Category Archives: Health Insurance

2016 Is Ramping Up For Telemedicine Developments

Two months in and this year has already seen significant movement in regulatory action across the country to expand the ability to provide telemedicine services. Below please find some of the more significant items that have already gone into effect in 2016 or are under consideration, including commercial payor and Medicaid reimbursement coverage for telemedicine services, reciprocal licenses for out-of-state providers and the ability to prescribe without an in-person evaluation.

Parity Laws in New York and Connecticut

Effective January 1, 2016, New York passed a Chapter Amendment clarifying last year’s telemedicine commercial coverage statute.  Under the 2016 Chapter Amendment, private insurers are required to cover services via telemedicine if provided by hospitals, home care and hospice agencies, licensed physicians, physician assistants, dentists, nurses, midwives, podiatrists, optometrists, ophthalmic dispensers, psychologists, social workers, speech language pathologists and audiologists.  The parity law prohibits an insurer from excluding from coverage a service provided via telehealth if that service is otherwise covered in-person.

The law also provides for Medicaid reimbursement to providers for telehealth services, which is defined broadly to include real-time two-way electronic audio visual communications, asynchronous store and forward technology and remote patient monitoring. However, with the exception of remote patient monitoring, telehealth will not be reimbursed by Medicaid when the patient is located in their home.  The New York Department of Health is expected to release telemedicine regulations later this year.

Similarly, Connecticut also recently passed a new telemedicine parity law that went into effect January 1, 2016. Under Connecticut’s parity law, commercial insurers must provide coverage for services rendered via telemedicine under the same terms and conditions as would apply if that service was provided in-person.  Connecticut broadly defines telehealth to include services performed by a telehealth provider at a distant site as well as synchronous interactions, asynchronous store and forward transfers and remote patient monitoring.

Notably, Connecticut went even farther than New York in its telehealth parity law by expressly preventing a health plan from excluding a service from coverage solely because the service is provided through telehealth and not in-person. In this way, a health plan cannot exclude a telehealth service, such as remote patient monitoring, simply because it does not lend itself to an in-person professional service.

Florida’s Controlled Substance Teleprescription Law

Florida recently implemented a new rule to permit physicians to prescribe controlled substances via telemedicine exclusively for the treatment of psychiatric disorders, effective March 4, 2016. Specifically, the amended regulation provides that controlled substances may not be prescribed through the use of telemedicine, “except for the treatment of psychiatric disorders.”

However, after passing this new rule, the Florida Board of Medicine recognized that it is still restricted by the Federal Ryan Haight Online Pharmacy Consumer Protection Act of 2008.  The Ryan Haight Act narrowly permits the remote prescription of controlled substances for patients without an in-person evaluation so long as the patient is: (1) physically located in a hospital or clinic with a valid DEA registration; and (2) treated by a DEA registered practitioner in the usual course of professional practice and in accordance with state law.  Accordingly, while Florida is expanding its telemedicine laws, the prescription of controlled substances via telemedicine will only be broadly permissible if the American Telemedicine Association, or other organizations, are successful in amending the Ryan Haight Act.

Newly Introduced Telemedicine Bills in New Jersey and Ohio

Various other states are also in the process of trying to pass telemedicine bills. For example, New Jersey recently introduced a bill on February 8, 2016, that would require private payors to provide coverage for telemedicine to the same extent that the services would be covered if they were provided through an in-person consultation.

Additionally, another NJ telemedicine bill was introduced on January 12, 2016, which would provide a mechanism for physicians and other health care providers to obtain reciprocal licenses to practice in New Jersey if the providers are licensed by another state in their particular specialty.  The bill would also provide a parity law for telemedicine services to be reimbursed under NJ Medicaid.  As a similar bill was proposed in 2015 and has now carried over into the 2016 session, the likelihood of its passing is even greater.

An Ohio legislative bill is also headed to the Senate that would allow patients to obtain prescriptions (for non-controlled substances) without an in-person exam or visit from a health care provider.

For more information on telehealth and telemedicine legal and regulatory considerations, continued legislative developments or related issues, please feel free to contact Daniel Meier or any member of our health care practice group for a further discussion.

The U.S. Supreme Court Rules on the ACA – The Individual Mandate is Constitutional

This morning, June 28, 2012, the United States Supreme Court released its decision upholding the constitutionality of the individual mandate – the centerpiece of President Obama’s health care law.

The individual mandate requires that all Americans maintain “minimum essential” health insurance coverage. Beginning in 2014, individuals that do not comply with the mandate must make a “shared responsibility payment” to the Federal Government. The amount of the payment varies with household income, subject to a floor and a ceiling based on the average annual premium that the individual would have to pay for private health insurance.

Interestingly, the Supreme Court rejected the Obama administration’s argument that the individual mandate was permissible under the Commerce Clause, instead concluding that the individual mandate was permissible under Congress’ taxing authority.

Another key provision of the Affordable Care Act is the expansion of the Medicaid program. The Affordable Care Act expands the scope of the Medicaid program and increases the number of individuals that states must cover. For example, the Act requires state programs to provide Medicaid coverage to adults that earn up to 133 percent of the federal poverty level. Many states only provide Medicaid to individuals whose incomes are significantly lower.

While the Act increases federal funding to cover the states’ costs in expanding coverage, it also threatened to withdraw all federal Medicaid funds for failure to comply. This morning, the Supreme Court ruled that while it was permissible to expand the Medicaid program, the Act could not withdraw existing Medicaid funds for states that opt out of the expansion.

A copy of the full opinion can be found here–> USCT ACA Opinion

For more information on the U.S. Supreme Court’s decision,  please feel free to contact any member of our health care practice group for a further discussion.

Please all check back here often for further posts on the decision.

HHS and Other Federal Departments Issue New Rule on Health Plans

The U.S. Departments of Health and Human Services, Labor and Treasury issued a final rule on February 9, 2012 requiring health insurers and group health plans to provide consumers with an easy-to-understand summary of benefits and coverage and a uniform glossary of commonly used health insurance terms. These disclosure requirements are intended to help those shopping for insurance, as well as those already enrolled in a plan, to make comparisons to better evaluate their health insurance coverage options. The Final Rule is slated for publication in the February 14, 2012 Federal Register. Continue reading

UPDATE: President Signed into Law – Exemption of Tricare Providers from Federal Acquisition Regulation Requirements

President Obama signed the National Defense Authorization Act on 12/31/11. The Act includes a provision that healthcare providers are not subject to Department of Labor Office of Contract Compliance Programs (OFCCP) affirmative action requirements on the basis of participation in TRICARE. TRICARE is the Department of Defense’s healthcare program for the military. Continue reading

U.S. Senate Passes a Bill Including Langauge that Exempts Tricare Providers from Federal Acquisition Regulation Requirements

The U.S. Senate recently passed an armed services authorization bill (S. 1867) that includes language designed to exempt Tricare providers from FAR compliance.

Health care providers that provide services pursuant to Tricare, VA and Medicare Advantage contracts have continuously struggled to determine whether or not they are considered subcontractors under the Federal Acquisition Regulation (“FAR”), by simply being a provider, and therefore required to comply with its provisions.  Compliance with the FAR as a subcontractor requires providers to implement affirmative actions plans and other related requirements.  The interpretation of the applicability of the FAR to providers has also subjected providers to significant audits by the Office of Federal Contract Compliance Programs  (“OFCCP”) at the U.S Department of Labor. Continue reading

CMS Demonstration Project to Require Prior Authorization for Certain Medical Equipment

Begining in January of 2012, a CMS demonstration program will start requiring prior authorization for certain medical equipment before Medicare beneficiaries can recieve the equipment. CMS is initiating a three-year demonstration program as a program integrity initiative in states that CMS believes have higher instances of fraud and error-prone providers. The initial seven states are – CA, FL, IL, MI, NY, NC and TX

The demonstration will be implemented in two phases. During the first phase (the first three to nine months), the Medicare Administrative Contractors will conduct prepayment reviews on certain medical equipment claims. The second phase, for the remainder of the three-year demonstration, will implement prior authorization,  as a mechanism to prevent improper payments and deter the fraudulent provision of items or services. 

A CMS Fact Sheet on this demonstration and other program integrity intiatives can be found here —-> CMS Fact Sheet

A Summary of the Shared Savings Program with Accountable Care Organizations Final Rule – MLN Fact Sheet, ICN 907404

 CMS’ Medicare Learning Network (MLN) just released Fact Sheet, ICN 907404, which is designed to provide education on the provisions of the final rule that implements the Medicare Shared Savings Program with Accountable Care Organizations (ACOs). It includes background, information on how ACOs impact beneficiaries, eligibility requirements to form an ACO, and information on monitoring and tying payment to improved care at lower costs.

You can get a copy of the Fact Sheet here —> ICN 907404