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

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

5. 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.

6. Telehealth Policy So Far in 2018
National Telehealth Resource Center
Webinar Series
March 15, 2018
cchpca.org
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7. 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.
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8. 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.
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9. CENTER FOR CONNECTED HEALTH POLICY

10. TELEHEALTH STATE-BY-STATE POLICIES, LAWS & REGULATIONS
Current Laws, Regulations, Pending Bills
State & Federal
Interactive Policy Map
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11. medicare

12. 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
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13. 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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14. 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
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15. 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
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16. 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 – telehealth restrictions don’t apply
Establishment of Chronic Care Management codes to be used by RHCs and FQHCs
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17. Chronic care management & Remote patient monitoring

18. 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.
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19. 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.
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20. 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.”
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21. 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 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.
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22. HR 1892: Bipartisan Budget bill
TELEHEALTH ELEMENTS
HR 1892: Bipartisan Budget bill

23. 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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24. 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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25. 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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26. 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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27. Other federal developments

28. 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
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29. 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.
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30. 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
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31. 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
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32. State policy trends

33. CENTER FOR CONNECTED HEALTH POLICY
2018 Legislative Trends
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34. 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)
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35. 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)
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36. 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
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37. 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
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38. RESOURCES Center for Connected Health Policy www.cchpca.org
Telehealth Resource Center
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39. THANK YOU!

40. 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.
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