In a proposed rule issued this week, CMS is boosting telehealth coverage in Medicare Advantage plans for members with end-stage renal disease and giving MA members more telehealth coverage for specialist care.

 By Eric Wicklund

February 07, 2020 – CMS is proposing giving patients with end-stage renal disease in Medicare Advantage plan access to more telehealth benefits, allowing them to receive care at home.

In a proposed rule issued on February 5, the Centers for Medicare & Medicaid Services announced that it is following through with mandates included in the 21st Century Cures Act by eliminating barriers to enrollment in MA plans for people with ESRD.

“This proposed rule takes an important step in improving the lives of beneficiaries with ESRD, which is a priority in alignment with the Executive Order on Advancing American Kidney Health,” CMS said in a fact sheet accompanying the proposed rule. “By removing the barrier that beneficiaries with ESRD now face in terms of enrolling in MA plans, we are empowering them to choose the type of Medicare coverage that best meets their needs.”

The telehealth-specific changes are part of a larger proposed rule targeting prescription drug programs.

The rule references an executive order issued last July by President Donald Trump that aimed to change how people living with ESRD are treated and how care providers are reimbursed for that treatment. The order opens the door to, among other things, home-based dialysis programs that use remote patient monitoring technology for care management and transplant programs that use telehealth to improve organ procurement and post-operative recovery.

“For decades, across all of American healthcare, and kidney care in particular, the focus has been on paying for procedures, rather than paying for good outcomes,” Health and Human Services Secretary Alex Azar noted in a press release. “We need to flip that around: We’re going to start paying providers for better health outcomes, rather than procedures, and we’re going to pay for health, rather than simply paying once people are already sick.”

Roughly 30 million Americans, or 15 percent of the adult population, are affected by chronic kidney disease. Of that number, more than 660,000 have kidney failure, and almost 470,000 are on dialysis. More than 193,000, meanwhile, have a functioning kidney transplant, which requires them to follow a very strict daily medication regimen.

According to the National Kidney Foundation, telemedicine offers a promising alternative to in-person care, most often delivered in a doctor’s office or dialysis clinic. Clinicians can remotely monitor a patient’s blood pressure and other vital signs, as well as offering resources for medication adherence and diet plans.

More importantly, nephrologists and nephrology nurses can coordinate care online with a patient’s primary care provider (a model now being used by the Indian Health Service) and interact at home with patients undergoing hemodialysis and peritoneal dialysis, offering on-demand care between regularly scheduled office visits.

In its proposed rule this week, CMS also announced that it’s giving MA beneficiaries access to new telehealth benefits not available in Medicare fee-for-service plans for a number of specialty care services.

“CMS proposes to strengthen network adequacy rules for MA plans by codifying our existing network adequacy methodology, but we are also proposing new policies to improve access in rural areas and encourage the use of telehealth in all areas,” the agency said. “In rural areas, we are proposing to reduce the required percentage of beneficiaries that must reside within the maximum time and distance standards from 90 percent to 85 percent and inviting comment regarding additional changes to improve MA access in rural areas. To encourage and account for telehealth providers in contracted networks, we are proposing that MA plans receive a 10 percent credit towards the percentage of beneficiaries that must reside within required time and distance standards when the plan contracts with telehealth providers for Dermatology, Psychiatry, Cardiology, Otolaryngology, and Neurology.”

CMS also said that it would solicit comments on whether the credit should be expanded to other specialties.

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