Counting telehealth encounters in risk adjustment programs

On behalf of the undersigned organizations, we write to urge the Centers for Medicare and Medicaid Services (CMS) to make permanent a recent agency decision (memorialized in an April 10 HPMS memo) to allow diagnoses made over telehealth encounters to count toward risk adjustment for Medicare Advantage (MA), Accountable Care Organizations (ACOs), and other Medicare risk-adjusted programs.

We appreciate CMS’s leadership to expand access to telehealth services in MA and other risk-adjusted programs, particularly during the COVID-19 public health emergency (PHE). Plans and providers have seen the value in delivering services remotely to reach populations who may not otherwise have been served in a way that is convenient, clinically effective, and cost-effective.

CMS’s implementation of its new statutory authority to include telehealth in MA plan bids (rather than as a supplemental benefit) as of January 1, 2020, is a huge step toward greater adoption of telehealth in MA. Additionally, CMS’ work to update rules to allow more flexibility to include telehealth providers to meet network adequacy requirements will allow plans to reach populations in a new way. ACOs are generally afforded flexibility to offer telehealth to beneficiaries without the geographic or originating site restrictions that apply to fee-for-service Medicare.

However, a very large barrier to robust telehealth adoption remains. Prior to the April 10 memo, diagnoses gathered over a telehealth encounter were not clearly and consistently allowed to be counted towards risk adjustment. This is a significant disincentive to widescale plan adoption of telehealth for services otherwise deemed safe and effective, limiting beneficiary access to needed remote services. It also potentially makes risk adjustment less accurate and less reflective of the
beneficiaries’ true clinical experience

Fortunately, CMS acted in the April 10 memo to temporarily solve this problem during the COVID-19 public health emergency. We urge CMS to update its policies to make this change to permanent; CMS should allow diagnoses made over telehealth visits to count towards risk adjustment. We believe that this change would be consistent with CMS’ other actions on telehealth and would achieve the goal of increased access to care for patients. We also believe this policy change is fully within CMS’s authority.

Thank you for your attention and we look forward to working with you to solve this important issue. Please do not hesitate to reach out to the Telehealth Encounters Count Coalition (TECC) and the undersigned organizations with questions or to discuss further.

The Telehealth Encounters Count Coalition (TECC)
CVS Health/Aetna
Doctor On Demand
Ochsner Health
Alliance of Community Health Plans (ACHP)
America’s Physician Groups
American Telemedicine Association (ATA)
America’s Health Insurance Plans
Association for Community Affiliated Plans (ACAP)
Atrius Health
Banner Health
Better Medicare Alliance
Cambia Health Solutions
Capital District Physicians’ Health Plan
Coalition for Affordable Health Coverage
Concerto Healthcare, Inc.
Dean Health Plan
Harvard Pilgrim Health Care
Health Alliance
Health Alliance Plan
Health Care Service Corporation
Health Care Transformation Task Force
Health Innovation Alliance
Independent Health
Intermountain Healthcare
Iora Health
Kindred Healthcare
Premier healthcare alliance
SSM Health
The Villages Health
Visiting Nurse Service of New York (VNSNY)
CC: Demetrios Kouzoukas, Cheri Rice

You can view the letter here.