CMS Removes Restrictions around RNs and Pharmacists Furnishing DSMT via Telehealth
In early August, the Centers for Medicare & Medicaid Services (CMS) issued updated guidance clarifying that accredited and recognized diabetes self-management training (DSMT) programs, eligible to bill Medicare Part B directly for DSMT services, may furnish and bill for DSMT services provided via telehealth during the COVID-19 Public Health Emergency (PHE). Adding DSMT programs to list of “professionals” eligible to provide telehealth services removes the final regulatory barriers preventing registered nurses (RNs) and pharmacists from furnishing DSMT services via telehealth. This is a huge win for diabetes care and education specialists and the Medicare beneficiaries with diabetes whom they serve. Click here to review ADCES’ updated FAQ page. For more information and resources related to telehealth and getting started, visit diabeteseducator.org/telehealth
Since the start of the COVID-19 pandemic, ADCES has been advocating before Congress and CMS to expand the telehealth requirements around the DSMT. As part of these advocacy efforts, over 700 diabetes care and education specialists sent letters to CMS urging the agency to add pharmacists and RNs to the list of providers eligible to furnish DSMT services via telehealth. In April, CMS released guidance allowing RNs and pharmacist to furnish DSMT services via telehealth in Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs), and hospital outpatient settings, but restrictions remained for those in provider practices, pharmacies, and other outpatient settings.
ADCES continued to work with healthcare associations like the Academy of Nutrition & Dietetics, the American Pharmacists Association, and the National Community Pharmacists Association, the Diabetes Advocacy Alliance, our congressional champions, and other stakeholders to make these changes. We submitted comments to CMS through the formal rulemaking process and raised this issue with the CMS 1135 waiver team and the COVID-19 team. Most importantly, diabetes care and education specialists contacted CMS to tell their stories and discussed how the pandemic and regulatory limitations around telehealth were preventing people with diabetes from accessing DSMT services. These efforts paid off as now DSMT programs can furnish and bill for DSMT services provided via telehealth. Our advocacy work continues; however, as Congress considers permanent telehealth expansion.
Telehealth Expansion: What’s Next?
As telehealth becomes more widely utilized, healthcare providers, consumers, and advocacy groups have called on policymakers and legislators to make these temporary telehealth flexibilities permanent. To do so, Congress must act to change the law, specifically section 1834(m) of the Social Security Act, which dictates how CMS covers telehealth services. There have been a series of congressional hearings examining the future of telehealth expansion, and many legislators have introduced legislation aimed at making some of the temporary changes permanent.
On the Senate side, we’ve seen the introduction of the Telehealth Modernization Act and the HEALS Act. ADCES has also long-supported legislation like the CONNECT for Health Act which would direct CMS to make important updates to how telehealth is provided in this country. On the House side, we’ve seen the introduction of legislation like the Protecting Access to Post-COVID-19 Telehealth Act of 2019 and the Evaluating Disparities and Outcomes of Telehealth During the COVID-19 Emergency Act of 2020, a bill that seeks to better understand how telehealth is being utilized, especially among Black and Latinx communities.
Many of the legislative proposals under consideration share common themes. Congress appears interested in expanding the list of eligible telehealth providers, permanently allowing FQHCS and RHCs to utilize telehealth services, taking important steps to remove originating site requirements, and calling for the collection of data to inform future policy changes. In terms of next steps, we believe that the key committees in Congress like the House Ways & Means and Senate Finance Committee will work to include telehealth language in the next coronavirus relief bill. ADCES has been working with our congressional champions and our coalition partners like the Health Innovation Alliance to advocate to expand telehealth to include all DSMT providers and to make these changes permanent. As these policies are finalized, we encourage diabetes care and education specialists to be part of the conversation.
Call to Action: ADCES has identified long-term telehealth priorities (see below) and we urge diabetes care and education specialists to contact your members of Congress and advocate for these changes.
ADCES Telehealth Policy Priorities
As discussions continue to permanently expand access to telehealth services, ADCES is urging Congress and the Administration to make the following provisions permanent to ensure that Medicare beneficiaries with diabetes have improved access to critical services via telehealth:
- Expand the List of Eligible Telehealth Providers and Services to Include DSMT Programs: Authorize the Secretary of the U.S. Department of Health and Human Services (HHS) to expand the list of eligible telehealth providers and telehealth services. ADCES specifically requests that accredited and recognized diabetes self-management training programs, authorized to bill Medicare Part B, be added to the list of eligible practitioners/entities approved to furnish telehealth services.
- Increase Flexibility within the DSMT Benefit: For calendar years 2020-2021, ADCES requests that CMS waive the requirement that the initial 10 hours of DSMT training must be furnished within a continuous 12-month period. Currently, many Medicare beneficiaries have been unable to participate in DSMT and have already lost valuable time in utilizing their full DSMT benefit within the calendar year, especially those that have reached the end of this 12-month period since COVID-19 began. ADCES also continues to advance the Expanding Access to DSMT Act (H.R. 1840, S. 814), which addresses additional barriers, such as limitations on virtual DSMT providers, that Medicare beneficiaries face when accessing DSMT.
- Remove Geographic and Originating Site Requirements: Permanently remove geographic and originating site requirements so that Medicare beneficiaries can continue to receive telehealth services, including DSMT and other diabetes-related services, from their homes
- Expand Telehealth in FQHCs and RHCs: Permanently expand telehealth services in Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs). Maintain flexibilities to ensure that any provider type, including diabetes care and education specialists (i.e. registered nurses, pharmacists, registered dietitians, etc.), can provide Medicare telehealth services within their scope of practice.
- Reimbursement Parity for Telehealth Services: Continue to reimburse Medicare telehealth services at the same rate as services provided in-person.
- Allow Services to be Provided in an Audio Only Format: DSMT is one of only a limited number of telehealth services during the PHE that can be provided via audio only in cases when audio and video telecommunications technology is not available. This has allowed diabetes care and education specialists to reach more individuals with diabetes who otherwise would not have been able to receive care. ADCES believes that audio only telehealth services should be available during any future PHE, and that Congress and the Administration should explore ways to permanently expand audio only coverage in certain situations.
- Explore New Ways to Reduce Telehealth Disparities: Audio only communication has been discussed as a means of improving health disparities in areas that do not have broadband access. This is one possible solution; however, people with diabetes also report limits on the number of cellphone minutes and other barriers that make telehealth prohibitive in many circumstances. ADCES encourages Congress and the Administration to consider community-based approaches to making access to care more accessible for all beneficiaries. For example, despite the increased risk of COVID-19 related complications for people with diabetes, access to DSMT via telehealth is limited only to a few specific provider types in a few practice settings (hospital outpatient, FQHCs and RHCs). If CMS decreased restrictions around providing DSMT services in community-based locations, like churches, community centers, and libraries, Medicare beneficiaries could receive safe, physically-distanced, diabetes services without having to travel to a hospital or other facility or rely on cellphone minutes or Internet access to receive care. This type of care delivery has been successfully occurring in Native American and American Indian health programs across the country.
- Medicare Diabetes Prevention Program: Make permanent the flexibilities offered to MDPP suppliers including, expanding the use of virtual sessions (both make-up, and replacement for regular sessions) and eliminating the once-per-lifetime benefit restriction.
- Access to Diabetes Technology
- Continue to waive in-person requirements for CGM and insulin pumps so that people with diabetes could continue to get necessary supplies without having to have an in-person appointment with their healthcare provider.
- Permanently reconsider the enforcement of the clinical indications for CGM and insulin pumps, specifically removing the barrier to CGM coverage by eliminating the “four times per day” testing requirement.