H.R. 5081 — Telehealth Modernization Act

This section extends through September 30, 2027 (from September 30, 2025), multiple Medicare telehealth flexibilities originally provided during the COVID-19 public health emergency (i.e., under SSA §1834(m)), including (1) waiver of geographic restrictions on services and expanded eligible originating sites; (2) additional types of practitioners eligible to furnish telehealth services; (3) telehealth services furnished by Federally Qualified Health Centers (FQHCs) or Rural Health Clinics (RHCs), with a new payment rule for FY2026-FY2027 treating such services and associated costs as FQHC services under the prospective payment system (SSA §1834(o)) or RHC services under the all-inclusive rate methodology (SSA §1833(a)(3)); (4) audio-only telehealth services; and (5) use of telehealth to satisfy the face-to-face encounter requirement prior to hospice eligibility recertification (SSA §1814(a)(7)), except for encounters on or after September 30, 2025, involving beneficiaries in moratorium areas for hospice enrollment (SSA §1866(j)(7)), those receiving care from providers under enhanced oversight (SSA §1866(j)(3)), or non-enrolled hospice physicians or nurse practitioners who have not opted out of Medicare (SSA §1802(b)(6)(D)). This section also delays until October 1, 2027 (from October 1, 2025), the in-person requirement for mental health telehealth services furnished by Medicare telehealth providers (SSA §1834(m)(7)(B)(i)), RHCs (SSA §1834(y)(2)), and FQHCs (SSA §1834(o)(4)(B)). (Thus, these flexibilities continue to expand beneficiary access to telehealth beyond Medicare's standard rural-only, facility-specific restrictions.)

This section requires hospice claims for face-to-face encounters conducted via telehealth prior to recertification of Medicare hospice care eligibility, if occurring on or after January 1, 2026, to include one or more modifiers or codes (as specified by the Secretary of Health and Human Services) indicating telehealth use. (Thus, such telehealth encounters remain permissible as previously determined appropriate by the Secretary, subject to this reporting requirement.)

This section extends the Acute Hospital Care at Home waiver flexibilities—allowing eligible hospitals to furnish Medicare inpatient hospital-level acute care services in beneficiaries' homes—through 2030 (from 2025). (As background, the waiver originated as a COVID-19 emergency flexibility under section 1866G of the Social Security Act.) The section further requires the Secretary of Health and Human Services to conduct a study by September 30, 2028, analyzing (1) hospital criteria for selecting patients for the initiative; (2) quality of care, outcomes, readmissions, mortality, length of stay, infections, staffing, transfers, and patient experience compared to traditional inpatient care (including by diagnosis-related groups and controlling for selection bias); (3) costs and service intensity (e.g., in-person visits, virtual contacts, caregiver involvement); (4) clinical conditions treated; and (5) patient socioeconomic characteristics (e.g., race, income, dual eligibility); and to submit a report on the study to the House Ways and Means Committee and Senate Finance Committee by September 30, 2028.

This section establishes enhanced Medicare program integrity requirements for durable medical equipment (DME), prosthetic devices, orthotics, and prosthetics (DMEPOS) under part B of the Medicare statute. Specifically, it adds a new paragraph to subsection 1834(a) requiring, beginning January 1, 2028, that DME items with aberrant billing patterns—defined as a substantial number of claims (absent explanatory factors such as emergent care) for items ordered by a physician or practitioner lacking a prior 24-month service history with the beneficiary—be included on the Master List under 42 CFR 414.234(b) (or successor regulation); it further authorizes prepayment claim review for such listed items furnished on or after that date if not subject to prior coverage determination under 1834(a)(15)(C); and it applies these requirements to prosthetic devices, orthotics, and prosthetics. Separately, this section requires the HHS Inspector General to submit a report to Congress by January 1, 2026, identifying clinical diagnostic laboratory tests (under Medicare part B, 42 USC 1395m-1) at high risk of fraud, analyzing contributing factors and billing patterns (e.g., orders from providers without prior beneficiary relationships and use of certain payment modifiers), and recommending mitigation strategies (e.g., outlier provider monitoring and targeted education).

This section directs the Secretary of Health and Human Services, not later than one year after enactment and in consultation with entities such as health information technology providers (e.g., electronic medical record companies, remote patient monitoring companies, and telehealth vendors), health care providers (e.g., physicians and hospitals), health insurers, language service companies, interpreter associations, health and language services certification organizations, and patient advocates, to issue guidance on best practices for furnishing telehealth services (as defined in section 1834(m) of the Social Security Act) to individuals with limited English proficiency. The guidance addresses (1) facilitating and integrating use of interpreters during telemedicine appointments, (2) providing accessible instructions on accessing telecommunications systems, (3) improving access to digital patient portals, (4) integrating video platforms that enable multi-person video calls for interpretation during telemedicine appointments, and (5) providing patient materials, communications, and instructions (e.g., text message reminders and prescription information) in multiple languages.

This section temporarily expands Medicare coverage under the cardiopulmonary rehabilitation program (i.e., outpatient Part B services furnished by hospitals or critical access hospitals to beneficiaries with diagnosed cardiac or pulmonary conditions) to include (1) items and services furnished through audio and video real-time communications technology (excluding audio-only) in the home of a hospital outpatient on or after September 30, 2025, and before January 1, 2027; and (2) virtual presence of a physician, physician assistant, nurse practitioner, or clinical nurse specialist under the program during the same period. The section further authorizes the Secretary of Health and Human Services to implement these changes by program instruction or otherwise.

This section directs the Secretary of Health and Human Services to revise Medicare regulations by January 1, 2026, to permit, for 2026 through 2030, suppliers in the Medicare Diabetes Prevention Program (MDPP) expanded model—tested by the Center for Medicare and Medicaid Innovation to furnish lifestyle change interventions to Medicare beneficiaries at risk of type 2 diabetes—to participate by offering only online MDPP services via synchronous or asynchronous technology if enrolled as an MDPP supplier. For such virtual suppliers, (1) the administrative location is the entity's address on file under the Diabetes Prevention Recognition Program; (2) entities may submit payment claims for services furnished to beneficiaries located in other states; and (3) no limit applies to the number of times a beneficiary may enroll in MDPP.