ICYMI: American Relief Act

Some big things happened (or didn't) while you were away for Xmas, Chanukah, Quansa, New Years, and otherwise partying season. The first thing discussed below is the American Relief Act which was supposed to put a patch on physician payment--which it didn't. The OPPS changes for Q1 were not released until January 10, 2025--so we are summarizing it for you in the next article

The American Relief Act

At the close of 2024, US Congress passed a short-term extension of Medicare telehealth flexibilities as part of the American Relief Act, 2025 (ARA). The Medicare telehealth waivers, originally enacted as part of the COVID-19 public health emergency (PHE) and subsequently extended through legislation, were set to end on December 31, 2024. These flexibilities, along with the Acute Hospital Care at Home waiver program, are now set to expire March 31, 2025. The ARA failed to extend other waivers, such as the temporary safe harbor for high-deductible health plans (HDHPs) to provide first-dollar coverage of telehealth without interfering with health savings account (HSA) eligibility. While the short-term extension provides continued access to telehealth for Medicare patients, stakeholders should continue to engage with Congress for a more permanent solution.

First and foremost, there was NO FIX to the cut in physician pay. This means we have to wait until mid-March to see if there will be any kind of fix this year at all. Tax cuts may be on the horizon--so these cuts may stand for all of 2025.

Historically, prior to the Pandemic, Medicare has provided coverage for telehealth services in instances where patients would otherwise be geographically distant from approved providers (e.g., physicians, nurse practitioners, and clinical psychologists)--this is called an 'underserved' area. Section 1834(m) of the Social Security Act provides that telehealth services are only covered if the beneficiary is seen:

• At an approved “originating site” (e.g., physician office, hospital, or skilled nursing facility) that is located within a rural health professional shortage area that is either outside of a metropolitan statistical area (MSA), in a rural census tract, or in a county outside of an MSA
• By an approved provider
• For a defined set of services that are listed
• Using certain telecommunications technologies.
• Many of these Medicare restrictions regarding coverage and payment for telehealth services were waived via authority delegated in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Congress subsequently extended the waivers in other pieces of legislation, including the Consolidated Appropriations Act (CAA) 2022 and CAA 2023, with the flexibilities most recently set to expire on December 31, 2024.

 

The ARA extended the following Medicare flexibilities through March 31, 2025--at which time we HOPE these will be extended until AT LEAST 12/31/2025:

• Geographic restrictions and originating sites. Patients’ homes will continue to serve as eligible originating sites for all telehealth services (ARA § 3207(a)(2)). Geographic restrictions also remain waived (ARA § 3207(a)(1)).
• Eligible practitioners. The expanded definition of the term “practitioner” will continue to apply. The expanded definition includes qualified occupational therapists, physical therapists, speech-language pathologists, and audiologists.
• Audio-only. Audio-only telehealth services remain eligible for reimbursement. This is a problem, kiddies. Why? As you know, the telephone call codes were deleted. So, how do you report Audio-only telehealth? Different coders have differing opinions--but one thing is for sure: there is no specific guidance from CMS.
• There are coders who say to to use to use 98016 which is actually for a brief check-in and has certain visit restrictions such as the patient cannot have been seen in the last 7 days AND this check in must be patient initiated.
• The Final Regs originally stated that, for telephone services in 2025, you would:
• Use the CPT or HCPCS code that best describes the service
• Append CPT modifier 93 to the claim
• Document that the physician has audio-video available, but the patient preferred audio-only or was unable to use audio-video
• Federally qualified health centers and rural health centers should use modifier FQ, 93, or both where appropriate
• There is no official Medicare guidance, but I go with the second option, unless you hear otherwise.
• Extending telehealth services for federally qualified health centers (FQHCs) and rural health clinics (RHCs). The US Department of Health and Human Services will cover telehealth services furnished via FQHCs and RHCs to eligible individuals.
• In-person requirements for mental health. The in-person requirement for mental health care to be reimbursed under Medicare has been delayed until April 1, 2025.
• Telehealth for hospice. Telehealth can continue to be used for the required face-to-face encounter prior to the recertification of a patient’s eligibility for hospice care.
• The ARA also extended the Acute Hospital Care at Home waiver program through March 31, 2025. In the midst of the PHE, the Centers for Medicare & Medicaid Services (CMS) used its PHE flexibilities to issue waivers to certain Medicare hospital conditions of participation (CoPs). These waivers, along with the PHE-related telehealth flexibilities, allowed Medicare-certified hospitals to furnish inpatient-level care in patients’ homes. Addressing hospital bed capacity during the pandemic was a high priority for CMS. These waivers and flexibilities, collectively referred to as the AHCAH Initiative, included:
• Also, the ever-repealed GPCI floor is reinstated until 3/31/2025 as authorized Section 3206 of the American Relief Act, 2025. Fee schedules have been adjusted for this.

 

Other than these provisions, nothing else changed for 2025--until the Trump Administration is fully installed.