Medicare Updated Telehealth Factsheet

By Center for Connected Health Policy - Recently, the Centers for Medicare and Medicaid Services (CMS) updated and released their Medicare Learning Network (MLN) factsheet on Telehealth Services. Pre-COVID, CMS published an updated Telehealth Factsheet annually, although throughout the course of COVID the factsheet had been updated less frequently as temporary policy changes made it difficult to keep pace. Earlier this year, the factsheet was taken down and had been listed as unavailable on the CMS website for the past few months. Presumably, CMS was working to update it with the most recent telehealth policy changes given the extension of many of the COVID telehealth flexibilities until December 31, 2024 due to the passage of the Consolidated Appropriations Act, 2023. Some key clarifications made in the updated factsheet include:

• Through December 31, 2024, all patients can get telehealth wherever they’re located. They don’t need to be at a specific type of originating site, and there aren’t any geographic restrictions.

• After December 31, 2024:

  • For non-behavioral or mental telehealth, there may be originating site requirements and geographic location restrictions

  • For behavioral or mental telehealth, all patients can continue to get telehealth wherever they’re located, with no originating site requirements or geographic location restrictions if certain conditions are met

• Through December 31, 2024, all providers who are eligible to bill Medicare for professional services can provide distant site telehealth.

• Providers can use audio-only telehealth for some non-behavioral or mental telehealth through December 31, 2024.

• CMS requires patient consent for all care management and virtual communication services, including non-face-to-face services. Consent can be obtained at the same time a provider initially provides the services. The person getting consent can be an employee, independent contractor, or leased employee of the billing practitioner.

• Starting July 1, 2023, providers must report the use of telehealth technology (see factsheet for G-Codes) in providing home health (HH) services on HH payment claims.

• Through December 31, 2024:

  • Telehealth can be used to conduct hospice care eligibility recertification

  • For behavioral or mental telehealth, providers don’t have to conduct an in-person visit within 6 months of the initial telehealth visit or annually thereafter

  • CMS has extended the Acute Hospital Care at Home Program.

In addition to adding the information above, CMS also made significant deletions from the previous version of their factsheet, including the permanent eligible originating site list, explanation of the requirement for patients to be located in rural areas and the permanent distant site provider list. In this current version, CMS merely mentions in one bullet point that originating site requirements and geographic restrictions for non-behavioral or mental telehealth ‘may’ go back into effect after Dec. 31, 2024. This was likely done for the sake of clarity so as not to confuse providers between current reimbursement policy (effective for the most part until December 31, 2024) and permanent policy (which will go into effect on Jan. 1, 2025). It could also indicate an expectation that permanent policy (which is in statute) could potentially be amended before Jan. 1, 2025.

For more on current Medicare telehealth policy, see the MLN Telehealth Services Factsheet.

New pregnancy bias law broadly protects workers, US agency says

By Daniel Wiessner - The U.S. Equal Employment Opportunity Commission on Monday proposed a rule endorsing a broad application of a new federal law extending stronger legal protections to pregnant workers. The EEOC proposal is designed to implement the Pregnant Workers Fairness Act (PWFA), which took effect last month after President Joe Biden signed it into law late last year. The commission is tasked with enforcing the law. Read Full Article…

VBA Article Summary

1. PWFA's Bipartisan Passage and Aim: The Pregnant Workers Fairness Act (PWFA) was passed by Congress with the backing of both parties and the strong endorsement of major business groups, including the U.S. Chamber of Commerce. The law aims to clearly define the legal responsibilities of employers. This legislation mandates that businesses offer reasonable adjustments to pregnant workers, such as restrictions on heavy lifting and increased breaks. Before the enactment of the PWFA, these accommodations were only necessary if they were also extended to employees with medical conditions or injuries.

2. EEOC's Proposal and Recommendations: The Equal Employment Opportunity Commission (EEOC) detailed various possible accommodations under the new law, like altered work schedules, more breaks, equipment and uniform modifications, seating provisions, remote work options, and both paid and unpaid leave. Furthermore, employees have the right to request a temporary pause in certain essential job functions during their pregnancy, with the expectation to resume post-pregnancy. The EEOC plans to publish this proposal formally, initiating a 60-day period for public commentary. EEOC Chair Charlotte Burrows expressed the importance of this civil rights legislation for the well-being and financial security of pregnant and postpartum workers, emphasizing its significance for workplace retention.

3. Scope, Controversies, and Impact: The PWFA is comprehensive, covering not only pregnancy but also childbirth and related medical situations. The EEOC clarified that the "related medical conditions" encompasses matters like abortion, birth control usage, menstruation, lactation, fertility procedures, and miscarriages. While some Republicans and conservative groups voiced concerns about potential religious exemptions, particularly regarding abortion, the EEOC maintained that the law's implications for employers would be minimal. In their statement, the EEOC highlighted that in 2021, women between the ages of 16 and 50 constituted around a third of the American workforce, and a fraction, under 5%, had given birth in the preceding year.

Medicare Advantage in 2023: Premiums, Out-of-Pocket Limits, Cost Sharing, Supplemental Benefits, Prior Authorization, and Star Ratings

By Nancy Ochieng, Jeannie Fuglesten Biniek, Meredith Freed, Anthony Damico, and Tricia Neuman - People with Medicare have the option of receiving their Medicare benefits through the traditional Medicare program administered by the federal government or through a private Medicare Advantage plan, such as an HMO or PPO. In Medicare Advantage, the federal government contracts with private insurers to provide Medicare benefits to enrollees. Medicare pays insurers a set amount per enrollee per month, which varies depending on the county in which the plan is located, the health status of the plan’s enrollees, and the plan’s estimated costs of covering Medicare Part A and Part B services. Read Full Article…

VBA Article Summary

1. Medicare Advantage Coverage and Benefits: Medicare Advantage (MA) plans utilize payments to cover Medicare services while often offering additional benefits with reduced costs. These plans are required to adhere to federal standards, including setting an out-of-pocket cap. MA plans have the flexibility to restrict networks and mandate pre-approval for specific services.

2. Enrollment and Enhanced Benefits in 2023: In 2023, approximately 73% of individual MA plan enrollees solely pay the Medicare Part B premium, making these plans appealing to beneficiaries. These plans include supplementary benefits such as vision, dental, and hearing coverage, facilitated by rebates exceeding costs ($2,350 per enrollee on average), a figure more than doubled since 2018. Nearly all enrollees (99%) are subject to prior authorization for certain services and are confined to limited provider networks.

3. Quality Ratings and Accessibility: A significant majority of MA plans achieve 4 out of 5 stars in quality ratings, a reflection of 73% of enrollees in 2023 who pay no extra premium beyond Part B. Premiums have experienced a decrease since 2015, averaging $15 per month in 2023. Out-of-pocket limits average at $4,835 for in-network services and $8,659 for both in-network and out-of-network services. Enrollees enjoy a range of benefits, with Special Needs Plans (SNPs) offering more services tailored to specific needs. Prior authorization is common, impacting almost all enrollees (99%). Approximately 71% of enrollees in 2023 are part of plans with 4 or more stars. The conclusion of COVID-19-related measures affects ratings.

In summary, Medicare Advantage plans offer diverse benefits, with the majority of enrollees not incurring extra premiums. Rebates play a role in funding supplementary coverage, although details about utilization and out-of-pocket costs lack transparency.

By Dan Cook - When the Internal Revenue Service decided in 2019 to include more preventive services in the list of covered services for HSA health plans, the move was hailed as a step in the direction of better health outcomes for plan members. The theory: by encouraging plan members to use preventive services not just for general health but to address chronic conditions, more would take advantage of the “free” services and health outcomes would improve. Read Full Article…

VBA Article Summary

1. Shift from Deductibles to Copayments and Coinsurance: The study revealed that following the IRS's decision to move certain chronic condition treatments and medications to the pre-deductible covered list, employers typically shifted cost-sharing mechanisms from deductibles to copayments and coinsurance. This was mainly observed in HSA-eligible health plans and not in non-HSA plans. Despite the change, the overall cost-sharing as a percentage of total spending remained almost consistent.

2. Minimal Influence on Enrolment and Overall Cost-Sharing: While the IRS notice had expanded the HSA pre-deductible list with several chronic condition medical measures, its influence on overall cost-sharing was found to be minor. This might be because employers often altered the nature of cost-sharing rather than entirely removing it. Furthermore, enrollment in HSA-eligible plans among those with health conditions mentioned in the IRS notice did not show significant change, suggesting that the trend was already leaning towards higher enrollment among such individuals even before the notice was issued.

3. Potential Positive Outcomes for Patients: The modification in cost-sharing could have a silver lining, possibly enhancing patient outcomes. By distributing cost-sharing across the year instead of imposing a hefty amount upfront, patients might be more inclined to access high-value services earlier, possibly preventing complications arising from treatment nonadherence. As an added note, in response to the IRS's move, a significant majority of large employers enhanced pre-deductible coverage, indicating a proactive approach to manage and prevent exacerbation of chronic conditions.

The article also highlights that there are ongoing legal and legislative matters related to these provisions and their constitutionality. The outcome of these might influence the continuation or alteration of such practices by employers in the future.

Comer Opens Probe into FTC Regulation of Vision Care Market

WASHINGTON—House Committee on Oversight and Accountability Chairman James Comer (R-Ky.) is today requesting information from the Federal Trade Commission (FTC) to ensure accountability of the FTC’s role in overseeing the vision care market. The vision insurance market is structured to place only a handful of companies in charge of the vast majority of vision insurance plans for Americans, raising concerns about effects on consumers, including potentially higher costs. In a letter to FTC Chair Lina Khan, Chairman Comer requests a staff-level briefing to understand the extent to which the FTC has worked to ensure that the vision care market serves the best interests of American consumers. Read Full Article… 

VBA Article Summary

1. Market Dominance: Two companies control a staggering 85% of the stand-alone vision insurance plans market. In particular, in 42 states, one company has at least a plurality of the market, while in 28 states, a single company controls over 75% of the vision insurance plan market. This concentration can potentially lead to increased costs for consumers due to the lack of competition.

2. FTC Oversight: The House Committee on Oversight and Accountability is examining the Federal Trade Commission’s role in preventing harmful and unfair practices in the marketplace. Given the dominance of certain companies in the vision insurance industry, such as VSP Vision Care which covers over two-thirds of U.S. enrollees with vision-only insurance plans, the oversight of the FTC in ensuring fair market practices becomes crucial.

3. Vertical Consolidation Concerns: Not only do companies like VSP Vision Care have a significant market share in vision insurance, but they are also involved in vertically consolidating by creating their own retail stores. This consolidation allows them to offer favorable co-pays and pricing, thereby driving consumers away from competitors. Furthermore, the fact that many insurers also own lens and frame manufacturers has led to price mark-ups, sometimes as high as 1,000%. This combination of factors raises concerns over market fairness and the potential for consumer exploitation.

Read the letter to FTC Chair Khan here.

Why insurers are paying double for the same procedure in the same hospital

By Arielle Dreher - Hospitals charge commercial health plans two to three times more than what they charge the same insurer's Medicare Advantage plans for the same procedure, a new study in Health Affairs found. Read Full Article… 

VBA Article Summary

1. Pricing Disparity between Plans: Commercial health plans were found to have median prices for 46 medical procedures and services in 2022 that ranged from 1.8 to 2.7 times more expensive than those under Medicare Advantage. The most significant price disparity was seen in the field of surgery and medicine, with commercial prices at a median of $1,702 and Medicare Advantage at $928.

2. Variables Affecting Pricing: Larger, system-affiliated hospitals and teaching institutions, as well as sizeable national insurers, exhibited larger price ratios. Interestingly, the presence of big insurers typically suggests lower prices. Yet, the study proposed that these insurers might not be pushing hospitals on commercial prices to prevent potential exclusion from the profitable Medicare Advantage market. From a regional perspective, the Southeast exhibited the most substantial price ratios, whereas the Pacific Northwest and Midwest had the lowest.

3. Research Gaps and Implications: Due to the hospital price transparency law of 2021, this study is pioneering in detailing price discrepancies between different health plans provided by the same insurer and provider. However, there are reliability concerns as not all hospitals report data consistently, and the study covered only 2,434 out of 4,331 hospitals. The results may not apply universally, particularly to independent and rural hospitals. The authors emphasize the need to investigate how differing incentives among major insurers might influence the prices commercial plans pay, given the substantial price gap discovered in the study and its financial implications for employers and their employees.

What we know — and don't know — about the FDA-approved postpartum depression pill

By Rachel Treisman - The Food and Drug Administration has approved the first ever pill for treating postpartum depression, a potentially life-threatening condition that affects hundreds of thousands of new parents across the U.S. each year. Manufacturers Sage Therapeutics and Biogen Inc. say the drug, Zurzuvae (zuranolone), will be commercially available in the fourth quarter of this year, which could be as soon as October. Read Full Article… 

VBA Article Summary

1. Zurzuvae's Potential and Delivery Method: Zurzuvae is an oral medication intended to be taken once daily for a span of 14 days. Preliminary results from two company studies are encouraging, with some patients experiencing relief in as little as three days. This rapid onset of action makes it notably quicker than many existing antidepressants. The only other FDA-approved treatment for postpartum depression, also from Sage, requires an invasive 60-hour IV process, costing around $34,000. Zurzuvae offers a less intrusive alternative, though the exact price remains undisclosed.

2. Impacts on Maternal Mental Health: Postpartum depression (PPD) is a pressing concern, affecting up to 1 in 7 mothers and 1 in 10 fathers. It’s a severe condition distinguished from typical post-pregnancy "baby blues." Postpartum Support International states that approximately 500,000 women in the U.S. suffer from PPD annually. The Policy Center for Maternal Mental Health heralds Zurzuvae as a "new ray of hope." While Zurzuvae presents a significant advancement, it's crucial that individuals consult healthcare professionals to determine the best treatment strategy tailored to their needs.

3. Broader Context on Postpartum Depression: Postpartum depression starts typically within one to three weeks following childbirth. Symptoms include intense feelings of anxiety, sadness, and fatigue which can hinder new parents from adequately caring for their child and themselves. It's not just a fleeting state of mind; untreated PPD can have severe consequences. Notably, death by suicide accounts for around 20% of postpartum fatalities. A rising concern, the CDC observed that the rate of depression diagnoses at childbirth in 2015 was seven times that of 2000.