HHS Announces Expanded Medicare Telehealth Coverage

For most services, the beneficiary must be in a rural area, defined as a health professional shortage area or a county that is not a Metropolitan Statistical Area.

Exceptions to this rule are for certain places in Alaska and Hawaii and certain services—ESRD, acute stroke or substance use.

For most services, the patient must go to one of nine facility locations, called the “originating site”: a physician office, hospital, critical access hospital, skilled nursing facility, rural health clinic, federally qualified health center, community mental health center, renal dialysis center, hospital or critical access hospital-based renal dialysis center. The originating site facility receives a fee for hosting the patient.

Telehealth at home is available for ESRD and substance abuse, and there is also an exception for acute stroke services (which can be delivered at a mobile stroke unit), but no originating site facility fees are paid in these cases.

Locational licensing requirements for the physician or practitioner waived (if physician or practitioner has any state license, may provide service in any state), but:

• No effect on state licensure (states may still restrict practice of out-of-state physician or practitioner);
• Waiver authority applies only where existing patient relationship has existed for at least three years, but CMS has stated it will not audit this requirement;¹¹  and
• No effect on malpractice coverage limitations (although Secretary’s Declaration shields from liability those providing FDA-cleared or approved diagnostics or treatments).

When the patient’s originating site is a hospital or critical access hospital (CAH), Medicare requires:

• That the distant-site physician or practitioner be at a hospital or “distant site telemedicine entity” that has certain medical staff credentialing and privileging processes;
• A written agreement with the distant-site entity;
• That the distant-site physician or practitioner hold a license from the state in which the patient is located; and
• Certain information sharing between the originating site and distant site.

As noted above, locational licensing requirements for the physician or practitioner waived (if physician or practitioner has any state license, may provide service in any state), but:

• No effect on state licensure (states may still restrict practice of out-of-state physician or practitioner);
• Waiver authority applies only where existing patient relationship has existed for at least three years, but CMS has stated it will not audit this requirement;¹²  and
• No effect on malpractice coverage limitations (although Secretary’s Declaration shields from liability those providing FDA-cleared or approved diagnostics or treatments).

No change to other requirements. Individual hospitals and CAHs may seek an 1135 waiver from CMS for privileging and credentialing requirements.

An “interactive telecommunications system,” meaning multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and the physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet this definition.

(Exceptions apply for certain programs in Alaska and Hawaii.)

Prohibition on use of a telephone waived, but only if the telephone has “audio and video capabilities that are used for two-way, real-time interactive communication.”

This can include Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype or other non-public facing apps. (Normally, use of these apps would be subject to HIPAA penalties as they may not comply with HIPAA privacy and security rules.) However, providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications.

Apart from Medicare telehealth services (as described above), Medicare reimburses for certain other services that are furnished remotely using communications technology, primarily:

• Virtual check-ins, short patient-initiated communications (by an established patient) with a health care practitioner, which can be conducted with a broader range of communication methods than telehealth services;
• E-visits, non-face-to-face patient-initiated communications (by an established patient) with a health care practitioner through an online patient portal; and
• Remote evaluations, evaluation by a health care practitioner of recorded video and/or images submitted by an established patient, including interpretation and follow-up with the patient (which may be by phone call, audio/video communication, secure text messaging, email, or patient portal communication) within 24 business hours.