Medicare Next Generation ACO Model Telehealth Expansion Waiver

telehealth waiver

In the United States traditional fee-for-service system of Medicare, use of the telehealth benefit is limited to rural Health Professional Shortage Areas (HPSA). As of January 2018, this restriction has changed for more than 50 “Accountable Care Organizations” (ACOs). ACOs are groups of doctors, hospitals, and other health care providers who voluntarily form a group voluntarily to give coordinated care to Medicare recipients seeking healthcare.

With regard to telehealth, CMS defines telehealth originating sites and synchronous telehealth services. However, since January 2018, the Next Generation ACO Telehealth Expansion Wavier eliminates CMS’ requirement for the rural geographic component of originating sites, allowing the originating site to extend to a beneficiary’s home. However, the waiver applies only to beneficiaries aligned to a Next Generation ACO and for services furnished by a Next Generation Participant or Preferred Provider approved to use the waiver.

Currently, then, an aligned beneficiary is eligible for the Telehealth Expansion Waiver if the beneficiary is located at their home or one of the Centers for Medicare & Medicaid Services (CMS) defined telehealth originating sites at the time of service delivery.

Next Generation ACO Model Telehealth Expansion Waiver FAQ

This Next Generation ACO Model Telehealth Expansion Waiver document provides frequently asked questions (FAQ) and answers related to the Telehealth Expansion Waiver. The first section includes questions around waiver policy, and the second section describes questions around data submission requirements. Keep your eyes peeled for more such waivers.


For more information about other telebehavioral health and telemental health reimbursement, see the Telebehavioral Health Institute’s “Maximizing Telehealth Reimbursement: New Billing, Coding & Credentialing Strategies for 2019.” This online professional training event addresses a number of successful strategies to get paid for telepractice today as well as the 2019 CPT codes. It comes with a handout and CME or CE hour, valid toward licensure renewal for most healthcare disciplines.


Recommended Reimbursement Articles

99091: New Telehealth CPT Code for Remote Patient Monitoring

Remote patient monitoring (RPM) is the term used to refer to a broad range of technologies that allow clients/patients to be monitored when in non-professional settings, such as their homes, at work, and even at play. While such systems have been at the periphery of telehealth for almost two decades, they now can be brought into the mainstream of telehealthcare by allowing a client or patient to monitor their own behavior (thoughts) or bodily processes (heart rate, temperature, etc.) continuously, that is, throughout the day.

CMS Congressional report

CMS Congressional Report: 85.4% of all Telehealth Users Had Mental Health Diagnosis

Professionals looking for current metrics related to opportunities in telemental health or telebehavioral health will find a treasure-trove in the recent Centers for Medicare and Medicaid (CMS) Congressional report. The November 15, 2018 CMS Congressional report is entitled, Information on Medicare Telehealth. It offers a wide number of recently compiled metrics, expressed concerns and overall telehealth opportunities about the overall industry serving Medicare recipients, and succinctly compiles a useful array of facts that can be of use to behavioral professionals and their organizations.

Epstein Becker & Green 2018 Telehealth Report

Telehealth services became notably more popular amount clients/patients, practitioners, employers and legislators according to a 2018 telehealth report from law firm, Epstein Becker & Green. Their 3rd annual telebehavioral healthcare report focused on laws, regulations and policies. They also noted that adoption amongst insurance companies continues to lag.


MACRA & Telehealth Reimbursement

MACRA is of potential interest to the telehealth community for several reasons. First, let us give you a little background. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is bipartisan legislation. It was signed into law on April 16, 2015 and is commonly called the Permanent Doc Fix. It is a United States statute that revises the Balanced Budget Act of 1997 to change the payment system for professionals who treat Medicare patients.

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