Before Covid-19, only a small sliver of Medicare beneficiaries could access virtual care. They had to be in a rural setting, not an urban or suburban setting. They also could only use telehealth in an approved originating site, like a hospital or physician’s office. Just 2% of Medicare beneficiaries meet this criteria, according to McDermott+Consulting.
These restrictions were waived during Covid-19, thereby greatly expanding access to telehealth services for Medicare beneficiaries. Congress has extended the waivers twice — most recently through the Consolidated Appropriations Act of 2023 — but they are set to expire on December 31. This would result in telehealth returning to a rural-only benefit once again for Medicare enrollees.
Unless Congress acts, that is, and the clock is ticking.
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Legislative days are limited in an election year, which is why telehealth advocates are calling on Congress to pick up the pace so key healthcare stakeholders like the Centers for Medicare and Medicaid Services (CMS) have adequate time to prepare for the reimbursement of telehealth.
“Congress should just go ahead and do what we know they’re going to do anyhow and not allow these flexibilities to expire and save us from sweating it up until the very last minute,” said Kyle Zebley, senior vice president of public policy at the American Telemedicine Association, in an interview. “I’m very confident that Congress will do that. But just because of how Congress works … the Christmas decorations will be up when we see this and we’ll be within throwing distance of all these flexibilities expiring before Congress finally takes action.”
CMS’ hands are tied
Each year, CMS has to establish Medicare payment policies through the physician fee schedule, which is usually proposed in June or July, finalized around November 1 and then goes into effect January 1. CMS usually revises what telehealth services are reimbursable in the physician fee schedule.
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However, Congress’ deadline for extending the waivers isn’t until December 31. Currently, the House Ways & Means Committee and House Energy & Commerce Committee both have pieces of legislation that would extend telehealth flexibilities for another two years, but nothing has been passed yet. There are also bills that would make Medicare telehealth flexibilities permanent, but it is more likely for there to be an extension, Zebley said.
According to Rachel Stauffer, vice president of McDermott+ Consulting, Congress has indicated that they’re not going to address Medicare telehealth flexibilities until after the election. This means it’s possible CMS will go through the rulemaking process without official word from Congress on Medicare telehealth flexibilities, Stauffer said.
“I think that Congress will extend these flexibilities,” she said in an interview. “I don’t think they’re going to let them lapse. It’s really more about the impact of the timing of those policies.”
A report from McDermott+ Consulting showed that there are a few possible outcomes if Congress passes legislation after CMS’ proposed regulation is released.
- Legislation is passed between June/July and November 1: If this happens, CMS may be able to make some changes in the final regulation based on the legislation and could create a small interim final regulation to establish new policies that weren’t previously proposed.
- Legislation isn’t passed before November 1: The policies in CMS’ final regulation will go into effect on January 1 without including Medicare telehealth flexibilities.
- Legislation is passed between November 1 and December 31: If Congress passes legislation after the physician fee schedule final rule, CMS could issue a separate interim final rule for telehealth policies. However, this could be difficult to do before January 1.
Zebley, however, is confident that CMS can move quickly.
“We know CMS is extremely nimble and adept at rolling with changing circumstances,” he said. “When these telehealth flexibilities were originally put in place, it was contingent on the ongoing Covid-19 public health emergency, which was only renewed in 90-day increments for the rest of the Trump administration.” Meaning that CMS would be in a difficult position if Congress waited until the last minute to allow telehealth waivers to remain, but has experience acting quickly.
The benefit of telehealth for seniors
Despite there being a stereotype that seniors don’t like to use technology, that is not actually the case, research shows.
According to a study published in the Journal of the American Geriatrics Society, most seniors prefer in-person care, but still want telehealth to be available. Seniors also reported being satisfied with telehealth and find it convenient.
“Medicare beneficiaries have really come to rely upon telehealth,” Zebley said. “It has become a term that Medicare beneficiaries — like the rest of the healthcare population — are very comfortable with. They’ve grown to rely upon it and expect it.”
He noted that telehealth doesn’t just mean video sessions but audio-only sessions through the phone, which is something seniors tend to be very comfortable with.
Zebley gave the example of his own two grandmothers, Althea and Virginia.
“Althea has never typed on a keyboard, has never handled a smartphone. … But she knows how to take a phone call and she’s very comfortable with receiving care that way,” Zebley said. “My 96-year-old grandmother, Virginia, just friended me on Instagram last year. She’s had email for 30 years. She’s very comfortable having an online presence and interacting with physicians through audio/visual telehealth.”
What’s at stake
If an extension is not made, there will be “significant issues with access to care,” Stauffer said.
“People will have to go back to in-person for everything,” she said. “They wouldn’t have the ability to call or have a video visit if it’s a cold, if it’s a cough, maybe a dermatological issue.”
Telehealth companies that primarily serve Medicare patients will also be severely hampered.
“If they can’t bill, they don’t exist,” Stauffer urged. “Some of these things are very real for patients and they’re very real for providers. Some of them are small startups, innovative companies that are really trying to make a difference in the space and they can’t function and thrive if those flexibilities go away.”
Leslie Krigstein, vice president of communications and government affairs at San Francisco-based Transcarent, echoed Stauffer’s comments.
“I think everyone would say they just can’t imagine these flexibilities going away because it has become so mainstream in the delivery of care across payers, Medicare, Medicaid, commercial,” Krigstein said in an interview. “So it would be a huge setback for the industry. I think it would be a huge loss for patients and I think would also put providers at a significant disadvantage in meeting the needs of their patients.”
Transcarent offers virtual services for everyday health, pharmacy, behavioral health, surgery and oncology. It primarily serves employers, though Medicare is a small portion of its business.
Krigstein added that while Transcarent strongly supports the extension of telehealth Medicare flexibilities, the company is more focused on the High-Deductible Health Plan (HDHP) Safe Harbor, which allows employers and health plans to offer coverage for telehealth services on a pre-deductible basis for those with HSA-eligible HDHPs. This is also set to expire at the end of the year.
Zebley noted that there are a host of other telehealth flexibilities that could expire December 31, including the virtual prescribing of controlled substances. And he added that the healthcare system tends to follow what happens in Medicare.
“Medicare fee-for-service, Medicare Part B, is the biggest single payer in the country,” he said. “It covers tens of millions, and it sets the standard for the rest of the healthcare system.”
In other words, if Congress fails to extend telehealth flexibilities for Medicare, the entire healthcare system could possibly follow suit, sounding the death knell for wide swaths of telehealth.
Photo: Maria Symchych-Navrotska, Getty Images
