare Advantage (MA) plans to use telemedicine providers to meet network adequacy standards. This means, for example, that in a rural and underserved area where a specialist for your grandmother’s condition is not available, she can have access to such a specialist using technology. The ATA looks forward to working with CMS and MA plans to appropriately and effectively implement this policy in a way that ensures beneficiary access to the right balance of both virtual and in-person care.”

The news is the latest in an already busy year for telehealth and MA plans.

Earlier this year, CMS finalized a plan to eliminate geographical restrictions in telehealth coverage, enabling reimbursements for MA program in both urban and rural areas, as well as home-based virtual visits.

“The proposed rule would give MA plans more flexibility to offer telehealth benefits to all their enrollees, whether they live in rural or urban areas,” the agency stated. “It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places including their homes, rather than requiring them to go to a health care facility to receive telehealth services. Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries.”

“While MA 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 MA plans will offer them and that more enrollees will be able to use the benefits,” CMS added.

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