The National Telehealth Webinar Series Thursday, Mar. 15th, 2018 Presented by The National Consortium of Telehealth Resource Centers

Webinar Tips & Notes Your phone &/or computer microphone has been muted Time is reserved at the end for Q&A Please fill out the post-webinar survey Webinar is being recorded Recordings will be posted to our YouTube Channel https://www.youtube.com/channel/UCOzpvd1OZ221AWBSF3QK-yg

Telehealth Policy So Far Presenter Christine Calouro, Policy Associate The Center for Connected Health Policy

Objectives Overview of national telehealth policy developments in the first quarter of 2018. Summary of changes made by the Calendar Year 2018 Medicare Physician Fee Schedule Review of telehealth elements included in the Bipartisan Budget Bill Share some general trends in state telehealth legislation across the nation.

Telehealth Policy So Far in 2018 National Telehealth Resource Center Webinar Series March 15, 2018 877-707-7172 cchpca.org CENTER FOR CONNECTED HEALTH POLICY

CENTER FOR CONNECTED HEALTH POLICY DISCLAIMERS Any information provided in today’s talk is not to be regarded as legal advice. Today’s talk is purely for informational purposes. Always consult with legal counsel. CCHP has no relevant financial interest, arrangement, or affiliation with any organizations related to commercial products or services discussed in this program. CENTER FOR CONNECTED HEALTH POLICY

CCHP is an independent, public interest organization that strives to advance state and national telehealth policies that promote better systems of care, improved health outcomes and provides greater health equity of access to quality, affordable care and services. CENTER FOR CONNECTED HEALTH POLICY

CENTER FOR CONNECTED HEALTH POLICY

TELEHEALTH STATE-BY-STATE POLICIES, LAWS & REGULATIONS Current Laws, Regulations, Pending Bills State & Federal Interactive Policy Map CENTER FOR CONNECTED HEALTH POLICY

medicare

CENTER FOR CONNECTED HEALTH POLICY MEDICARE SOCIAL SECURITY ACT OF 1835(m) or 42 USC 1395m Only Live Video reimbursed Store & Forward (Asynchronous) only for Alaska & Hawaii demonstration pilots Specific list of providers eligible for reimbursement Originating site restrictions Limited to rural HPSA, non-MSA, or telehealth demonstration projects Limited types of facilities eligible Limited list of reimbursable services, but CMS decides what can be delivered via telehealth and reimbursed CENTER FOR CONNECTED HEALTH POLICY

MEDICARE REIMBURSED SERVICES HCPCS CODE CPT CODE Telehealth consultations, emergency department or initial inpatient G0425-G0427   Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs G0406-G0408 Office or other outpatient visits 99201-99215 Subsequent hospital care services, w/limitation of 1 telehealth visit every 3 days 99231-99233 Subsequent nursing facility care services, w/limitation of 1 telehealth visit every 30 days 99307-99310 Individual and group kidney disease education services G0420-G0421 Individual & group diabetes self-management training services w/min. 1 hour of in-person instruction in initial year training period to ensure effective injection training G0108-G0109 Individual & group health & behavior assessment & intervention 96150-96154 Individual psychotherapy 90832-90834, 90836-90838 Telehealth Pharmacologic Management G0459 Psychiatric diagnostic interview examination 90791-90792 ESRD-related services included in the monthly capitation payment 90951-90952, 90954-90955, 90957-90958, 90960-90961 ESRD-related services for home dialysis per full month for patients <2 years to 19 includes monitoring for nutrition, growth & development & counseling of parents 90963-90965 ESRD-related services for home dialysis per full month patients 20 & older 90966 Individual & group medical nutrition therapy G0270 97802-97804 Neurobehavioral status examination 96116 Smoking cessation services G0436-G0437 99406-99407 Alcohol and/or substance (other than tobacco) abuse structured assessment & intervention services G0396-G0397 CENTER FOR CONNECTED HEALTH POLICY

MEDICARE REIMBURSED SERVICES Annual alcohol misuse screening, 15 minutes G0442   Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes G0443 Annual depression screening, 15 minutes G0444 High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills raining & guidance, performed semi-annually, 30 minutes G0445 Annual, face-to-face intensive behavioral h therapy for cardiovascular disease, individual 15 minutes G0446 Face-to-face behavioral counseling for obesity, 15 minutes G0447 Transitional care management services w/moderate medical decision complexity (face-to-face w/in 14 days of discharge 99495 Transitional care management services w/high medical decision complexity (face-to-face visit w/in 7 days of discharge) 99496 Psychoanalysis 90845 Family psychotherapy w/o the patient present 90846 Family psychotherapy (conjoint psychotherapy w/patient present) 90847 Prolonged service in office or other outpatient setting requiring direct patient contact beyond the usual service; first hour & additional 30 minutes 99354, 99355 Prolonged service in inpatient or observation setting requiring unit/floor time beyond usual service, first hour & each additional 30 minutes 99356, 99357 Annual Wellness Visit, first visit & subsequent visit G0438, G0439 Approximately 80 codes reimbursed if provided via telehealth out of 10,000 possible codes Medicare FY 2014 only $14 million in telehealth payments our of $600 billion CENTER FOR CONNECTED HEALTH POLICY

MEDICARE ELIGIBLE PROVIDERS ELIGIBLE ORIGINATING SITE (FACILITY) Physicians Nurse practitioners Physician assistants Nurse midwives Clinical nurse specialists Certified registered nurse anesthetists Clinical psychologists & clinical social workers Registered dietitians or nutrition professionals Offices of physicians or practitioners Hospitals Critical Access Hospitals Rural Health Clinics Federally Qualified Health Centers Hospital-based or CAH-based renal dialysis centers (including satellites) Skilled Nursing Facilities Community Mental Health Centers CENTER FOR CONNECTED HEALTH POLICY

Physician Fee Schedule Medicare allowed to determine services eligible for reimbursement. Allows approx. 80 codes Updated once per year in PFS Reimbursement for non face-to-face chronic care management Telehealth restrictions don’t apply 2018 changes: Addition of more codes for reimbursement (Psychotherapy codes, add on codes related to administration and assessment of chronic care management services) Removal of use of GT modifier; use of 02 place of service Request for information on ways they can expand telehealth services without a law change, particularly around RPM Unbundling RPM code 99091 – telehealth restrictions don’t apply Establishment of Chronic Care Management codes to be used by RHCs and FQHCs CENTER FOR CONNECTED HEALTH POLICY

Chronic care management & Remote patient monitoring

CHRONIC CARE MANAGEMENT CODE 2015 Medicare Physician Fee Schedule Final Rule Pays for chronic care management code 99490 Non face-to-face services At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following elements: Multiple chronic conditions expected to last at least 12 months or until death Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline Comprehensive care plan established, implemented, revised or monitored. CENTER FOR CONNECTED HEALTH POLICY

CHRONIC CARE MANAGEMENT CODE Eligible Practitioners Certified Nurse Midwives Clinical Nurse Specialists Nurse Practitioners Physician Assistants Advanced patient consent required Services typically fall outside of face-to-face visit, and focus on characteristics of advanced primary care. Examples of services: Continuous relationship with a designated member of the care team Patient support for chronic diseases to achieve health goals 24/7 patient access to care and health information Receipt of preventive care Patient and caregiver engagement Timely sharing and use of health information. CENTER FOR CONNECTED HEALTH POLICY

CCM and Remote Patient Monitoring 2017 Medicare Physician Fee Schedule Finalized additional Codes for complex CCM 99487 and 99489 CMS issued a toolkit to raise awareness 2018 Medicare Physician Fee Schedule Unbundled remote monitoring code 99091 “collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.” CENTER FOR CONNECTED HEALTH POLICY

99091 - RPM Code Requirements Patient Consent Face-to-face visit with the patient (e.g., an annual wellness visit or physical) required. Reported no more than once in a 30-day period per patient. The service must include the physician or other qualified health care professional time involved with data accession, review and interpretation, modification of care plan as necessary (including communication to patient and/or caregiver), and associated documentation. CPT 99091 can be billed once per patient during the same service period as CCM services, TCM services, and behavioral health integration services. Typical telehealth restrictions don’t apply, because doesn’t fall under Medicare’s definition. CENTER FOR CONNECTED HEALTH POLICY

HR 1892: Bipartisan Budget bill TELEHEALTH ELEMENTS HR 1892: Bipartisan Budget bill

CENTER FOR CONNECTED HEALTH POLICY MEDICARE ADVANTAGE Beginning 2020 – MA plans allowed to provide “additional telehealth benefits” Treated the same as Medicare fee-for-service option Additional telehealth benefits include: Part B benefits without restrictions Other services identified as clinically appropriate HHS Secretary must solicit comments on types of telehealth services that should be considered additional telehealth benefits by Nov. 30, 2018. Secretary shall establish requirements around: Physician or practitioner licensure Care coordination with in-person services Other areas specified by the Secretary CENTER FOR CONNECTED HEALTH POLICY

ACCOUNTABLE CARE ORGANIZATIONS Beginning 2020 ACOs have the ability to expand telehealth services by: Including home as originating site Eliminating geographic requirements The Secretary required to conduct study on utilization and expenditures for telehealth by applicable ACOs and report to Congress no later than Jan. 1, 2026. Similar waiver made in: Next Generation ACO Comprehensive Care for Joint Replacement Model CENTER FOR CONNECTED HEALTH POLICY

Acute Stroke and End Stage Renal Disease Beginning Jan. 1, 2019, the following sites are eligible originating sites and exempt from the rural geographic requirement, but NOT eligible for the facility fee: ESRD-related visits Renal dialysis facility * Hospital based or CAH based renal dialysis center Home (in-person visit 1/month)* Acute Stroke Treatment Hospital CAH Mobile Stroke Unit* Any site determined appropriate by the Secretary* * Not currently an eligible originating site. CENTER FOR CONNECTED HEALTH POLICY

Proposed Legislative Solutions HR 2550 (Thompson & Harper) - Medicare Telehealth Parity Act of 2017 Expands under Medicare eligible facilities and a phased-in approach to eliminate geographic restrictions Allow FQHCs and RHCs to act as distant sites Expand list of eligible providers Include RPM HR 2291 (Duffy) - Helping Expand Access to Rural Telemedicine (HEART) Act of 2017 For Medicare, allow S&F for CAHs, RHCs and sole community hospitals Allow for RPM under certain circumstances Distant site can be an RHC Adds sole community hospital to originating site Expands list of eligible providers to some allied professionals (PT, OT, etc.) HR 3360 - Telehealth Enhancement Act Of 2017 Exempt new sites from Medicare’s current geographical restrictions (CAHs, sole community hospitals, home) Allow for S&F for CAHs and sole community hospitals Encourages but not mandates use of telehealth in certain programs such as authority to CMS to contract with State Medicaid agencies to coordinate care through a home health for patients with chronic conditions and requires provider to report a plan for use of RPM CENTER FOR CONNECTED HEALTH POLICY

Other federal developments

CENTER FOR CONNECTED HEALTH POLICY Veterans Affairs Push to allows VA providers to treat VA eligible beneficiaries from anywhere, no matter their state of licensure or whether or not they are located in a federal facility. Proposed Rule Legislation: S. 925 and HR 2123 CENTER FOR CONNECTED HEALTH POLICY

CENTER FOR CONNECTED HEALTH POLICY PRESCRIBING Controlled Substances Federal Laws/DEA Initial prescription must be in person or when the patient is physically located in a hospital or clinic registered with the DEA.  The telehealth provider must also be registered with the DEA under section 823(f) of the CSA. DEA allowed to create special registration for prescribing controlled substances without in-person exam under certain circumstances. Has not released proposed regulations. Draft Bill: Improving Access to Remote Behavioral Health Treatment Requires DEA to register community mental health or addiction treatment centers as eligible patient site for initial controlled substances prescription. CENTER FOR CONNECTED HEALTH POLICY

Federal Communications Commission Healthcare Connect Fund Offers funding for high speed broadband to eligible rural health care providers. 65% discount Desire to increase funds available Connect2HealthFCC Task Force to raise consumer awareness of value of broadband Net-Neutrality Rollback Potential impact for telehealth CENTER FOR CONNECTED HEALTH POLICY

Other Federal Agencies Office of the Inspector General Medicare: Telehealth aspect focused on originating site eligibility OIG also looking into Medicaid reimbursement Federal Trade Commission (FTC) Past Activities: North Carolina Board of Dental Examiners v. Federal Trade Commission Supreme Court case that ruled in favor of FTC and found that the make-up of licensing board can unfairly influence trade practices FTC Comment letter on Alaskan State legislation SB 75 FTC comments indicated that by allowing out-of-state providers to have equal capabilities of in-state providers (in this situation prescribing), it would create better competition, cost savings and more options for consumers Raised concerns about bill directing Medical Board to create telehealth practice standards Opened investigation into Texas Medical Board vs. TelaDoc dispute. It has since been closed. The Latest FTC Comment letter on Washington State legislation SB 5411/HB 1473. FTC voiced concerns regarding in-person requirement before prescribing eye glasses or contact lenses. May limit competition CENTER FOR CONNECTED HEALTH POLICY

State policy trends

CENTER FOR CONNECTED HEALTH POLICY 2018 Legislative Trends CENTER FOR CONNECTED HEALTH POLICY

2018 Bills in State Legislatures California AB 2861: Requires the State Department of Health Care Services to allow a licensed practitioner of the healing arts or a certified substance use disorder counselor to receive Medi-Cal reimbursement for substance use disorder services provided through telehealth in accordance with the Medicaid state plan. (2/16/18: Introduced) Connecticut HB 5152: Creates an exception to Connecticut’s requirement that no provider is allowed to prescribe a controlled substance through telehealth, allowing for only the prescribing of controlled substances used in medication-assisted treatment of substance use disorders through the use of telehealth. (2/16/18: Joint Committee on Public Health) New Hampshire HB 1471: This bill requires the same rate of payment for services delivered through telehealth, as those delivered in the office or facility as long as the rate doesn’t exceed the rate for an in-person consultation at the originating site. (3/2/18: Subcommittee work session) CENTER FOR CONNECTED HEALTH POLICY

2018 Bills in State Legislatures Kansas HB 2674: Establishes telehealth practice standards and coverage parity between in-person and telemedicine-delivered healthcare services and providers (3/1/18: To Senate Committee on Public Health and Welfare.) Minnesota HB 2919 & SB 2765: Allows community health workers to provide telemedicine services and eliminates the medical assistance limit for certain telemedicine encounters. (2/20/18: House Committee on Health and Human Services Reform) Hawaii SB 2718: Specifies that a physician-patient relationship or bona fide APRN-patient relationship may be established via telehealth. (2/13/18: Senate Committee on Judiciary; Ways and Means) Illinois HB 5473: Requires insurers maintain provider directories that include whether the provider offers the use of telehealth or telemedicine to deliver services, what modalities the provider uses and what services through telehealth or telemedicine are provided. (2/26/18: House Committee on Insurance) CENTER FOR CONNECTED HEALTH POLICY

CENTER FOR CONNECTED HEALTH POLICY Other Common Themes Allowing schools to be originating sites Prohibiting insurers from limiting reimbursement to a specific technology Allowing telehealth to meet network adequacy standards Pilots related to incorporating telehealth into substance use treatment programs CENTER FOR CONNECTED HEALTH POLICY

CENTER FOR CONNECTED HEALTH POLICY Licensing Compacts 16 states have cross state licensing legislation Almost all relate to Compacts Interstate Medical Licensure Compact Not a multi-state license; it’s an expedited process to get a license State needs to pass legislation to join Compact 22 states have adopted Other Compacts: Enhanced Nurses Licensure Compact Physical Therapy Interstate Licensure Compact CENTER FOR CONNECTED HEALTH POLICY

RESOURCES Center for Connected Health Policy www.cchpca.org Telehealth Resource Center www.telehealthresourcecenter.org CENTER FOR CONNECTED HEALTH POLICY

THANK YOU! CHRISTINEC@CCHPCA.ORG

Telehealth Connect Webinar Series March 26th and 28th Introduction to utilizing Telehealth Connect, a tool created by the TRCs to help better understand the telehealth provider landscape across the US. Register HERE: https://docs.google.com/forms/d/e/1FAIpQLScpGL1X3pMaOYt4zamQrZjnMx-isJzgYvBw_Ggm0OHHpFF41w/viewform

The National Telehealth Webinar Series 3rd Thursday of every month Next Webinar: Telehealth Topic: TBA Presenter: Don Graft Date: Thursday, April 19th, 2018 Times: 9:00AM HST, 10:00AM AKST, 11:00AM PST, 12:00PM MST, 1:00PM CST, 2:00PM EST

Your opinion of this webinar is valuable to us Your opinion of this webinar is valuable to us. Please participate in this brief perception survey: https://www.surveymonkey.com/r/M7NL3F3 TRC activity is supported by grants from the Office for the Advancement of Telehealth, Federal Office of Rural Health Policy, Health Resources and Services Administration, DHHS