Administration expands use of telehealth in Medicare in response to COVID-19 outbreak
The Trump administration is exercising waiver authority that will allow for greater use of telehealth services for all Medicare beneficiaries during the COVID-19 public health emergency. By temporarily waiving Medicare restrictions on the use of telehealth, more Medicare patients will be able to access certain health care services without having to travel to a health care facility.
Current Medicare rules on telehealth services
The traditional Medicare program limits the use of telehealth services to beneficiaries who live in rural areas and who are receiving the service from a designated “originating site” such as a health clinic, physician’s office or hospital. A patient’s home does not qualify as an originating site.
The Centers for Medicare and Medicaid Services (CMS) maintains a list of services that can be furnished via telehealth, and they include office visits, psychotherapy, consultations, and certain other medical or health services. These services must be provided by a qualified provider, which includes physicians, nurse practitioners, physician assistants, clinical social workers, clinical psychologists, and registered dietitians or nutrition professionals.
In order for Medicare to cover a telehealth service furnished by a qualified provider, there must be a prior established relationship with the patient, meaning the provider provided a service to the patient within the last three years.
Patient cost-sharing requirements for Medicare deductible and coinsurance apply to telehealth services, just as they do for in-person services.
Technology used for telehealth services must have audio and video capabilities that are used for two-way, real-time interactive communication.
The traditional Medicare program has more restrictions on the use of telehealth services compared to the commercial market and other public health programs. States have greater flexibility to cover telehealth services in the Medicaid program, and Medicare Advantage plans have more flexibility to offer telehealth for their enrollees.
Waiver of certain Medicare telehealth rules during the COVID-19 public health emergency
As part of recently passed legislation to address the COVID-19 outbreak, the Department of Health and Human Services (HHS) was granted the authority to waive certain Medicare requirements in order to expand the use of telehealth for beneficiaries. The waiver of the following requirements will be in place until the COVID-19 public health emergency ends:
- Patient geographic and originating site requirements are waived, so beneficiaries living in non-rural areas may receive telehealth services, and all beneficiaries can receive services from their homes.
- HHS will not be enforcing the patient-provider prior established relationship requirement for services provided during the public health emergency.
- Providers will have the flexibility to waive patient cost-sharing for telehealth services, but are not required to do so.
Medicare rules on qualified providers and the list of services that can be furnished via telehealth are not changed by the waiver, as well as the requirement that technology have audio and video capabilities that are used for two-way, real-time interactive communication. However, HHS is allowing more flexibility for providers to use everyday communications technologies such as FaceTime or Skype, which are not compliant with rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HHS encourages providers who choose to use these applications to notify patients that third-party applications potentially introduce privacy risks.
Potential impact on Medicare beneficiaries with kidney disease
For Medicare beneficiaries with end-stage renal disease (ESRD) and who receive in-center dialysis, they still need to go to their clinic to dialyze. However, they may be able to use telehealth for other office visits or services they need to manage their kidney disease and comorbidities. This is an important option for ESRD patients, who are more vulnerable to COVID-19 due to their chronic condition and therefore it is imperative for them to practice social distancing.
ESRD beneficiaries receiving home dialysis already have the option to receive their monthly clinical assessment via telehealth from their home, regardless of their geographic location. However, Medicare rules require that in the first three months of home dialysis, and once every three months thereafter, clinical assessments be conducted in-person. It is not completely clear if the telehealth waiver in place for the COVID-19 public health emergency will allow these clinical assessments to be done via telehealth. That is because CMS guidance released one week prior to the telehealth announcement suggests that the required onsite facility appointments for home dialysis patients must be maintained. More clarification from CMS would be helpful.
For transplant recipients with Medicare coverage and on immunosuppressive drug regimens, the waiver provides an opportunity for them to use telehealth for certain routine visits and services, allowing this vulnerable population to limit their exposure to others.