[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5081 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 5081
To amend title XVIII of the Social Security Act to extend certain
telehealth flexibilities under the Medicare program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 2, 2025
Mr. Carter of Georgia (for himself and Mrs. Dingell) 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 extend certain
telehealth flexibilities under the Medicare program.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Telehealth Modernization Act''.
SEC. 2. EXTENSION OF CERTAIN TELEHEALTH FLEXIBILITIES.
(a) Removing Geographic Requirements and Expanding Originating
Sites for Telehealth Services.--Section 1834(m) of the Social Security
Act (42 U.S.C. 1395m(m)) is amended--
(1) in paragraph (2)(B)(iii), by striking ``ending
September 30, 2025'' and inserting ``ending September 30,
2027''; and
(2) in paragraph (4)(C)(iii), by striking ``ending on
September 30, 2025'' and inserting ``ending on September 30,
2027''.
(b) Expanding 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 by striking ``ending on September 30, 2025''
and inserting ``ending on September 30, 2027''.
(c) Extending Telehealth Services for Federally Qualified Health
Centers and Rural Health Clinics.--Section 1834(m)(8) of the Social
Security Act (42 U.S.C. 1395m(m)(8)) is amended--
(1) in subparagraph (A), by striking ``ending on September
30, 2025'' and inserting ``ending on September 30, 2027'';
(2) in subparagraph (B)--
(A) in the subparagraph heading, by inserting
``before fiscal year 2026'' after ``rule'';
(B) in clause (i), by striking ``during the periods
for which subparagraph (A) applies'' and inserting
``before October 1, 2025''; and
(C) in clause (ii), by inserting ``furnished to an
eligible telehealth individual before October 1, 2025''
after ``telehealth services''; and
(3) by adding at the end the following new subparagraph:
``(C) Payment rule for fiscal years 2026 and
2027.--
``(i) In general.--A telehealth service
furnished to an eligible telehealth individual
by a Federally qualified health center or rural
health clinic on or after October 1, 2025, and
before October 1, 2027, shall be paid 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 the
methodology for all-inclusive rates established
under section 1833(a)(3), respectively.
``(ii) Treatment of costs.--Costs
associated with the furnishing of telehealth
services by a Federally qualified health center
or rural health clinic on or after October 1,
2025, and before October 1, 2027, shall be
considered allowable costs for purposes of the
prospective payment system established under
section 1834(o) and the methodology for all-
inclusive rates established under section
1833(a)(3), as applicable.''.
(d) Delaying In-Person Requirements Under Medicare for Mental
Health Services Furnished Through Telehealth and Telecommunications
Technology.--
(1) Delay in requirements for mental health services
furnished through telehealth.--Section 1834(m)(7)(B)(i) of the
Social Security Act (42 U.S.C. 1395m(m)(7)(B)(i)) is amended,
in the matter preceding subclause (I), by striking ``on or
after October 1, 2025'' and inserting ``on or after October 1,
2027''.
(2) Mental health visits furnished by rural health
clinics.--Section 1834(y)(2) of the Social Security Act (42
U.S.C. 1395m(y)(2)) is amended by striking ``October 1, 2025''
and inserting ``October 1, 2027''.
(3) Mental health visits furnished by federally qualified
health centers.--Section 1834(o)(4)(B) of the Social Security
Act (42 U.S.C. 1395m(o)(4)(B)) is amended by striking ``October
1, 2025'' and inserting ``October 1, 2027''.
(e) Allowing for the Furnishing of Audio-Only Telehealth
Services.--Section 1834(m)(9) of the Social Security Act (42 U.S.C.
1395m(m)(9)) is amended by striking ``ending on September 30, 2025''
and inserting ``ending on September 30, 2027''.
(f) Extending Use of Telehealth To Conduct Face-to-Face Encounter
Prior to Recertification of Eligibility for Hospice Care.--Section
1814(a)(7)(D)(i)(II) of the Social Security Act (42 U.S.C.
1395f(a)(7)(D)(i)(II)) is amended--
(1) by striking ``ending on September 30, 2025'' and
inserting ``ending on September 30, 2027''; and
(2) by inserting ``, except that this subclause shall not
apply in the case of such an encounter with an individual
occurring on or after September 30, 2025, if such individual is
located in an area that is subject to a moratorium on the
enrollment of hospice programs under this title pursuant to
section 1866(j)(7), if such individual is receiving hospice
care from a provider that is subject to enhanced oversight
under this title pursuant to section 1866(j)(3), or if such
encounter is performed by a hospice physician or nurse
practitioner who is not enrolled under section 1866(j) and is
not an opt-out physician or practitioner (as defined in section
1802(b)(6)(D))'' before the semicolon.
SEC. 3. REQUIRING MODIFIER FOR USE OF TELEHEALTH TO CONDUCT FACE-TO-
FACE ENCOUNTER PRIOR TO RECERTIFICATION OF ELIGIBILITY
FOR HOSPICE CARE.
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 section 2(f), is further amended
by inserting ``, but only if, in the case of such an encounter
occurring on or after January 1, 2026, any hospice claim includes 1 or
more modifiers or codes (as specified by the Secretary) to indicate
that such encounter was conducted via telehealth'' after ``as
determined appropriate by the Secretary''.
SEC. 4. EXTENDING ACUTE HOSPITAL CARE AT HOME WAIVER FLEXIBILITIES.
(a) In General.--Section 1866G(a)(1) of the Social Security Act (42
U.S.C. 1395cc-7(a)(1)) is amended by striking ``2025'' and inserting
``2030''.
(b) Requiring Additional Study and Report on Acute Hospital Care at
Home Waiver Flexibilities.--Section 1866G of the Social Security Act
(42 U.S.C. 1395cc-7), as amended by subsection (a), is further
amended--
(1) in subsection (b), in the subsection heading, by
striking ``Study'' and inserting ``Initial Study'';
(2) by redesignating subsections (c) and (d) as subsections
(d) and (e), respectively; and
(3) by inserting after subsection (b) the following new
subsection:
``(c) Subsequent Study and Report.--
``(1) In general.--Not later than September 30, 2028, the
Secretary shall conduct a study to--
``(A) analyze, to the extent practicable, the
criteria established by hospitals under the Acute
Hospital Care at Home initiative to determine which
individuals may be furnished services under such
initiative; and
``(B) analyze and compare (both within and between
hospitals participating in the initiative, and relative
to comparable hospitals that do not participate in the
initiative, for relevant parameters such as diagnosis-
related groups)--
``(i) quality of care furnished to
individuals with similar conditions and
characteristics in the inpatient setting and
through the Acute Hospital Care at Home
initiative, including health outcomes, hospital
readmission rates (including readmissions both
within and beyond 30 days post-discharge),
hospital mortality rates, length of stay,
infection rates, composition of care team
(including the types of labor used, such as
contracted labor), the ratio of nursing staff,
transfers from the hospital to the home,
transfers from the home to the hospital
(including the timing, frequency, and causes of
such transfers), transfers and discharges to
post-acute care settings (including the timing,
frequency, and causes of such transfers and
discharges), and patient and caregiver
experience of care;
``(ii) clinical conditions treated and
diagnosis-related groups of discharges from
inpatient settings relative to discharges from
the Acute Hospital Care at Home initiative;
``(iii) costs incurred by the hospital for
furnishing care in inpatient settings relative
to costs incurred by the hospital for
furnishing care through the Acute Hospital Care
at Home initiative, including costs relating to
staffing, equipment, food, prescriptions, and
other services, as determined by the Secretary;
``(iv) the quantity, mix, and intensity of
services (such as in-person visits and virtual
contacts with patients and the intensity of
such services) furnished in inpatient settings
relative to the Acute Hospital Care at Home
initiative, and, to the extent practicable, the
nature and extent of family or caregiver
involvement;
``(v) socioeconomic information on
individuals treated in comparable inpatient
settings relative to the initiative, including
racial and ethnic data, income, housing,
geographic proximity to the brick-and-mortar
facility and whether such individuals are
dually eligible for benefits under this title
and title XIX; and
``(vi) the quality of care, outcomes,
costs, quantity and intensity of services, and
other relevant metrics between individuals who
entered into the Acute Hospital Care at Home
initiative directly from an emergency
department compared with individuals who
entered into the Acute Hospital Care at Home
initiative directly from an existing inpatient
stay in a hospital.
``(2) Selection bias.--In conducting the study under
paragraph (1), the Secretary shall, to the extent practicable,
analyze and compare individuals who participate and do not
participate in the initiative controlling for selection bias or
other factors that may impact the reliability of data.
``(3) Report.--Not later than September 30, 2028, the
Secretary of Health and Human Services shall submit to the
Committee on Ways and Means of the House of Representatives and
the Committee on Finance of the Senate a report on the study
conducted under paragraph (1).''.
SEC. 5. ENHANCING CERTAIN PROGRAM INTEGRITY REQUIREMENTS FOR DME UNDER
MEDICARE.
(a) Durable Medical Equipment.--
(1) In general.--Section 1834(a) of the Social Security Act
(42 U.S.C. 1395m(a)) is amended by adding at the end the
following new paragraph:
``(23) Master list inclusion and claim review for certain
items.--
``(A) Master list inclusion.--Beginning January 1,
2028, for purposes of the Master List described in
section 414.234(b) of title 42, Code of Federal
Regulations (or any successor regulation), an item for
which payment may be made under this subsection shall
be treated as having aberrant billing patterns (as such
term is used for purposes of such section) if the
Secretary determines that, without explanatory
contributing factors (such as furnishing emergent care
services), a substantial number of claims for such
items under this subsection are for such items ordered
by a physician or practitioner who has not previously
(during a period of not less than 24 months, as
established by the Secretary) furnished to the
individual involved any item or service for which
payment may be made under this title.
``(B) Claim review.--With respect to items
furnished on or after January 1, 2028, that are
included on the Master List pursuant to subparagraph
(A), if such an item is not subject to a determination
of coverage in advance pursuant to paragraph (15)(C),
the Secretary may conduct prepayment review of claims
for payment for such item.''.
(2) Conforming amendment for prosthetic devices, orthotics,
and prosthetics.--Section 1834(h)(3) of the Social Security Act
(42 U.S.C. 1395m(h)(3)) is amended by inserting ``, and
paragraph (23) of subsection (a) shall apply to prosthetic
devices, orthotics, and prosthetics in the same manner as such
provision applies to items for which payment may be made under
such subsection'' before the period at the end.
(b) Report on Identifying Clinical Diagnostic Laboratory Tests at
High Risk for Fraud and Effective Mitigation Measures.--Not later than
January 1, 2026, the Inspector General of the Department of Health and
Human Services shall submit to Congress a report assessing fraud risks
relating to claims for clinical diagnostic laboratory tests for which
payment may be made under section 1834A of the Social Security Act (42
U.S.C. 1395m-1) and effective tools for reducing such fraudulent
claims. The report may include information regarding--
(1) which, if any, clinical diagnostic laboratory tests are
identified as being at high risk of fraudulent claims, and an
analysis of the factors that contribute to such risk;
(2) with respect to a clinical diagnostic laboratory test
identified under paragraph (1) as being at high risk of
fraudulent claims--
(A) the amount payable under such section 1834A
with respect to such test;
(B) the number of such tests furnished to
individuals enrolled under part B of title XVIII of the
Social Security Act (42 U.S.C. 1395j et seq.);
(C) whether an order for such a test was more
likely to come from a provider with whom the individual
involved did not have a prior relationship, as
determined on the basis of prior payment experience;
and
(D) the frequency with which a claim for payment
under such section 1834A included the payment modifier
identified by code 59 or 91;
(3) suggested strategies for reducing the number of
fraudulent claims made with respect to tests so identified as
being at high risk, including--
(A) an analysis of whether the Centers for Medicare
& Medicaid Services can detect aberrant billing
patterns with respect to such tests in a timely manner;
(B) any strategies for identifying and monitoring
the providers who are outliers with respect to the
number of such tests that such providers order; and
(C) targeted education efforts to mitigate improper
billing for such tests; and
(4) such other information as the Inspector General
determines appropriate.
SEC. 6. GUIDANCE ON FURNISHING SERVICES VIA TELEHEALTH TO INDIVIDUALS
WITH LIMITED ENGLISH PROFICIENCY.
(a) In General.--Not later than 1 year after the date of the
enactment of this section, the Secretary of Health and Human Services,
in consultation with 1 or more entities from each of the categories
described in paragraphs (1) through (7) of subsection (b), shall issue
and disseminate, or update and revise as applicable, guidance for the
entities described in such subsection on the following:
(1) Best practices on facilitating and integrating use of
interpreters during a telemedicine appointment.
(2) Best practices on providing accessible instructions on
how to access telecommunications systems (as such term is used
for purposes of section 1834(m) of the Social Security Act (42
U.S.C. 1395m(m))) for individuals with limited English
proficiency.
(3) Best practices on improving access to digital patient
portals for individuals with limited English proficiency.
(4) Best practices on integrating the use of video
platforms that enable multi-person video calls furnished via a
telecommunications system for purposes of providing
interpretation during a telemedicine appointment for an
individual with limited English proficiency.