INSIGHT: The Digital and the Biologic—Telehealth Expansion During a Global Pandemic

April 3, 2020, 8:01 AM

Covid-19 has challenged traditional in-patient health-care practices, and the health-care industry has adapted by rapidly implementing digital health platforms that enable virtual consultation while protecting vulnerable populations.

To ensure care continuity during this time, health-care payers have come together to shift regulations and policies surrounding access to telehealth. Such essential modifications of telehealth requirements will help pave the way for future response plans to unanticipated public health crises.

The Federal Government’s Response: Medicare

Prior to Covid-19, the Centers for Medicare & Medicaid Services limited the circumstances under which a Medicare beneficiary could use telehealth as a substitute for in-person evaluation. Medicare restricted reimbursement for telehealth visits to beneficiaries receiving services in a designated rural area, and then only if the patient went to an approved medical facility (“originating site” requirement).Some of these restrictions were eased in 2019 when Medicare coverage was expanded to include virtual check-ins and short E-visits with practitioners. In addition, Medicare Advantage plans were permitted to offer enhanced telehealth coverage as part of the standard coverage offering, instead of as a supplemental benefit making telehealth services more accessible to Medicare Advantage enrollees.

The landscape of telehealth reimbursement changed quickly in response to Covid-19. On March 13, President Donald Trump issued an emergency declaration under the Stafford Act and a proclamation under the National Emergencies Act. In response, Medicare’s telehealth benefits were rapidly expanded in an effort to leverage technology to protect beneficiaries from exposure to Covid-19.

With the new telehealth rules applying retroactively, providers may bill for telehealth visits with dates of service beginning March 6, and receive reimbursement at the same rate as in-person services paid under Medicare’s Physician Fee Schedule (PFS). These visits may be conducted by a range of providers (including doctors, nurse practitioners, psychologists, dieticians, physician assistants, and social workers), and are available to all beneficiaries for services that typically occur in-person.

Telehealth visits may be completed from the patient’s home, meaning the originating site requirement has been temporarily waived, and may be conducted using a range of audio and visual communication tools. The U.S. Drug Enforcement Administration even relaxed restrictions on controlled substance prescriptions, which may now be provided through telehealth under certain circumstances. These altered requirements reflect the need for flexibility in digital health access and reimbursement during Covid-19, and allow providers to concentrate their in-person care on the sickest patients.

Significant Telehealth Barriers Removed

Beyond increasing coverage and reimbursement for telehealth, the Department of Health and Human Services and Centers for Medicare & Medicaid Services have removed significant barriers to telehealth adoption by altering licensure, cost-sharing, and auditing requirements.

Normally, a physician must be licensed in the state where the patient is located at the time of treatment. The Centers for Medicare & Medicaid Services have now waived the prohibition against practicing across state lines for Medicare beneficiaries. Additionally, the Office of Inspector General will not sanction practitioners under fraud and abuse laws for temporarily reducing or waiving telehealth cost-sharing obligations.

Finally, while a patient must normally have a prior relationship with the physician providing telehealth services, the Centers for Medicare & Medicaid Services have indicated that it will not audit this requirement during the public health emergency. These temporary changes ease regulatory and compliance burdens for practitioners, thus encouraging widespread telehealth adoption and enhanced access for Medicare beneficiaries, and likely other patients as well.

The Role of the States: Medicaid

While the federal government’s relaxation of telehealth requirements has been swift and comprehensive, Medicaid’s telehealth coverage varies by state. Similar to Medicare’s original telehealth restrictions, Medicaid reimbursement has been limited to remote services offered at originating sites.

However, as more states shut down nonessential services and issue shelter-in-place orders, states’ coverage of telehealth services for Medicaid enrollees is expanding. At least 18 states and the District of Columbia have already issued new declarations and guidance expanding Medicaid telehealth usage and reimbursement during Covid-19.

These guidelines range from encouraging Medicaid managed care plans to use telehealth to adopting telehealth coverage expansion and provider incentives that mirror those used by Medicare—and everything in between. The Centers for Medicare & Medicaid Services have even permitted states to seek waivers temporarily suspending provider enrollment requirements and enabling providers to offer care in alternative settings. Thus, as Covid-19 continues to consume limited health-care resources, more states are anticipated to enhance their telehealth coverage policies.

The Private Industry: Commercial Insurers

Finally, responses by private insurers to Covid-19 have generally kept pace with broad adoption of telehealth coverage policies and practices. With some payers receiving encouragement from state governors, and others simply acting proactively, telehealth coverage has been a focal point for private insurers in the last few weeks.

Key players such as Aetna, CareFirst, UnitedHealthcare, Humana, and state Blue Cross and Blue Shield organizations have announced significant expansions of telehealth coverage and reimbursement in line with Medicare’sexpanded guidance and policies. Aetna, for example, now offers zero co-pay telemedicine visits for commercial plan members, and is expanding its Medicare Advantage virtual evaluation benefit to all fully insured members.

Similarly, UnitedHealthcare has waived state-based originating site restrictions for Medicare Advantage, Medicaid, and commercial members. Thus, like the federal government, private payers are leveraging telehealth platforms to protect their members and public health generally.

As the world faces an uncertain future during Covid-19, telehealth’s ability to ensure care continuity while minimizing exposure to dangerous pathogens cannot be overstated. Federal, state, and private payers are fueling telehealth’s rapid expansion and are helping to maximize the availability of safe care to patients nationwide.

This column does not necessarily reflect the opinion of The Bureau of National Affairs, Inc. or its owners.

Author Information

Rachel A. Alexander, partner in Wiley’s Health Care Practice and member of the firm’s Covid-19 Task Force, counsels clients on health care regulatory, transactional, and litigation matters with an emphasis on advising health plans regarding compliance with federal law.

Bethany A. Corbin, consulting counsel in Wiley’s Health Care Practice, provides legal guidance to health care organizations on federal and state law, including representation in judicial and administrative proceedings.

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