The COVID-19 public health emergency (PHE) led to a significant expansion of telehealth that has continued over the last 5 years. This has increased access to diabetes self-management and support (DSMES) services for people who would otherwise not be able to use them, including increased access to the Medicare diabetes self-management training (DSMT) benefit.
Early in the PHE, the Association of Diabetes Education & Care Specialists (ADCES) focused its telehealth advocacy efforts on ensuring that the new flexibilities were meeting the needs of programs and that programs had clarity on how these flexibilities applied to them. As we approached the end of the PHE, ADCES recognized the need to ensure that as many of these policies were made permanent before they expired to ensure seamless continuation of telehealth access into the future. The wins described in the following showcase the role of advocacy not just in improving from the status quo but also in working behind the scenes to protect gains so that access is not rolled back.
Although we are still in a period of uncertainty as to the long-term fate of overall telehealth access in Medicare, the advocacy efforts of ADCES and other organizations have resulted in several key wins in permanent telehealth policy with positive practice implications for DSMES programs.
One of the biggest challenges of providing DSMT via telehealth to Medicare beneficiaries prior to and early on in the PHE was the long-standing regulations governing which providers are eligible to deliver care via telehealth, also known as being a “distant site provider.” The distant site provider list has historically been a subset of the Medicare billable provider list, which includes practitioners such as physicians, registered dietitians, and nurse practitioners but omits registered nurses and pharmacists.
In early 2020, Congress gave the Centers for Medicare and Medicaid Services (CMS) the flexibility to temporarily expand the distant site provider list and, after requests from ADCES and the American Diabetes Association, CMS issued guidance indicating all members of the DSMT care team could provide DSMT via telehealth, which would then be billed under another member of the care team (eg, RD, NP, MD), as occurs with in-person DSMT.
Over the next several years, ADCES consistently requested that CMS make this change permanent, and in 2023, CMS proposed to permanently allow all members of the DSMT team to provide the service via telehealth. ADCES supported the proposal overall, providing feedback on ways they could improve clarity. CMS incorporated ADCES’s feedback on their proposal, and the policy was made permanent beginning January 1, 2024.
Had ADCES not pushed CMS for this change, DSMT programs would have lost the ability for their RNs and pharmacists to provide care via telehealth once the temporary telehealth extensions ended. This change ensures that DSMT teams can continue to provide multidisciplinary care via telehealth.
With extremely low use of telehealth in Medicare prior to 2020, many of CMS’s policies surrounding the practice had never been widely used or scrutinized. Included in that was how telehealth regulations interfaced with payment regulations for care delivered from the Hospital Outpatient Department (HOPD) setting, particularly when billed under the hospital’s National Provider Identifier (NPI). As of 2020, CMS’s position was that telehealth DSMT from the HOPD setting was not permanently eligible to be delivered via telehealth and could only be done temporarily under the flexibilities.
Although telehealth DSMT from the HOPD setting was continuing to be paid for over the last several years, ADCES’s concern was what would happen when the HOPD telehealth flexibilities ended, which nearly occurred several times, including in May 2023, when the PHE expired, and again at the end of 2023. ADCES worked for years with CMS to attempt to understand their interpretation of these rules and unfortunately received conflicting reasoning, including repeated conflation of DSMT with other “therapy services,” such as speech therapy or physical therapy, which, unlike DSMT, were not eligible for telehealth prior to the PHE and whose billing providers were similarly not eligible to provide telehealth.
One concern raised by CMS was their interpretation that they could not permanently pay for telehealth DSMT from the HOPD setting when billed under the hospital’s NPI because hospitals as entities were not on the distant site provider list. In a 2024 joint letter with the ADA, ADCES pushed back on this interpretation, outlining potential options for a path forward. A few months later, CMS issued a proposal to align their rules for telehealth billing from the HOPD setting with those from the physician fee schedule. This change took effect January 1, 2025.
Although some questions and opportunities to improve clarity on these regulations remain, ADCES is cautiously optimistic that telehealth coverage rules will now permanently be aligned across settings.
We have heard from DSMT providers in HOPD settings that there has been confusion in billing and compliance departments on using the hospital’s NPI to bill for telehealth DSMT. Our hope is that by working with CMS to temporarily extend this access and then permanently align payment policies across settings, we will ultimately achieve clarity and alignment that will facilitate continued telehealth DSMT from the HOPD setting.
Since the inception of telehealth in the Medicare program, providers were generally required to use real time via audio-video platforms. The rapid proliferation of telehealth in spring 2020 coupled with the new, temporary ability for patients to receive care via telehealth from their homes revealed that many Medicare beneficiaries in rural areas, those of lower income, and those with limited access to or understanding of technology were inequitably left out of this expansion. CMS proactively allowed audio-only to be an acceptable modality for certain services (including DSMT) to address this equity issue.
After over 4 years of studying the impacts of this policy and receiving supportive input from across the health care community, CMS decided to permanently allow audio-only telehealth for certain services under certain conditions. These conditions include that telehealth providers must be capable of and offer the use of audio-video telehealth so that audio-only is used only as an alternative when the beneficiary is not capable of or does not consent to the use of video technology. If these conditions are met, care can proceed via audio-only. This change permanently took effect January 1, 2025.
Audio-only telehealth allows greater reach for DSMT services, and the permanent change ensures that DSMT programs can continue to provide audio-only telehealth services without interruption to beneficiaries that meet the aforementioned conditions. However, audio-video technology should still be viewed as the default delivery of telehealth. To proceed with audioonly telehealth moving forward, DSMT providers must first assess each Medicare beneficiary to determine that the conditions have been met and use their clinical judgment to determine that audio-only technology is sufficient to furnish the DSMT service.
Since DSMT was first allowed to be provided via telehealth to Medicare beneficiaries nearly 2 decades ago, there have been limitations placed on its use, including that any injection training that was ordered as part of DSMT could only be provided in person, even if all other hours of DSMT were provided via telehealth. This requirement was waived several months into the PHE, and after 3 years with no measurable increases in complications from providing injection training via telehealth, CMS decided to permanently remove the requirement that injection training still be done in person. ADCES supported this change, and it took effect January 1, 2024.
Permanently allowing injection training to be done via telehealth will continue to allow DSMT programs to provide this service without interruption. DSMES programs may ultimately still recommend that a Medicare beneficiary attend an in-person appointment for injection training, but the ability to offer this service via telehealth may result in increased access and more timely care for people that may have difficulty getting to a physical location due to cost, distance, and availability. Had this change not been made permanent, DSMES programs would have eventually lost the option to do injection training via telehealth once the temporary waivers were allowed to expire, and all Medicare beneficiaries would have to receive this aspect of training in person.
Despite numerous telehealth wins over the last 5 years, more still needs to be done. As of winter 2025, Medicare beneficiaries’ overall access to telehealth remains uncertain as Congress wrestles with whether and for how long to extend major policies such as allowing beneficiaries to receive care from their home and allowing all beneficiaries to access telehealth regardless of whether they live in a rural or medically underserved area.
ADCES members have sent thousands of messages to Congress about telehealth access, and we call on members to continue using their voice in raising this issue through the ADCES Legislative Action Center.
Hannah Martin https://orcid.org/0000-0002-8382-5301
Hannah Martin, MPH, RDN is director of advocacy with ADCES and based in Washington, DC, and Julia Socke, RDN, LDN, CDCES, is director of Diabetes Education and Accreditation Program (DEAP) with ADCES in Chicago, IL.
