Telehealth has existed for quite a while, and as its use has expanded in recent years, some healthcare groups have even provided the services to their entire network of facilities. These networks often paid for telehealth access out of their own pockets, as accessibility and financial assistance for Medicare beneficiaries has previously been very limited, with coverage only available to facilities in designated rural areas and only for patients who had a previously-established relationship with their doctor. However, on March 6, the $8.3 billion dollar Coronavirus Preparedness and Response Supplemental Appropriations Act was passed, which allowed the Department of Health and Human Services (HHS) “to temporarily waive certain Medicare restrictions and requirements regarding telehealth services during the coronavirus public health emergency.”
Then, on March 13, President Trump declared the COVID-19 outbreak a national emergency. And thus, we received the 1135 waiver, which expanded telehealth services:
Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients. Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
On March 27, CMS provided the Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit. The Tool Kit expanded the types of telehealth services that would be covered, as well as who was able to provide services via telehealth.
Furthermore, to ensure the healthcare system had the most flexibility during the COVID-19 pandemic to provide telehealth services, on March 28, CMS released the Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19. This memo opened the doors to telehealth for many Medicare residents in skilled nursing/nursing facilities, stating:
Physician visits in skilled nursing facilities/nursing facilities: CMS is waiving the requirement in 42
CFR 483.30 for physicians and non-physician practitioners to perform in-person visits for nursing
home residents and allow visits to be conducted, as appropriate, via telehealth options.
Alongside this memo, on March 29, the Coronavirus Aid, Relief, and Economic Security (CARES) Act was passed, allocating funding for telehealth access and infrastructure.
All of these efforts were undertaken to expand telehealth services and help reduce transmission of COVID-19. Now is a critical time for directors of nursing to embrace telehealth services in their facilities. Below are some frequently asked questions and answers about telehealth that DNSs need to know to ensure residents get the most out of these newly-accessible benefits.
1. What is Telehealth?
In the Coverage and Benefits Related to COVID-19: Medicaid and CHIP fact sheet, CMS defines telehealth as “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.”
2. What services are available for Medicare beneficiaries under these temporary emergency provisions, and where can beneficiaries receive services?
In the MLN Booklet: Telehealth Services, CMS states:
The specific set of services [Medicare] beneficiaries can get include evaluation and management visits (common office visits), mental health counseling, and preventive health screenings. Beneficiaries can get telehealth services in any health care facility including a physician’s office, hospital, nursing home or rural
health clinic, as well as from their homes.
3. Other than Medicare beneficiaries, who else is eligible for telehealth services during the COVID-19 pandemic?
Coverage of telehealth services for Medicaid beneficiaries still varies greatly among states. In the guidance entitled “Medicaid State Plan Fee-for-Service Payments for Services Delivered Via Telehealth,” published on March 17, CMS encourages states to consider offering telehealth services to Medicaid beneficiaries during the COVID-19 pandemic.
The Center for Connected Health Policy has put together a list of recent state actions in response to COVID-19, and you can also find out on their website if Medicaid covers telehealth in your state.
Accountable Care Organizations (ACOs)
Many ACOs are changing their current model to implement telehealth services during the COVID-19 crisis. Shared Savings Program ACOs are also receiving some financial and reporting help from CMS during this public health emergency. Facilities should contact the ACOs they utilize to find out what telehealth health options are covered.
4. Medicare telehealth visits are now available to both new and established patients
“One of the biggest changes to come out of the COVID-19 temporary relief efforts for nursing homes and telehealth services is that although some of the service types are still for established patients only, such as virtual check-ins via phone and e-visits via online patient portals, Medicare telehealth visits are now available for new or established patients,” says Denise Winzeler, BSN, RN, LNHA, DNS-CT, QCP, curriculum development specialist for AADNS.
In the Medicare Telemedicine Health Care Provider Fact Sheet, CMS included a chart that breaks down the relationship required for each type of telehealth service:
5. How can telehealth be implemented in my facility? How do I get started?
Assess your facility’s needs
Every facility is different and will have particular device needs, depending on the residents who require and are eligible for telehealth services. Review your residents to determine how many of them may need access to telehealth, as well as what devices they prefer or are able to use. Then, look at cost options, depending on the equipment you need and the packages vendors in your area provide.
In the recently-published QSO memo, QSO-20-28-NH (Question 3, Page 4), CMS mentions that Civil Money Penalty (CMP) funds may be requested for telehealth devices. CMS also states that there are some limitations such as, “applications to use CMP funds for this purpose are limited to purchasing one device per 7-10 residents with a maximum of $3,000 per facility. To apply to receive CMP funds for this purpose, please contact your state agency’s CMP contact.
Winzeler notes, “Some vendors may provide devices such as webcams, laptops, smartphones, and tablets for free. Some may also provide stethoscopes and otoscopes that can be connected to a device so that the doctor can see and hear the resident for certain assessments.”
Review CMS’s list of resources for telehealth implementation and setup on page 6 of the Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit.
Know these important resident rights and device requirements
As a prerequisite, Winzeler notes, “Before telehealth services can happen, the resident must verbally consent, and that consent must be documented in the medical record prior to the patient using the service.”
In the Interim Final Rule published April 6, 2020, CMS temporarily adjusted the requirements for telehealth consent:
[W]e are finalizing on an interim basis during the PHE for the COVID-19 pandemic that, while consent to receive these services must be obtained annually, it may be obtained at the same time that a service is furnished. We are also re-emphasizing that this consent may be obtained by auxiliary staff under general supervision, as well as by the billing practitioner.
Medicare Telehealth Visits – Must be conducted via an interactive audio and video telecommunications system.
Virtual Check-Ins – Can use a telephone, audio/video, secure text messaging, email, or a patient portal.
E-Visits – Must use an online patient portal.
For a more detailed overview of the requirements, review CMS’s Medicare Telemedicine Health Care Provider Fact Sheet.
6. Why is telehealth so important right now?
Ultimately, telehealth services are imperative right now to prevent the exposure and transmission of the coronavirus (COVID-19) to facility staff and residents.
“Many facilities are restricting who comes into the facility, as well as restricting what kind of patients they are accepting,” says Winzeler. To keep residents safer and to ensure necessary care services continue, telehealth allows appointments that would otherwise take place with an in-person doctor or at an outpatient facility to be conducted wherever the resident is located.
Telehealth also reduces travel time for doctors and practitioners—many of whom are stretched for time during this crisis. By prioritizing treatment availability over its delivery mechanism, telehealth eases practitioners’ time constraints and makes services more available to residents who need them.
7. Will SNFs continue to use this technology after the crisis is over?
“I think once they use it, people will see all of the positives as to what telehealth can do; and after that, I think facilities will want to continue to use it. However, how much we are going to be able to utilize these services after the crisis depends in part on whether CMS puts billing restrictions back in place. Or, after the crisis is over, who will qualify for it? Will CMS roll back the Medicare requirements to only those who have an established relationship, or will they continue to allow new admissions?” questions Winzeler.
While the future is uncertain, in the present it may be time for facilities to embrace this option for providing telehealth services for their residents. What begins as one more precautionary measure to prevent transmission of COVID-19 may even become something you and your residents can’t live without.
“Telehealth is a fantastic opportunity that could open so many doors to rural, or even urban, areas that cannot normally provide these services for their residents,” says Winzeler.
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