Final CMS Rule Expands Medicare Advantage Telehealth Services

Last month, The U.S. Centers for Medicare & Medicaid Services (CMS) finalized its plan to expand telehealth access and coverage in Medicare Advantage (MA) plans. There’s good news for MA plans, their members and providers: plans will be able to expand telehealth access and coverage beginning with plan year 2020 under a final rule published on April 5, 2019.

According to CMS Administrator Seema Verma: “Today’s policies represent a historic step in bringing innovative technology to Medicare beneficiaries. With these new telehealth benefits, Medicare Advantage enrollees will be able to access the latest technology and have greater access to telehealth. By providing greater flexibility to Medicare Advantage plans, beneficiaries can receive more benefits, at lower costs and better quality.”

CHQI originally provided an update on the new Telehealth Rule for MA plans in February. Click here for details.

Historically, MA plans have been able to offer more telehealth services, compared to Medicare FFS arrangements, as part of their supplemental benefits. But with the CMS final rule, MA plans will be more likely to offer the additional telehealth benefits outside of supplemental benefits, expanding patients’ access to telehealth services from more providers and in more parts of the country than before, whether they live in rural or urban areas.

Now, effective for plan year 2020, MA plans will be allowed to offer telehealth to deliver any service already covered under Medicare Part B and not be subject to geographical restrictions on telehealth access. MA members will be able to access telehealth from their own home – whether they live in a rural or urban area. Previously, MA members who lived outside a rural area had to travel to a healthcare facility to receive telehealth services.

In addition, historically, seniors in Medicare FFS could only receive certain telehealth services if they lived in rural areas. Starting this year, Medicare FFS began paying for virtual check-ins across the U.S., meaning Medicare beneficiaries can connect with their doctors by phone or video chat.

Perhaps the biggest change under the new rule (which implements Section 50323 of the Bipartisan Budget Act of 2018 (Public Law 115-123)) relates to Medicare funding: Beginning in 2020, MA plans can offer Part B telehealth benefits as part of their basic benefit package. Plans can’t replace in-person visits with telehealth visits—if a plan offers a Part B service as an additional telehealth benefit, it must also provide access to the service through in-person visits. In addition, MA plans can continue to offer supplemental telehealth benefits for services that don’t qualify for this expanded coverage because they aren’t covered under Medicare Part B or Medicare FFS.

The ability to offer telehealth services as part of a basic government-funded benefit gives MA plans more options in benefit design and service delivery. With supplemental benefits, telehealth services could only be financed through rebate dollars or enrollee premiums. MA plans may use differential cost-sharing for telehealth services but can’t use it to steer enrollees towards one delivery mechanism or another. Use of telehealth has been shown to reduce plan costs and out-of-pocket expense by members.

The new flexibility may make it more likely that plans will offer the additional telehealth benefits outside of supplemental benefits, expanding patients’ access to telehealth services from more providers, in more parts of the country. According to Jerry Penso, MD, CEO and President of the American Medical Group Association, the final rule “creates a framework that will encourage MA plans to work with the provider community to develop coverage policies that encourage the appropriate use of telehealth.”

Still, the Medicare FFS limitations on what types of providers may offer telehealth services applies to MA plans. Additional telehealth services can be provided by a:

  • Physician
  • Physician assistant
  • Nurse practitioner
  • Clinical nurse specialist
  • Certified registered nurse anesthetist
  • Certified nurse-midwife
  • A clinical social worker
  • A clinical psychologist
  • Registered dietitian or nutrition professional

Providers of additional telehealth services must also be contracted, network providers who meet all relevant state laws such as those related licensing and telehealth.

Of note, CMS did not adopt specific regulatory defining text or provide examples of electronic information/telecommunications technology. The technology needed to provide additional telehealth benefits will vary based on the service. And, this will allow inclusion of future technological advances. Examples of electronic exchange may include, but are not limited to: secure messaging, store and forward technologies, telephone, videoconferencing, other internet-enabled technologies, and other evolving technologies supporting virtual care communications.

CMS hopes the new policy creates incentives for MA plans to offer more telehealth services “giving enrollees more control to determine when, where, and how they access benefits.” CMS also expects $557 million in savings for enrollees over 10 years based on reduced travel time to providers. All this could accelerate senior adoption of telehealth: 20.4 million people or 34 percent of the Medicare population were enrolled in MA plans as of 2018, according to the Kaiser Family Foundation.

With the adoption of this new Rule for MA plans, CMS continues to assume a leadership role in opening opportunities for telemedicine reimbursement, which should also have an echo effect for the private sector. CHQI’s Telemedicine Accreditation Program is also assuming a critical role in establishing best practices for telemedicine programs throughout the U.S.

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