Federal

CURRENT LAWS & POLICY

AT A GLANCE

Medicare Program

Medicare

Administrator

Centers for Medicare and Medicaid Services (CMS)

Regional Telehealth Resource Center

N/A

Medicare Reimbursement

Live Video: Yes
Store-and-Forward: Yes
Remote Patient Monitoring: Yes, with limitations

Private Payer Law

Law Exists: No
Payment Parity: No

Professional Requirements

Licensure Compacts: N/A
Consent Requirements: Yes

Last updated 02/28/2021

Audio-Only Telephone

CMS: COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 PHE (additional allowances)

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 PHE (original rule)

STATUS: Active, Expires at end of PHE

CMS: COVID-19 Frequently Asked Questions

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 – MIPS Update

STATUS: Active, Expires at end of PHE

HR 6074: Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020

STATUS: Enacted

HR 748: CARES Act

STATUS: Enacted

S 150: Ensuring Parity in MA for Audio-Only Telehealth Act of 2021

STATUS: Introduced

Last updated 02/28/2021

Cross-State Licensing

Health and Human Services: 4th Declaration under the PREP Act: Cross State Licensing for delivering medical countermeasures

STATUS: Active, Expires at end of PHE

HR 688/S 155: Equal Access to Care Act

STATUS: Introduced

HR 708/S 168: Temporary Licensure Reciprocity

STATUS: Pending

Last updated 02/28/2021

Easing Prescribing Requirements

CMS: COVID-19 Frequently Asked Questions

STATUS: Active, Expires at end of PHE

Drug Enforcement Agency:  Questions and Answers for Telemedicine

STATUS: Active, Expires at end of PHE

Last updated 02/28/2021

Miscellaneous

Federal Office of Civil Rights: FAQs on Telehealth and HIPAA during COVID-19

STATUS: Active, Expires at end of PHE

Federal Office of Civil Rights: Notification of Enforcement Discretion for Telehealth Remote Communication during COVID

STATUS: Active, Expires at end of PHE

HR 1319: American Rescue Plan Act of 2021

STATUS: Enacted

S 355: COVID-19 Medical Debt Relief

STATUS: Introduced

HR 1406: COVID-19 Emergency Telehealth Impact Reporting Act

STATUS: Introduced

Last updated 02/28/2021

Originating Site

CMS: COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 PHE (additional allowances)

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 PHE (original rule)

STATUS: Active, Expires at end of PHE

CMS: COVID-19 Frequently Asked Questions

STATUS: Active, Expires at end of PHE

CMS: FAQs for Hospitals and Critical Access Hospitals regarding EMTALA

STATUS: Active

HR 6074: Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020

STATUS: Enacted

HR 748: CARES Act

STATUS: Enacted

HR 133: Consolidated Appropriations Act, 2021

STATUS: Enacted

HR 596: Nursing facility telehealth services during PHE

STATUS: Pending

HR 318: Safe Testing at Residence Telehealth Act of 2021

STATUS: Pending

Last updated 02/28/2021

Private Practice

S 150: Ensuring Parity in MA for Audio-Only Telehealth Act of 2021

STATUS: Introduced

Last updated 02/28/2021

Provider Type

CMS: COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 PHE (additional allowances)

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 PHE (original rule)

STATUS: Active, Expires at end of PHE

CMS: COVID-19 Frequently Asked Questions

STATUS: Active, Expires at end of PHE

CMS: FAQs for Hospitals and Critical Access Hospitals regarding EMTALA

STATUS: Active

HR 6074: Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020

STATUS: Enacted

HR 748: CARES Act

STATUS: Enacted

Last updated 02/28/2021

Service Expansion

CMS: COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 PHE (additional allowances)

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 PHE (original rule)

STATUS: Active, Expires at end of PHE

CMS: COVID-19 Frequently Asked Questions

STATUS: Active, Expires at end of PHE

CMS: Interim Final Rule on COVID-19 – MIPS Update

STATUS: Active, Expires at end of PHE

CMS: FAQs for Hospitals and Critical Access Hospitals regarding EMTALA

STATUS: Active

HR 6074: Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020

STATUS: Enacted

HR 748: CARES Act

STATUS: Enacted

HR 133: Consolidated Appropriations Act, 2021

STATUS: Enacted

HR 796/HR 898: Coverage for COVID-19 Treatment

STATUS: Introduced

HR 596: Nursing facility telehealth services during PHE

STATUS: Pending

Last updated 02/28/2021

POLICY

Although not considered to fall under the definition of telehealth, in 2018 CMS began making separate payment for the collection and interpretation of physiologic data.  In 2019, they expanded their reimbursement to three remote physiologic monitoring codes, and an add-on code was added in 2020.  Currently eligible codes include 99091, 99453, 99454, 99457, 99458.  Each code has its own requirements in the code description.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125 & CY 2020 Final Physician Fee Schedule, CMS, p. 429.

Note that chronic care management, principle care management, and transitional care management may also have remote monitoring applications.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 126-128; CY 2020 Final Physician Fee Schedule. CMS, p. 390-421 & Medicare Learning Network Booklet, Chronic Care Management Services, July 2019 (Accessed Feb. 2021). 


CONDITIONS

Note that specific condition requirements apply for chronic care management, principle care management, and transitional care management which may also have remote monitoring applications.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125; CY 2020 Final Physician Fee Schedule, CMS, p. 429 & Medicare Learning Network Booklet, Chronic Care Management Services, July 2019.


PROVIDER LIMITATIONS

For remote physiologic monitoring, we note that the term, ‘‘other qualified healthcare professionals,’’ used in the code descriptor is defined by CPT, and that definition can be found in the CPT Codebook.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125.

CMS has designated RPM codes 99457 and 99458 as defined in Sec. 410.26(b)(5).  See below for referenced definition:

In general, services and supplies must be furnished under the direct supervision of the physician (or other practitioner). Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner). The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly. However, only the supervising physician (or other practitioner) may bill Medicare for incident to services.

SOURCE: CY 2020 Final Physician Fee Schedule. CMS, p. 431 & 42 CFR 410.26.

FQHCs/RHCs

Services such as RPM are not separately billable because they are already included in the RHC AIR or FQHC PPS payment.

SOURCE: CY 2020 Final Physician Fee Schedule. CMS, p. 432.

Home Health Agencies

An individualized plan of care must be established and periodically reviewed by the certifying physician or allowed practitioner.  The plan of care must include all of the following: … Any provision of remote patient monitoring or other services furnished via telecommunications technology (as defined in § 409.46(e)) or audio-only technology. Such services must be tied to the patient-specific needs as identified in the comprehensive assessment, cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment.

Telecommunications technology, as indicated on the plan of care, can include: remote patient monitoring, defined as the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency; teletypewriter (TTY); and 2-way audio-video telecommunications technology that allows for real-time interaction between the patient and clinician. The costs of any equipment, set-up, and service related to the technology are allowable only as administrative costs. Visits to a beneficiary’s home for the sole purpose of supplying, connecting, or training the patient on the technology, without the provision of a skilled service, are not separately billable.

SOURCE:  42 CFR Sec. 409.43 & 409.46 as updated by CMS Final Rule for CY 2021 Home Health Prospective Payment System (Accessed Feb. 2021).


OTHER RESTRICTIONS

No reference found.

Last updated 02/28/2021

Definitions

Interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.

For the duration of the Public Health Emergency as defined in § 400.200 of this chapter, Interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

Telehealth services:  You must use an interactive audio and video telecommunications system that permits real-time

communication between you at the distant site, and the beneficiary at the originating site.

SOURCE:  Medicare Learning Network Factsheet. Telehealth Services, p. 7 (Accessed Feb. 2021).

 

Last updated 02/28/2021

Email, Phone & Fax

For the duration of the Public Health Emergency as defined in § 400.200 of this chapter, Interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

Communication Technology-Based Services (CTBS)

‘Brief communication technology-based service, e.g. virtual check-in’ allows for real-time audio-only telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40.

Interprofessional consultations are reimbursable by CMS as part of their CTBS services (CPT codes include 99451, 99452, 99446, 99447, 99448, and 99449). Cost sharing will apply. These interprofessional services may be billed only by practitioners that can bill Medicare independently for evaluation and management services.  Includes telephone and internet assessments.

SOURCE CY 2019 Final Physician Fee Schedule. CMS, p. 31-40 (Accessed Feb. 2021).

Online digital evaluation services (e-visit) are reimbursable for physicians and qualified non-physician health care professionals.  These are non-face-to-face codes that describe patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office.

SOURCE: CY 2020 Final Physician Fee Schedule. CMS, p. 799 (Accessed Feb. 2021).

Medicare waives the RHC and FQHC face-to-face requirements when an RHC or FQHC furnishes communication technology-based services (Includes the Brief Communication Technology-Based Service, Remote Evaluation of Pre-Recorded Patient Information) to an RHC or FQHC patient. RHCs and FQHCs receive payment for communication technology-based services or remote evaluation services when an RHC or FQHC practitioner provides at least 5 minutes of communications-based technology or remote evaluation services to a patient who has been seen in the RHC or FQHC within the previous year.

G0071 should be billed for both services.

SOURCE:  Medicare Learning Network Matters Factsheet, MM10843, Aug. 10, 2018, & Virtual Communication Services RHCs and FQHCs FAQs, December 2019, (Accessed Feb. 2021).

RHCs and FQHCs are not eligible for reimbursement of interprofessional consultation services, as only practitioners that can bill Medicare independently for evaluation and management services are eligible.

SOURCE CY 2019 Final Physician Fee Schedule. CMS, p. 31-40 (Accessed Feb. 2021).

Home Health Agencies

An individualized plan of care must be established and periodically reviewed by the certifying physician or allowed practitioner.  The plan of care must include all of the following: … Any provision of remote patient monitoring or other services furnished via telecommunications technology (as defined in § 409.46(e)) or audio-only technology. Such services must be tied to the patient-specific needs as identified in the comprehensive assessment, cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment.

Telecommunications technology, as indicated on the plan of care, can include: remote patient monitoring, defined as the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency; teletypewriter (TTY); and 2-way audio-video telecommunications technology that allows for real-time interaction between the patient and clinician. The costs of any equipment, set-up, and service related to the technology are allowable only as administrative costs. Visits to a beneficiary’s home for the sole purpose of supplying, connecting, or training the patient on the technology, without the provision of a skilled service, are not separately billable.

SOURCE:  42 CFR Sec. 409.43 & 409.46 as updated by CMS Final Rule for CY 2021 Home Health Prospective Payment System (Accessed Feb. 2021).

No reference found for email and fax.

Last updated 02/28/2021

Live Video

POLICY

The Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician or a practitioner to an eligible telehealth individual notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

Medicare Part B pays for covered telehealth services included on the telehealth list when furnished by an interactive telecommunications system if certain conditions are met.


ELIGIBLE SERVICES/SPECIALTIES

The term “telehealth service” means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes 99241–99275, 99201–99215, 90804–90809, and 90862 (and as subsequently modified by the Secretary)), and any additional service specified by the Secretary.  The Secretary shall establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes), as appropriate.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

Medicare Part B pays for covered telehealth services included on the telehealth list when furnished by an interactive telecommunications system if certain conditions are met, except that for the duration of the Public Health Emergency as defined in § 400.200 of this chapter, Medicare Part B pays for office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management and end stage renal disease related services included in the monthly capitation payment furnished by an interactive telecommunications system if certain conditions are met.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

The physician visits required for rehabilitative services such as physical therapy, speech-language pathology, occupational therapy, and rehabilitative services for mental disorders and intellectual disability may not be furnished as telehealth services.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

A physician, NP, PA, or CNS must furnish at least one ESRD-related “hands on visit” (not telehealth) each month to examine the beneficiary’s vascular access site.

SOURCE:  Medicare Learning Network Factsheet. Telehealth Services, p. 7-10 (Accessed Feb. 2021).

Changes to the list of Medicare telehealth services are made through the annual physician fee schedule rulemaking process. During the Public Health Emergency for the COVID-19 pandemic, as defined in § 400.200 of this chapter, we will use a sub-regulatory process to modify the services included on the Medicare telehealth list during the Public Health Emergency taking into consideration infection control, patient safety, and other public health concerns resulting from the emergency. A list of the services covered as telehealth services under this section is available on the CMS website.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

See page 7-10 of the Telehealth Medicare Learning Network Factsheet for a full list of permanently eligible codes.

SOURCE:  Medicare Learning Network Factsheet. Telehealth Services, p. 7-10 (Accessed Feb. 2021).

List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth is available on the CMS website, including temporary codes during the public health emergency.

SOURCE:  Centers for Medicare and Medicaid Services. List of Telehealth Services.  (Accessed Feb. 2021).

Communication Technology-Based Services (CTBS)

CMS makes separate payment for brief communication technology-based services. This includes ‘brief communication technology-based service, e.g. virtual check-in’ by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion). The code (G2012) allows real-time audio-only telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission. The service is limited to established patients.

Interprofessional consultations are reimbursable by CMS as part of their CTBS services (CPT codes include 99451, 99452, 99446, 99447, 99448, and 99449). Cost sharing will apply. These interprofessional services may be billed only by practitioners that can bill Medicare independently for evaluation and management services.  Includes telephone and internet assessments.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40.


ELIGIBLE PROVIDERS

The Secretary shall pay to a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth individual an amount equal to the amount that such physician or practitioner would have been paid under this title had such service been furnished without the use of a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

The physician or practitioner at the distant site must be licensed to furnish the service under State law. The physician or practitioner at the distant site who is licensed under State law to furnish a covered telehealth service may bill, and receive payment for, the service when it is delivered via a telecommunications system.

The practitioner at the distant site is one of the following:

  • A physician
  • A physician
  • A nurse practitioner
  • A clinical nurse specialist
  • A nurse-midwife
  • A clinical psychologist
  • A clinical social worker
  • A registered dietitian or nutrition professional
  • A certified registered nurse anesthetist

SOURCE: 42 CFR Sec. 410.78 & Medicare Learning Network Factsheet. Telehealth Services, p. 6 (Accessed Feb. 2021).

A clinical psychologist and a clinical social worker may bill and receive payment for individual psychotherapy via a telecommunications system, but may not seek payment for medical evaluation and management services.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

CPs and CSWs cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services. They cannot bill or get paid for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838.

SOURCE:  Medicare Learning Network Factsheet. Telehealth Services, p. 6 (Accessed Feb. 2021).

CMS allows Opioid Treatment Programs (OTPs) to use two-way interactive audio-video communication technology, as clinically appropriate, in furnishing substance use counseling and individual and group therapy services.

SOURCE:  CY 2020 Final Physician Fee Schedule. CMS, p. 249.

Communication Technology-Based Services

Payment for communication technology-based and remote evaluation services. For communication technology-based and remote evaluation (including the virtual check-in) services furnished on or after January 1, 2019, payment to RHCs and FQHCs is at the rate set for each of the RHC and FQHC payment codes for communication technology-based and remote evaluation services.

SOURCE:  42 CFR 405.2464 (Accessed Feb. 2021).

RHCs and FQHCs are not eligible for reimbursement of interprofessional consultation services, as only practitioners that can bill Medicare independently for evaluation and management services are eligible.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40.

Medicare waives the RHC and FQHC face-to-face requirements when an RHC or FQHC furnishes communication technology-based services (Includes the Brief Communication Technology-Based Service, Remote Evaluation of Pre-Recorded Patient Information) to an RHC or FQHC patient. RHCs and FQHCs receive payment for communication technology-based services or remote evaluation services when an RHC or FQHC practitioner provides at least 5 minutes of communications-based technology or remote evaluation services to a patient who has been seen in the RHC or FQHC within the previous year.

G0071 should be billed for both services.

SOURCE:  Medicare Learning Network Matters Factsheet, MM10843, Aug. 10, 2018, & Virtual Communication Services RHCs and FQHCs FAQs, December 2019, (Accessed Feb. 2021).


ELIGIBLE SITES

Eligible Sites:

  • The office of a physician or practitioner.
  • A critical access hospital
  • A rural health clinic
  • A Federally qualified health center
  • A hospital
  • A hospital-based or critical access hospital- based renal dialysis center (including satellites).
  • A skilled nursing facility
  • Rural emergency hospital
  • A community mental health center
  • A renal dialysis facility for purposes of individuals with end-stage renal disease getting home dialysis.
  • The home of an individual, but only for purposes of individuals with end-stage renal disease getting home dialysis or telehealth services to treat substance use disorder or individuals with co-occurring mental health disorders, or mental health disorders under certain circumstances.

SOURCE:  Social Security Act, Sec. 1834(m) & Medicare Learning Network Factsheet. Telehealth Services, p. 4 & 5 & 42 CFR Sec. 410.78.  (Accessed Feb. 2021).

Treatment of stroke telehealth services

The originating site and geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke, as determined by the Secretary.

With respect to telehealth services for acute stroke, the term “originating site” shall include any or critical access hospital, any mobile stroke unit, or any other site determined appropriate by the Secretary, at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m) & Medicare Learning Network Factsheet. Telehealth Services, p. 5.  (Accessed Feb. 2021).

Providers qualify as originating sites, regardless of location, if they were participating in a Federal telemedicine demonstration project approved by (or getting funding from) the U.S. Department of Health & Human Services as of December 31, 2000.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 4 (Accessed Feb. 2021).

Accountable Care Organizations (two-sided model tested or expanded under 1115A of the Social Security Act)

In the case of telehealth services for which payment would otherwise be made under this title furnished on or after January 1, 2020, the home of a beneficiary shall be treated as an originating site.  In the case of telehealth services where the home of a Medicare fee-for-service beneficiary is the originating site, the following shall apply:

  • There shall be no facility fee paid to the originating site.
  • No payment may be made for such services that are inappropriate to furnish in the home setting such as services that are typically furnished in inpatient settings such as a hospital.

SOURCE:  Social Security Act Sec. 1899 (Accessed Feb. 2021).


GEOGRAPHIC LIMITS

The term “originating site” means only those sites described below:

·       In an area that is designated as a rural health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act

·       In a county that is not included in a Metropolitan Statistical Area; or

·       From an entity that participates in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary of Health and Human Services as of December 31, 2000.

The geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of the home dialysis monthly ESRD-related visit, at a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home.

Additional exceptions exist for treatment of acute stroke, substance use disorder and mental health (see below).

SOURCE:  Social Security Act, Sec. 1834(m) & Medicare Learning Network Factsheet. Telehealth Services, p. 4 & 5.  (Accessed Feb. 2021).

Treatment of stroke telehealth services

The geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke, as determined by the Secretary.

With respect to telehealth services to treat acute stroke, the term “originating site” shall include any hospital or critical access hospital, any mobile stroke unit, or any other site determined appropriate by the Secretary, at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

Substance Use Disorder

The geographic requirements shall not apply with respect to telehealth services furnished on or after July 1, 2019, to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or cooccurring mental health disorder, as determined by the Secretary, or, on or after the first day after the end of the emergency period described in section 1135(g)(1)(B), subject to subparagraph (B), to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder, as determined by the Secretary at any originating site except a renal dialysis facility.

Requirements for mental health services furnished through telehealth

Payment may not be made under this paragraph for telehealth services furnished by a physician or practitioner to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder unless such physician or practitioner furnishes an item or service in person, without the use of telehealth, for which payment is made under this title:

  • within the 6-month period prior to the first time such physician or practitioner furnishes such a telehealth service to the eligible telehealth individual; and
  • during subsequent periods in which such physician or practitioner furnishes such telehealth services to the eligible telehealth individual, at such times as the Secretary determines appropriate.

These requirements do not apply to services:

  • Under this paragraph (with respect to telehealth services furnished to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder); or
  • under this subsection without application of this paragraph.

SOURCE:  Social Security Act, Sec. 1834(m) & Medicare Learning Network Factsheet. Telehealth Services, p. 4 (Accessed Feb. 2021).

Originating sites must be:

  • Located in a health professional shortage area (as defined under section 332(a)(1)(A) of the Public Health Service Act that is either outside of a Metropolitan Statistical Area (MSA) as of December 31st of the preceding calendar year or within a rural census tract of an MSA as determined by the Office of Rural Health Policy of the Health ReSOURCEs and Services Administration as of December 31st of the preceding calendar year, or
  • Located in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act as of December 31st of the preceding year, or
  • An entity participating in a Federal telemedicine demonstration project that has been approved by, or receive funding from, the Secretary as of December 31, 2000, regardless of its geographic location.

The geographic requirements specified above do not apply to the following telehealth services:

  • Home dialysis monthly ESRD-related clinical assessment services furnished on or after January 1, 2019, at a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home; and
  • Services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
  • Services furnished on or after July 1, 2019 to an individual with a substance use disorder diagnosis, for purposes of treatment of a substance use disorder or a co-occurring mental health disorder.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

The Health ReSOURCEs and Services Administration (HRSA) decides HPSAs, and the Census Bureau decides MSAs. To see a potential Medicare telehealth originating site’s payment eligibility, go to HRSA’s Medicare Telehealth Payment Eligibility Analyzer.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 4 (Accessed Feb. 2021).

Accountable Care Organizations (two-sided model tested or expanded under 1115A of the Social Security Act)

In the case of telehealth services for which payment would otherwise be made under this title furnished on or after January 1, 2020, the geographic limitation shall not apply with respect to any eligible originating site (including the home of a beneficiary) subject to State licensing requirements.

SOURCE:  Social Security Act Sec. 1899 (Accessed Feb. 2021).


FACILITY/TRANSMISSION FEE

Eligible originating sites are eligible for a facility fee equal to:

  • for the period beginning on October 1, 2001, and ending on December 31, 2001, and for 2002, $20; and
  • for a subsequent year, the facility fee specified in subclause (I) or this subclause for the preceding year increased by the percentage increase in the MEI (as defined in section 1842(i)(3)) for such subsequent year.

No facility fee shall be paid under this subparagraph to an originating site that is the home.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

Treatment of Acute Stroke:  No facility fee shall be paid to an originating site with respect to a telehealth service if the originating site does not otherwise meet the requirements for an originating site, including geographic requirements.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

HCPCS Code Q3014 describes the Medicare telehealth originating sites facility fee. Bill your MAC for the separately billable Part B originating site facility fee. The originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services when a CMHC serves as an originating site.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 11 (Accessed Feb. 2021).

Last updated 02/28/2021

Miscellaneous

Submit telehealth services claims, using Place of Service (POS) 02-Telehealth, to indicate you furnished the billed service as a professional telehealth service from a distant site. As of January 1, 2018, distant site practitioners billing telehealth services under the CAH Optional Payment Method II must submit institutional claims using the GT modifier.

Bill covered telehealth services to your Medicare Administrative Contractor (MAC). They pay you the appropriate telehealth services amount under the Medicare Physician Fee Schedule (PFS). If you are located in, and you reassigned your billing rights to, a CAH and elected the Optional Payment Method II for outpatients, the CAH bills the telehealth services to the MAC. The payment is 80 percent of the Medicare PFS facility amount for the distant site service.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 11 (Accessed Feb. 2021).

Medicaid Requirements

Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal requirements of efficiency, economy and quality of care. States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telemedicine technology.

States are not required to submit a (separate) SPA for coverage or reimbursement of telemedicine services, if they decide to reimburse for telemedicine services the same way/amount that they pay for face-to-face services/visits/consultations.

States must submit a (separate) reimbursement (attachment 4.19-B) SPA if they want to provide reimbursement for telemedicine services or components of telemedicine differently than is currently being reimbursed for face-to-face services.

States may submit a coverage SPA to better describe the telemedicine services they choose to cover, such as which providers/practitioners are; where it is provided; how it is provided, etc. In this case, and in order to avoid unnecessary SPA submissions, it is recommended that a brief description of the framework of telemedicine be placed in an introductory section of the State Plan and then a reference made to telemedicine coverage in the applicable benefit sections of the State Plan. For example, in the physician section it might say that dermatology services can be delivered via telemedicine provided all state requirements related to telemedicine as described in the state plan are otherwise met.

SOURCE: Medicaid.gov.  Telemedicine (Accessed Nov 2020).

Last updated 02/28/2021

Out of State Providers

Doctors of Medicine and Osteopathy – The requirement that a doctor of medicine be legally authorized to practice medicine and surgery by the State in which he/she performs his/her services means a physician is licensed to practice medicine and surgery. (Similar regulations exist for other types of practitioners, see manual).

SOURCE:  Medicare General Information, Eligibility and Entitlement, Chapter 5 – Definitions, Updated 11/2/2018, Sec. 70, p. 31-32.  (Accessed Feb. 2021).

Items and services furnished outside the United States are excluded from coverage (with exceptions for beneficiaries traveling in Canada and emergency situations).

Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India.

SOURCE:  Medicare Benefit Policy Manual, Chapter 16 – General Exclusions from Coverage, Revised 11/6/14, Sec. 60, p. 24.  (Accessed Feb. 2021).

Last updated 02/28/2021

Overview

CMS reimburses for live video under certain circumstances and for specific services when the patient is in a rural area and at a specified originating site with a few exceptions.  They also pay for traditional services delivered via store-and-forward in Alaska and Hawaii telehealth demonstration pilots.  Additionally, they also define communication technology-based services separately and provide reimbursement for those services when delivered via live video, asynchronously as well as remote physiologic monitoring depending on the applicable code’s description. However, as communication technology-based services are not considered “telehealth” by CMS, they are not under the same statutory restrictions telehealth-delivered services face.  More details are provided below.

Last updated 02/28/2021

Store and Forward

POLICY

Asynchronous store-and-forward technologies means the transmission of a patient’s medical information from an originating site to the physician or practitioner at the distant site. The physician or practitioner at the distant site can review the medical case without the patient being present. An asynchronous telecommunications system in single media format does not include telephone calls, images transmitted via facsimile machines and text messages without visualization of the patient (electronic mail). Photographs visualized by a telecommunications system must be specific to the patient’s medical condition and adequate for furnishing or confirming a diagnosis and or treatment plan. Dermatological photographs, for example, a photograph of a skin lesion, may be considered to meet the requirement of a single media format under this provision.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

For Federal telemedicine demonstration programs conducted in Alaska or Hawaii only, Medicare payment is permitted for telehealth when asynchronous store and forward technologies, in single or multimedia formats, are used as a substitute for an interactive telecommunications system.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

In the case of any Federal telemedicine demonstration program conducted in Alaska or Hawaii, the term “telecommunications system” includes store-and-forward technologies that provide for the asynchronous transmission of health care information in single or multimedia formats.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

You must use an interactive audio and video telecommunications system that permits real-time communication between you at the distant site, and the beneficiary at the originating site.  Transmitting medical information to a physician or practitioner who reviews it later is permitted only in Alaska or Hawaii Federal telemedicine demonstration programs.

If you performed telehealth services “through an asynchronous telecommunications system”, add the telehealth GQ modifier with the professional service CPT or HCPCS code (for example, 99201 GQ). You are certifying the asynchronous medical file was collected and transmitted to you at the distant site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 4 & 11 (Accessed Feb. 2021).


ELIGIBLE SERVICES/SPECIALTIES

For Telehealth Demonstration Projects Only:

The term “telehealth service” means professional consultations, office visits, and office psychiatry services (identified as of July 1, 2000, by HCPCS codes 99241–99275, 99201–99215, 90804–90809, and 90862 (and as subsequently modified by the Secretary)), and any additional service specified by the Secretary.  The Secretary shall establish a process that provides, on an annual basis, for the addition or deletion of services (and HCPCS codes), as appropriate.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

Medicare Part B pays for covered telehealth services included on the telehealth list when furnished by an interactive telecommunications system if certain conditions are met, except that for the duration of the Public Health Emergency as defined in § 400.200 of this chapter, Medicare Part B pays for office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management and end stage renal disease related services included in the monthly capitation payment furnished by an interactive telecommunications system if certain conditions are met.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

Changes to the list of Medicare telehealth services are made through the annual physician fee schedule rulemaking process. During the Public Health Emergency for the COVID-19 pandemic, as defined in § 400.200 of this chapter, we will use a sub-regulatory process to modify the services included on the Medicare telehealth list during the Public Health Emergency taking into consideration infection control, patient safety, and other public health concerns resulting from the emergency. A list of the services covered as telehealth services under this section is available on the CMS website.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

See page 7-10 of the Telehealth Medicare Learning Network Factsheet for a full list of permanently eligible codes.

SOURCE:  Medicare Learning Network Factsheet. Telehealth Services, p. 7-10 (Accessed Feb. 2021).

List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth is available on the CMS website, including temporary codes during the public health emergency.

SOURCE:  Centers for Medicare and Medicaid Services. List of Telehealth Services.  (Accessed Feb. 2021).

The Secretary shall pay to a physician or practitioner located at a distant site that furnishes a telehealth service to an eligible telehealth individual an amount equal to the amount that such physician or practitioner would have been paid under this title had such service been furnished without the use of a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021). 

The physician or practitioner at the distant site must be licensed to furnish the service under State law. The physician or practitioner at the distant site who is licensed under State law to furnish a covered telehealth service may bill, and receive payment for, the service when it is delivered via a telecommunications system.

The practitioner at the distant site is one of the following:

  • A physician
  • A physician
  • A nurse practitioner
  • A clinical nurse specialist
  • A nurse-midwife
  • A clinical psychologist
  • A clinical social worker
  • A registered dietitian or nutrition professional
  • A certified registered nurse anesthetist

SOURCE: 42 CFR Sec. 410.78 & Medicare Learning Network Factsheet. Telehealth Services, p. 6 (Accessed Feb. 2021).

Eligible Sites:

  • The office of a physician or practitioner.
  • A critical access hospital
  • A rural health clinic
  • A Federally qualified health center
  • A hospital
  • A hospital-based or critical access hospital- based renal dialysis center (including satellites).
  • A skilled nursing facility
  • Rural emergency hospital
  • A community mental health center
  •  A renal dialysis facility for purposes of individuals with end-stage renal disease getting home dialysis.
  • The home of an individual, but only for purposes of individuals with end-stage renal disease getting home dialysis or telehealth services to treat substance use disorder or individuals with co-occurring mental health disorders, or mental health disorders under certain circumstances.

SOURCE:  Social Security Act, Sec. 1834(m) & Medicare Learning Network Factsheet. Telehealth Services, p. 4 & 5 & 42 CFR Sec. 410.78.  (Accessed Feb. 2021).

The originating site and geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke, as determined by the Secretary.

With respect to telehealth services for acute stroke, the term “originating site” shall include any or critical access hospital, any mobile stroke unit, or any other site determined appropriate by the Secretary, at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m) & Medicare Learning Network Factsheet. Telehealth Services, p. 5.  (Accessed Feb. 2021).

Providers qualify as originating sites, regardless of location, if they were participating in a Federal telemedicine demonstration project approved by (or getting funding from) the U.S. Department of Health & Human Services as of December 31, 2000.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 4 (Accessed Feb. 2021). https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

Communication Technology-Based Services (CTBS)

CMS makes separate payment for remote evaluation of recorded video and/or images submitted by the patient. The code, G2010 describes remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

HCPCS code G2010 may be billed only for established patients. The follow-up with the patient could take place via phone call, audio/video communication, secure text messaging, email, or patient portal communication.

SOURCE CY 2019 Final Physician Fee Schedule. CMS, p. 31-40.

Online digital evaluation services (e-visit) are reimbursable for physicians and qualified non-physician health care professionals.  These are non-face-to-face codes that describe patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office.

SOURCE CY 2020 Final Physician Fee Schedule. CMS, p. 799.

Interprofessional consultations are reimbursable by CMS as part of their CTBS services (CPT codes include 99451, 99452, 99446, 99447, 99448, and 99449). Cost sharing will apply. These interprofessional services may be billed only by practitioners that can bill Medicare independently for evaluation and management services.  Includes telephone and internet assessments.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40.

Medicare waives the RHC and FQHC face-to-face requirements when an RHC or FQHC furnishes communication technology-based services (Includes the Brief Communication Technology-Based Service, Remote Evaluation of Pre-Recorded Patient Information) to an RHC or FQHC patient. RHCs and FQHCs receive payment for communication technology-based services or remote evaluation services when an RHC or FQHC practitioner provides at least 5 minutes of communications-based technology or remote evaluation services to a patient who has been seen in the RHC or FQHC within the previous year.

G0071 should be billed for both services.

SOURCE:  Medicare Learning Network Matters Factsheet, MM10843, Aug. 10, 2018, & Virtual Communication Services RHCs and FQHCs FAQs, December 2019, (Accessed Feb. 2021). 

RHCs and FQHCs are not eligible for reimbursement of interprofessional consultation services, as only practitioners that can bill Medicare independently for evaluation and management services are eligible.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 31-40.


GEOGRAPHIC LIMITS

For asynchronous store and forward telecommunications technologies, the only originating sites are Federal telemedicine demonstration programs conducted in Alaska or Hawaii.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

For Telehealth Demonstration Projects Only:

The term “originating site” means only those sites described below:

  • In an area that is designated as a rural health professional shortage area under section 332(a)(1)(A) of the Public Health Service Act
  • In a county that is not included in a Metropolitan Statistical Area; or
  • From an entity that participates in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary of Health and Human Services as of December 31, 2000.

The geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of the home dialysis monthly ESRD-related visit, at a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home.

Additional exceptions exist for treatment of acute stroke and substance use disorder (see below).

SOURCE:  Social Security Act, Sec. 1834(m) & Medicare Learning Network Factsheet. Telehealth Services, p. 4 & 5.  (Accessed Feb. 2021).

Treatment of stroke telehealth services

The geographic requirements shall not apply with respect to telehealth services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke, as determined by the Secretary.

With respect to telehealth services to treat acute stroke, the term “originating site” shall include any hospital or critical access hospital, any mobile stroke unit, or any other site determined appropriate by the Secretary, at which the eligible telehealth individual is located at the time the service is furnished via a telecommunications system.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

Substance Use Disorder

The geographic requirements shall not apply with respect to telehealth services furnished on or after July 1, 2019, to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or cooccurring mental health disorder, as determined by the Secretary, or, on or after the first day after the end of the emergency period described in section 1135(g)(1)(B), subject to subparagraph (B), to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder, as determined by the Secretary at any originating site except a renal dialysis facility.

Requirements for mental health services furnished through telehealth

Payment may not be made under this paragraph for telehealth services furnished by a physician or practitioner to an eligible telehealth individual for purposes of diagnosis, evaluation, or treatment of a mental health disorder unless such physician or practitioner furnishes an item or service in person, without the use of telehealth, for which payment is made under this title:

  • within the 6-month period prior to the first time such physician or practitioner furnishes such a telehealth service to the eligible telehealth individual; and
  • during subsequent periods in which such physician or practitioner furnishes such telehealth services to the eligible telehealth individual, at such times as the Secretary determines appropriate.

These requirements do not apply to services:

  • Under this paragraph (with respect to telehealth services furnished to an eligible telehealth individual with a substance use disorder diagnosis for purposes of treatment of such disorder or co-occurring mental health disorder); or
  • Under this subsection without application of this paragraph.

SOURCE:  Social Security Act, Sec. 1834(m) & Medicare Learning Network Factsheet. Telehealth Services, p. 4 (Accessed Feb. 2021).

Originating sites must be:

  • Located in a health professional shortage area (as defined under section 332(a)(1)(A) of the Public Health Service Act that is either outside of a Metropolitan Statistical Area (MSA) as of December 31st of the preceding calendar year or within a rural census tract of an MSA as determined by the Office of Rural Health Policy of the Health ReSOURCEs and Services Administration as of December 31st of the preceding calendar year, or
  • Located in a county that is not included in a Metropolitan Statistical Area as defined in section 1886(d)(2)(D) of the Act as of December 31st of the preceding year, or
  • An entity participating in a Federal telemedicine demonstration project that has been approved by, or receive funding from, the Secretary as of December 31, 2000, regardless of its geographic location.

The geographic requirements specified above do not apply to the following telehealth services:

  • Home dialysis monthly ESRD-related clinical assessment services furnished on or after January 1, 2019, at a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home; and
  • Services furnished on or after January 1, 2019, for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
  • Services furnished on or after July 1, 2019 to an individual with a substance use disorder diagnosis, for purposes of treatment of a substance use disorder or a co-occurring mental health disorder.

SOURCE: 42 CFR Sec. 410.78 (Accessed Feb. 2021).

The Health ReSOURCEs and Services Administration (HRSA) decides HPSAs, and the Census Bureau decides MSAs. To see a potential Medicare telehealth originating site’s payment eligibility, go to HRSA’s Medicare Telehealth Payment Eligibility Analyzer.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 4 (Accessed Feb. 2021).

Communication Technology-Based Services (CTBS)

Geographic limits do not apply to Communication Technology-Based Services.


TRANSMISSION FEE

Eligible originating sites are eligible for a facility fee equal to:

  • for the period beginning on October 1, 2001, and ending on December 31, 2001, and for 2002, $20; and
  • for a subsequent year, the facility fee specified in subclause (I) or this subclause for the preceding year increased by the percentage increase in the MEI (as defined in section 1842(i)(3)) for such subsequent year.

No facility fee shall be paid under this subparagraph to an originating site that is the home.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

Treatment of Acute Stroke:  No facility fee shall be paid to an originating site with respect to a telehealth service if the originating site does not otherwise meet the requirements for an originating site, including geographic requirements.

SOURCE:  Social Security Act, Sec. 1834(m).  (Accessed Feb. 2021).

HCPCS Code Q3014 describes the Medicare telehealth originating sites facility fee. Bill your MAC for the separately billable Part B originating site facility fee. The originating site facility fee does not count toward the number of services used to determine payment for partial hospitalization services when a CMHC serves as an originating site.

SOURCE: Medicare Learning Network Factsheet. Telehealth Services, p. 11 (Accessed Feb. 2021).

Communication Technology-Based Services (CTBS)

No originating site or transmission fee for Communication Technology-Based Services.

Last updated 02/28/2021

Definition

Medicare Advantage (MA)

The term “additional telehealth benefits” means services—

  • For which benefits are available under part B, including services for which payment is not made under section 1834(m) due to the conditions for payment under such section; and
  • That are identified for such year as clinically appropriate to furnish using electronic information and telecommunications technology when a physician or practitioner providing the service is not at the same location as the plan enrollee.

The term “additional telehealth benefits” does not include capital and infrastructure costs and investments relating to such benefits.

SOURCE:  Social Security Act, Sec. 1852 (Accessed Feb. 2021).

Additional telehealth benefits means services:

  • For which benefits are available under Medicare Part B but which are not payable under section 1834(m) of the Act; and
  • That have been identified by the MA plan for the applicable year as clinically appropriate to furnish through electronic exchange when the physician or practitioner providing the service is not in the same location as the enrollee.

Electronic exchange means electronic information and telecommunications technology.

SOURCE:  42 CFR Sec. 422.135 (Accessed Feb. 2021).

Last updated 02/28/2021

Parity

SERVICE PARITY

There is service parity with what is covered through telehealth by Medicare Part B, however there is not service parity with all covered services generally.  See:

Subject to the conditions and limitations set forth in this subpart, an MA organization offering an MA plan must provide enrollees in that plan with coverage of the basic benefits (except that additional telehealth benefits may be, but are not required to be, offered by the MA plan) and, to the extent applicable, supplemental benefits by furnishing the benefits directly or through arrangements, or by paying for the benefits.

Basic benefits are all items and services (other than hospice care or coverage for organ acquisitions for kidney transplants) for which benefits are available under parts A and B of Medicare, including additional telehealth benefits.

SOURCE:  42 CFR Sec. 422.100 (Feb. 2021).


PAYMENT PARITY

MA plans offering additional telehealth benefits may maintain different cost sharing for the specified Part B service(s) furnished through an in-person visit and the specified Part B service(s) furnished through electronic exchange.

SOURCE:  42 CFR § 422.254 (Accessed Feb. 2021).

Last updated 02/28/2021

Requirements

Medicare Advantage (MA)

For plan year 2020 and subsequent plan years, an MA plan may provide additional telehealth benefits to enrolled individuals.

The Secretary shall specify requirements for the provision or furnishing of additional telehealth benefits, including with respect to the following:

  • Physician or practitioner qualifications (other than licensure) and other requirements such as specific training.
  • Factors necessary for the coordination of such benefits with other items and services including those furnished in-person.
  • Such other areas as determined by the Secretary.

If an MA plan provides a service as an additional telehealth benefit –

  • the MA plan shall also provide access to such benefit through an in-person visit (and not only as an additional telehealth benefit); and
  • an individual enrollee shall have discretion as to whether to receive such service through the in-person visit or as an additional telehealth benefit.

If a plan provides additional telehealth benefits, such additional telehealth benefits shall be treated as if they were benefits under the original Medicare fee-for-service program option.

SOURCE:  Social Security Act, Sec. 1852 (Accessed Feb. 2021).

An MA plan may treat additional telehealth benefits as basic benefits covered under the original Medicare fee-for-service program provided that the requirements of this section are met. If the MA plan fails to comply with the requirements of this section, then the MA plan may not treat the benefits provided through electronic exchange as additional telehealth benefits, but may treat them as supplemental benefits, subject to CMS approval.

An MA plan furnishing additional telehealth benefits must:

  • Furnish in-person access to the specified Part B service(s) at the election of the enrollee.
  • Advise each enrollee that the enrollee may receive the specified Part B service(s) through an in-person visit or through electronic exchange.
  • Comply with the provider selection and credentialing requirements provided in § 422.204, and, when providing additional telehealth benefits, ensure through its contract with the provider that the provider meet and comply with applicable State licensing requirements and other applicable laws for the State in which the enrollee is located and receiving the service.
  • Make information about coverage of additional telehealth benefits available to CMS upon request. Information may include, but is not limited to, statistics on use or cost, manner(s) or method of electronic exchange, evaluations of effectiveness, and demonstration of compliance with the requirements of this section.

An MA plan furnishing additional telehealth benefits may only do so using contracted providers. Coverage of benefits furnished by a non-contracted provider through electronic exchange may only be covered as a supplemental benefit.

MA plans offering additional telehealth benefits must exclude any capital and infrastructure costs and investments directly incurred or paid by the MA plan relating to such benefits from their bid submission for the unadjusted MA statutory non-drug monthly bid amount.

SOURCE:  42 CFR § 422.135 (Accessed Feb. 2021).

Last updated 02/28/2021

Cross State Licensing

Veterans Benefits

Notwithstanding any provision of law regarding the licensure of health care professionals, a covered health care professional may practice the health care profession of the health care professional at any location in any State, regardless of where the covered health care professional or the patient is located, if the covered health care professional is using telemedicine to provide treatment to an individual.

For purposes of this section, a covered health care professional is any health care professional who—

  • is an employee of the Department;
  • is authorized by the Secretary to provide health care under this chapter;
  • is required to adhere to all standards for quality relating to the provision of medicine in accordance with applicable policies of the Department; and
  • has an active, current, full, and unrestricted license, registration, or certification in a State to practice the health care profession of the health care professional.

The provisions of this section shall supersede any provisions of the law of any State to the extent that such provision of State law are inconsistent with this section.

No State shall deny or revoke the license, registration, or certification of a covered health care professional who otherwise meets the qualifications of the State for holding the license, registration, or certification on the basis that the covered health care professional has engaged or intends to engage in activity covered by subsection (a).

SOURCE:  38 USCS Sec. 1770C, (Accessed Feb. 2021).

Last updated 02/28/2021

Definitions

Controlled Substances Act

The term “practice of telemedicine” means, for purposes of this title, the practice of medicine in accordance with applicable Federal and State laws by a practitioner (other than a pharmacist) who is at a location remote from the patient and is communicating with the patient, or health care professional who is treating the patient, using a telecommunications system referred to in section 1834(m) of the Social Security Act, which practice—

  • is being conducted—
    • while the patient is being treated by, and physically located in, a hospital or clinic registered under section 303(f); and
    • by a practitioner—
      • acting in the usual course of professional practice;
      • acting in accordance with applicable State law; and
      • registered under section 303(f) in the State in which the patient is located, unless the practitioner—
        • is exempted from such registration in all States under section 302(d); or
        • is—
          • an employee or contractor of the Department of Veterans Affairs who is acting in the scope of such employment or contract; and
          • registered under section 303(f) in any State or is utilizing the registration of a hospital or clinic operated by the Department of Veterans Affairs registered under section 303(f)
  • is being conducted while the patient is being treated by, and in the physical presence of, a practitioner—
    • acting in the usual course of professional practice;
    • acting in accordance with applicable State law; and
    • registered under section 303(f) in the State in which the patient is located, unless the practitioner—
      • is exempted from such registration in all States under section 302(d); or
      • is—
        • an employee or contractor of the Department of Veterans Affairs who is acting in the scope of such employment or contract; and
        • registered under section 303(f) in any State or is using the registration of a hospital or clinic operated by the Department of Veterans Affairs registered under section 303(f);
  • is being conducted by a practitioner—
    • who is an employee or contractor of the Indian Health Service, or is working for an Indian tribe or tribal organization under its contract or compact with the Indian Health Service under the Indian Self-Determination and Education Assistance Act;
    • acting within the scope of the employment, contract, or compact described in clause (i); and
    • who is designated as an Internet Eligible Controlled Substances Provider by the Secretary under section 311(g)(2).
      • is being conducted during a public health emergency declared by the Secretary under section 319 of the Public Health Service Act; and
      • involves patients located in such areas, and such controlled substances, as the Secretary, with the concurrence of the Attorney General, designates, provided that such designation shall not be subject to the procedures prescribed by subchapter II of chapter 5 of title 5, United States Code;
  • is being conducted by a practitioner who has obtained from the Attorney General a special registration under section 311(h);
  • is being conducted –
    • in a medical emergency situation—
      • that prevents the patient from being in the physical presence of a practitioner registered under section 303(f) who is an employee or contractor of the Veterans Health Administration acting in the usual course of business and employment and within the scope of the official duties or contract of that employee or contractor;
      • that prevents the patient from being physically present at a hospital or clinic operated by the Department of Veterans Affairs registered under section 303(f);
      • during which the primary care practitioner of the patient or a practitioner otherwise practicing telemedicine within the meaning of this paragraph is unable to provide care or consultation; and
      • that requires immediate intervention by a health care practitioner using controlled substances to prevent what the practitioner reasonably believes in good faith will be imminent and serious clinical consequences, such as further injury or death; and
  • by a practitioner that—
    • is an employee or contractor of the Veterans Health Administration acting within the scope of that employment or contract;
    • is registered under section 303(f) in any State or is utilizing the registration of a hospital or clinic operated by the Department of Veterans Affairs registered under section 303(f); and
    • issues a controlled substance prescription in this emergency context that is limited to a maximum of a 5-day supply which may not be extended or refilled; or
  • is being conducted under any other circumstances that the Attorney General and the Secretary have jointly, by regulation, determined to be consistent with effective controls against diversion and otherwise consistent with the public health and safety.

SOURCE:  21 USCS Sec. 802, (Accessed Feb. 2021).

Last updated 02/28/2021

Licensure Compacts

No reference found.

Last updated 02/28/2021

Miscellaneous

No reference found.

Last updated 02/28/2021

Online Prescribing

Controlled Substance Act

No controlled substance that is a prescription drug as determined under the Federal Food, Drug, and Cosmetic Act may be delivered, distributed, or dispensed by means of the Internet without a valid prescription … Nothing in this subsection shall apply to the delivery, distribution, or dispensing of a controlled substance by a practitioner engaged in the ‘practice of telemedicine’ [see definition in section above].

SOURCE:  21 USCS Sec. 829, (Accessed Feb. 2021).

Note that the practice of telemedicine is allowed to be used in prescribing controlled substances during a public health emergency declared by the Secretary under section 319 of the Public Health Service Act; and when the patients involved are located in such areas, and such controlled substances, as the Secretary, with the concurrence of the Attorney General, designates.

SOURCE:  21 USCS Sec. 802, (Accessed Feb. 2021).

The Attorney General may issue to a practitioner a special registration to engage in the practice of telemedicine for purposes of section 102(54)(E) if the practitioner, upon application for such special registration—

  • demonstrates a legitimate need for the special registration; and
  • is registered under section 303(f) in the State in which the patient will be located when receiving the telemedicine treatment, unless the practitioner—
  • is exempted from such registration in all States under section 302(d); or
  • is an employee or contractor of the Department of Veterans Affairs who is acting in the scope of such employment or contract and is registered under section 303(f) in any State or is utilizing the registration of a hospital or clinic operated by the Department of Veterans Affairs registered under section 303(f).

Regulations. Not later than 1 year after the date of enactment of the SUPPORT for Patients and Communities Act, in consultation with the Secretary, the Attorney General shall promulgate final regulations specifying—

  • the limited circumstances in which a special registration under this subsection may be issued; and
  • the procedure for obtaining a special registration under this subsection.

SOURCE:  21 USCS Sec. 831, (Accessed Feb. 2021).

Last updated 02/28/2021

Professional Board Standards

No reference found.