II 114th CONGRESS 2d Session S. 2484 IN THE SENATE OF THE UNITED STATES February 2, 2016 Mr. Schatz (for himself, Mr. Wicker , Mr. Cochran , Mr. Cardin , Mr. Thune , and Mr. Warner ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend titles XVIII and XI of the Social Security Act to promote cost savings and quality care under the Medicare program through the use of telehealth and remote patient monitoring services, and for other purposes.

1. Short title; table of contents (a) Short title This Act may be cited as the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act or the CONNECT for Health Act . (b) Table of contents The table of contents of this Act is as follows: Sec. 1. Short title; table of contents. TITLE I—Telehealth and remote patient monitoring services bridge demonstration waivers Sec. 101. Telehealth and remote patient monitoring services bridge demonstration waivers. TITLE II—Telehealth and remote patient monitoring services furnished by qualifying APM participants Sec. 201. Telehealth and remote patient monitoring services furnished by qualifying APM participants. TITLE III—Medicare coverage of telehealth and remote patient monitoring services Sec. 301. Remote patient monitoring services for individuals with certain chronic health conditions. Sec. 302. Allowing telehealth to meet monthly clinician in-person visit requirement for certain home dialysis. Sec. 303. Allowing stroke evaluation sites and Native American health service facilities as sites eligible for telehealth payment. Sec. 304. Rural health clinics and Federally qualified health centers authorized to be distant sites. Sec. 305. Addressing gaps in quality measures for telehealth and remote patient monitoring services. TITLE IV—Use of telehealth and remote patient monitoring services to provide basic benefits under Medicare part C Sec. 401. Use of telehealth and remote patient monitoring services to provide basic benefits under Medicare part C. TITLE V—Clarification regarding telehealth and remote patient monitoring technologies provided to beneficiaries Sec. 501. Clarification regarding telehealth and remote patient monitoring technologies provided to beneficiaries. I Telehealth and remote patient monitoring services bridge demonstration waivers 101. Telehealth and remote patient monitoring services bridge demonstration waivers Title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) is amended by adding at the end the following new section: 1899C. Telehealth and remote patient monitoring services bridge demonstration waivers (a) Implementation (1) In general Subject to the succeeding provisions of this subsection, the Secretary shall solicit proposals from, and issue telehealth or remote patient monitoring services bridge demonstration waivers under this title to, eligible applicants who, for the duration of time for which the demonstration waiver would apply, are furnishing telehealth or remote patient monitoring services (as defined in section 1861(iii)) to individuals under this title in a manner that is consistent with the goals of the Merit-based Incentive Payment System under section 1848(q), including the goals of quality, resource utilization, and clinical practice improvement (including care coordination and patient engagement), or the incentive payments for participation in eligible alternative payment models under section 1833(z). (2) Eligible applicant defined In this section, the term eligible applicant means the following: (A) A professional described in section 1848(q)(1)(C)(i)(I). (B) A qualifying APM participant (as defined in section 1833(z)(2)). (C) Any other provider, including a professional described in section 1848(q)(1)(C)(i)(II), determined appropriate by the Secretary, and a group that includes such providers. (b) Demonstration waiver application requirements An eligible applicant seeking a demonstration waiver under this section shall submit an application to the Secretary on an annual basis that includes the following: (1) An attestation of the intent of the applicant to use telehealth or remote patient monitoring services to meet the goals described in subsection (a)(1), and details (as specified by the Secretary) on how the eligible applicant will use those services to meet such goals. (2) An agreement by the applicant to— (A) submit the information described in subsection (d) in accordance with such subsection; and (B) cooperate in any audit conducted under subsection (e) with respect to claims for telehealth or remote patient monitoring services furnished by the applicant under the waiver. (c) Waiver of limitations for telehealth or remote patient monitoring services (1) In general The Secretary shall waive certain applicable provisions of sections 1834(m) and 1861(iii) as a condition of payment for telehealth or remote patient monitoring services for eligible applicants whose application for a demonstration waiver was approved under this section. The provisions to be waived under the preceding sentence include any limitation on what qualifies as an originating site, any geographic limitation (subject to State licensing requirements), any limitation on the use of store-and-forward technologies, or any limitation on the type of health care provider who may furnish such services (provided the provider is a Medicare enrolled provider). (2) General supervision The Secretary shall permit an eligible applicant whose application for a demonstration waiver was approved under this section to furnish telehealth or remote patient monitoring services under the general supervision of the applicant. (d) Annual submission of data An eligible applicant whose application for a demonstration waiver under this section was approved shall, on an annual basis, submit to the Secretary— (1) information requested by the Secretary for evaluation of the demonstration, including information on utilization and expenditures for telehealth or remote patient monitoring services under the demonstration waiver during the preceding year; (2) data on applicable quality measures during the preceding year, consistent with sections 1848 and 1833(z); and (3) such other information as the Secretary determines is necessary to complete the report under subsection (g). (e) Random audits The Secretary shall conduct audits of randomly selected claims under the demonstration waiver program under this section to ensure that waivers under the program are being used as intended to furnish telehealth or remote patient monitoring services. (f) Implementation (1) Sunset Except as provided in paragraph (2), the authority to carry out the demonstration waiver program under this section shall expire on December 31, 2019. (2) Expansion Taking into account the report under subsection (g), the Secretary may, through rulemaking, expand (including implementation on a nationwide basis) the duration and the scope of the demonstration waiver program under this section, to the extent determined appropriate by the Secretary, if— (A) the Secretary determines that such expansion is expected to— (i) reduce spending under this title without reducing the quality of care; or (ii) improve the quality of patient care without increasing spending; (B) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce (or would not result in any increase in) net program spending under this title; and (C) the Secretary determines that such expansion would not deny or limit the coverage or provision of benefits under this title for individuals. (g) Report to congress Not later than December 31, 2020, the Chief Actuary of the Centers for Medicare & Medicaid Services shall submit to Congress a report containing an evaluation of the impact of telehealth and remote patient monitoring services under the demonstration waiver program on— (1) spending under this title; and (2) achieving the additional MIPS adjustment factors for exceptional performance described in section 1848(q)(6)(C) and incentive payments for participation in eligible alternative payment models described in section 1833(z)(1). . II Telehealth and remote patient monitoring services furnished by qualifying APM participants 201. Telehealth and remote patient monitoring services furnished by qualifying APM participants (a) In general Title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ), as amended by section 101, is amended by adding at the end the following new section: 1899D. Telehealth and remote patient monitoring services furnished by qualifying APM participants (a) In general The Secretary shall waive certain applicable provisions of section 1834(m) and section 1861(iii) as a condition of payment for telehealth or remote patient monitoring services for a qualifying APM participant (as defined in section 1833(z)(2)). The provisions to be waived under the preceding sentence include any limitation on what qualifies as an originating site, any geographic limitation (subject to State licensing requirements), any limitation on the use of store-and-forward technologies, or any limitation on the type of health care provider who may furnish such services (provided the provider is a Medicare enrolled provider). (b) Annual submission of data A qualifying APM participant (as so defined) who furnishes telehealth or remote patient monitoring services under this section shall, on an annual basis, submit to the Secretary information requested by the Secretary for evaluation of the implementation of this section, including information on utilization and expenditures for telehealth or remote patient monitoring services under this section during the preceding year and data on any applicable quality measures, consistent with sections 1848 and 1833(z). (c) No increase in expenditures If the Secretary determines payments for telehealth or remote patient monitoring services under this section will increase expenditures under this title, the Secretary shall make adjustments to such payments to eliminate such increased expenditures. . (b) Effective date The amendment made by this section shall apply with respect to services furnished on or after January 1, 2017. III Medicare coverage of telehealth and remote patient monitoring services 301. Remote patient monitoring services for individuals with certain chronic health conditions (a) Coverage (1) In general Section 1861(s)(2) of the Social Security Act ( 42 U.S.C. 1395x(s)(2) ) is amended— (A) in subparagraph (EE), by striking and at the end; (B) in subparagraph (FF), by inserting and at the end; and (C) by inserting after subparagraph (FF) the following new subparagraph: (GG) applicable remote patient monitoring services for individuals with certain chronic health conditions (as defined in subsection (iii)); . (2) Coverage as rural health clinic services and Federally qualified health center services Section 1861(aa) of the Social Security Act ( 42 U.S.C. 1395x(aa) ) is amended— (A) in paragraph (1)— (i) in subparagraph (B), by striking , and and inserting a comma; (ii) in subparagraph (C), by inserting and after the comma at the end; and (iii) by inserting after subparagraph (C) the following new subparagraph: (D) applicable remote patient monitoring services for individuals with certain chronic health conditions (as defined in subsection (iii)), ; and (B) in paragraph (3)— (i) in subparagraph (A), by striking ; and and inserting a semicolon; (ii) in subparagraph (B), by striking the comma and inserting ; and ; and (iii) by inserting after subparagraph (B) the following new subparagraph: (C) applicable remote patient monitoring services for individuals with certain chronic health conditions (as defined in subsection (iii)), . (b) Services described Section 1861 of the Social Security Act ( 42 U.S.C. 1395x ) is amended by adding at the end the following new subsection: (iii) Remote patient monitoring services for individuals with certain chronic health conditions (1) (A) The term applicable remote patient monitoring services for individuals with certain chronic health conditions means remote patient monitoring services (as defined in subparagraph (B)) furnished to an applicable individual (as defined in subparagraph (C)) under general supervision of the provider, with the exception of those services covered under subsection (s)(1). (B) The term remote patient monitoring services means personal medical data transmitted from an applicable individual in one location via electronic communications technologies to an eligible provider (as defined in subparagraph (D)) in a different location and used by the eligible provider in furnishing remote patient monitoring services to such individual that complies with the Federal regulations (concerning the privacy and security of individually identifiable health information) promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996, as part of an established plan of care for that individual that includes the review and interpretation of that data by an eligible provider. Such term includes those services furnished in a Federally qualified health center or a rural health clinic (C) The term applicable individual means an individual— (i) with 2 or more covered chronic conditions (as defined in paragraph (2)); and (ii) who has a history of 2 or more hospitalizations or emergency room visits related to such covered chronic conditions of the individual in the preceding 12 months. (D) The term eligible provider means a physician (as defined in section 1861(r)) or a practitioner described in section 1842(b)(18)(C). (E) The Secretary shall establish procedures under which eligible providers who furnish remote patient monitoring services are required to annually submit data on applicable quality measures under sections 1848 and 1833(z). (2) (A) For purposes of paragraph (1)(C), subject to subparagraph (B), the term covered chronic condition means— (i) a condition that qualifies an individual for chronic care management services under section 1848(b)(8); and (ii) any other condition the Secretary may specify. (B) If the Chief Actuary of the Centers for Medicare & Medicaid Services determines that the inclusion of a condition described in subparagraph (A) in the definition of the term covered chronic condition under such subparagraph will result in increased expenditures under this title, the Secretary shall make adjustments to such definition to eliminate such increased expenditures. (3) (A) Payment may be made under this part for applicable remote patient monitoring services for individuals with certain chronic health conditions furnished to an applicable individual during a period of up to 90 days (beginning with the commencement of such services) and such additional period as provided for under subparagraph (B). (B) The 90-day period described in subparagraph (A), with respect to an applicable individual, may be renewed by the eligible provider who provides chronic care management services to such individual if the individual has had one or more hospitalizations, not including emergency room visits, related to the covered chronic conditions of the individual described in paragraph (1)(C) since the beginning of such period. . (c) Payment (1) In general Section 1848(j)(3) of the Social Security Act ( 42 U.S.C. 1395w–4(j)(3) ) is amended by inserting (2)(GG), after health risk assessment), . (2) Rural health clinic services and Federally qualified health center services Section 1833 of the Social Security Act ( 42 U.S.C. 1395l ) is amended by adding at the end the following new subsection: (aa) Payment for applicable remote patient monitoring services for individuals with certain chronic health conditions furnished by a rural health clinic or a Federally qualified health center Notwithstanding any other provision of law, in the case of applicable remote patient monitoring services for individuals with certain chronic health conditions (as defined in section 1861(iii)) furnished by a rural health clinic or a Federally qualified health center under paragraphs (1) and (3), respectively, of section 1861(aa), payment shall be made in an amount equal to the national average payment amount for such service, as determined by the Secretary, in accordance with section 1848 (without regard to any adjustment under subsections (a)(5), (a)(7), (a)(8), (p), or (q) of such section). . (d) Effective date The amendments made by this section shall apply to services furnished on or after January 1, 2017. 302. Allowing telehealth to meet monthly clinician in-person visit requirement for certain home dialysis (a) In general Section 1881(b)(3) of the Social Security Act ( 42 U.S.C. 1395rr(b)(3) ) is amended— (1) by redesignating subparagraphs (A) and (B) as clauses (i) and (ii), respectively; (2) in clause (ii), as redesignated by subparagraph (A), strike on a comprehensive and insert subject to subparagraph (B), on a comprehensive ; (3) by striking With respect to and inserting (A) With respect to ; and (4) by adding at the end the following new subparagraph: (B) For purposes of subparagraph (A)(ii), an individual determined to have end stage renal disease receiving home dialysis may elect to receive the monthly end stage renal disease-related visits via telehealth if the individual receives an in-person examination at least once every three consecutive months. For purposes of the preceding sentence, a dialysis facility shall be the originating site at which the individual is located at the time the service is furnished via telehealth. . (b) Conforming amendment Section 1881(b)(1) of such Act ( 42 U.S.C. 1395rr(b)(1) ) is amended by striking paragraph (3)(A) and inserting paragraph (3)(A)(i) . (c) Effective date The amendments made by this subsection shall apply with respect to the monthly fee or other basis of payment for home dialysis services furnished on or after January 1, 2017. 303. Allowing stroke evaluation sites and Native American health service facilities as sites eligible for telehealth payment (a) Stroke evaluation sites Section 1834(m)(4)(C) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(C) ) is amended— (1) in clause (i), by striking The term and inserting Subject to clause (iii), the term ; and (2) by adding at the end the following new clause: (iii) Stroke telehealth services The originating site requirements described in clauses (i) and (ii) shall not apply with respect to services related to the evaluation or management of an acute stroke for the purpose of determining optimal acute stroke therapy. . (b) Native American health service facilities Section 1834(m)(4)(C) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(C) ), as amended by subsection (a), is amended— (1) in clause (i), by striking clause (iii) and inserting clauses (iii) and (iv) ; and (2) by adding at the end the following new clause: (iv) Native American health service facilities The originating site requirements described in clauses (i) and (ii) shall not apply with respect to a facility of the Indian Health Service, whether operated by such Service, or by an Indian tribe (as that term is defined in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 )) or a tribal organization (as that term is defined in section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 450b )), or a facility of the Native Hawaiian health care systems authorized under the Native Hawaiian Health Care Improvement Act ( 42 U.S.C. 11701 et seq. ). . (c) No originating site facility fee for new sites Section 1834(m)(2)(B) of the Social Security Act ( 42 U.S.C. 1395m(m)(2)(B) ) is amended, in the matter preceding clause (i), by inserting (other than an originating site that is only described in clause (iii) or (iv) of paragraph (4)(C), and does not meet the requirement for an originating site under clause (i) of such paragraph) after the originating site . (d) Effective date The amendments made by this section shall apply to services furnished on or after January 1, 2017. 304. Rural health clinics and Federally qualified health centers authorized to be distant sites (a) In general Section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ) is amended— (1) in the first sentence of paragraph (1)— (A) by striking or a practitioner (described in section 1842(b)(18)(C)) and inserting , a practitioner (described in section 1842(b)(18)(C)), a Federally qualified health center, or a rural health clinic ; and (B) by striking or practitioner and inserting , practitioner, Federally qualified health center, or rural health clinic ; (2) in paragraph (2)(A)— (A) by inserting the following after eligible telehealth individual : or to a Federally qualified health center or rural health clinic that serves as a distant site and whose clinician furnishes a telehealth service to an eligible telehealth individual ; and (B) by striking such physician or practitioner and inserting such physician, practitioner, Federally qualified health center, or rural health clinic ; and (3) in paragraph (4)(A), by inserting the following before the period at the end: and includes a Federally qualified health center or rural health clinic whose clinician furnishes a telehealth service to an eligible individual . (b) Effective date The amendments made by this section shall apply to services furnished on or after January 1, 2017. 305. Addressing gaps in quality measures for telehealth and remote patient monitoring services Section 1848(s)(1)(C) of the Social Security Act ( 42 U.S.C. 1395w–4(s)(1)(C) ) is amended— (1) by redesignating clauses (i) through (iv) as subclauses (I) through (IV), respectively, and indenting appropriately; (2) by striking Consideration .—In developing and inserting “ Consideration .— (i) In general Subject to clause (ii), in developing ; and (3) by adding at the end the following new clause: (ii) Addressing gaps in measures for telehealth and remote patient monitoring services Consistent with this subsection, the Secretary shall ensure that the plan identifying measure development priorities and timelines developed under this subsection addresses relevant gaps in measures with respect to telehealth services, remote patient monitoring services, and the use of such services to address health disparities (as described in section 1890(b)(1)(B)(ii)) that are not otherwise addressed through existing quality measures. . IV Use of telehealth and remote patient monitoring services to provide basic benefits under Medicare part C 401. Use of telehealth and remote patient monitoring services to provide basic benefits under Medicare part C (a) In general Section 1852 of the Social Security Act ( 42 U.S.C. 1395w–22 ) is amended— (1) in subsection (a)(1)(B)(i), by striking part, the term and inserting part, subject to subsection (m), the term ; and (2) by adding at the end the following new subsection: (m) Use of telehealth and remote patient monitoring services To provide basic benefits For plan year 2017 and subsequent plan years, the following shall apply: (1) In general An MA plan may elect to use telehealth or remote patient monitoring services to provide benefits under the original medicare fee-for-service program option, including items or services furnished to treat medical or behavioral health conditions. (2) Waiver of limitations Notwithstanding any other provision of law, in the case where an MA plan elects to use telehealth or remote patient monitoring services to provide such benefits, with respect to enrollees, such services may be furnished without application of any provision under section 1834(m) or any other provision of this Act that applies a limitation on what qualifies as an originating site, any geographic limitation (subject to State licensing requirements), any limitation on the use of store-and-forward technologies, or any limitation on the type of health care provider who may furnish such services (provided the provider is a Medicare enrolled provider). (3) Treatment as basic benefits In the case where an MA plan makes such election under paragraph (1), the use of such telehealth or remote patient monitoring services shall be considered part of the provision of benefits under the original medicare fee-for-service program option for purpose of this part. (4) Availability of benefits in person In the case where an MA plan makes such election under paragraph (1), any benefits provided using such telehealth services shall continue to be made available in person to enrollees under the plan. (5) Provision of data An MA plan that makes such an election under paragraph (1) with respect to a plan year shall provide to the Secretary (at such time and in such manner as the Secretary may specify) data on expenditures and utilization for telehealth or remote patient monitoring services under the plan for enrollees during that plan year. . (b) Clarification regarding inclusion in bid amount Section 1854(a)(6)(A)(ii)(I) of the Social Security Act ( 42 U.S.C. 1395w–24(a)(6)(A)(ii)(I) ) is amended by inserting , including, for plan year 2017 and subsequent plan years, the use of telehealth or remote patient monitoring services to provide such benefits as described in section 1852(m) before the semicolon at the end. (c) Rule of construction Nothing in this section shall be construed as affecting the furnishing of items or services under the original Medicare fee-for-service program. V Clarification regarding telehealth and remote patient monitoring technologies provided to beneficiaries 501. Clarification regarding telehealth and remote patient monitoring technologies provided to beneficiaries Section 1128A(i)(6) of the Social Security Act (42 U.S.C. 1320a–7a(i)(6)) is amended— (1) in subparagraph (H), by striking ; or and inserting a semicolon; (2) in subparagraph (I), by striking the period at the end and inserting ; or ; and (3) by adding at the end the following new subparagraph: (J) the provision of telehealth or remote patient monitoring technologies to individuals under title XVIII by a health care provider for the purpose of furnishing telehealth or remote patient monitoring services. .