Telemedicine

THE ISSUE:

Telemedicine allows physicians and other health care clinicians to evaluate, diagnose, and treat patients at a distance using telecommunications technology. The dramatic increase in telemedicine utilization prompted by the COVID-19 pandemic has underscored the vital role telemedicine plays in providing continuity of and improved access to care. Telemedicine has quickly become an essential part of the core health care infrastructure in the Commonwealth.

Telemedicine technology can address some of the greatest health care challenges in Massachusetts, including inequities in access to care, quality, and cost of care. Uses of the technology span from: monitoring the most critical ICU patients; providing 24-7 access to urgent care; better follow-up care after a procedure with frequent, check-ins by physicians and nursing staff; and greater care coordination, increasing medication adherence, etc. Telemedicine:

• Helps overcome access barriers for patients; extending geographic reach and expertise of physicians;
• Addresses inequities in access to care for patients who have difficulty traveling to a physician office because of location-, age-, disability-, and/or socioeconomic status-related challenges;
• Reduces missed appointments; increasing the capacity and efficiency of physical workspaces;
• Improves the quality of care provided;
• Ultimately helps lower health care costs as a result of the efficiencies and improved quality of care.

In January 2021, the Massachusetts legislature passed Chapter 260 of the Acts of 2020, which established a comprehensive framework for the coverage and reimbursement of health care services delivered via telemedicine for all state-regulated commercial plans and public plans. Chapter 260 includes an expansive definition of telehealth, mandates coverage for all services that are covered in-person and can appropriately be delivered via telehealth, and requires parity in reimbursement for behavioral health services (delivered via both interactive audio-visual and audio-only technologies) in perpetuity and parity in reimbursement for primary care and chronic disease management services through the calendar year 2022. Chapter 260 also includes important patient protections, including, for example, a prohibition on requiring a documented barrier to in-person services in order to access care via telehealth.

The COVID-19 State of Emergency was lifted on June 15th, 2021, triggering the sunset of certain requirements for telehealth parity reimbursement. While all services that can be appropriately delivered via telehealth will continue to be covered permanently, per Chapter 260 of the Acts of 2020, requirements for parity in reimbursement are scheduled to sunset at various times, depending on the type of care. Specifically:

• Behavioral health services, including those delivered through interactive audio-visual and audio-only technologies, will continue to be reimbursed on par with in-person services in perpetuity;
• Primary care and chronic disease management services* will be reimbursed at parity for 2 years from the effective date of C.260, through the calendar year 2022;
• The requirement to reimburse all other services delivered via telehealth at parity will no longer be statutorily mandated starting 90 days after the close of the state of emergency, or September 13, 2021.

*The Division of Insurance will be issuing regulations in 2021 to provide detailed definitions of these terms.

OUR STANCE:

The MMS supports:

• Mandated coverage for all medically necessary health care services appropriately delivered through telemedicine technology, as determined by physicians
• Parity in reimbursement for services appropriately delivered via telemedicine on par with services delivered in-person
• Parity in the application of deductibles, copayments, or coinsurance requirements for services delivered via telemedicine consistent with payments that would be charged for the same service delivered in-person
• Prohibiting the requirement of a documented barrier to an in-person visit
• Prohibiting setting limitations on where telemedicine services can be provided
• Proxy credentialing and privileges for physicians providing care through telemedicine consistent with federal Medicare Conditions of Participation telemedicine standards
• Mechanisms to promote the appropriate practice of medicine, including via telemedicine, across state lines
• Efforts to promote equity in access to care via telemedicine, including investments in telecommunications services, broadband and internet connectivity services, digital technology, and support for expanded access to telehealth technologies and technological literacy for patients

To learn more about MMS telemedicine policies, click here.

RECENT ADVOCACY:

The Medical Society played a key role in advocating for the passage of telehealth policies as part of Chapter 260 of the Acts of 2020. The MMS actively engaged with the Division of Insurance and MassHealth, submitting comments throughout a 5-part listening session series related to the regulatory implementation of key telehealth provisions in Chapter 260. Chapter 260 included sweeping policy provisions subject to varying interpretation by different stakeholders, making regulatory advocacy critical to ensure that any guidance or rules promulgated by the Division are in alignment with the spirit of Chapter 260, which is ultimately to improve access to care for patients through telemedicine. The physician community provided a unified, leading voice with a clear foundational message: telehealth is an evolving modality for care delivery that should be treated and compensated on par with in-person services. MMS advocated for physician autonomy, payment parity, and patient access, with the physician voice playing a prominent role in shaping how the state will ultimately implement the recently enacted telehealth law. Notably, MMS advocated for:

• Consistent policies across payors and flexibility in the use of telehealth technologies;
• Limiting unnecessary regulation of telemedicine visits and expansive, inclusive definitions of behavioral health, primary care, and chronic disease management services.
• Reimbursement frameworks that do create bright-line distinctions (e.g. between interactive A/V and audio-only technologies) that may codify policies that perpetuate racial disparities and other forms of discrimination into our payment system; and use of the full panoply of existing CPT, office-based E&M, and other codes used for health care services with a modifier to indicate delivery through telehealth.
• Primacy of clinical decisions related to the appropriateness of telemedicine to deliver services, alongside critical safeguards to ensure that we do not create new barriers to accessing care through telemedicine through unfettered, unnecessary, or burdensome utilization review and prior authorization requirements.

MMS anticipates the promulgation of regulations by the Division of Insurance in the near term. In the interim, the DOI has issued guidance via Bulletin 2021-10 outlining expectations on carriers relative to changes in telehealth payment policies. Specifically, carriers electing to change their telehealth rates of reimbursement are subject to Chapter 175 section 24B, which requires 60 days’ notice of such material changes. Therefore, carriers amending their telehealth reimbursement policies must submit an implementation plan to be reviewed by the DOI and may not implement any changes to its telehealth rate policies or notify providers of any changes prior to submitting its implementation plan to the Division.

Separately, MassHealth issued All Provider Bulletin 327, announcing updated telehealth policies which took effect October 16th, 2021. MassHealth continues to provide robust, comprehensive coverage for all medically necessary health care services that the provider has determined is clinically appropriate to deliver and that meet additional program requirements. This covers delivery through any telehealth modality, including telephone and asynchronous services. Notably, successful advocacy has secured continued parity in reimbursement on par with in-person services for eligible services through December 31, 2022, after which MassHealth may evaluate and choose to amend these policies.

The MMS continues to work actively with key stakeholders, including more than 35 health care provider organizations, consumer advocates, and technology organizations, through the statewide tMED Coalition, the Massachusetts Telemedicine Coalition, to advocate for passage of telehealth legislation (H.1101/S.678) that builds upon the framework laid out in chapter 260 to promote equitable access to care through telehealth for all patients.