On March 27th, Congress passed and the President signed the Coronavirus Aid, Relief, and Economic Security Act (the CARES Act). On both the federal and state levels we have seen efforts to support social distancing in the health care sector by increasing the use of telehealth. On the federal side, we have seen the continued relaxation of Medicare statutes and regulations allowing for telehealth to be rendered to patients in any location, among many other recently published relaxations, and many states have relaxed state licensure requirements allowing physicians to render telehealth services across state lines without the delays of obtaining specific licensure. In line with these efforts, and others, comes the third bill aimed at the COVID-19 public health emergency (PHE) and overall pandemic. The CARES Act contains many measures to increase the use of telehealth through the waiver of certain in-person requirements and increased funding to enhance access to telehealth services.
Under the Telehealth Services During Certain Emergency Periods Act of 2020 (the TSDCEPA) that was part of the larger bipartisan Coronavirus Preparedness and Response Supplemental Appropriations Action 2020, which was one of the first pieces of legislation aimed at fighting the COVID-19 pandemic, only limited waivers of Medicare telehealth coverage requirements were authorized. These primarily related to the location of the Medicare beneficiaries receiving telehealth services. Under the CARES Act, the Secretary of Health and Human Services (Secretary) now has the authority to waive “the requirements of Section 1834(m)” which is the Section of the Social Security Act containing all statutory Medicare coverage requirements for telehealth. What the Secretary does with this new waiver authority is yet to be seen fully, but a large number of telehealth related changes and expansion have already been published as of March 30, 2020 and made effective as of March 1, 2020. Further, CMS has indicated that additional waivers or changes to statutes and regulations to provider even greater flexibility for telehealth services are already in the works.
Prior to the CARES Act, neither a FQHC nor RHC were included on the list of specified distant site providers who could render Medicare-covered telehealth services. Now, both FQHCs and RHCs may serve as the distant site provider and telehealth services rendered by an FQHC and/or RHC to a Medicare beneficiary will be covered. The Secretary will issue separate payment rates for these services which will be comparable to current physician fee schedule rates. Note, however, that costs associated with telehealth services shall not be used to determine the amount of FQHC payments under their prospective payment systems or the amount payable to RHC under their all-inclusive rates.
Normally, Medicare beneficiaries must be certified to receive Medicare covered hospice benefits via an in-person face-to-face encounter. However, during the emergency period, a hospice physician or nurse practitioner may conduct such required face-to-face encounter via telehealth.
Pre-COVID-19, Medicare beneficiaries could receive the required monthly End Stage Renal Disease (ESRD) related clinical assessments via telehealth but only if, during the initial three month period of the beneficiary’s home dialysis services the beneficiary received a monthly face-to-face clinical assessment without the use of telehealth (i.e., an in-person clinical assessment) and thereafter once every three months. The CARES Act now allows the Secretary to waive these in-person requirements, so that during the COVID-19 emergency, Medicare beneficiaries may receive additional clinical assessments via telehealth.
Currently, the costs of remote patient monitoring (RPM) in the home health setting are allowable as administrative costs only. Visits to the home for the purpose of training a patient on use of the RPM technology is not a billable service. Note, this is different in other provider settings, such as physician practices/clinics, which can bill separate CPT codes specifically attributable to patient education and set up of the RPM equipment (i.e., CPT Code 99453). Under the CARES Act, the Secretary is required to consider ways to encourage the use of tele-communications systems, including for RPM. Thus, in addition to new waivers and expansions of telehealth for home health agencies already issued under the CARES Act on March 30 2020, it is possible that the Secretary will further expand access to telehealth for home health agencies, including through further expansion of the availability of RPM.
A veteran’s enrollment or re-enrollment in a Veteran Directed Care Program typically requires an in-person visit with the applicable area agency. The CARES Act allows this in-person visit to be conducted via telehealth. In addition, the CARES Act directs the Secretary of Veterans Affairs is to ensure telehealth capabilities are available during the COVID-19 emergency for use by case managers working with homeless veterans participating in the Department of Housing and Urban Development Department of Veterans Affairs Supportive Housing program (HUD-VASH).
High deductible commercial health plans with health savings accounts (HSAs) may cover telehealth services and other remote care services prior to patients reaching their deductible without risking the tax advantages of an HSA.
The CARES Act provides for increased funding to address a broad spectrum of COVID-19 concerns which often specifically call out the expanded use of telehealth and remote care technologies, which include among others, the following funding sources:
On March 30, 2020, CMS published an interim final rule implementing many portions of the CARES Act, a broad array of blanket 1135 waivers including those related to Stark self-referral provisions, and issues raised by the CARES Act, as well as provider specific guidance on additional waivers made available by the Secretary and CMS. CMS also recently indicated that additional waivers and/or rulemaking will be forthcoming to further implement the CARES Act and many of its provisions referenced here that are expected to further relax requirements related to telehealth and make it more broadly available during the current COVID-19 pandemic.