On March 6, 2020, the "Coronavirus Preparedness and Response Supplemental Appropriations Act" became law. In addition to providing healthcare agencies with more money to address the COVID-19 outbreak, it also loosens existing telehealth restrictions in order to enhance patient access to care services. On March 17, 2020, the Centers for Medicare & Medicaid Services (CMS) announced that they have expanded the waiver for telehealth in several areas, including the care of new patients for the diagnosis and treatment of COVID-19 as well as other conditions unrelated to the public health emergency. However, it does not open up telehealth billing to new practitioners. On March 27, 2020, the “Coronavirus Aid, Relief, and Economic Security Act" (CARES Act) was passed. Along with provisions centered on shoring up the economy and providing additional support for medical response, CARES includes additional funding and flexibility for telehealth provision.
Telehealth Regulations Waiver
The new laws give the Health & Human Services (HHS) Secretary the authority to waive certain restrictions on telehealth during a declared public health emergency. As of March 30, 2020, the Secretary has waived requirements in several different areas:
- Originating site: The Secretary has waived the “originating site” requirement for identified geographic areas designated an “emergency area.” Under normal conditions, a beneficiary must travel to an actual site of care – the originating site -- to receive telehealth services, but the waiver authority allows beneficiaries to receive services wherever they are. Because of the COVID-19 public health emergency, the Secretary has also waived the geographical site restrictions on Medicare telehealth services to allow all areas and locations within the country delivery of these services, including patients’ homes.
- Device Type: The Secretary has loosened restrictions on the types of devices that can be used for telehealth services so that personal phones and tablets may be utilized, provided that the beneficiary has both audio and visual feeds to the clinician. Practitioners are able to use everyday communication technologies such as FaceTime or Skype during the COVID-19 public health emergency without breaking HIPAA rules.
- Patient and Service Eligibility: Both new and existing patients may now access telehealth for a wide range of services. Previously, telehealth was available for a fairly limited range of services and required that the provider or another practitioner within the provider’s practice had provided telehealth services to the patient within the past three years. Now, new patients can receive telehealth services. Although the telehealth expansion still requires informed consent and beneficiary initiation of the encounter, the changes significantly increase the number of patients who can take advantage of telehealth services.
All other telehealth regulations, including the list of “qualified providers” remain in effect. Thus, ASHP’s understanding is that pharmacists can provide telehealth services incident to a Medicare-eligible provider, but cannot directly bill Medicare for these services. However, because CMS did not explicitly address this issue in its FAQ document, ASHP will seek further clarification from CMS on this point.
New Funding and Other Changes
The CARES Act further enhances flexibility for COVID-19 response. CARES expands the waiver authority of the HHS Secretary beyond what was initially allowed by the national emergency declarations, empowering him to waive any Social Security Act provision that impedes patient care delivered via telehealth during the public health emergency. The law also removes access barriers for individuals with high-deductible health plans, who previously could not access telehealth services until their deductible was satisfied without risking their eligibility for Health Savings Accounts. Further, CARES extends telehealth coverage to Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) (to be implemented by CMS) and removes periodic in-person requirements for home dialysis and hospice services during the COVID-19 public health emergency. Finally, CARES invests in expanding the telehealth infrastructure nationally by authorizing $29 million per year for the next four years for the telehealth network and telehealth resource center grant programs.
Practical Implications and Questions
It is important to note that any state restriction on telehealth services, such as scope-of-practice or licensure requirements, remains in effect. Thus, restrictive state laws could impede the federal telehealth expansion. To facilitate unimpeded patient access, ASHP has recommended that states/state boards of pharmacy remove any regulatory barriers to telehealth provision.
Because of the extremely rapid changes to telehealth provision over the past month, ASHP is also seeking CMS clarification on certain telehealth provisions. Specifically, we are asking CMS to provide additional detail on the following:
- Which codes should supervising providers or organizations bill for pharmacists’ services to reflect the complexity of the pharmacist’s work? Can CMS increase the value of the G-codes to more closely reflect the payment for the same services when they are provided face-to-face and billed under evaluation and management (E/M) codes?
- Can telehealth services be provided under general supervision? At present, some sites of care are requiring practitioners to be on-site to ensure they meet direct supervision requirements. This places providers at unnecessary risk by keeping them in close proximity even when there is no patient benefit to doing so.
ASHP anticipates an ongoing dialogue with CMS as the COVID-19 response continues. If you have any questions regarding provision of telehealth, or if you have communications from your Medicare Administrative Contractor or CMS regarding telehealth that you are willing to share with ASHP to inform our conversations with the agency, please send them to Jillanne Schulte Wall at firstname.lastname@example.org