Issue: Legislative update
In the past few months, Congress has introduced three new major bills — two in the Senate and one in the House — that address important telemedicine reimbursement issues and propose substantial funding for expanding rural health care via telehealth technology.

Discussion
On May 6, Sen. Max Baucus (D-Mont.) introduced Senate Bill 980, known as the "Promoting Health in Rural Areas Act of 1999," which broadly addresses rural health care issues. It incorporates much of a bill proposed by Sen. Kent Conrad (D-N.D.) on April 14: S.B. 770, known as the "Comprehensive Rural Telehealth Act of 1999," in its entirety. These two bills recognize that telehealth technology is a tool that can extend the reach of rural health care services. Thus, they propose reimbursement for services under the current procedural terminology (CPT) billing codes reimbursed by Medicare, even if telehealth technology is used to provide these services. On March 25, Rep. Jim Nussle (R-Iowa) introduced House Bill 1344, known as the "Triple-A Rural Improvement Act of 1999," which is more narrowly focused on "fixing" some of the telehealth restrictions associated with the language of the Balanced Budget Act of 1997 (BBA), as discussed below.

Medicare Reimbursement

• Store-and-Forward Technology: The BBA restricts Medicare reimbursement to teleconsultations involving physician, patient & consulting physician using real-time interactive technology, thus store-and-forward technology, which is used by many telemedicine projects on a regular basis, is not reimbursable under current law. All three bills propose reimbursement but H.B. 1344 focuses on particular uses for store and forward technology whereas the other two bills reimburse use of any store and forward technology even "if patient, referring physician or health provider is not present."
• Eligible Practitioners and Presenters: Many rural clinics or health facilities do not have a full time physician or nurse practitioner on staff. However, the BBA’s definition of eligible presenters does not recognize that the majority of presenters in rural telemedicine settings are registered nurses, licensed practical nurses or similar health care professionals who are not eligible presenters under the BBA. H.B. 1344 expands the definition of "presenter" to include a registered nurse in a telehomecare setting. The Conrad and Baucus bills greatly expand the presenter definition to include "any health care provider acting on instruction from the referring physician or practitioner." All three bills expand the definition of eligible practitioner to include physical, occupational and speech therapists. S.B. 770 and S.B. 980 also include clinical psychologists as eligible practitioners.
• Medicare reimbursement for current eligible services provided through the use of telehealth technology: As discussed above, both S.B. 770 and S.B. 980 propose broad reimbursement of telehealth services.
• Payment methodology: Only H.B.1344/Nussle bill revises the payment methodology in the BBA.

Telehealth grants and loans

All three bills propose a Health and Human Services Department rural telehealth grant and loan program administered by the Director of the Office for the Advancement of Telehealth. All three recommend a 10-year loan limit for the program. HB 1344 appropriates $25 million for FY 2000 for rural network development and SB770 and SB980 appropriate $40 million for FY 2000 and "for such sums as may be necessary for each of FY 2001 through 2006."

The Joint Working Group on Telehealth and Studies

All three bills recommend expanding the scope of the Joint Working Group on Telemedicine to Telehealth and request annual congressional reports on telehealth. Funds are appropriated to cover the cost of these studies.

What You Need to Know

• Library of Congress' Thomas Web site - for legislation and updates
• An Overview of the Three Telehealth Bills