Congress Mulls Audio-Only Telehealth Coverage for MA, PACE Members

A new bill before Congress aims to ensure Medicare coverage for audio-only telehealth services during the coronavirus pandemic for Medicare Advantage and PACE (Program of All-Inclusive Care for the Elderly) members.

The Ensuring Parity in MA and PACE for Audio-Only Telehealth Act (HR 2166), introduced this week by US Reps. Terri Sewell (D-AL), Rep. Gus Bilirakis (R-FL), Tony Cárdenas  (D-CA), Brian Fitzpatrick (R-PA), Chrissy Houlahan (D-PA), Ron Kind (D-WI), Jason Smith (R-MO) and Jackie Walorski (R-IN), would set payment parity for “qualified diagnoses” obtained through a telehealth platform that does not include a video encounter.

The bill aims to improve access to care for members in those Medicaid programs who don’t have the means – either because of location, finances or broadband resources – to connect with providers on an audio-visual telemedicine platform.

“As we recover from COVID-19, we must ensure vulnerable patients, especially our seniors and those managing chronic conditions, are able to safely and conveniently access the appropriate care management and related services they need,” Bilirakis said in a press release. “To do this, we need to empower patients and their providers with more, not less, options to accurately, safely, and conveniently capture patient health statuses.”

The bill targets two programs managed by the Centers for Medicare & Medicaid Services that have started using connected health more frequently during the COVID-19 public health emergency, when access to in-person care is limited, but still require that those services be delivered over an audio-visual platform.

And it focuses on a modality – the audio-only phone – that may often be the only source of contact for seniors and their care providers.

“We know that in-person physician office visits dropped precipitously during the pandemic, and many seniors lack the tools to complete an audio-video telehealth appointment,” Allyson Schwartz, president and CEO of the Better Medicare Alliance, said in a press release supporting the bill. “Medicare Advantage must be equipped to meet beneficiaries where they are by allowing access to care through a simple phone call where appropriate or when beneficiaries lack other technological means. In addition, it is critical that information on health conditions and diagnoses that are obtained via audio-only telehealth be allowed to count for risk adjustment purposes.”

The bill would also affect the roughly 135 PACE programs in 31 states, serving more than 54,000 seniors. PACE was created by CMS for seniors who need long-term support services (LTSS), or a nursing home level of care. Developed as a capitated model of care for dual-eligible beneficiaries (ninety percent are dual eligible), it provides all necessary medical care, therapies, long term care and services, meals, socialization, transportation, day center services and activities.

These programs have traditionally shied away from telehealth in favor of hands-on care, but more and more are looking at remote patient monitoring and telehealth platforms to improve access to care and expand their operations.

“The ability to provide care remotely has been key to keeping PACE enrollees and PACE staff safe during the pandemic,” National PACE Association President and CEO Shawn Bloom said in the House press release. “The ability to submit diagnoses obtained through audio-only encounters during our national health emergency is key to ensuring providers are paid adequately.” 

The bill defines a qualified diagnosis as “a diagnosis made with respect to a chronic disease or condition of an individual during a plan year if such diagnosis was also made with respect to such individual in one of the last of the 3 plan years preceding such plan year.”

While several states and federal agencies have enacted emergency measures during the pandemic to allow coverage for audio-only telehealth, critics say the platform isn’t good enough for most healthcare services because it doesn’t establish a good doctor-patient relationship.