Congress Considers Permanent Telehealth Waivers for Medicare

Ken Terry

July 17, 2020

A bill introduced on Thursday in the US House of Representatives would make permanent some temporary changes that the Centers for Medicare & Medicaid Services (CMS) has initiated in its telehealth coverage during the COVID-19 pandemic.

Cosponsored by members of the House Telehealth Caucus, the bipartisan legislation would eliminate most geographic and originating site restrictions on the use of telehealth in Medicare. The bill would allow telehealth visits to be conducted in a patient's home. It would also permit rural health clinics and federally qualified health clinics to furnish telehealth services.

In addition, the bill would authorize the Department of Health and Human Services to waive or modify telehealth requirements in Medicare during and for 90 days after any emergency period. It would also require HHS to submit a report to Congress on telehealth utilization within 6 months after the end of the emergency period.

The measure was cosponsored by Mike Thompson (D-CA), Peter Welch (D-VT), Bill Johnson (R-OH), David Schweikert (R-AZ), and Doris Matsui (D-CA).

Industry groups hailed the introduction of this legislation. But many other details of how Congress or CMS might regulate telehealth coverage after the pandemic is over remain unclear. Moreover, the bill affects only Medicare. States would have to pass their own legislation to make permanent the temporary changes many of them have created in their Medicaid regulations on telehealth. And commercial insurers would not be bound by the House bill, should it be adopted and signed into law.

CMS seems disposed to keeping some of the temporary changes it has made in Medicare regulations. In a Health Affairs blog post this week, Seema Verma, administrator of CMS, said, "With the transformative changes unleashed over the last several months, it's hard to imagine merely reverting to the way things were before. As the country re-opens, CMS is reviewing the [telehealth] flexibilities the administration has introduced and their early impact on Medicare beneficiaries to inform whether these changes should be made a permanent part of the Medicare program."

Emergency Changes

Among the temporary waivers CMS introduced under the authority of President Trump's March 13 emergency declaration and the CARES Act, the agency:

  • Allowed patients to receive services anywhere, including at home

  • Added 135 allowable telehealth services, more than doubling the number of services it allowed before

  • Established reimbursement parity for in-person and telehealth visits

  • Allowed telephone Evaluation and Management visits to be paid at the same rate as in-person visits

  • Allowed the use of telehealth in post-acute care facilities

  • Covered telehealth in rural health clinics and federally qualified health centers

  • Expanded the types of providers who can supply telehealth services

  • Waived the collection of copays for telehealth visits

Prior to the COVID-19 crisis, CMS also expanded allowable telehealth services and introduced "virtual check-ins," which doctors can use to determine whether patients should be seen in person. In addition, it gave Medicare Advantage plans the option of offering telehealth services to their members.

At a panel discussion Thursday sponsored by the Healthcare Information and Management Systems Society, the leading association of health information technology professionals, HIMSS Vice President of Government Relations Tom Leary said that Congress will have to consider "the impact on new and existing patients and on payment rates for telehealth. Currently, there is parity [of reimbursement] between in-person and telehealth visits. But [CMS] only has the temporary authority to do this. So we expect a lot of discussion on that and on what impact there will be in post-COVID care delivery and reimbursement."

In addition, Leary noted, Congress will have to evaluate the long-range impact of telehealth on Medicare costs. The Congressional Budget Office [CBO], he said, has argued that widespread telehealth will increase the use of Medicare services, because patients who don't go to the doctor very often will be able to access their provider online or by telephone. While there is some Veterans Affairs and private sector data rebutting this theory, he said, the CBO notes there is little Medicare data on this point.

"Given the fact that 1.7 million Medicare patients used telehealth in April, that's plenty enough data for CBO to truly understand the impact," Leary said.

Analysis of Early Data

CMS has already started to use the information it has collected on telehealth use in the pandemic to inform its decisions going forward. "Early CMS data have shown telehealth to be an effective way for people to access health care safely during the COVID-19 pandemic, whether it's getting a prescription refilled, managing chronic conditions, or obtaining mental health counseling," Verma writes in the blog post.

Before the public health emergency, Verma said, an average of 13,000 fee-for-service Medicare beneficiaries received telehealth services each week. In the last week of April, nearly 1.7 million beneficiaries received telehealth services. More than 9 million beneficiaries received telehealth visits from mid-March through mid-June, including audio-only visits, virtual check-ins, and e-visits via patient portals.

In rural areas, she notes, 22% of Medicare patients used telehealth; 30% used it in urban areas. Patients in the Northeast and mid-Atlantic used more telehealth than did patients elsewhere.

Evaluation and Management visits were the most common type of telehealth encounter, Verma said. Mental health was another big area of utilization: 60% of beneficiaries who received mental health services got them through telehealth. The same was true for 26% of patients who received nursing home visits from providers.

Audio-only visits have been a boon for people who don't have telehealth technology or don't feel comfortable with it, Verma noted. More than 3 million beneficiaries received telehealth services via telephone.

As CMS reviews the temporary changes in its telehealth policy, it will decide which of these flexibilities should be made permanent through regulatory action, she said. Besides considering the factors of access, outcomes, and cost, she noted, CMS will assess the impact of telehealth on patient safety. For example, although CMS expanded telemedicine services to both new and established patients, after the emergency is over, the agency must decide whether severely ill patients can be treated safely via telehealth by providers they've never seen before.

In addition, Verma said, CMS must police fraud in telehealth. The agency is currently monitoring program integrity implications, including "practitioners who may be offering shorter telehealth visits with patients to maximize payment, or billing more visits than are possible in a day."

Whatever the challenges, she concluded, "The rapid adoption of telemedicine among providers and patients has shown that telehealth is here to stay."

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