1. TELEHEALTH FEDERAL AND STATE POLICY OVERVIEW
TELEHEALTH AT THE CROSSROADS
TEXLA Regional Conference
May 31, 2018
cchpca.org
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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.
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3. 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 provide greater health equity of access to quality, affordable care and services.
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4. CENTER FOR CONNECTED HEALTH POLICY

5. TELEHEALTH STATE-BY-STATE POLICIES, LAWS & REGULATIONS
Current Laws, Regulations, Pending Bills
State & Federal
Interactive Policy Map
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6. MEDICARE HISTORY OF FEDERAL TELEHEALTH POLICY
Medicare beneficiaries in rural HPSAs may receive care via telehealth
Practitioner required to be w/patient during consult
Consulting & Referring physicians share fee (75/25)
Balanced Budget Act of 1997
Included non-MSA sites
Eliminated fee sharing
Expanded eligible services for reimbursement
Benefits Improvement & Protection Act 2000
Expanded list of facilities that may act as an originating (patient location) site
Medicare Improvements for Patients & Providers Act, 2008
Credentialing & Privileging Regulations
Increase in number of codes reimbursed
Redefinition of “rural”
Inclusion of Chronic Care Management Codes
Various Changes Made Administratively
Medicare telehealth policy very limited & has not changed much in recent years

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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
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
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8. ELIGIBLE SITE (FACILITY) CENTER FOR CONNECTED HEALTH POLICY
MEDICARE
ELIGIBLE PROVIDERS
ELIGIBLE 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
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9. 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
Subsequent hospital care services, w/limitation of 1 telehealth visit every 3 days
Subsequent nursing facility care services, w/limitation of 1 telehealth visit every 30 days
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
Individual psychotherapy ,
Telehealth Pharmacologic Management
G0459
Psychiatric diagnostic interview examination
ESRD-related services included in the monthly capitation payment
, , ,
ESRD-related services for home dialysis per full month for patients <2 years to 19 includes monitoring for nutrition, growth & development & counseling of parents
ESRD-related services for home dialysis per full month patients 20 & older
90966
Individual & group medical nutrition therapy
G0270
Neurobehavioral status examination
96116
Smoking cessation services
G0436-G0437
Alcohol and/or substance (other than tobacco) abuse structured assessment & intervention services
G0396-G0397
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10. 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
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11. CENTER FOR CONNECTED HEALTH POLICY
FEDERAL UPDATE
Current Legislation
MEDPAC/MACPAC
Office of the Inspector General Report
Recently passed policies
Net neutrality
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12. CENTER FOR CONNECTED HEALTH POLICY
FEDERAL UPDATE
Current Legislation
Opioid bill passes Senate Health Panel – Opioid Crisis Response Act of 2018 (S 2680) – Makes changes to Ryan Haight
Forces DEA to create special registration to prescribe via telehealth without an in-person exam
Existing legislation that continues to look at expanding the utilization of telehealth, but has not moved
HR 5603 (Matsui) - Access to Telehealth Services for Opioid Use Disorders Act – For treatment of SUD waive certain telehealth limitations under Medicare around originating site, geography and S&F. – Passed out of committee.
VA legislation passed Senate but remains in the House – House introduced VA Mission Act of 2018
VA proposed regs became final May 14 – allows providers practice across state lines regardless of provider or patient location.
RAND ECHO report
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FEDERAL UPDATE
MEDPAC/MACPAC
Recent reports from both MEDPAC & MACPAC
MACPAC more general recommendations, first report on telehealth
MEDPAC continues to express caution in expanding telehealth suggestions mainly for pilots and in Medicare Advantage and ACOs
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14. CENTER FOR CONNECTED HEALTH POLICY
FEDERAL UPDATE
Office of the Inspector General Report
Reported that $3.7 million in payments that should not have been made
Issues were primarily regarding oversight in not disallowing inaccurate payments, certain edits/requirements not put in place and lack of knowledge by providers on what and how to bill
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15. 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
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16. 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
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17. 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.
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18. 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 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
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FEDERAL UPDATE
Net neutrality
FCC Roll back of net neutrality is partly in effect
Parts of the rollback delayed by the FCC because they say OMB needs to sign off on parts of it. Would need to publish these parts in the Federal Register.
More than two dozen states looking to pass own net neutrality state laws
Fully in effect June 11, 2018
Likely lawsuits will be filed
Senate passed legislation to stop end of net neutrality
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2018 LEGISLATIVE TRENDS
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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
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22. CENTER FOR CONNECTED HEALTH POLICY
45 states
36 states
have a definition for telemedicine
(and DC) have a definition for telehealth
1 states
Alabama has no definition for either
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As of April 2018

23. MEDICAID REIMBURSEMENT BY SERVICE MODALITY
Live Video
49 states and DC
Store and Forward
Only in 15 states
Remote Patient Monitoring
20 states
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As of April 2018

24. PARITY IN PAYMENT WITH IN-PERSON
38 states and DC
have telehealth private payer laws
Some go into effect at a later date.
This is the most common policy change at the state level!
Parity is difficult to determine:
-Parity in services covered vs. parity in payment
-many states make their telehealth private payer laws “subject to the terms and conditions of the contract”
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As of April 2018

25. THANK YOU!