CMI testing of coverage of expanded telehealth services

(a)

In general

Section 1115A of the Social Security Act (42 U.S.C. 1315a) is amended— (1)in subsection (b)(2)— (A)in subparagraph (A), by adding at the end the following new sentence: The models selected under this subparagraph shall include the model described in subparagraph (D), which shall be implemented by not later than January 1, 2018.; and (B)by adding at the end the following new subparagraph:

(D)

Telehealth services in delivery reform models

The model described in this subparagraph is a model that meets the requirements of subsection (h) with respect to coverage of, and payment for, expanded telehealth services, which shall include remote monitoring services, furnished in conjunction with models that test the use of accountable care organizations under title XVIII, bundled payments under such title, and such other coordinated care models under such title as the Secretary determines to be appropriate.

;

(2)in subsection (b)(4), by striking

Evaluation.—

and inserting Evaluation.—Subject to subsection (h)(6):; and (3)by adding at the end the following new subsection:

(h)

Medicare coverage of expanded telehealth services under accountable care organization models, bundled payment models, and other appropriate models tested by the Secretary

(1)

Establishment of telehealth service models

(A)

In general

Subject to the succeeding provisions of this subsection, for the 5-year period that begins on January 1, 2018, the Secretary shall test coverage of, and payment for, expanded telehealth services (as defined in paragraph (2)) furnished to applicable individuals who are Medicare beneficiaries (as defined in paragraph (3)(B)) in conjunction with models tested under subsection (b), and expanded under subsection (c) (if applicable), that test the use of accountable care organizations under title XVIII, bundled payments under such title, and such other coordinated care models under such title as the Secretary determines to be appropriate. (B)

Model design considerations

In establishing models to be tested for enhanced telehealth services under subsection (b)(2)(D), the Secretary shall design such models in a manner to permit comparisons of Medicare beneficiaries who are participating in models under subsection (b) that include access to expanded telehealth services with Medicare beneficiaries in models under subsection (b) who do not have access to such services. (2)

Expanded telehealth services defined

(A)

In general

Subject to subparagraphs (B) and (C), in this subsection, the term expanded telehealth services means services furnished by an eligible physician or practitioner to a Medicare beneficiary as part of an episode of care for one or more of the conditions specified under paragraph (4) through one or more of the following: (i)Remote monitoring technologies, including remote device management for purposes of remotely interrogating or programming a medical device (such as a pacemaker or a cardiac resynchronization therapy device) outside the office of the physician specialist involved. (ii)Bi-directional audio/video technologies. (iii)Physiologic and behavioral monitoring technologies. (iv)Engagement prompt technologies. (v)Store and forward technologies. (vi)Point-of-care testing technologies. (vii)Such other technologies as the Secretary may specify. (B)

Inclusion of Medicare telehealth services; non-application of certain restrictions

(i)

Inclusion of medicare telehealth services

The term expanded telehealth services shall include a telehealth service, as defined in section 1834(m)(4)(F), without regard to the limitations specified under section 1834(m)(4). (ii)

Rule of construction

Nothing in this section shall be construed as imposing a requirement on the furnishing of expanded telehealth services that such services be furnished in real time through interactive audio or video telecommunications systems between the eligible physician or practitioner and the Medicare beneficiary. (iii)

No limitations on geographic areas or location of patient

The term expanded telehealth services shall include services furnished (as described in subparagraph (A)) without regard to the location of the Medicare beneficiary at the time the telehealth service is furnished and without regard to the area in which the Medicare beneficiary resides. (C)

Requirements

The term expanded telehealth services shall not include a service furnished (as described in subparagraph (A)) unless it can be demonstrated that the service, when furnished as an expanded telehealth service, is likely to do one or more of the following: (i)The service assists eligible physicians or practitioners to coordinate care for patients. (ii)The service enhances collaboration among providers of services and suppliers, including eligible physicians and practitioners, in the provision of care to patients. (iii)The service improves quality of care furnished to patients. (iv)The service results in reduced hospital admissions and readmissions. (v)The service reduces or substitutes for physician office visits. (vi)The service results in reduced utilization of skilled nursing facility services. (vii)The service facilitates the return of patients to the community more quickly than would otherwise occur in the absence of the service. (3)

Additional definitions

In this subsection: (A)

Eligible physician or practitioner

The term eligible physician or practitioner means— (i)a physician (as defined in section 1861(r)); and (ii)a practitioner (as defined in section 1842(b)(18)(C)). (B)

Medicare beneficiary

The term Medicare beneficiary means an individual who is entitled to benefits under part A or enrolled under part B of title XVIII who is not enrolled in a Medicare Advantage plan under part C of such title, an eligible organization under section 1876, or a PACE program under section 1894. (4)

Conditions

For purposes of paragraph (2)(A), the conditions with respect to which a coverage of an expanded telehealth service is furnished under this subsection shall include the following conditions or diseases: chronic hypertension, ischemic heart diseases, chronic obstructive pulmonary disease, heart failure, heart attack, osteoarthritis, diabetes, chronic kidney disease, depression, atrial fibrillation, cancer, asthma, stroke, total hip replacement procedures, total knee replacement procedures, Parkinson’s disease, and such other conditions or diseases with respect to which the Secretary determines that expanded telehealth services would satisfy one or more of the requirements of clauses (i) through (vii) of paragraph (2)(C). (5)

Payment

(A)

In general

Subject to subparagraph (B), with respect to expanded telehealth services furnished under a model tested under subsection (b) and expanded under subsection (c) (if applicable), the Secretary shall establish payment amounts under this subsection for such services. The Secretary may use one or more of the following payment methodologies for expanded telehealth services: (i)

Medicare fee schedule

Fee schedules established under title XVIII for telehealth services and remote monitoring services. (ii)

New fee schedule

A new fee schedule that the Secretary establishes for expanded telehealth services covered by reason of this subsection. (iii)

Payment amounts based on shared risk

A payment methodology for shared savings and losses that is designed to ensure savings with respect to expanded telehealth services covered under the model. (B)

Consideration of certain costs

In determining the amount of payment for an expanded telehealth service under the payment methodologies referred to in subparagraph (A), the Secretary shall take into account costs incurred by eligible physicians and practitioners— (i)for the acquisition and implementation information systems necessary to furnish such services, including costs of equipment and requisite software; (ii)for non-physician clinical personnel in conjunction with such service; and (iii)for physician interpretation of clinical data through the expanded telehealth service as well as for the supervision or oversight of the system for such service. (6)

Evaluation of models

(A)

Use of independent entity

In lieu of the evaluations conducted by the Secretary under subsection (b)(4) for models tested under subsection (b), the Secretary shall provide for evaluations of enhanced telehealth service models under subsection (b)(2)(D) by an independent entity. Such evaluation shall be conducted with respect to the specific enhanced telehealth service and condition or conditions involved that are tested under such models. (B)

Timing of evaluation

An evaluation of such enhanced telehealth service and condition or conditions involved conducted by the independent entity under this paragraph shall begin three years after the implementation of the model that provides for coverage of and payment for the expanded telehealth service with respect to such condition. (C)

Criteria

An evaluation of such enhanced telehealth service models conducted by the independent entity under this paragraph shall include an analysis of— (i)the quality of care furnished under the model, including the measurement of patient-level outcomes and patient-centeredness criteria determined appropriate by the Secretary; (ii)the changes in spending under parts A and B of title XVIII by reason of the model, taking into account costs and savings under such parts across the continuum of care for the episode of care and condition or conditions involved; and (iii)any impediments that were encountered under the model, such as— (I)explicit telehealth restrictions under Federal or State laws that are not related to health care reimbursement, such as scope of practice limitations; (II)licensing or credentialing barriers; and (III)limited broadband access or limited health information technology capabilities. (D)

Information

The provisions of subsection (b)(4)(B) shall apply to evaluations conducted under this paragraph in the same manner as such provisions apply to evaluations conducted under subsection (b)(4). (7)

Application of expanded telehealth services to all CMI models

The Secretary shall expand the application of an enhanced telehealth service with respect to the condition or conditions involved to all models tested under subsection (b), and expanded under subsection (c) (if applicable), that apply with respect to services furnished under title XVIII to provide for coverage of, and payment for, such enhanced telehealth service or services with respect to such condition or conditions under all such models for years beginning after the 5-year period described in paragraph (1)(A) if— (A)the independent evaluation conducted under paragraph (6) with respect to such models demonstrates that such enhanced telehealth service or services with respect to the condition or conditions involved resulted in— (i)reduced spending under parts A and B of title XVIII without reducing the quality of care; or (ii)improved quality of patient care without increasing such spending; and (B)the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce net program spending under parts A and B of title XVIII.

(b)

Coverage of and payment for certain enhanced telehealth services that are certified as providing savings under the medicare program

(1)

Coverage

Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by adding at the end the following new subsection:

(v)

Certified enhanced telehealth services

(1)

In general

The Secretary shall pay for certified enhanced telehealth services (as defined in paragraph (2)(A)) furnished by a physician (as defined in section 1861(r)) or a practitioner (as defined in section 1842(b)(18)(C)) to a Medicare fee-for-service beneficiary (as defined in paragraph (2)(B)) for one or more of the conditions specified under section 1115A(h)(4) in an amount determined under paragraph (3) without regard to— (A)the location of the Medicare fee-for-service beneficiary at the time the certified enhanced telehealth service is furnished; and (B)the area in which the Medicare fee-for-service beneficiary resides. (2)

Definitions

In this subsection: (A)

Certified enhanced telehealth service

The term certified enhanced telehealth service means, with respect to a condition or conditions specified under section 115A(h)(4), an enhanced telehealth service (as defined in section 1115A(h)(2)) with respect to which— (i)an independent evaluation conducted under section 1115A(h)(6) demonstrates that the service tested under a model under section 1115A(b)(2)(D) with respect to the condition or conditions resulted in— (I)reduced spending under parts A and B without reducing the quality of care; or (II)improved quality of patient care without increasing such spending; and (ii)the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce net program spending under such parts. (B)

Medicare fee-for-service beneficiary

The term Medicare fee-for-service beneficiary has the meaning given such term in section 1899(h)(3). (3)

Payment amount

The amount of payment for certified enhanced telehealth services shall be determined in the same manner as payments for enhanced telehealth services are determined under section 1115A(h)(5).

(2)

Payment

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended by striking and before (BB) and inserting before the semicolon at the end the following: , and (CC) with respect to certified enhanced telehealth services (as defined in section 1834(v)(2)(A)), the amount paid shall be an amount equal to 80 percent of the lesser of the actual charge for the services or the amount determined under section 1834(v)(3).