FEDERAL TELEHEALTH POLICY
Medicare
Overall, now that 2023 is over, not much will change federally – for 2024 at least. While the federal COVID-19 Public Health Emergency (PHE) ended last year, the 2023 Consolidated Appropriations Act and the Centers for Medicare and Medicaid Services’ (CMS) 2024 Physician Fee Schedule (PFS) have extended most emergency flexibilities related to Medicare telehealth policy expansions until the end of 2024.
It is still unknown whether further extensions or permanent policy expansions will be passed this year, but post-2024 the following permanent policies that are currently waived or expanded will be re-instituted unless further action is taken before January 1, 2025:
Other than these above permanent policies, the expanded list of approved Medicare telehealth services and eligible telehealth providers implemented during the PHE, as well as audio-only for non-mental health visits, are currently slated to expire post-2024, when permanent geographic and locational limitations would return. To monitor whether any pending federal legislative changes will modify existing policies and extensions, you can visit CCHP’s federal legislation tracker.
Privacy and Prescribing
While PHE privacy flexibilities have expired, prescribing allowances, allowing practitioners to prescribe controlled substances without an initial in-person visit, have also been extended through 2024.
STATE TELEHEALTH POLICY
State telehealth policies vary widely from state to state so it is always best to look at each individual state directly to understand the full picture. However, it is important to note that at this point in time most state emergencies have also ended and the respective temporary policies either expired, or more often than not, somehow incorporated into permanent policies. Though we should also note that there are a few states that have decided to further extend emergency policies consistent with the federal emergency policy extension through the end of next year, as evidenced in West Virginia’s Medicaid policies. Additionally, some states have incorporated a specific expiration date for certain policies into statute, such as Maryland’s policy related to maintaining audio-only through June 30, 2025.
In addition, for states that may have just passed new laws impacting telehealth, please review CCHP’s recently released 2023 Legislative Roundup. As noted in the roundup, while cross-state licensing remains the hottest topic across states, the number of bills addressing out-of-state providers was down this past year, while the number of bills addressing both Medicaid and private payer reimbursement went up. New regulatory requirements have been popular as well, so while state policies may have stabilized a bit post-PHE, they continue to change often in nuanced and varied ways.
VIEW TELEHEALTH POLICY BY STATE
CMS released improper payment data and corrective actions in the agency Fiscal Year 2023 Financial Report associated with the payment of the Advance Premium Tax Credit, Medicare Fee-for-Service (FFS), Part C (Medicare Advantage), Part D (prescription drugs) and Medicaid/Children’s Health Insurance Program (CHIP) programs. Improper payments can be overpayments or underpayments or payments where insufficient information was provided to determine whether a payment was proper. Most involve situations where a state or provider missed an administrative step. The vast majority are not fraud, and improper payment estimates are not fraud estimates. Additional information can be found in the fact sheet. This data aligns with the Biden-Harris Administration’s goal of maintaining the long-term sustainability of CMS’ programs.
The federal No Surprises Act (NSA) prohibits out-of-network health care providers and facilities from balance
billing commercially insured patients, in certain circumstances. The NSA and its implementing regulations set a
method for determining the patient cost-sharing for these out-of-network situations, and when state law does not
establish a provider payment methodology, the NSA establishes an independent dispute resolution (IDR) arbitration
system to establish provider payment.
LEARN MORE – CMS HOW TO USE TOOLKIT
LEARN MORE – CMS OVERVIEW OF RULES & FACT SHEETS
For the public health emergency (PHE), CMS altered the definition of “direct supervision” to permit the presence
and “immediate availability” of the supervising practitioner through “real-time audio and visual interactive
telecommunications.” CMS will continue this policy through December 31, 2024 (it will also be extended to FQHCs
and RHCs). (Reference Page, p. 167).
Additionally, for the supervision of teaching residents, the teaching physician may continue to have a virtual presence
in all teaching settings but only in clinical instances when the service is furnished virtually. Otherwise, the teaching
physician would need a physical presence unless the service is performed at a residency training site outside
of a Metropolitan Statistical Area (MSA). This exception for virtual presence in teaching settings during services
furnished virtually will continue through December 31, 2024. Both supervision temporary waivers exclude this from happening via audio-only. (Reference Page, p. 171).
CMS will establish an RTM general supervision policy for physical and occupational therapy practitioners in private practice who are supervising physical therapist (PT) and occupational therapist (OT) assistants. The direct supervision requirement for unenrolled PTs and OTs will continue. (Page Reference, p. 495)
Remote Monitoring Services
In the Final Rule, CMS provided a clarification on how remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) are addressed and billed. CMS clarified the following points:
• After the PHE ends, RPM services are only for established patients. Patients who had received services during
the PHE are considered established patients. (Page Reference, p. 180).
• The 16-day monitoring requirement is reinstated after the PHE. See the specific details of the requirements for
each code’s description. (Page Reference, p. 180).
• Although multiple devices can be provided to a patient, the services associated with all of the medical devices
“can be billed only once per patient per 30-day period and only when at least 16 days of data have been
collected.” This applies even when multiple devices are used. (Page Reference, p. 182).
• Practitioners may bill RPM or RTM, but not both, concurrently with the following services:
o Chronic Care Management (CCM)
o Transitional Care Management (TCM)
o Behavioral Health Integration (BHI)
o Principle Care Management (PCM)
o Chronic Pain Management (CPM) (Page Reference, p. 182).
• RTM and RPM cannot be billed together (Page Reference, p. 183).
• Regarding global payment and how RTM and RPM maybe used, CMS notes that when a beneficiary’s
procedure/surgery and related services are covered by a global payment, RPM or RTM services may be
furnished separately and the provider will be paid for them separately from the global payment. If the
beneficiary is currently receiving services during a global period, the provider may also furnish RPM or RTM
services and the provider will receive a separate payment if the RPM/RTM services are unrelated to the diagnosis for the global procedure and are separate and distinct from the global procedure. See the 2024 Final Rule for more details. (Page Reference, 183).
More details and explanations are relayed in the Final Rule. (Page Reference, p. 178).
FQHC/RHC & RTM/RPM
CMS will include the CPT codes related to RPM and RTM in the general care management code HCPCS G0511 which will provide FQHCs/RHCs payment for RTM and RPM services. CMS noted that these services are similar to the Non face-to-face requirements for general care management services and reflect the additional resources needed to provide such services by an FQHC/RHC. (Page Reference, p. 760).