In January 2020, the Secretary of the Department of Health & Human Services declared a federal public health emergency (PHE) associated with COVID-19. All 50 states, the District of Columbia, and territories followed suit. Some states followed the federal PHE while other states established their own timelines. PHEs at the state and federal level allowed the government to increase flexibilities such as authorization for audiologists and speech-language pathologists (SLPs) to be paid for telepractice services or to waive enforcement of certain laws such as the Health Insurance Portability and Accountability Act (HIPAA) for the duration of the federal PHE.
By law, the federal PHE must be renewed every 90 days. The Biden Administration notified Congress that it will end the PHE on May 11, 2023, which ends many of the legal and regulatory flexibilities designed to mitigate the impact of COVID-19. However, the Consolidated Appropriations Act, 2023 extends the authority for audiologists and SLPs to provide telehealth services to Medicare beneficiaries and continues waivers of geographic and originating site restrictions through December 31, 2024.
Audiologists and SLPs need to begin preparing now to stay in compliance with state and federal laws and regulations as well as payer policies once the federal PHE ends. This resource provides an overview of the major considerations that may affect how audiologists and SLPs provide and bill for services beyond the PHE, including services delivered via telepractice.
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Many federal flexibilities and waivers were put into place during the PHE, including Medicare coverage of audiology and speech-language pathology telehealth services. Despite the end of the federal PHE, Medicare telehealth flexibilities will remain in place through December 31, 2024, because of the Consolidated Appropriations Act, 2023, which extends the authority for audiologists and SLPs to provide telehealth services to Medicare beneficiaries and continues waivers of geographic and originating site restrictions.
Enforcement of HIPAA rules were also loosened for Medicare services during the PHE to help clinicians choose telepractice platforms that may not comply with HIPPA privacy and security requirements. However, enforcement will resume at the end of the federal PHE. Resources to help you stay in compliance following the PHE include:
Audiologists and SLPs will also need to continue to monitor changes to state PHEs [PDF], as states may also set different dates for ending the PHE locally. This means that temporary state licensing, Medicaid, and local education agency expansions could end at different times than federal expansions. It is important to note that most states have already ended their local PHEs.
Payer policies and coverage of audiology and speech-language pathology services vary widely. It’s important for clinicians to understand the unique requirements for each payer source they bill both during and after the PHE, including coding, billing, and coverage of telepractice services. Keep in mind that Medicaid and private payers may not follow the federal PHE.
Federal law authorizes Medicare payment to audiologists and SLPs to provide telehealth services to Medicare Part B (outpatient) beneficiaries until at least December 31, 2024. See ASHA’s webpage on Medicare coverage of telehealth services for details. Here’s what clinicians need to know after December 31, 2024, when the extension of federal flexibilities ends.
After December 31, 2024, Medicare will no longer reimburse audiologists for any telehealth services. You can enter into private pay arrangements with Medicare beneficiaries to continue providing telehealth services, if the patient agrees. HIPAA flexibilities, which applied to Medicare telehealth services, will also expire at the end of the federal PHE.
After December 31, 2024, Medicare will no longer reimburse SLPs directly for any telehealth services. The HIPAA flexibilities, which applied to Medicare telehealth services, will expire May 11, 2023, the end of the federal PHE. SLPs will have two options for reimbursement of Medicare telehealth services: private pay arrangements and/or billing select services “incident to” a physician. For more information, see what SLPs can expect after the PHE.
Because Medicaid is a state and federal partnership program, each state Medicaid program has chosen to handle the federal PHE, and the program flexibilities it offered, differently. For example, all state Medicaid programs allowed some form of telepractice during the beginning of the pandemic. Some states began unwinding this flexibility early on, and others have maintained flexibilities throughout the entire PHE thus far, with no official policy change while the PHE is still in existence. Clinicians should check directly with their state Medicaid programs to see which telepractice policies are still in place during the PHE, which policies will end when the PHE ends, and which policies will be made permanent beyond the PHE. The Centers for Medicare & Medicaid Services (CMS) can’t mandate state Medicaid programs to make certain flexibilities they had during the PHE permanent. However, CMS is strongly encouraging state Medicaid programs to make certain flexibilities, like telepractice, permanent going forward.
The Families First Coronavirus Response Act (FFCRA) (P.L. 116-127) was signed into law on March 18, 2020. The FFCRA added a new optional Medicaid eligibility group for uninsured individuals during the PHE. This new eligibility group’s coverage will end on May 11, 2023, when the federal PHE expires. This will affect Medicaid coverage for people who have enrolled under this new eligibility group. Individuals enrolled under this new group will need to seek alternative health care coverage (e.g., marketplace or private health plans) when the PHE ends. Additionally, the FFRCA created the requirement that state Medicaid programs keep all Medicaid beneficiaries continuously enrolled in the program, halting periodic eligibility redeterminations that occurred before the Act. However, the Consolidated Appropriations Act ended this requirement for continuous enrollment as of March 31, 2023. State Medicaid programs will resume Medicaid redeterminations and can disenroll beneficiaries based on eligibility as of April 1, 2023, if they no longer meet eligibility requirements.
FMAPs are used to determine the portion of matching funds states can expect from the federal government for state programs like state Medicaid programs. The FFCRA provided for a temporary 6.2% FMAP increase for each qualifying state’s FMAP during the PHE. The FMAP increase will extend through the last day of the calendar quarter in which the PHE ends. State Medicaid programs are eligible for a stepped reduction of the FMAP increase through the end of 2023, if they comply with certain provisions around eligibility.
Private payers may act autonomously and don’t have to follow the same rules as government payers such as Medicare and state Medicaid programs. Although many private and commercial plans expanded telepractice services quickly during the pandemic, coverage has varied widely and continues to change. It’s important for clinicians to evaluate each payer on a case-by-case basis to determine their requirements and level of coverage both during and after the PHE.
Clinicians should report Current Procedural Terminology (CPT ® American Medical Association) codes and follow the same guidelines for billing telepractice services as you would when providing in-person services. Payers typically also require a specific modifier or place of service code to distinguish telepractice services from in-person services. ASHA provides general guidance on coding for telepractice services but payer guidelines vary widely. Payers may also have a specific list of CPT codes approved for telepractice services. Always verify with the payer before initiating services, especially as coverage policies continue to evolve as the PHE ends.
Most payers, including Medicare, currently pay providers at the same rate for both in-person and telepractice services, when covered. When establishing payment rates for telepractice services, ASHA recommends following that precedent, given that most telepractice services are billed using the same CPT codes for in-person services. Some adjustments to rates can be made to accommodate the financial needs of the patient under a written policy that applies to all patients, regardless of the type of insurance or service delivery model used.
As payers assess their telepractice coverage after the federal or local PHEs end, they may also consider setting lower rates for services provided via telepractice. Although many states have passed parity laws to ensure some coverage and payment for telepractice services, many of these laws require coverage of services provided via telepractice but do not explicitly discuss payment rates. As a result, clinicians may see different rates between in-person and telepractice visits. ASHA is advocating for true payment parity between telepractice and in-person services. ASHA continues to advocate for true payment parity between telepractice and in-person services, and clinicians can too! Audiologists and SLPs can use ASHA’s telehealth data factsheet [PDF] to help start conversations with payers regarding payment parity and the value of telepractice services.
Please contact ASHA at firstname.lastname@example.org.