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Medicare Advantage Issuers Can Put Telehealth In 2020 Basic Benefits: CMS

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The agency that manages the Medicare Advantage program has made a rule change that could lead to a dramatic increase in use of telehealth services by all Americans.

The Centers for Medicare and Medicaid Services (CMS) today posted a final Medicare regulation package that includes the rules health insurers can use when adding telehealth benefits to 2020 Medicare Advantage plans.

CMS has implemented Section 50323 of the Bipartisan Budget Act of 2018 — which encourages CMS to expand Medicare use of telehealth benefits — by letting insurers put telehealth benefits in their basic benefits packages for 2020 Medicare Advantage plans.

(Related: Getting Paid for Using Telehealth to Keep Women Alive Is Hard: Startup Exec)

The new regulation will have no direct on ordinary individual or group major medical coverage.

But, because Medicare is such big program, any changes it makes may end up leading to voluntary changes at commercial health insurers.

The Background

The Medicare Advantage program gives private insurers a chance to offer plans that serve as an alternative to traditional Medicare Part A hospitalization coverage and Medicare Part B outpatient and physician services coverage.

Medicare Advantage plans now cover about 23 million people, or about 7% more than they were covering a year ago, according to enrollment data from Mark Farrah Associates.

Health insurers go through a complicated bidding process to get plans into the Medicare Advantage program.

In the past, Medicare Advantage plan issuers had to offer telehealth benefits, such as care delivered through videoconferencing, as supplemental benefits. Plans would reimburse providers for telehealth services only if the patients getting the services were in medical facilities in rural areas.

The New Regulation

Starting in 2020, a Medicare Advantage plan will be able to pay for primary care, a dermatology consultation or any other care normally included in Medicare Part B benefits when the care is provided through any “electronic exchange.”

CMS officials have defined “electronic exchange” to refer to “electronic information and telecommunications technology.”

Some commenters asked CMS to give examples of “electronic exchange” systems.

“We do not include this specific regulation text in the final rule because technology will vary based on user and over time,” CMS officials say in the introduction to the rule text.

CMS wants to avoid limiting plans to covering telehealth services provided in specific information formats, or through specific technologies, officials say.

Limitations in the New Regulations

CMS says plans must continue to provide coverage for traditional, in-person care for any services that will be covered through telehealth services.

A plan cannot, for example, cover dermatology visits through videoconferencing and end coverage for in-person dermatology care.

Because of statutory provisions, issuers must exclude the cost of setting up telehealth program infrastructure from their bids.

CMS officials say they’re trying to interpret that provision in a narrow way.

The bid for basic benefits submitted by a Medicare Advantage plan must simply exclude capital and instructure costs directly or incurred by the Medicare Advantage plan itself, officials say.

 

Officials say they will not give a specific definition of “capital and infrastructure costs or investments” because telehealth strategies and costs will vary from plan to plan.

Procedural Details

The regulation is set to appear in the Federal Register April 16.

The contact people for the telehealth section of the regulation are Theresa Wachter and Cali Diehl.

Resources

A link to the final rule is available here.

A link to a summary of the final rule is available here.

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