New telehealth coverage for Medicare Advantage patients

April 15, 2019

New telehealth coverage for Medicare Advantage patients

The Centers for Medicare and Medicaid Services (CMS) is moving forward with implementation of the Bipartisan Balanced Budget Act of 2018 (BBA) by offering more options to Medicare Advantage (MA) patients that want access to telehealth.  In final rules recently published, CMS announced that beginning in plan year 2020, MA plans may cover, as part of basic benefits, any telehealth service covered under Medicare Part B, without regard to the geographic restrictions or facility setting requirements that apply to regular Medicare. “Today’s policies represent a historic step in bringing innovative technology to Medicare beneficiaries,” said CMS Administrator Seema Verma in announcing the new policy.

While MA plans have always been able to offer certain telehealth benefits to enrollees, they have been classified as supplemental benefits and either funded through patient cost-sharing or rebates. The BBA allows MA plans to include these services in the capitated rate they receive from CMS. This change is expected to incentivize offering of telehealth by MA plans.

What does this mean for you?

If you are currently providing telehealth services, this could bring a new population into your practice. If you have been thinking about adopting telehealth but were concerned about reimbursement, this could change the economic picture. As more physicians participate in telehealth, those that do not could be at a competitive disadvantage, especially as tech savvy baby boomers move into Medicare and begin to demand the convenience of virtual visits.  

What types of telehealth services would be reimbursed?

MA plans would be permitted to provide, as part of basic benefits, any Part B service the plan decided was clinically appropriate to provide through telehealth. This could include evaluation and management visits and even diagnostic tests such as spirometry, in the future. These services could be provided when the patient is at home – they would not need to live in a rural area or be in a medical facility. 

There are a few restrictions however. MA plans would have to use in-network contracted providers for telehealth services and would have to provide equal coverage for in-person services.

What about other payers?

Many states have implemented coverage parity laws which require private insurers to cover services provided through telehealth to the same extent as when provided in person. In addition, some states have gone farther and require reimbursement parity thereby equalizing reimbursement of telehealth and in-person services.  In addition, 49 states require Medicaid coverage of telehealth services, although the category of service may differ from state to state.

Why doesn’t CMS expand coverage of telehealth for those enrolled in regular Medicare?

Right now, the law is clear that coverage under regular Medicare is limited to patients residing in designated rural areas who must be located in a health care facility when the remote encounter occurs. CMS does not have authority to expand coverage beyond these statutory limitations.  However, as support for telehealth ramps up, Congress may soon consider legislation that would make telehealth services available to all Medicare beneficiaries.