I 118th CONGRESS 1st Session H. R. 4189 IN THE HOUSE OF REPRESENTATIVES June 15, 2023 Mr. Thompson of California (for himself, Ms. Matsui , Mr. Schweikert , and Mr. Johnson of Ohio ) introduced the following bill; which was referred to the Committee on Energy and Commerce , and in addition to the Committee on Ways and Means , for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned A BILL To amend title XVIII of the Social Security Act to expand access to telehealth 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 for Health Act of 2023 or the CONNECT for Health Act of 2023 . (b) Table of contents The table of contents of this Act is as follows: Sec. 1. Short title; table of contents. Sec. 2. Findings and sense of Congress. TITLE I—Removing barriers to telehealth coverage Sec. 101. Removing geographic requirements for telehealth services. Sec. 102. Expanding originating sites. Sec. 103. Expanding authority for practitioners eligible to furnish telehealth services. Sec. 104. Improvements to the process for adding telehealth services. Sec. 105. Federally qualified health centers and rural health clinics. Sec. 106. Native American health facilities. Sec. 107. Repeal of six-month in-person visit requirement for telemental health services. Sec. 108. Waiver of telehealth requirements during public health emergencies. Sec. 109. Use of telehealth in recertification for hospice care. TITLE II—Program integrity Sec. 201. Clarification for fraud and abuse laws regarding technologies provided to beneficiaries. Sec. 202. Additional resources for telehealth oversight. Sec. 203. Addressing significant outlier billing patterns for telehealth services. TITLE III—Beneficiary and provider supports, quality of care, and data Sec. 301. Beneficiary engagement on telehealth. Sec. 302. Provider supports on telehealth. Sec. 303. Ensuring the inclusion of telehealth in measuring quality of care. Sec. 304. Posting of information on telehealth services. 2. Findings and sense of Congress (a) Findings Congress finds the following: (1) The use of technology in health care and coverage of telehealth services are rapidly evolving. (2) Research has found that telehealth services can expand access to care, improve the quality of care, and reduce spending. (3) In 2021, 91 percent of patients receiving telehealth services were satisfied with their experiences. (4) Health care workforce shortages are a significant problem in many areas and for many types of health care clinicians. (5) Telehealth increases access to care in areas with workforce shortages and for individuals who live far away from health care facilities, have limited mobility or transportation, or have other barriers to accessing care. (6) The use of health technologies can strengthen the expertise of the health care workforce, including by connecting clinicians to specialty consultations. (7) Prior to the COVID–19 pandemic, the utilization of telehealth services in the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ) was low, accounting for 0.1 percent of Medicare Part B visits in 2019. (8) Telehealth now represents a critical component of care delivery. As of February 2023, 15 percent of Medicare fee-for-service beneficiaries have had a telehealth service in the past quarter. (9) Long-term certainty about coverage of telehealth services under the Medicare program is necessary to fully realize the benefits of telehealth. (b) Sense of Congress It is the sense of Congress that— (1) health care providers can furnish safe, effective, and high-quality health care services through telehealth; (2) the Secretary of Health and Human Services should promptly take all necessary measures to ensure that providers and beneficiaries can continue to furnish and utilize, respectively, telehealth services in the Medicare program, including modifying, as appropriate, the definition of interactive telecommunications system in regulations and program instruction under the Medicare program to ensure that providers can utilize all appropriate means and types of technology, including audio-visual, audio-only, and other types of technologies, to furnish telehealth services; and (3) barriers to the use of telehealth should be removed. I Removing barriers to telehealth coverage 101. Removing geographic requirements for telehealth services Section 1834(m)(4)(C) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(C) ) is amended— (1) in clause (i), in the matter preceding subclause (I), by striking clause (iii) and inserting clauses (iii) and (iv) ; and (2) by adding at the end the following new clause: (iv) Removal of geographic requirements The geographic requirements described in clause (i) shall not apply with respect to telehealth services furnished on or after January 1, 2025. . 102. Expanding originating sites (a) Expanding the home as an originating site Section 1834(m)(4)(C)(ii)(X) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(C)(ii)(X) ) is amended to read as follows: (X) (aa) Prior to January 1, 2025, the home of an individual but only for purposes of section 1881(b)(3)(B) or telehealth services described in paragraph (7). (bb) On or after January 1, 2025, the home of an individual. For purposes of the preceding sentence, the home of an individual includes temporary lodging and, in the case where, for privacy or other personal reasons, an individual chooses to travel a short distance from the home for the furnishing of a telehealth service, includes such location, as described in the final rule entitled Medicare Program; CY 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Provider Enrollment Regulation Updates; and Provider and Supplier Prepayment and Post-Payment Medical Review Requirements published in the Federal Register on November 19, 2021 (86 Fed. Reg. 64996), or a successor regulation. . (b) Allowing additional originating sites Section 1834(m)(4)(C)(ii) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(C)(ii) ) is amended by adding at the end the following new subclause: (XII) Any other clinically appropriate site at which an eligible telehealth individual is located at the time a telehealth service is furnished via a telecommunications system. Not later than January 1, 2025, the Secretary shall issue regulations that establish parameters for the determination of whether a site is clinically appropriate for purposes of the preceding sentence. . (c) Parameters for new originating sites Section 1834(m)(4)(C) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(C) ), as amended by section 101, is amended by adding at the end the following new clause: (v) Requirements for new sites (I) In general The Secretary may establish requirements for the furnishing of telehealth services at sites described in clause (ii)(XII) to provide for beneficiary and program integrity protections. (II) Rule of construction Nothing in this clause shall be construed to preclude the Secretary from establishing requirements for other originating sites described in clause (ii) . (d) No originating site facility fee for new sites Section 1834(m)(2)(B)(ii) of the Social Security Act ( 42 U.S.C. 1395m(m)(2)(B)(ii) ) is amended— (1) in the heading, by striking if originating site is the home and inserting for certain sites ; and (2) by striking paragraph (4)(C)(ii)(X) and inserting subclause (X) or (XII) of paragraph (4)(C)(ii) . 103. Expanding authority for practitioners eligible to furnish telehealth services Section 1834(m)(4)(E) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(E) ) is amended— (1) by striking Practitioner .—The term and inserting “ Practitioner .— (i) In general Subject to clause (ii), the term ; and (2) by adding at the end the following new clause: (ii) Expanding practitioners eligible to furnish telehealth services (I) In general Notwithstanding any other provision of this subsection, in the case of telehealth services furnished on or after January 1, 2024, the Secretary may waive any limitation on the types of practitioners who are eligible to furnish telehealth services (other than the requirement that the practitioner is enrolled under section 1866(j)) if the Secretary determines that such waiver is clinically appropriate. (II) Implementation In implementing a waiver under this clause, the Secretary may establish parameters, as appropriate, for telehealth services under such waiver, including with respect to beneficiary and program integrity protections. (III) Public comment The Secretary shall establish a process by which stakeholders may (on at least an annual basis) provide public comment on such waiver under this clause. (IV) Periodic review The Secretary shall periodically, but not more frequently than every 3 years, reassess the waiver under this clause to determine whether such waiver continues to be clinically appropriate. The Secretary shall terminate any waiver that the Secretary determines is no longer clinically appropriate. . 104. Improvements to the process for adding telehealth services (a) Review The Secretary shall undertake a review of the process established pursuant to section 1834(m)(4)(F)(ii) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(F)(ii) ), and based on the results of such review— (1) implement revisions to the process so that the criteria to add services prioritizes, as appropriate, improved access to care through clinically appropriate telehealth services; and (2) provide clarification on what requests to add telehealth services under such process should include. (b) Temporary coverage of certain telehealth services Section 1834(m)(4)(F) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(F) ) is amended by adding at the end the following new clause: (iii) Temporary coverage of certain telehealth services The Secretary may add services with a reasonable potential likelihood of clinical benefit and improved access to care when furnished via a telecommunications system (as determined by the Secretary) on a temporary basis to those specified in clause (i) for authorized payment under paragraph (1). . 105. Federally qualified health centers and rural health clinics Section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ) is amended— (1) in paragraph (4)(C)(i), in the matter preceding subclause (I), by striking and (7) and inserting (7), and (8) ; and (2) in paragraph (8)— (A) in subparagraph (A)— (i) in the matter preceding clause (i), by striking During and all that follows through December 31, 2024— and inserting the following: During and after the emergency period described in section 1135(g)(1)(B)— ; (ii) in clause (ii), by striking and at the end; (iii) by redesignating clause (iii) as clause (iv); and (iv) by inserting after clause (ii) the following new clause: (iii) the geographic requirements described in paragraph (4)(C)(i) shall not apply with respect to such a telehealth service; and ; and (B) by striking subparagraph (B) and inserting the following: (B) Payment (i) In general A telehealth service furnished by a Federally qualified health center or a rural health clinic to an individual pursuant to this paragraph on or after the date of the enactment of this subparagraph shall be deemed to be so furnished to such individual as an outpatient of such clinic or facility (as applicable) for purposes of paragraph (1) or (3), respectively, of section 1861(aa) and payable as a Federally qualified health center service or rural health clinic service (as applicable) under the prospective payment system established under section 1834(o) or under section 1833(a)(3), respectively. (ii) Treatment of costs for FQHC PPS calculations and RHC AIR calculations Costs associated with the delivery of telehealth services by a Federally qualified health center or rural health clinic serving as a distant site pursuant to this paragraph shall be considered allowable costs for purposes of the prospective payment system established under section 1834(o) and any payment methodologies developed under section 1833(a)(3), as applicable. . 106. Native American health facilities (a) In general Section 1834(m)(4)(C) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(C) ), as amended by sections 101 and 102, is amended— (1) in clause (i), by striking and (iv) and inserting , (iv), and (vi) ; and (2) by adding at the end the following new clause: (vi) Native American health facilities With respect to telehealth services furnished on or after January 1, 2024, 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. 5304 )), 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. ). . (b) No originating site facility fee for Certain Native American facilities Section 1834(m)(2)(B)(i) of the Social Security Act ( 42 U.S.C. 1395m(m)(2)(B)(i) ) is amended, in the matter preceding subclause (I), by inserting (other than an originating site that is only described in clause (v) of paragraph (4)(C), and does not meet the requirement for an originating site under clauses (i) and (ii) of such paragraph) after the originating site . 107. Repeal of six-month in-person visit requirement for telemental health services Section 1834(m)(7) of the Social Security Act ( 42 U.S.C. 1395m(m)(7)(B) ) is amended— (1) in subparagraph (A), by striking , subject to subparagraph (B), ; (2) by striking (A) In general .—The geographic and inserting The geographic ; and (3) by striking subparagraph (B). 108. Waiver of telehealth requirements during public health emergencies Section 1135(g)(1) of the Social Security Act ( 42 U.S.C. 1320b–5(g)(1) ) is amended— (1) in subparagraph (A), in the matter preceding clause (i), by striking subparagraph (B) and inserting subparagraphs (B) and (C) ; and (2) by adding at the end the following new subparagraph: (C) Exception for waiver of telehealth requirements during public health emergencies For purposes of subsection (b)(8), in addition to the emergency period described in subparagraph (B), an emergency area is a geographical area in which, and an emergency period is the period during which, there exists a public health emergency declared by the Secretary pursuant to section 319 of the Public Health Service Act. . 109. Use of telehealth in recertification for hospice care (a) In general Section 1814(a)(7)(D)(i)(II) of the Social Security Act ( 42 U.S.C. 1395f(a)(7)(D)(i)(II) ) is amended by striking during the emergency period and all that follows through ending on December 31, 2024 and inserting the following: during and after the emergency period described in section 1135(g)(1)(B) . (b) National Academy of Medicine report The Secretary of Health and Human Services shall request the National Academy of Medicine to submit a report to Congress, not later than 3 years after the date of enactment of this Act, evaluating the impact of section 1814(a)(7)(D)(i)(II) of the Social Security Act ( 42 U.S.C. 1395f(a)(7)(D)(i)(II) ), as amended by subsection (a), on— (1) the number and percentage of beneficiaries recertified for the Medicare hospice benefit at 180 days and for subsequent benefit periods; (2) the appropriateness for hospice care of the patients recertified through the use of telehealth; and (3) any other factors determined appropriate by the National Academy of Medicine. II Program integrity 201. Clarification for fraud and abuse laws regarding 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 (I), by striking ; or and inserting a semicolon; (2) in subparagraph (J), by striking the period at the end and inserting ; or ; and (3) by adding at the end the following new subparagraph: (K) the provision of technologies (as defined by the Secretary) on or after the date of the enactment of this subparagraph, by a provider of services or supplier (as such terms are defined for purposes of title XVIII) directly to an individual who is entitled to benefits under part A of title XVIII, enrolled under part B of such title, or both, for the purpose of furnishing telehealth services, remote patient monitoring services, or other services furnished through the use of technology (as defined by the Secretary), if— (i) the technologies are not offered as part of any advertisement or solicitation; and (ii) the provision of the technologies meets any other requirements set forth in regulations promulgated by the Secretary. . 202. Additional resources for telehealth oversight In addition to amounts otherwise available, there are authorized to be appropriated to the Inspector General of the Department of Health and Human Services for each of fiscal years 2024 through 2028, out of any money in the Treasury not otherwise appropriated, $3,000,000, to remain available until expended, for purposes of conducting audits, investigations, and other oversight and enforcement activities with respect to telehealth services, remote patient monitoring services, or other services furnished through the use of technology (as defined by the Secretary). 203. Addressing significant outlier billing patterns for telehealth services (a) Identification and notification of outlier billers of telehealth (1) In general The Secretary shall, using national provider identifiers on claims for telehealth services furnished to individuals under section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ), identify physicians and practitioners that demonstrate significant outlier billing patterns (such as coding of telehealth services for inappropriate length of time and inaccurate complexity and inappropriate or duplicate billing) for telehealth services or items or services ordered or prescribed concurrent to a telehealth service over a period of time specified by the Secretary. (2) Establishment of thresholds For purposes of this subsection, the Secretary shall establish thresholds for outlier billing patterns to identify whether a physician or practitioner is a significant outlier biller for telehealth services or items or services ordered or prescribed concurrent to a telehealth service as compared to other physicians or practitioners within the same specialty and geographic area. (b) Notification (1) In general The Secretary shall notify any physician or practitioner identified as a significant outlier biller for telehealth services or items or services ordered or prescribed concurrent to a telehealth service under subsection (a). Each notification under the preceding sentence shall include the following: (A) Information on how the physician or practitioner compares to physicians or practitioners within the same specialty and geographic area with respect to billing for telehealth services or items or services ordered or prescribed concurrent to a telehealth service under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ). (B) Information on telehealth billing guidelines under the Medicare program. (C) Other information determined appropriate by the Secretary. (2) Clarification Nothing in this subsection or subsection (a) shall be construed as directing the Centers for Medicare & Medicaid Services to pursue further audits of providers of services and suppliers outside of those permitted or required under titles XI or XVIII of the Social Security Act, or otherwise under applicable Federal law. (c) Public Availability of Information The Secretary shall make aggregate information on outlier billing patterns identified under subsection (a) available on the internet website of the Centers for Medicare & Medicaid Services. Such information shall be in a form and manner determined appropriate by the Secretary and shall not identify any specific physician or practitioner. (d) Other activities Nothing in this section shall preclude the Secretary from conducting activities that provide physicians and practitioners with information as to how they compare to other physicians and practitioners that are in addition to the activities under this section. (e) Telehealth resource centers education activities Section 330I(j)(2) of the Public Health Service Act ( 42 U.S.C. 254c–14(j)(2) ) is amended— (1) in subparagraph (F), by striking and at the end; (2) in subparagraph (G), by striking the period at the end and inserting ; and ; and (3) by adding at the end the following new subparagraph: (H) providing technical assistance and education to physicians and practitioners that the Secretary identifies pursuant to section 203(a) of the CONNECT for Health Act of 2023 as having significant levels of outlier billing patterns with respect to telehealth services or items or services ordered or prescribed concurrent to a telehealth service under the Medicare program under title XVIII of the Social Security Act, including— (i) education on practices to ensure coding of telehealth services for appropriate length of time and accurate complexity; (ii) education on prevention of inappropriate or duplicate billing; and (iii) information on— (I) services specified in paragraph (4)(F)(i) of section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ) for authorized payment under paragraph (1) of such section; and (II) the process used to update such services under clauses (ii) and (iii) (as added by section 104) of paragraph (4)(F) of such section 1834(m); and (iv) referral to the appropriate medicare administrative contractor for specific questions that fall outside of the scope of broad best practices. . (f) Definitions In this section: (1) Secretary The term Secretary means the Secretary of Health and Human Services. (2) Telehealth service The term telehealth service has the meaning given that term in section 1834(m)(4)(F) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(F) ). (3) Physician; practitioner The terms physician and practitioner have the meaning given those terms for purposes of section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ). III Beneficiary and provider supports, quality of care, and data 301. Beneficiary engagement on telehealth (a) Resources, guidance, and training sessions Section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ) is amended by adding at the end the following new paragraph: (10) Resources, guidance, and training sessions (A) In general Not later than 6 months after the date of the enactment of this paragraph, the Secretary, in consultation with stakeholders, shall issue resources, guidance, and training sessions for beneficiaries, physicians, practitioners, and health information technology software vendors on best practices for ensuring telehealth services are accessible for— (i) individuals with limited English proficiency, including instructions on how to— (I) access telehealth platforms; (II) utilize interpreter services; and (III) integrate telehealth and virtual interpreter services; and (ii) individuals with Disabilities, including instructions on accessibility of the telecommunications system being used for telehealth services, engagement with beneficiaries with disabilities prior to, during, and after the furnishing of the telehealth service, and training on captioning and transcripts. (B) Accounting for age and other differences Resources, guidance, and training sessions issued under this paragraph shall account for age and sociodemographic, geographic, literacy, cultural, cognitive, and linguistic differences in how individuals interact with technology. . (b) Study and report on tactics To improve beneficiary engagement on telehealth (1) Study The Secretary of Health and Human Services shall collect and analyze qualitative and quantitative data on strategies that clinicians, payers, and other health care organizations use to improve beneficiary engagement on telehealth services (as defined in section 1834(m)(4)(F) of the Social Security Act ( 42 U.S.C. 1395m(m)(4)(F) )), with an emphasis on underserved communities, such as the use of digital navigators, providing patients with pre-visit information on telehealth, caregiver engagement, and training on telecommunications systems, and the investments necessary for health care professionals to effectively furnish telehealth services, including the costs of necessary technology and of training staff. (2) Report Not later than 1 year after the date of the enactment of this Act, the Secretary shall submit to Congress and make available on the internet website of the Centers for Medicare & Medicaid Services a report containing the results of the study under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines appropriate. (c) Funding There are authorized to be appropriated such sums as necessary to carry out the provisions of, including the amendments made by, this section. 302. Provider supports on telehealth (a) Educational resources and training sessions Not later than 6 months after the date of enactment of this Act, the Secretary of Health and Human Services shall develop and make available to health care professionals educational resources and training sessions on requirements relating to the furnishing of telehealth services under section 1834(m) of the Social Security Act ( 42 U.S.C. 1395m(m) ) and topics including— (1) requirements for payment for telehealth services; (2) telehealth-specific health care privacy and security training; (3) utilizing telehealth services to engage and support underserved, high-risk, and vulnerable patient populations; and (4) other topics as determined appropriate by the Secretary. (b) Telehealth resource centers The Secretary shall consider including technical assistance, education, and training on telehealth services as a required activity for telehealth resource centers under section 330I of the Public Health Service Act ( 42 U.S.C. 254c–14 ). (c) Funding There are authorized to be appropriated such sums as necessary to carry out this section. 303. Ensuring the inclusion of telehealth in measuring quality of care Section 1890A of the Social Security Act ( 42 U.S.C. 1395aaa–1 ) is amended by adding at the end the following new subsection: (h) Measuring quality of telehealth services (1) In general Not later than 180 days after the date of the enactment of this subsection, the Secretary shall review quality measures to ensure inclusion of measures relating to telehealth services, including care, prevention, diagnosis, patient experience, health outcomes, and treatment. (2) Consultation In conducting the review and assessment under paragraph (1), the Secretary shall consult external technical experts in quality measurement, including patient organizations, providers, and experts in telehealth. (3) Review and assessment The review and assessment under this subsection shall— (A) include review of existing and under development quality measures to identify measures that are currently inclusive of, and measures that fail to account for, telehealth services; and (B) identify gaps in areas of quality measurement that relate to telehealth services, including health outcomes and patient experience of care. (4) Technical guidance The Secretary shall issue technical guidance on— (A) how to effectively streamline, implement, and assign accountability for health outcomes for quality measures for telehealth services across health care settings and providers; (B) how to stratify measures by care modality and population to identify differences in health outcomes; (C) the use of uniform data elements; (D) how to identify and catalogue best practices related to the use of quality measurement and quality improvement for telehealth services; and (E) other areas determined appropriate by the Secretary. (5) Report Not later than 2 years after the date of the enactment of this subsection, the Secretary shall submit to Congress and post on the internet website of the Centers for Medicare & Medicaid Services a report on the review and assessment conducted under this subsection. . 304. Posting of information on telehealth services Not later than 180 days after the date of enactment, and quarterly thereafter, the Secretary of Health and Human Services shall post on the internet website of the Centers for Medicare & Medicaid Services information on— (1) the furnishing of telehealth services under the Medicare program under title XVIII of the Social Security Act ( 42 U.S.C. 1395 et seq. ), described by patient population, type of service, geography, place of service, and provider type; (2) the impact of telehealth services on expenditures and utilization under the Medicare program; and (3) other outcomes related to the furnishing of telehealth services under the Medicare program, as determined appropriate by the Secretary.