CMS Proposes Major Telehealth Flexibility for Medicare Advantage Plans

New telehealth benefits will be available for Medicare Advantage (MA) members if a proposed rule published November 1, 2018 by the Department of Health and Human Services Center for Medicare and Medicaid Services (CMS) becomes final, as expected. The rule implements provisions of the Bipartisan Budget Act of 2018, effective for plan year 2020.

The proposed CMS rule would permit Medicare Advantage (MA) plans to offer telehealth benefits not otherwise available to other Medicare beneficiaries, potentially creating new incentives to join such plans.  As reported in a recent CMS press release:

The proposed rule would give MA plans more flexibility to offer government-funded telehealth benefits to all their enrollees, whether they live in rural or urban areas.  It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places like their homes, rather than requiring them to go to a health care facility to receive telehealth services. Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries.

The importance of these recommended changes cannot be underestimated as MA plan enrollment continues to skyrocket.  According to CMS, enrollment in MA plans is projected to be at an all-time high in 2019 with 22.6 million Medicare beneficiaries. CMS is projecting a 2.4 million (11.5 percent) increase from 20.2 million in 2018.

CMS has recently acknowledged – through their report and revised policy – that restrictions on reimbursement have sharply limited the use of telehealth services. In addition to the changes discussed in this blog for MA plans, CMS also has relaxed restrictions on the Medicare Fee-For-Service (FFS) program as detailed in three recent CHQI blogs.

Under current policy, MA plans are required to offer all the Medicare Part A and B benefits, so they are subject to the same Medicare FFS limiting requirements of geographic area (primarily rural); originating site (not including home) and communications technology (e.g., interactive audio-and-video technology only that permit real-time communication between provider and patient, with no store and forward).

Under the proposed rule, the expansion of reimbursement by geography and originating sites in place for Medicare FFS would also apply to MA plans, effective for the 2020 plan year. CMS goes further, however, and would allow MA plans to offer government-financed telehealth benefits as a basic benefit, providing services that other Medicare beneficiaries do not receive. MA plans could also continue offering telehealth services as supplemental benefits financed through CMS rebates and/or a separate supplemental premium paid by MA plan members.

Specifically, MA plans would be able to offer telehealth services as basic benefits and not meet any of the Part B traditional requirements as long as the services are “clinically appropriate” and delivered through “electronic exchange.” CMS does not define these terms but does mention in the preamble that secure messaging, telephone, store and forward technologies, and videoconferencing are examples of services provided via electronic exchange.

In order to have telehealth services paid as a basic benefit, MA plans will need to include them in their annual bid submissions. Telehealth services that don’t qualify as “additional telehealth benefits” may still be offered as supplemental benefits.

A few additional requirements exist that MA plans must satisfy when offering telehealth services. As required under Medicare FFS, any service provided through telehealth must also be offered as an in-person visit to MA enrollees. Some have suggested this would be a problem for certain services such as remote patient monitoring. CMS has requested comment on how this provision might best be implemented.

Also, telehealth services offered as a basic benefit by an MA plan must be provided by contracted telehealth providers. Selection and credentialing requirements must be followed, and MA plans must comply with state licensing requirements, which vary by state. Any telehealth services provided by non-contracted providers may only be covered as a supplemental benefit.

The final version of the Medicare Advantage telehealth rule has the potential to accelerate utilization of telehealth in meaningful ways. We’ll keep you posted on what happens next…

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