Telehealth Coverage, Technologies, Vital in the Fight Against COVID-19
March 10, 2020 | Mei Wa Kwong
Telehealth Technologies May Prove Vital in the Fight Against COVID-19
As more cases of COVID-19 emerge throughout the United States, the Centers for Disease Control (CDC) is encouraging communities, including first responders, healthcare providers and health systems to take advantage of the benefits offered by telehealth tools to direct patients to the right level of care. One of the most obvious benefits telehealth offers the healthcare delivery system in dealing with this pandemic includes keeping patients with less severe cases at home with access to their provider through live video, telephone or asynchronous secure messages. This reduces the risk of the patient further spreading the disease to others. However, there are a number of barriers that prevent the widespread use of telehealth generally, that become exceedingly apparent during an emergency situation. This includes barriers to reimbursement when the patient is located in their home, limitations in the modality (live video, store-and-forward, remote patient monitoring) that can be used, and state licensing laws that require providers needing to be licensed in the state the patient is physically located in.
Some laws currently exist on the state level that provide for relaxing of telehealth restrictions when an emergency occurs. For example,
- Delaware and Missouri have exceptions from licensing laws in the case of an emergency or disaster if no charge is made for medical assistance.
- California last year passed a bill that removed barriers to Medicaid reimbursement for community health clinics (CHCs) during states of emergency for telephonic services, and when services are provided in the beneficiary’s home.
- Last week Congress brought forward and the President signed HR 6074, the “Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020.” Among the bill’s provisions is the section titled Telehealth Services During Certain Emergency Periods, which would give the Secretary authority to waive or modify the application of some of Medicare’s telehealth restrictions in any emergency area (For more on HR 6074 and an in-depth analysis of other policy barriers that could impede efforts to utilize telehealth to fight the coronavirus, see our analysis below).
The Centers for Medicare and Medicaid Services (CMS) recently released a factsheet on coverage and payment related to COVID-19 in Medicare which includes a section on telehealth and virtual services. However, some of the telehealth limitations may be adjusted with the passage of HR 6074. Other CMS factsheets and resources related to the COVID-19 include:
- Medicaid and Children's Health Insurance Program (CHIP) Fact Sheet
- Insurance and Small Group Market Insurance Coverage Fact Sheet
- Summary of CMS Public Health Action on COVID-19
- CMS New Code for Coronavirus
- Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness
- Updates on Coronavirus and Public Health Emergencies
COVID-19 Frequently Asked Questions (FAQs)
Coronavirus & Telehealth – The New Federal Law & the Policy Hurdles That Remain
On March 6, 2020, the president signed HB 6074, the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020. In addition to the $8 billion appropriated to address coronavirus, HB 6074 grants certain powers to the Secretary of Health and Human Services to waive some of the telehealth limitations in Medicare. As many have noted in recent days, telehealth can be an effective tool in helping to address the current health crisis, however, existing policy barriers limit when, where and how it can be used. By providing the Secretary with the ability to waive some of those limitations, it does allow telehealth to be used more widely. But HB 6074 only addresses the barriers in Medicare. Millions of Americans do not receive their health care through the Medicare program and restrictions on the use of telehealth still exist for them.
HB 6074 – What Does It Say?
Currently in Medicare, telehealth-delivered services need to take place in specifically designated geographical areas, a specific type of site, be provided by a certain type of provider, using essentially only live video, and only certain services are reimbursed. HB 6074 allows the Secretary to only waive the geographic and site restrictions. While definitely a major change, especially the site limitation which would make the home an eligible site which is very important as many people are in self-quarantine, there still remain limits on who the provider can be and what service can be provided via telehealth. Certain providers who could be utilizing telehealth to treat patients exposed to or having coronavirus would still not qualify, such as Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs). FQHCs and RHCs under Medicare can only act as originating sites, they cannot act as a distant site provider and HB 6074 does not change that.
HB 6074 notes that the provider must be a “qualified provider” which is a physician or practitioner as defined under the telehealth section for Medicare who:
furnished to such individual an item or service for which payment was made under title XVIII during the 3-year period ending on the date such telehealth service was furnished; or
is in the same practice (as determined by tax identification number) of a physician or practitioner (as so defined) who furnished such an item or service to such individual during such period.
In Medicare, these additional requirements for a “qualified provider” do not currently exist in telehealth policy. These additional requirements appear to only apply to services related to treatment for coronavirus.
Another change HB 6074 makes from what is seen in the typical telehealth policies for Medicare is that it will lift the limitation on phone use if, “such telephone has audio and video capabilities that are used for two-way, real-time interactive communications,” which essentially means a smartphone can be used to engage with a provider.
The waivers in HB 6074 appear to apply to all eligible services delivered via telehealth and not only the ones related to coronavirus. However, it is not clear if that is the intent. We will have to wait to see how the Centers for Medicare and Medicaid Services (CMS) implements this new policy.
What About the States?
Changes in the telehealth policy for Medicare will only cover some of the American population. States and state Medicaid programs have their own limitations on how telehealth can be used.
Depending on the state and who is covering the health service, telehealth may be limited in how it can be used. For example, many state Medicaid programs do not allow the home to be an eligible originating site. For treating those who are quarantined at home during this crisis, telehealth would not be an option if they are covered by one of those Medicaid programs that do not allow the home to be an originating site. There are some state Medicaid programs that also limit the types of specialties for which telehealth can be used. For example, Pennsylvania Medicaid limits the use of telehealth to only mental and behavioral health services. To see what your Medicaid program covers, check CCHP’s 50 State Report.
One would think that if a state of emergency is declared in a state, then surely these currently existing telehealth limitations could be waived. However, very few states have in statute utilization of telehealth when a state of emergency is declared. California is one of the few states with actual law having recently passed AB 1494 which removed barriers to Medicaid reimbursement for community health clinics (CHCs) during states of emergency for telephonic services, and when services are provided in the beneficiary’s home. Depending on how broad the policies are, other states may have to pass legislation in order to allow telehealth to be used more extensively.
Private payer policies can be even more limiting on the use of telehealth. Some states do not have requirements on what health plans are required to cover if a service is delivered via telehealth. So there is a possibility that if a person has coverage through their employer, a service via telehealth may not be covered.
All of the aforementioned issues relate to telehealth reimbursement. For the most part, there is nothing that prohibits a person from receiving services via telehealth (provided all other laws such as licensing, privacy, etc. are met). However, will your insurance cover it or will you have to pay for it out-of-pocket is another story. As the situation and landscape constantly changes with each new piece of information, we should ensure our health care providers have access to every tool available to care for patients safely and effectively.
INSURERS EXPAND TELEHEALTH COVERAGE IN WAKE OF CORONAVIRUS
On Friday March 6, 2020, CVS announced that it is providing coronavirus diagnostic testing and telemedicine visits with no out-of-pocket costs or cost sharing for Aetna members. This means no co-pays for telemedicine visits for 90 days. They will also waive copays for the testing kit for patients who meet the CDC’s guidelines for testing. Additionally, Aetna is extending its Medicare advantage virtual evaluation and monitoring visit benefit to all Aetna Commercial members as a fully covered benefit. Read the press release for more information. Other insurers have taken similar measures, with BlueCross BlueShield announcing that it will allow for enhanced telehealth and other clinical support, and encourage the use of virtual care. Cigna’s Chief Medical Officer Rahul Rajkumar, also indicated via tweet that the company may be implementing some impactful telehealth policy expansions.
After a meeting with the CEOs of health insurance companies including UnitedHealth Group, Anthem, Cigna, Humana, Aetna and the Blue Cross Blue Shield Association on March 10, Vice President Mike Pence said the insurers had "agreed to cover telemedicine to allow people to speak to their doctors remotely about the coronavirus."
Mei Wa Kwong is the director of PHI's Center for Connected Health Policy