CCHP: CMS Releases CY 2024 Physician Fee Schedule as States Incorporate Telehealth Pandemic Flexibilities into Permanent Policies - CCHP's July Newsletter

CMS Releases CY 2024 Physician Fee Schedule with Restructuring of Telehealth Service Code System and Other Changes

Last week the Centers for Medicare and Medicaid Services (CMS) released their proposed Calendar Year (CY) 2024 Physician Fee Schedule (PFS), which outlines a variety of proposed modifications to telehealth policy in the Medicare program for 2024. One of the major takeaways from the proposed 2024 PFS is the clarification that certain telehealth flexibilities that were previously extended until 151 days after the end of the public health emergency (PHE) have now been extended until December 31, 2024 in accordance with amendments made by the Consolidated Appropriations Act, 2023. These extensions have been known since the CAA’s passage in December last year and has also been addressed in a series of factsheets and FAQ documents previously released by CMS. However, there were also some new changes addressed in the 2024 PFS. For example, every year CMS considers adding new services to their list of codes that are reimbursable via telehealth. While they did not decide to add any new codes on a permanent basis to the list (though many remain on the list temporarily through the end of 2024), they did propose to add a number of codes to Category 3 (CMS’ current temporary list), including certain codes for health and well-being coaching services. Additionally, CMS announced a proposed revision to their telehealth code classification process moving from a Category 1, 2 and 3 classification system to a binary ‘permanent’ or ‘provisional’ classification in an attempt to simplify the process beginning in CY 2025. In order to make the steps for getting a code accepted for inclusion in either the permanent or provisional telehealth lists transparent, CMS proposes a five-step process that is detailed in the proposed 2024 PFS, which includes consideration of the evidence of clinical benefits.

A few additional changes proposed in the document are listed below: The list of telehealth practitioners is amended to recognize marriage and family therapists and mental health counselors as telehealth practitioners effective Jan. 1, 2024. CMS will pay for place of service (POS) 10 at the non-facility PFS rate, while 02 will be paid at the facility rate beginning Jan. 1, 2024 Frequency limitation would be removed for subsequent inpatient visits through the duration of CY 2024. Multiple clarifications are provided for billing both remote physiologic monitoring (RPM) and remote therapy monitoring (RTM) codes. Allows direct supervision to include real time audio video interactive telecommunication through Dec. 31, 2024 (including for FQHCs and RHCs). Direct supervision requirements are also addressed for occupational therapists in private practice (OTPP) and physical therapists in private practice (PTPP) for unenrolled physical and occupational therapists when providing remote RTM. In light of the Hospital Without Walls waiver during COVID-19, CMS is considering whether certain institutions, as the furnishing providers, can bill for certain remotely furnished services personally performed by employed practitioners. Extends PHE temporary waiver of in-person requirement related to the Medicare Diabetes Prevention Program (MDPP) Expanded Model, allowing MDPP suppliers with an in-person CDC organization code to offer MDPP services virtually using distance learning until December 31, 2027. The above list is merely a snapshot and not comprehensive of all the telehealth related changes in the proposed 2024 PFS. Stay tuned until next Tuesday, July 25 for a CCHP Factsheet on the proposed rule that will take a deep dive into the issue areas noted above plus more. In the meantime, reference the proposed 2024 PFS text itself for CMS’ proposals and their commentary on each item. CMS will be accepting comments on their proposals until 5:00 PM EST on September 11, 2023. Emerging Trends Observed in Recent Updates to CCHP’s Telehealth Policy Finder and Policy Trends Map

As the Center for Connected Health Policy (CCHP) has updated sixteen states in our policy finder over the past month, we have begun to observe some key trends emerging as a result of the end of the federal COVID-19 Public Health Emergency (PHE). In response to the federal PHE’s expiration on May 11, 2023, many states used this as an opportunity to address the status of their own telehealth flexibilities within their respective state Medicaid programs. In most cases, states decided to incorporate their COVID telehealth expansions in some form into their permanent telehealth policies, although some have taken a more limited approach. For instance, some states have made audio-only coverage permanent, while others have decided to end reimbursement for the audio-only modality or place time-limits on when reimbursement will end (for example, through 2024), or included other limitations, such as only allowing audio-only for specific codes or types of services.

The latest states to be updated included Alabama, Alaska, California, District of Columbia, Florida, Hawaii, Idaho, Illinois, Indiana, Minnesota, New Mexico, New York, North Dakota, Ohio, Utah, and Washington. CCHP has provided some examples below of significant changes observed in various states. However, note that the changes were extensive and not all changes to each state could be listed below. CCHP’s policy finder should be referenced for complete information on each state. ALABAMA: Alabama Medicaid revamped their Telemedicine Policy based on the allowances that were made during COVID. The policy now contains an extensive list of allowed provider types and originating sites, and an allowance for audio-only in Medicaid although new rates will be established for audio-only services by Oct. 1, 2023. They also now have a requirement for an in-state or qualifying bordering state site of practice address from which telemedicine services can be provided. Additional practice, prescribing and documentation guidelines are also provided. CALIFORNIA: The Department of Health Care Services (DHCS) which administers Medi-Cal (California Medicaid) published revisions to the Family PACT Program Telehealth policy and announced the continuation of a COVID-19 allowance for providers to enroll and recertify patients through telehealth or virtual/telephonic modalities. The teledentistry policy was also expanded to allow providers the ability to establish new patient relationships through an asynchronous store-and-forward modality, consistent with Federally Qualified Health Center/Rural health Clinic (FQHC/RHC) providers. Additional modifications were made in the Local Educational Agency Medi-Cal Billing Option Program (LEA BOP) and an announcement was issued that reimbursement for HCPCS code G0071 (virtual telephonic communication) for FQHC, RHC, and Indian Health Services (IHS) has ended. Additionally, coverage for certain Continuous Glucose Monitoring (CGM) codes were added as Medi-Cal benefits and CGM was also incorporated into the California Children’s Services program. New enrollment procedures and exemptions were established for remote mental health services as well. California had a variety of additional changes. The full state in CCHP’s policy finder should be reviewed to see California’s complete updated policy. DISTRICT OF COLUMBIA: The Medicaid program released updated Telemedicine Guidance, allowing for reimbursement of audio-only services under certain circumstances when using the 93 modifier to bill. Additionally, place of service code 10 (indicating the patient is at home) and 03 (indicating the patient is at a school site) are both acceptable POS codes, along with 02, which indicates an originating site other than the patient’s home. FLORIDA: The Florida Medicaid program recently released a Medicaid Alert to clarify that they will continue to cover store-and-forward and remote patient monitoring services, but will no longer cover audio-only telehealth services. HAWAII: Medicaid released a notice based on recently enacted legislation (HB 907) that applies to both private payers and Medicaid allowing for reimbursement of audio-only interactions as listed in the Centers for Medicaid and Medicare professional fee schedule which meet specific conditions (including an in-person visit requirement). FQHCs and RHCs will be reimbursed the prospective payment system (PPS) rate when applicable. HB 907 requires reimbursement to be equivalent to eighty percent of the reimbursement for the same services provided via in-person contact between a health care provider and a patient. INDIANA: Passed HB 1352 which requires a provider or telehealth provider group that exclusively offers telehealth services to maintain a physical address or site in Indiana to be eligible to enroll as a Medicaid provider. NEW MEXICO: Passed HB 384 which modifies the state’s telemedicine license policies for physicians. It also specifies requirements related to a temporary or provisional license, including requirements for an expedited license for providers from other states. NEW YORK: Due to the expiration of the federal PHE, New York released a Medicaid Update incorporating most of their COVID telehealth allowances into permanent policy. Major changes include making POS codes 02, 10 and 11 required on claim forms for professional services. It also specifies that audio-only telehealth is allowable, along with store-and-forward technology and remote patient monitoring. See their Medicaid Update for details. UTAH: Passed HB 159 which establishes a temporary license for telemedicine and allows individuals with such a license to provide telemedicine services if the individual is licensed to perform the service in their state of residence, the patient is in Utah and performing the service would not otherwise violate the law. A temporary license still requires an application for license by endorsement, and comes into play when the division has determined that they will be unable to process the application within 15 days.

NORTH DAKOTA: The North Dakota Medicaid program released an updated General Information Provider Manual, where reimbursement was added for Digital Health Evaluation and Management Services. The service is described as a patient generated inquiry. See the manual for a list of services that are encompassed by Digital Health Evaluation and Management (E/M) Services and therefore not separately reimbursable. Reimbursement for audio-only telephone E/M services was also added to the manual as reimbursable when initiated by an established patient or guardian of an established patient. New professional coding requirements are listed including the 93 modifier to indicate audio-only telecommunication systems, and POS codes 02 and 10. Given the many nuances, multiple changes and varied approaches states are taking with their telehealth policies, please reference CCHP’s telehealth Policy Finder to link to additional details and access each states’ policies in their entirety.

CBO Telehealth Estimates for Telehealth Expansion Act

In June the Congressional Budget Office released its cost estimates for H.R. 1843, the Telehealth Expansion Act of 2023. If passed the bill would permanently establish a safe harbor, allowing high-deductible health plans to provide telehealth and other remote care services without making participants ineligible to use health savings accounts. The safe-harbor provision resulting from the COVID pandemic is currently in effect through 2024 but will expire after that. Subject to certain limits, contributions made by an individual to a health savings account are deductible for income tax purposes, and contributions made through a cafeteria plan are excludible from income for both income and payroll tax purposes. The projections estimate that the permanent extension would reduce revenue by $5.1 billion over the 2023-2033 period. Because of the high-cost estimate, the bill may face obstacles getting passed. However, this isn’t the first time the CBO has estimated costs associated with telehealth bills. In fact, in 2022, the CBO estimated significant additional costs (approx. $2.5 billion) associated with HR 4040, the Consolidated Appropriations Act of 2022, which was ultimately enacted and extended most Medicare telehealth flexibilities until December 31, 2024. The bill was also projected to reduce funding for the Medicare Improvement Fund. For more information on the CBO’s estimates on HR 1843, The Telehealth Expansion Act of 2023, read the full CBO Markup document. American Heart Association Launches Telehealth Certification

The American Heart Association (AHA) has launched its first individual certification, "Certified Professional by the American Heart Association - Telehealth," for health care professionals interested in demonstrating their commitment to telehealth. Supported by The Leona M. and Harry B. Helmsley Charitable Trust, this certification aims to improve the standard of care in telehealth and ensure equitable access to high-quality healthcare. This would be achieved through standardizing training, enhancing skills, and improving patient outcomes through telehealth integration. The AHA’s press release on the certification program states that telehealth has become essential during the COVID-19 pandemic, and its utilization has surged, with the potential to shift a significant portion of healthcare spending to virtual care. The AHA’s new certification process includes evidence-based online education, remote-proctored assessments, and offers personalized certificates and credentials for three years. It is available through the AHA's Intelligo Professional Education Hub™.

At this time, AHA’s certification is not required by any entity and is purely optional for clinicians. CCHP frequently receives technical assistance questions related to requirements around telehealth certification and business registration. In most states, special training, certification and registration is not required. Providers merely must possess a license to practice their profession within the state the patient is located in and act within their scope of practice. But we have found some exceptions which are listed below: WASHINGTON: A law in Washington requires healthcare professionals in the state to complete a telemedicine training. The requirement can be met by employers, institutions and hospitals developing an internal training program for their providers, or through an approved publicly available training developed by the WA Telehealth Collaborative. INDIANA: A law in Indiana requires every practitioner at the time of renewing their license to indicate whether or not they deliver heath care services through telehealth.

ALASKA: The Department of Commerce, Community and Economic Development adopted regulations to establish and maintain a registry of businesses performing telemedicine in Alaska. Before providing telemedicine services to a recipient located in Alaska, a business must submit a registration, a copy of the business’s valid business license and the applicable fee. CALIFORNIA: Recently passed legislation that requires applicants for licensure or license renewal as marriage and family therapists, educational psychologists, clinical social workers and professional clinical counselors to show completion of a minimum of three hours of training or coursework in the provision of mental health services via telehealth. For more information about telehealth training and registration requirements by state, see the Miscellaneous topic area of CCHP’s policy finder. Virginia Telehealth Network Provider Survey

A recent survey conducted by the Virginia Telehealth Network has revealed that telehealth providers are confident in the quality of virtual care in Virginia. The survey of over 10,500 healthcare professionals in the state found that 87% of providers feel confident in the quality of care they deliver through telehealth, and 80% have witnessed improvements in patients' continuity of care. Experts from the Virginia Telehealth Network attributed these positive results to the increasing familiarity with telehealth, better workflows, and improved documentation practices. While there has been a slight reduction in telehealth usage following the end of the public health emergency, providers are recognizing the flexibility and increased patient access offered by telehealth. The survey also highlighted the importance of addressing barriers to telehealth, such as internet connectivity and access to interpreter services, to improve the patient experience. Telehealth has allowed providers to extend their reach beyond local communities, addressing healthcare disparities and expanding access to underserved populations. However, concerns about reimbursement and the lack of clarity around its long-term viability are also impacting providers' plans for telehealth usage. Additionally, providers must navigate legal and regulatory considerations when serving patients across state lines which can be an obstacle to providing care via telehealth. For more on the survey, read the HealthcareIT News article which contains an interview with Virginia Telehealth Network’s executive director, Mara Servaites, and special projects director, Robin Cummings, discussing the survey’s results. Benefit of Direct-to-Consumer Telehealth for Employees

A study published in June by the American Journal of Managed Care, titled “Economics of a Health System’s Direct-to-Consumer Telemedicine for Its Employees” utilized a retrospective cohort methodology to compare the economics of a direct-to-consumer (DTC) telemedicine service, called OnDemand, with in-person care for employees and dependents of a large academic health system. They analyzed data from July 7, 2017, to December 31, 2019, and used propensity score matching to ensure a fair comparison. The findings showed that the mean per-episode unit cost for OnDemand encounters was significantly lower compared to non-OnDemand encounters for similar conditions, resulting in a mean savings of $113.73 per episode. While it is unclear exactly how the DTC encounters were reimbursed, the findings could suggest that using the DTC telemedicine service led to cost reductions in healthcare expenditures. Additionally, the study examined the impact of OnDemand on healthcare utilization. It was found that the availability of OnDemand only marginally increased the utilization of healthcare services for the top 10 clinical conditions managed by the telemedicine service. This indicates that although employees utilized the telemedicine option more, the overall increase in healthcare utilization was minimal. These results highlight the potential economic benefits of implementing a DTC telemedicine service within an academic health system. By reducing per-episode costs and having a limited impact on overall utilization, such services can offer cost-effective and convenient healthcare options for employees and their dependents. Read the full study for all the details on how it was conducted and the findings. In case you missed it: CCHP's 2023 Medicare Billing Guide Release

Last week the Center for Connected Health Policy (CCHP) released its 2023 Telehealth Billing Guide for Medicare Fee-For-Service. It contains up-to-date information (as of May 2023) on Medicare telehealth reimbursement policies as they currently stand (noting that many policies will expire at various points throughout the next two years, with many set to expire Dec. 31, 2024). Permanent Medicare policy is also included in call out boxes, though may not be currently effective due to the extension of temporary policies. The guide is organized into five sections covering telehealth terminology, codes, services, other considerations, and billing examples. It also provides a California Medicaid example, but it's important to note that Medicaid telehealth policies will vary by state. The guide offers tips and relevant information for billing telehealth but should not be considered legal advice or a guarantee of reimbursement. The 2023 Billing Guide for Medicare Fee-for-Service is available on CCHP's resources webpage.

FEDERAL LEGISLATION

Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2023 S. 2016 - Sen. Schatz (D-HI) – Expands reimbursement for telehealth in Medicare by making most of the COVID flexibilities for reimbursement permanent. This includes: Removing geographic requirements permanently; Expanding originating sites to include the home; Allowing additional originating sites to include any clinically appropriate site; Allowing the Secretary to waive any limitation on types of practitioners eligible to furnish telehealth services; Requiring implementation of revisions to the process to add services to the telehealth list in order to improve access to care through clinically appropriate telehealth services and clarification on what requests to add telehealth services should include; Allowing reimbursement of FQHCs and RHCs for telehealth services at the PPS rate; Exempting Indian health service (IHS) facilities from originating site requirements; Repealing six-month in-person visit requirement for telemental health services; Allowing for the waiver of telehealth requirements during a public health emergency; and Allowing the use of telehealth for recertification for hospice services in certain circumstances. The bill also provides additional clarification on fraud and abuse and oversight for telehealth issues, such as outlier billing patterns. Finally, the language would require additional telehealth resources be provided, including educational and training materials as well as a study to improve beneficiary engagement on telehealth. See text for the full scope of proposed changes. (Status: 6/15/23 - Introduced).

Telehealth Expansion Act of 2023 HR 1843 (Rep. Steel R-CA) – Makes permanent exemptions for telehealth from certain high deductible health plan rules, specifically creating a safe harbor for the absence of a deductible for telehealth. (Status: 6/13/23 – Reported amended by the Committee on Ways and Means).

Telehealth Benefit Expansion for Workers Act of 2023 HR 824 (Rep. Walberg R-MI) - Amends the Employee Retirement Income and Security Act of 1974 to treat benefits for telehealth services offered under a group health plan or group health insurance coverage as excepted benefits. (Status: 6/30/23 – Reported amended by the Committee on Education and Workforce).


STATE LEGISLATION

CALIFORNIA
SB 282 - Authorizes federally qualified health center (FQHC) and rural health clinic (RHC) reimbursement for a maximum of 2 visits that take place on the same day at a single site, whether through a face-to-face or telehealth-based encounter when one of the following exists: (1) if after the first visit the patient suffers illness or injury that requires additional diagnosis or treatment, or (2) if the patient has a medical visit and either a mental health visit or a dental visit.  The bill would require the department, by July 1, 2024, to submit a state plan amendment to the federal Centers for Medicare and Medicaid Services reflecting those provisions.  (Status: 7/11/23 – Passed Assembly Committee on Health)

FLORIDA
HB 967 - Requires the Agency for Health Care Administration (FL Medicaid), subject to the availability of funds and certain limitations and directions, to provide coverage for continuous glucose monitors under the Medicaid pharmacy benefit for treatment if certain conditions are met.   Coverage includes the cost of any repairs or replacements. To qualify, Medicaid recipients must participate in follow-up care either in person or through telehealth at least once every 6 months during the first 18 months after the first prescription and every 12 months thereafter.  (Status: 6/22/23 – Approved by Governor)

GEORGIA
SB 20 - Places restrictions on insurers related to their coverage for telehealth.  For example, the bill forbids an insurer from denying coverage solely based on the communication technology or application used; prohibits an insurer from requiring a provider to be part of a telehealth network; and bans an insurer from requiring a covered person to utilize telehealth or telemedicine in lieu of a nonparticipating provider accessible for in-person consultation or contact.  See bill for full list of restrictions.  (Status: 5/2/23 – Signed by Governor, Effective Jan. 1, 2024)

MASSACHUSETTS
H 2254 - Explicitly allows a physician to provide healthcare services via telehealth from any location within Massachusetts or outside Massachusetts provided the patient is physically located in Massachusetts at the time services are provided, the location from which the physician is providing services does not compromise patient confidentiality and privacy, the location the physician provides the service from does not exceed restrictions placed on the physician’s specific license. (Status: 6/27/23 – Introduced and scheduled for a hearing)

OHIO
SB 90 – Enters Ohio into the Social Worker Licensure Compact. (Status: 6/29/23 – Passed Senate, Introduced in House)

OREGON
SB 746 - Specifies that a health professional licensee who is authorized to use telehealth, telemedicine, telepharmacy or similar electronic health care services delivery methods may not be required by the health professional regulatory board to have a physical address in the state in order to be eligible for authorization to practice the health profession. (Status: 6/25/23 – In committee upon adjournment)

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