CMS Proposes Changes to Medicaid Network Adequacy Standards
In a proposal released on Nov. 8, 2018, CMS proposed changes to regulations on network adequacy standards. The changes would allow states to elect alternative quantitative standards to measure network adequacy, including but not limited to, minimum provider-to-enrollee ratios; maximum travel time or distance to providers, maximum wait times for an appointment, and other quantitative standards. Currently, regulations require states to establish network adequacy standards by developing and enforcing time and distance requirements for specified specialty providers. States have commented that these measurements are sometimes inaccurate, especially in locations where telehealth services are heavily used, where a provider-to-enrollee ratio provides a more accurate representation of access.
CMS proposes to allow states to use any combination of “quantitative network adequacy standards” that are appropriate for network adequacy measurement on the state level. States would select standards which provide the most accurate quantitative representation of network access for their enrollees and CMS suggests states use a combination of standards to avoid gaps in enrollee access. The proposal also clarifies that it is the responsibility of the state to define a “specialist” in determining what medical specialties will be measured under the selected network adequacy standards. Additionally, CMS proposes to eliminate the requirement on states to establish standards for “additional provider types when it promotes the objectives of the Medicaid program, as determined by CMS, for the provider type to be subject to time and distance access standards” because it may leave managed care plans with insufficient time to build network capacity to fulfill the network adequacy requirements imposed by CMS.
For more information on the changes to network adequacy standards, read the full proposal which includes additional revisions to Medicaid and CHIP managed care.
CY 2019 Physician Fee Schedule Telehealth Changes
On Nov. 1, 2018, the Center for Medicare and Medicaid Services (CMS) released their CY 2019 final revisions related to the Physicians Fee Schedule (PFS). The newly adopted policies in the rule aim to modernize the healthcare system and help “restore the doctor-patient relationship” by reducing administrative burden. The changes related to telehealth are significant, as it not only expands Medicare telehealth services, but communicates a new interpretation by CMS of the applicability of their statutory requirements for reimbursement of remote communication technology as separate from telehealth, and adds new services based on this interpretation. Specifically, it allows for reimbursement of virtual check-ins, remote evaluation of pre-recorded patient information and interprofessional internet consultations, although none of these items fall under Medicare’s definition of telehealth according to the finalized PFS. CMS also adds new codes to the Medicare telehealth list, chronic care management and remote patient monitoring and expands telehealth reimbursement for end stage renal disease and acute stroke based on requirements in the Bipartisan Budget Act of 2018. Additionally, within the final rule, is an interim final rule, which implements changes made by the SUPPORT for Patients and Communities Act, providing exemptions from some of CMS’ telehealth requirements for the treatment of substance use disorder (SUD), and providing a 60 day comment period.
For more information, read the full text, and see CCHP’s factsheet and infographic on the proposal. Additionally, check out CCHP’s infographic on how the rule will apply to FQHCs and RHCs specifically.
Medi-Cal Proposed Changes to Telehealth Policy
Last month The California Department of Health Care Services (DHCS) released two proposals impacting telehealth policy in the state’s Medicaid program known as Medi-Cal. The first was a proposal to update and clarify the Department’s telehealth policy manuals, and provide specific instructions for different programs across their care delivery system, including managed care, Indian Health Services, Family Plan, Access, Care and Treatment (Family PACT), dentistry and federally qualified health centers (FQHCs)/rural health clinics (RHCs) . Among the most intriguing and exciting proposals is allowing the distant site/treating provider to decide when it is appropriate for telehealth to be used and whether it should be via live video or store-and-forward. E-consult (provider to provider consultation), falling under the auspice of store-and-forward, would also be reimbursed through two CPT codes, making California along with Connecticut the only state Medicaid programs in the country reimbursing for that particular service. Other intriguing proposals include expansion of the originating site to include the home and what appears to be other non-clinical locations. DHCS will be hosting a webinar on December 17 to review the policy, discuss any revisions and feedback and chart a path forward.
The second proposal, is a State Plan Amendment (SPA) intended for submission to the Centers for Medicare and Medicaid Services (CMS) that provides clarification as to when services provided outside of the “Four Walls” of a federally qualified health center (FQHC) or rural health center (RHC) is eligible for the prospective payment system (PPS). It is proposed that all such services be paid the PPS rate when rendered to homebound, migratory, seasonal workers and homeless patients, patients in the hospital, dental services rendered to established patients by a contracted dental provider, and telehealth services provided to its established patients when certain requirements are met. The proposed SPA lays out several requirements that apply to all of the exceptions listed above for services rendered outside of the Four Walls, and others that apply specifically to telehealth and store-and-forward services.
To learn more about the proposed requirements for telehealth services billed at the PPS rate for FQHCs and RHCs outside the Four Walls, or any of the other exceptions, see the full text of the proposed SPA.
Omada Health Digital Diabetes Prevention Program Receives Full CDC Recognition
Earlier this year, Omada Health, an organization specializing in digital approaches to behavioral health, received full recognition status by the Centers for Disease Control and Prevention (CDC) for diabetes prevention. Omada received pending recognition in 2015 for its virtual diabetes prevention program and since then has undergone review to ensure that the program meets minimum standards for user engagement and participant weight loss.
While Omada Health states that it is now the largest virtual provider recognized under the National Diabetes Prevention Program, the organization is ineligible for Medicare reimbursement for its virtual diabetes prevention programs. The Medicare Diabetes Prevention Program (MDPP) is limited to in-person health education which may exclude participants who are unable or unlikely to attend an in-office session. While recent changes to CMS telehealth policies are likely to have no effect on reimbursement for virtual health behavior programs, the new virtual services in the CMS physician fee schedule may open a path for future reimbursement for these programs.
For more information on Omada Health’s virtual diabetes prevention program, visit their website for press releases.
FCC Urged to Expand Rural Broadband Expansion Efforts
The Federal Communications Commission (FCC) received a joint letter earlier this month from organizations requesting the Commission expand its support of White Spaces technology. The technology uses unused TV broadcasting channels to deliver broadband internet connections to rural areas which are difficult to reach with other technologies. Signals transmitted through white space technology safely travel around environmental obstacles such as mountains and valleys and are being used by organizations such as Tribal Digital Village (TDVNet) to deliver broadband services to rural tribal land in Valley Center, California to support schools, libraries, medical, and health care providers.
The FCC has been supporting the use of white spaces since 2010, when it adopted final rules expanding their use to radio transmitters and services such as wi-fi. The joint letter, supported by forty-four companies and organizations, suggests the FCC could further support white space technology through:
- Higher power or fixed devices in rural areas to allow operation without causing harmful interference to broadcasters;
- A new protection mechanism allowing antenna placement at larger heights;
- Narrowband IoT operations for supporting important applications including precision agriculture and environmental sensing; and
- Geofenced operation on moving vehicles.
The group is a part of Connect Americans Now (CAN), a community aimed at expanding broadband access to rural Americans. Microsoft, a member of CAN, has invested in rural internet providers through its Airband Grant Fund and granted royalty-free access to their white space technology patents.
More information about White Space technology and related policies is available through the FCC website.
Check out CCHP’s Newly Renovated Website & Updated Report on Telehealth Policies Nationwide
Last month CCHP unveiled the Fall 2018 edition of it’s State Telehealth Laws and Reimbursement Policies Report, which was released in conjunction with CCHP’s redesigned website. The Fall 2018 report offers policymakers, health advocates and other interested health care professionals a freshly redesigned compendium of state telehealth laws, regulations and Medicaid policies. The new report features the same detailed telehealth policy information (with references) found in previous reports, but in a fresh new format with policies grouped into three primary categories (Medicaid Reimbursement, Private Payer Laws, and Professional Regulation). This report was made possible through generous support from the Health Services & Resources Administration and the California Health Care Foundation. CCHP’s redesigned website, includes its interactive telehealth policy map version of the report, redesigned to correlate with the three primary policy categories listed above. CCHP’s website also now incorporates a new publicly available and free telehealth legislative and regulatory tracking U.S. map tool. The new tool allows users to easily view pending legislation and regulation as it progresses through state and federal legislative sessions and is updated on a daily basis with direct access to primary bill and regulatory text documents.
For more information check out the CCHP website!
State Regulation Updates
New York, Office for People with Developmental Disabilities
Emergency regulation that authorizes telehealth as a new mechanism to deliver clinical services is necessary to protect the health, safety, and welfare of individuals receiving services in the OPWDD system. The proposed/emergency regulation will allow individuals to receive clinical services via telehealth. VIEW REGULATION (Emergency Rule Filed Oct. 17, 2018 – Now effective)
Arkansas, Medical Board
Amends rules related to requirements around establishing a patient provider relationship to replace the words “physician/physician assistant” with “provider” and define “Provider” as a person licensed by the Arkansas State Medical Board. VIEW REGULATION (Comment Deadline: Dec. 6, 2018)
Oregon, Health Authority
Establishes regulations to provide guidance to Medicaid dental providers on the use of teledentistry. Includes guidance on live video, store-and-forward, remote patient monitoring, and mobile communication. Covers reimbursement for all the listed modalities. VIEW REGULATION (Comment Deadline: Dec. 20, 2018)
Missouri, Department of Social Services
Amends rules related to reimbursement of the telehealth originating site fee. Excludes costs and charges for the originating site fee from the outpatient cost-to-charge ratios. Effective November 30, 2018, establishes the originating site fee to be paid at the lesser of the billed amount or the outpatient fee schedule amount. VIEW REGULATION (Effective: January 1, 2019)
For more information on state legislation and regulations,