Promoting Telehealth for Low-Income Consumers, 36865-36883 [2019-16077]

Agencies

• FEDERAL COMMUNICATIONS COMMISSION

[Federal Register Volume 84, Number 146 (Tuesday, July 30, 2019)]
[Proposed Rules]
[Pages 36865-36883]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-16077]


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FEDERAL COMMUNICATIONS COMMISSION

47 CFR Part 54

[WC Docket No. 18-213; FCC 19-64]


Promoting Telehealth for Low-Income Consumers

AGENCY: Federal Communications Commission.

ACTION: Proposed rule.

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SUMMARY: In this document, the Federal Communications Commission 
(Commission) seeks to propose a Pilot program within the Universal 
Service Fund (USF or Fund) to support connected care for low-income 
Americans and veterans. The Commission specifically seeks to better 
understand how the Fund can play a role in helping patients stay 
directly connected to health care providers through telehealth services 
and improve health outcomes among medically underserved populations 
that are missing out on vital technologies.

DATES: Comments are due on or before August 29, 2019 and reply comments 
are due on or before September 30, 2019. If you anticipate that you 
will be submitting comments but find it

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difficult to do so within the period of time allowed by this document, 
you should advise the contact listed in the following as soon as 
possible.

ADDRESSES: You may submit comments, identified by WC Docket No. 18-213, 
by any of the following methods:
     Federal Communications Commission's Website: https://fjallfoss.fcc.gov/ecfs2/.
    Electronic Filers: Comments may be filed electronically using the 
internet by accessing the ECFS: https://fjallfoss.fcc.gov/ecfs2/.
     Paper Filers: Parties who choose to file by paper must 
file an original and one copy of each filing.
     Filings can be sent by hand or messenger delivery, by 
commercial overnight courier, or by first-class or overnight U.S. 
Postal Service mail. All filings must be addressed to the Commission's 
Secretary, Office of the Secretary, Federal Communications Commission.
     All hand-delivered or messenger-delivered paper filings 
for the Commission's Secretary must be delivered to FCC Headquarters at 
445 12th St. SW, Room TW-A325, Washington, DC 20554. The filing hours 
are 8:00 a.m. to 7:00 p.m. All hand deliveries must be held together 
with rubber bands or fasteners. Any envelopes and boxes must be 
disposed of before entering the building.
     Commercial overnight mail (other than U.S. Postal Service 
Express Mail and Priority Mail) must be sent to 9050 Junction Drive, 
Annapolis Junction, MD 20701.
     U.S. Postal Service first-class, Express, and Priority 
mail must be addressed to 445 12th St. SW, Washington, DC 20554.
     Availability of Documents. Comments, reply comments, and 
ex parte submissions will be publicly available online via ECFS. These 
documents will also be available for public inspection during regular 
business hours in the FCC Reference Information Center, which is 
located in Room CYA257 at FCC Headquarters, 445 12th Street SW, 
Washington, DC 20554. The Reference Information Center is open to the 
public Monday through Thursday from 8:00 a.m. to 4:30 p.m. and Friday 
from 8:00 a.m. to 11:30 a.m.
     People with Disabilities. To request materials in 
accessible formats for people with disabilities (braille, large print, 
electronic files, audio format), send an email to [email protected] or 
call the Consumer & Governmental Affairs Bureau at 202-418-0530 
(voice), 202-418-0432 (tty).
    For detailed instructions for submitting comments and additional 
information on the rulemaking process, see the SUPPLEMENTARY 
INFORMATION section of this document.

FOR FURTHER INFORMATION CONTACT: Jodie Griffin, Wireline Competition 
Bureau, (202) 418-7550 or TTY: (202) 418-0484.

SUPPLEMENTARY INFORMATION: This is a synopsis of the Commission's 
Notice of Proposed Rulemaking (NPRM) in WC Docket No. 18-213; FCC 19-
64, adopted on July 10, 2019 and released on July 11, 2019. The full 
text of this document is available for public inspection during regular 
business hours in the FCC Reference Center, Room CY-A257, 445 12th SW, 
Washington, DC 20554 or at the following internet address: https://docs.fcc.gov/public/attachments/FCC-19-64A1.pdf.

I. Introduction

    1. Telemedicine has assumed an increasingly critical role in health 
care delivery as technology and improved broadband connectivity have 
enabled patients to access health care services even when they cannot 
access a health care provider's physical location. Advances in 
telemedicine are transforming health care from a service delivered 
solely through traditional brick and mortar health care facilities to 
connected care options delivered via a broadband internet access 
connection directly to the patient's home or mobile location. Despite 
the numerous benefits of connected care services to patients and health 
care providers alike, patients who cannot afford or who otherwise lack 
reliable, robust broadband internet access connectivity are not 
enjoying the benefits of these innovative telehealth technologies. The 
Commission proposes a Pilot program within the USF to support connected 
care for low-income Americans and veterans. This Pilot program would 
help the Commission better understand how the Fund can play a role in 
helping patients stay directly connected to health care providers 
through telehealth services and improve health outcomes among medically 
underserved populations that are missing out on these vital 
technologies.
    2. Specifically, in the NPRM, the Commission proposes the creation 
of a Pilot program that would allow the Commission to obtain valuable 
data concerning connected care services and also help to better 
understand the relationship of affordable patient broadband internet 
access service to the availability of quality health care, the health 
care cost savings that result from connected care services, and the 
role of connected care on patient health outcomes. The Commission's 
proposal seeks to bring these innovative telemedicine technologies to 
medically underserved populations, including low-income communities and 
veterans, by empowering health care providers to connect directly with 
their patients.
    3. As discussed more fully in the following, the Commission 
proposes that the Connected Care Pilot program will operate as a new 
program within the USF, which would provide funding to eligible health 
care providers to defray the qualifying costs of providing connected 
care services to low-income Americans and veterans.
    4. The Commission expects this Pilot could benefit Americans that 
are responding to a wide breadth of health challenges, including 
diabetes management, opioid dependency, high-risk pregnancies, 
pediatric heart disease, mental health conditions, and cancer. Data 
gathered from the Pilot program will help the Commission understand 
whether and how USF funds can be used to promote health care provider 
and consumer adoption and use of connected care services. The data and 
information collected through this Pilot program might also aid in the 
consideration of broader reforms--whether statutory changes or updates 
to rules administered by other agencies--that could support this trend 
towards connected care.

II. Discussion

    5. To the extent that lack of affordable and robust broadband 
internet access service is an obstacle to the adoption of connected 
care services by health care providers and patients, the Commission 
believes universal service support could help address that obstacle. 
Further, by encouraging more health care providers to make use of 
connected care technologies, the Commission may help create a model for 
the nationwide adoption of such technologies, which could lead to 
improved health outcomes for patients and savings to the country's 
health care system overall.
    6. Thus, the Commission proposes a three-year Connected Care Pilot 
program (Pilot) with a $100 million budget that would provide support 
for eligible health care providers to obtain universal service support 
to offer connected care technologies to low-income patients and 
veterans. Through this Pilot program, the Commission seeks to develop a 
record that will help to understand the benefits that subsidization of 
broadband service for connected care brings.
    7. The Commission seeks to design a cost-effective and efficient 
Pilot program

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that incentivizes participation from a wide range of eligible health 
care providers and broadband service providers, provides meaningful 
data about the use of connected care services provided over broadband 
for low-income Americans and veterans, and provides insight into how 
universal service funds could better promote the adoption of connected 
care services among low-income Americans and veterans and their health 
care providers.
    8. The Commission proposes implementing a flexible Pilot program 
that will give health care providers some latitude to determine 
specific health conditions and geographic areas that will be the focus 
of the proposed projects. Under this proposal, the Pilot program would 
provide funding to selected Pilot project health care providers to 
defray the costs of purchasing broadband internet access service 
necessary for providing connected care services directly to qualifying 
patients. The Commission seeks comment on this proposal. The Commission 
believes its proposed approach will increase the variety of projects 
without discouraging or prejudging any applicants considering whether 
to participate. Nevertheless, the Commission proposes limiting the 
Pilot program to projects that primarily focus on health conditions 
that typically require at least several months or more to treat--such 
as behavioral health, opioid dependency, chronic health conditions 
(e.g., diabetes, kidney disease, heart disease, stroke recovery), 
mental health conditions, and high-risk pregnancies. The Commission 
believes that collecting data across at least several months would 
provide more meaningful, statistically significant data to track health 
outcomes and cost savings--health conditions that do not require at 
least several months of treatment, therefore, may not provide the type 
of meaningful data the Commission seeks to collect through the Pilot 
program.
    9. The Notice of Inquiry (FCC 18-112) sought comment on whether the 
Pilot program should focus on certain health conditions or geographic 
regions. Many commenters asserted that the Pilot program should not be 
limited to projects that treat specific health conditions. In addition, 
the record identifies numerous health conditions that can benefit from 
connected care services. To ensure that Pilot program funding is used 
for legitimate medical conditions and to guard against potential waste, 
fraud, and abuse, should the Commission adopt a specific definition of 
``health condition'' for purposes of the Pilot program? If so, is there 
a generally accepted authority that provides a definition of ``health 
condition'' that would be appropriate to adopt for the Pilot program? 
The Commission also seeks information from commenters regarding the 
marketplace for connected care services, specifically whether health 
care providers typically purchase complete packages or suites of 
services that include patient broadband internet access service and 
other functionality necessary to provide connected care services, or 
whether health care providers typically purchase broadband internet 
access service connections for connected care as a stand-alone product. 
Additionally, the Commission seeks comment on the costs health care 
providers incur to purchase such services.
    10. Supported Services. The Notice of Inquiry sought comment on 
providing funding for the costs of: (1) The broadband connectivity that 
eligible low-income patients of participating hospitals and clinics 
would use to receive connected care services; and (2) the broadband 
connectivity that a participating hospital or clinic would need to 
conduct its proposed connected care pilot project. The record 
demonstrates that many patients lack home broadband service or lack 
sufficient broadband service to receive connected care services, and 
evidences widespread support for funding broadband internet access 
connections for connected care through the Pilot program. Many 
commenters also expressed support for funding both fixed and mobile 
broadband for connected care. The record indicates that the VA's tablet 
program, which provides patient broadband connections for a small 
fraction of veterans who receive care through the VA, is the only 
federal agency program that currently funds patient broadband 
connections specifically for connected care.
    11. The record indicates that health care providers typically 
purchase broadband internet access service that enables connected care 
through a broadband carrier or a connected care company (for example, a 
remote patient monitoring company). The health care provider then 
provides a connected care service, including the broadband internet 
access service underlying that connected care service, to the patient 
directly. To what extent are health care providers already funding 
patient broadband connections for connected care services and what are 
the costs associated with funding those connections? To what degree 
would providing universal service funding to offset these costs enable 
health care providers to extend service to additional patients or treat 
additional health conditions? Several health care providers asserted 
that the Pilot program should not fund internet connections between 
health care providers. The Commission agrees, as doing so would be 
duplicative with the existing Rural Health Care (RHC) programs and 
propose to exclude such connections from the Pilot program.
    12. The Commission considers ``telehealth'' for the purposes of 
this proceeding to include a wide variety of remote health care 
services beyond the doctor-patient relationship; for example, involving 
services provided by nurses, pharmacists, or social workers. The 
Commission also defines the term ``telemedicine'' as using broadband 
internet access service-enabled technologies to support the delivery of 
medical, diagnostic, and treatment-related services, usually by 
doctors. The Commission seeks comment on these definitions and their 
applicability to the Connected Care Pilot program. In addition, the 
Commission also proposes to define the term ``connected care'' as a 
subset of telehealth that is focused on delivering remote medical, 
diagnostic, and treatment-related services directly to patients outside 
of traditional brick and mortar facilities. The Commission seeks 
comment on this proposed definition of connected care. Should the 
Commission place any additional qualifiers on this definition to ensure 
that the Pilot program is focused on medical services delivered 
directly to patients outside of traditional medical facilities through 
broadband-enabled technologies?
    13. The Commission seeks comment on common existing uses of 
connected care technologies, such as remote patient monitoring devices. 
The record indicates that such devices are generally single-purpose, 
meaning that they cannot be used to access the public internet or for 
uses outside of the health care context. Are there other circumstances 
where health care providers are providing patient connectivity that 
enables them to access the internet for non-health care purposes? Are 
there any barriers to receiving connected care services for low-income 
patients and veterans, and, if so, what are those barriers? Would this 
Pilot enable additional connectivity not currently available to low-
income patients and veterans?
    14. The Commission also seeks comment on whether there are packages 
or suites of services that health care providers use to provide 
connected care services (such as a turnkey solution that includes 
software, remote patient

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monitoring and remote monitoring devices, and patient broadband 
internet access) that are not currently funded under the existing RHC 
support programs that could be funded through the Pilot program as 
information services. What types of services would be considered 
information services, as well as any applicable precedents and should 
be funded through the Pilot program? How do service providers currently 
fund these types of services and what are the typical costs? Are 
specific types of health care providers or provider locations more 
likely to be unable to purchase these types of information services? 
Are there any federal or other grant programs or other funding sources 
that provide health care providers support for purchasing these types 
of services? Should the Commission provide support for internal 
connections for eligible health care providers through the Pilot 
program? Is such support needed for connected care services?
    15. Network Equipment. The Notice of Inquiry sought comment on 
whether the Pilot program should fund ``network equipment necessary to 
make a broadband service functional'' and for consortia applicants 
``equipment necessary to manage, control or maintain an eligible 
service or a dedicated health care broadband network'' as is done in 
the Healthcare Connect Fund program. At least one commenter supported 
funding this type of network equipment through the Pilot. Because the 
Commission currently funds the types of network equipment that are 
eligible for support through the Healthcare Connect Fund program, the 
Commission believes it has the authority to provide funding for similar 
equipment here, to the degree it is necessary to enable connectivity 
for the purposes of connected care. However, the Commission proposes 
not to permit duplication of funding for this equipment and equipment 
funded through the Healthcare Connect Fund program. The Commission 
seeks comment on this interpretation and approach. Would such network 
equipment be necessary to providing the broadband service underlying 
connected care, or part of a health care provider's purchase of a 
telehealth information service? Would health care providers still be 
interested in and be able to participate in the Pilot program if the 
Pilot program did not fund the types of health care provider network 
equipment that is eligible for support under the Healthcare Connect 
Fund program? If the Commission were to fund this type of equipment, 
how could the Commission ensure that the health care provider actually 
needs this equipment for the Pilot program and would not have needed or 
purchased this equipment but for participating in the Pilot program?
    16. The Commission also acknowledged that a few commenters stated 
that the Pilot program should support health care provider 
administrative and outreach costs associated with participating in the 
Pilot program (such as personnel costs, and program management costs). 
Consistent with the existing RHC support programs and the RHC Pilot 
program, however, the Commission does not propose funding these 
expenses as part of the Pilot. As the Commission has previously 
explained, past experience in the RHC support programs and RHC Pilot 
program demonstrates that ``[health care providers] will participate 
even without the program funding administrative expenses.'' The 
Commission seeks comment on this approach.
    17. End-User Devices, Medical Equipment, Mobile Applications, and 
Health Care Provider Administrative Expenses. The Notice of Inquiry 
also sought comment on whether the Pilot program should fund end-user 
equipment, medical devices, or mobile applications for connected care. 
Many commenters supported funding such items. That said, traditionally, 
the Commission has declined to fund these items through the Universal 
Service Fund because of section 254's focus on the availability of and 
access to services. As such, the Commission proposes to make end-user 
devices, medical devices, or mobile applications (excepting those 
applications that may be part of a service that could be considered an 
information service) ineligible for support in the Pilot program. Based 
on the record and other sources, some health care providers may be able 
to self-fund or obtain outside funding for end-user devices, medical 
devices, and connected care applications needed for their connected 
care pilot projects. The Commission seeks comment on the extent to 
which health care providers participating in the Pilot program may be 
able to obtain outside funding for end-user devices, medical devices, 
or mobile applications necessary to provide connected care services. 
Would health care providers still be interested in and be able to 
participate in the Pilot program if the Pilot program does not fund 
end-user devices, connected care medical devices, or connected care 
mobile applications?
    18. Other Program Structure Considerations. The Commission seeks 
comment on whether there are any medical licensing laws or regulations, 
or medical reimbursement laws or regulations that would have a bearing 
on how the Commission structures the Pilot program. If so, how would 
those specific laws or regulations impact the Pilot program, and how 
should the Commission design the structure of the Pilot program in 
light of those impacts? For example, commenters in the record identify 
reimbursement as a major barrier to telehealth adoption. They urge the 
Commission to coordinate with the Centers for Medicare and Medicaid 
Services (CMS)--whether through a Memorandum of Understanding or other 
means--to implement reforms to reimbursement policies for telehealth. 
How should the Commission structure the Pilot to best ensure 
coordination between the Commission and other federal agencies, such as 
CMS? How can the Commission most easily obtain data through the Pilot 
that would be informative on issues such as reimbursement and 
licensure? Additionally, the Commission seeks comment on whether the 
provision of USF support to health care providers to provide connected 
care to low-income patients (or any other Pilot program funded item 
used by individual patients as part of the Pilot program) raises any 
issues under the Medicare and Medicaid Anti-Kick Back Statute, the 
Civil Monetary Penalties Act, or any other federal statutes.
    19. Budget. The Notice of Inquiry sought comment on a potential 
$100 million budget for the Pilot program. Based on the broad support 
in the record, the Commission believes that targeting this amount of 
funding for the broadband underlying connected care technologies is 
substantial and sufficient to allow it to obtain meaningful data and 
ensure significant interest from a wide range of participants. The 
Commission therefore proposes to adopt that budget for the Pilot 
program. As discussed in the following, the Commission also proposes a 
three-year funding period for the Pilot program, during which selected 
projects would receive funding. The Commission seeks comment on these 
proposals. How should the total Pilot program budget be distributed 
over the three-year funding period? Should each selected project's 
funding commitment be divided evenly across the Pilot program duration? 
For example, if a selected project requests and receives a $9 million 
funding commitment and the funding period is three years, should the 
project receive $3 million for each year?
    20. Several commenters expressed concern that the budget for the 
Pilot

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program could be debited against the existing budgets for the Lifeline 
or Rural Health Care programs. However, the proposed Pilot program 
would not divert resources from the existing universal service support 
programs. Instead, the Commission proposes requiring the Universal 
Service Administrative Company (USAC) to separately collect on a 
quarterly basis the funds needed for the duration of the Pilot program. 
The Commission expects that funding the Pilot program in this manner 
would not significantly increase the contributions burden on consumers. 
This approach also would not impact the budgets or disbursements for 
the other universal service programs. The Commission seeks comment on 
this approach. Should the collection be based on the quarterly demand 
for the Pilot program? The Commission also proposes to have excess 
collected contributions for a particular quarter carried forward to the 
following quarter to reduce collections. Under this approach, the 
Commission also proposes to return to the Fund any funds that remain at 
the end of the Pilot program. Are there other approaches the Commission 
should consider for funding the Pilot program?
    21. Number of Pilot Projects and Amount of Funding per Project. The 
Notice of Inquiry sought comment on funding up to 20 projects with 
awards of $5 million each. First, the Commission proposes to provide a 
uniform percentage of eligible services or equipment to be funded, 
rather than fully funding any Pilot projects, consistent with the 
Healthcare Connect Fund program and the RHC Pilot program. Several 
commenters similarly suggest that the Pilot program should not fund 
100% of the eligible costs for each project. Based on the Commission's 
experience with the E-Rate and Rural Health Care programs, there are 
significant advantages to providing a set discount percentage that 
requires participants to contribute a portion of the costs, including 
being administratively simple, predictable, and equitable, and 
incentivizing participants to choose the most cost-effective services 
and equipment and refrain from purchasing a higher level of service or 
equipment than needed. In addition, the Commission believes that 
funding less than 100% of the costs minimizes the risk of non-usage of 
the supported services. The Commission seeks comment on this approach.
    22. For services supported under this structure, the Commission 
proposes a discount level of 85%--the discount amount participants 
received in the Rural Health Care Pilot Program--and seeks comment on 
whether this amount would strike the right balance between requiring a 
health care provider contribution for such services and encouraging a 
wide range of eligible health care providers to participate in the 
Pilot program. Are there other grant or support programs or data that 
the Commission could look to in order to determine an appropriate 
discount level for these types of services that could be funded under 
this structure? For example, in the E-Rate program, the lowest discount 
level is 20% and ranges up to 90%. In contrast, the discount level for 
the Healthcare Connect Fund is 65%. To further ensure the cost-
effective use of Pilot funds, in addition to adopting a flat, uniform 
discount percentage, should the Commission cap the monthly amount of 
support that can be paid for broadband internet access service to a 
health care provider for each participating patient? If so, what would 
be an appropriate cap, and what data and specific information would 
support this cap amount?
    23. For the Healthcare Connect Fund program, the health care 
provider is required to pay the non-discounted share of the eligible 
costs from eligible sources (e.g., the applicant, eligible health care 
provider, or state, federal, or Tribal funding or grants), and is 
prohibited from paying the non-discounted share of eligible costs from 
ineligible sources (e.g., direct payments from vendors or service 
providers). The Commission seeks comment on whether it should apply 
this same limitation to health care providers participating in the 
Pilot program. If so, should participating patients also be considered 
an eligible source of the non-discounted share for services funded 
under the Pilot? Should the Commission limit the portion of the non-
discounted costs that health care providers can require participating 
patients to pay for the supported broadband internet access service? If 
so, what would be an appropriate limit on the patient share of the 
costs? For purposes of the Pilot program, should the Commission place 
any limitation at all on the source of funding for the non-discounted 
share of the costs? Are there any other approaches the Commission 
should consider for limiting the source of funding that are not tied to 
the Healthcare Connect Fund program rules?
    24. Next, the Commission addresses the number of projects and the 
per-project budget cap. Some commenters agreed that the Commission 
should fund up to 20 projects with awards of $5 million per project. 
Other commenters argued for the selection of fewer projects with larger 
funding amounts, or for the selection of a larger number of projects 
with varied or smaller funding amounts. On further consideration of the 
record, the Commission proposes not to expressly limit the number of 
funded Pilot projects, and to permit flexible and varied funding for 
each selected Pilot project. The Commission believes setting a fixed 
number of funded projects would not serve the goals of the Pilot 
program because it would artificially limit the number of funded 
projects before any proposals are even submitted. In addition, not 
setting a fixed number of projects to be funded will allow the 
Commission to better focus on selecting quality projects that can 
provide meaningful data rather than selecting a pre-determined number 
of projects. The Commission seeks comment on this view. The record 
likewise indicates that a uniform $5 million funding amount per project 
could artificially limit the scope of potential pilot projects and the 
data collected. While the Commission proposes allowing varied funding 
amounts for selected projects, the Commission does not anticipate 
spending all of the Pilot program funds on one or two large projects. 
Should the Commission establish a ceiling on the amount of the total 
budget that can be allocated to a single project and, if so, what would 
be an appropriate maximum funding amount for a single project?
    25. Cost Allocation. The Commission also seeks comment on whether 
cost allocation should be required for services or other items 
supported through the Pilot program that are used for non-health care 
purposes or include ineligible components. For example, if a Pilot 
project permits patients to use the supported broadband service for 
non-health care purposes, should the Commission require cost allocation 
of the non-health care usage? If so, how should the cost allocation 
work? For supported patient broadband internet access service, should 
the cost allocations be based solely on the percentage of the service 
that is used for health care purposes? Should the cost allocations 
instead take into account the health care providers' savings associated 
with the use of the supported patient broadband internet access for 
health care purposes? If a health care provider contracts with a remote 
patient monitoring solution provider for a package that includes end-
user devices and other items that are not broadband internet access 
service, how should cost allocation work for those devices or items? 
Should cost allocations for all

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Pilot-supported costs follow the cost allocation rules and processes 
for the Healthcare Connect Fund? Which entity or entities (e.g., the 
health care provider or service provider) should be responsible for 
providing the cost allocation and supporting documentation? What type 
of documentation should the Commission require to support the cost 
allocation?
    26. Duration. The Notice of Inquiry sought comment on whether the 
Pilot program should have a two- or three-year funding duration and 
six-month ramp-up and wind-down periods. Many commenters asserted that 
a three-year duration is appropriate and would allow the Commission to 
obtain sufficient, meaningful data from the selected projects. A few 
commenters argued that more than three years would be necessary if 
broadband deployment was a Pilot program goal, or that the Pilot 
program duration should be as long as four or five years. USTelecom 
cautioned that a duration longer than three years (plus a ramp-up and 
wind-down and evaluation period) ``risks having the findings become 
obsolete by the time they could be effectuated . . . .'' Other 
commenters separately assert that a six-month ramp-up and six-month 
wind-down period should be part of the funding period.
    27. Based on the record and the proposed Pilot program goals (which 
do not include broadband deployment), the Commission proposes a three-
year funding period and separate ramp-up and wind-down periods of up to 
six months in order to give projects time to complete set up and other 
administrative matters related to the Pilot program. The Commission 
seeks comment on these proposals. When should the ramp-up period begin? 
Should the clock for the ramp-up period start after the selected 
project has been notified of its selection, or is there another event 
that should trigger the start of the ramp-up period? Should there be a 
uniform start date for funding under the Pilot program, and if so, how 
should the Commission determine that start date? Should the proposed 
three-year funding period for the Pilot program use a funding-year 
approach, with a fixed start date and end date for each Pilot program 
funding year, as is done in the E-Rate and Rural Health Care programs? 
If so, how would the ramp-up and wind-down periods work with a funding-
year approach (e.g., would the ramp-up period precede the start of the 
funding year)? Should funding disbursements begin during the ramp-up 
period, and if so how should funding be split between the ramp-up 
period and the Pilot project term? The Commission proposes setting a 
fixed end date for the Pilot program, with the possibility of 
extensions where circumstances warrant. The Commission seeks comment on 
this proposal.
    28. Eligible Health Care Providers. The Commission proposes to 
limit health care provider participation in the Pilot program to non-
profit or public health care providers within section 254(h)(7)(B): (i) 
Post-secondary educational institutions offering health care 
instruction, teaching hospitals, and medical schools; (ii) community 
health centers or health centers providing health care to migrants; 
(iii) local health departments or agencies; (iv) community mental 
health centers; (v) not-for-profit hospitals; (vi) rural health 
clinics; (vii) skilled nursing facilities; (viii) and consortia of 
health care providers consisting of one or more entities described in 
clauses (i) through (vii).
    29. The Commission seeks comment on whether section 254 requires it 
to limit health care provider participation to these categories of 
providers. And if not, the Commission believes that applying this 
limitation to the Pilot program would provide significant benefits: 
Leveraging the statutory definition of health care provider used for 
the Rural Health Care program would focus Pilot program funding on 
health care providers most in need of additional funding to reach 
eligible patients through connected care services, and would also 
realize administrative efficiencies by using existing definitions and 
application processes that parties are already familiar with through 
the Rural Health Care program. In addition, having a single uniform 
definition of ``health care provider'' would provide clarity for 
potential participants and facilitate the administration of the Pilot 
program.
    30. While the statutory definition of ``health care provider'' may 
exclude certain health care providers, the Commission believes that it 
would still allow for a wide range of health care providers to 
participate in the Pilot program. For example, the Healthcare Connect 
Fund program is subject to this definition and over 8,600 distinct 
health care providers received funding commitments in the Healthcare 
Connect Fund program for funding year 2018. Additionally, the statutory 
definition encompasses many facilities serving medically underserved 
communities, including VA health administration facilities and 
facilities run by the Indian Health Service. The Commission seeks 
comment on this interpretation. Is there an interpretation of section 
254(h)(7)(B) that would allow the Commission to provide funding to 
Emergency Medical Technicians, health kiosks, and school clinics 
through the Pilot program, as commenters request? Would the definition 
of ``health care provider'' under section 254(h)(7)(B) preclude sites 
like the VA's Virtual Living Room sites, community center or similar 
sites that provide dedicated rooms in convenient locations with 
broadband connections for patients to engage with technology and 
connect with the professionals providing them with medical care? The 
Commission seeks comment on whether limitations on eligible entities 
could limit the effectiveness of the Pilot program and the ability to 
obtain meaningful data on connected care services. Finally, are the 
proposed eligible health care providers sufficiently well versed in 
medical research methods to be able to properly evaluate the health 
outcomes linked to the provision of connected care?
    31. In the event that the Commission limits Pilot program 
participants to the statutory definition of ``health care provider'' 
under section 254, the Commission proposes requiring interested health 
care providers to indicate their respective category(ies) for 
eligibility by submitting FCC Form 460, which USAC uses to determine 
the eligibility of health care providers in the Healthcare Connect Fund 
Program. The Commission proposes requiring eligible health care 
providers to have prior experience with telehealth and long-term 
patient care.
    32. The Commission also proposes to borrow additional 
administrative procedures from the RHC programs in implementing the 
Pilot program. For example, the Commission proposes to have consortia 
applicants file FCC Form 460 identifying all sites that would 
participate in the Pilot program, including off-site data centers and 
administrative offices, and propose permitting consortia applicants to 
file FCC Form 460 on behalf of any site in the consortium that would 
participate in the Pilot program to determine that site's eligibility. 
Consistent with the Healthcare Connect Fund program, the Commission 
proposes requiring consortia applicants to have in place a Letter of 
Agency, which provides a consortium leader with authority to act on 
behalf of the participating health care providers. Additionally, the 
Commission proposes permitting third parties to ``submit forms and 
other documentation on behalf of the applicant'' if USAC receives 
written authorization from an ``officer, director, or other authorized 
employee stating that the [health care provider] or

[[Page 36871]]

Consortium Leader accepts all potential liability from any errors, 
omissions, or misrepresentations on the forms and/or documents being 
submitted by the third party.'' The Commission proposes that consortium 
applicants must update their FCC Form 460s if any information on their 
FCC Form 460 changes. Similarly, the Commission proposes that an 
eligible health care provider participating in the Pilot program, 
including those participating in consortia, submit an updated FCC Form 
460 within 30 days of a material change. The Commission seeks comment 
on these proposals.
    33. The Commission also proposes that the Pilot program be open to 
both urban and rural eligible health care providers. Several commenters 
assert that the Pilot should not be limited to projects serving only 
rural areas. To the extent that section 254(h)(2)(A) applies to the 
Pilot program, it does not limit universal service support to rural 
health care providers, and the Commission believes the Pilot program 
should not be limited to rural health care providers. The Fifth Circuit 
has found ``the language in section 254(h)(2)(A) demonstrates 
Congress's intent to authorize expanding support of `advanced 
services,' when possible, for non-rural health [care] providers.'' 
Likewise, section 254(h)(2)(A) authorizes the Commission ``to enhance 
public and non-profit health care providers' access'' to broadband 
services. The Commission seeks comment on this proposal.
    34. To promote geographic diversity, the Commission seeks comment 
on limiting participation in the Pilot program to health care providers 
that are located in or serve an area that has received the Health 
Resources and Services Administration's Health Professional Shortage 
Areas designation or Medically Underserved Areas designation, which 
correlate with professional shortages and lower-income areas, 
respectively, within a defined geographic area. What are the benefits 
and drawbacks of limiting participation by using these designations? 
Should the Commission also, or alternatively, consider limiting 
participation in the Pilot program only to eligible health care 
providers that currently provide care to at least a certain percentage 
of uninsured and underinsured patients, or to a certain percentage of 
Medicaid patients? The Commission seeks comment on these ideas. Would 
these types of limitations impact the interest and participation of 
health care providers in the Pilot program?
    35. As connected care services continue to grow, health care 
providers that only offer connected care have entered the marketplace. 
These new market entrants may bring innovative new services and inject 
competition that benefits patients, but it is not clear whether they 
would qualify as eligible health care providers under section 
254(h)(7)(B). The Commission seeks comment on this question. 
Additionally, the record indicates that these types of providers may 
not be involved in long-term patient treatment. What steps should the 
Commission take to ensure that participating health care providers have 
significant experience with providing long-term patient care, in order 
to guard against waste, fraud, and abuse in the Pilot program? The 
Commission also seeks comment on determining criteria that would 
demonstrate health care providers' experience with long-term care for 
patients. Are there types of connected care only companies that could 
demonstrate the level of experience with long-term patient care needed 
for the Pilot?
    36. To ensure projects meet the goals of the Pilot program, should 
the Commission require participating health care providers to have 
experience integrating remote monitoring and telehealth services? 
Specifically, should the Commission limit eligibility in the Pilot 
program to health care providers that are federally designated as 
Telehealth Resource Centers or as Telehealth Centers of Excellence, or 
to otherwise demonstrate their experience providing telehealth 
services? Should the Commission exclude health care providers that have 
no prior connected care experience? Should participating health care 
providers have experience, or be required to partner with research 
bodies or firms with experience, conducting clinical trials in order to 
ensure statistically sound evaluation of patient outcomes?
    37. Eligible Service Providers. In the RHC Program, the statute 
permits non-eligible telecommunications carriers (ETCs) to receive 
support; section 254(c)(3) makes clear that, in addition to the 
supported services included in the definition of universal service in 
section 254(c), ``the Commission may designate additional services for 
such support mechanisms for . . . health care providers for the 
purposes of subsection (h).'' Further, section 254(h)(2)(A) directs the 
Commission ``to enhance to the extent technically feasible and 
economically reasonable, access to advanced telecommunications services 
and information services'' for health care providers and, thus, allows 
support for non-ETCs. The Commission has previously explained that the 
ETC limitation in section 254(e) applies to the section 254(c) 
supported services, but not to additional supported services under 
section 254(h)(2)(A).
    38. The Notice of Inquiry sought comment on whether the Pilot 
should be limited to ETCs, including facilities-based ETCs. Numerous 
parties opposed limiting the Pilot program to ETCs or facilities-based 
ETCs and explained that such a limitation would artificially limit 
participation in the Pilot program and could also limit the 
effectiveness of the Pilot program. The Commission proposes not to 
limit Pilot program funding to only ETCs. The Commission anticipates 
that it would provide funding to eligible health care providers to 
purchase broadband internet access service that would be provided to 
the patient through a connected care offering, or that the health care 
provider would use USF funding to purchase telehealth services that 
qualify as information services. As such, the Commission does not 
believe that health care providers should be restricted to purchasing 
broadband internet access service from only ETCs.
    39. The Commission hopes that this will help incent participation 
in the program by a diverse range of both health care providers and 
service providers. The Commission seeks comment on this approach. What 
impact would this approach have on service provider and health care 
provider interest in participating in the Pilot program? If, instead, 
the Commission were to conclude that only ETCs would be able to receive 
support for providing broadband internet access service to patients 
participating in the Pilot, what impact would this approach have on 
service provider and health care provider participation in the Pilot 
program? As a practical matter, how could the Commission ensure that 
the Pilot program still leverages and supports the expertise of the 
health care provider as the main driver of each Pilot project, even if 
the monetary support must be paid to an ETC?
    40. Application Process. The Notice of Inquiry requested comment on 
the application process for the Pilot program and proposed several 
categories of information that should be contained in the application. 
The Commission proposes that interested health care providers first 
submit an application describing the proposed pilot project and 
providing information that will facilitate the selection of high-
quality projects that will best further the goals of the Pilot program. 
At the time of the application, should the

[[Page 36872]]

Commission require participating health care providers to have already 
identified specific broadband providers from which the health care 
provider will receive service? If the Commission requires broadband 
providers to be ETCs, should the Commission require all designations to 
be obtained prior to the application process? Or should the Commission 
require that if the project is selected, the service provider would 
obtain the necessary ETC designations before the project commences?
    41. Based on the Commission's review of the record and prior 
experience with Pilot programs, it proposes that applications contain, 
at a minimum, the following information:
     Names and addresses of all health care providers that 
would participate in the proposed project and the lead health care 
provider for proposals involving multiple health care providers.
     Contact information for the individual(s) that would run 
the proposed pilot project (telephone and email).
     Health care provider number(s) and type(s) (e.g., non-
profit hospital, community mental health center, community health 
center, rural health clinic, community mental health center), for each 
health care provider included in proposal.
     Description of each participating health care provider's 
experience with providing connected care services and conducting 
clinical trials or the experience of a partnering health care provider.
     Description of the connected care services the proposed 
project will provide, the conditions to be treated, the health care 
provider's experience with treating those conditions, the goals and 
objectives of the proposed project (including the health care 
provider's anticipated goals with respect to reaching new or additional 
patients, improved patient health outcomes, or cost savings), and how 
the project will achieve the goals of the Pilot program.
     Description of the clinical trial design intended to 
measure the effect of the connected care pilot on health outcomes.
     Description of the estimated number of eligible low-income 
patients to be served.
     Description of the plan for implementing and operating the 
project, including how the project intends to recruit eligible 
patients, plans to obtain the end-user and medical devices for the 
connected care services that the project would provide, and transition 
plans for participating patients after Pilot program funding ends.
     List of all Department of Health and Human Services, 
Health Resources and Services Administration (HRSA) designated Health 
Care Professional Shortage Areas (for primary care or mental health 
care only) or HRSA designated Medically Underserved Areas that will be 
served by the proposed project.
     Description of whether the health care provider will 
primarily serve veterans or patients located in a rural area, or the 
provider is located in a rural area, on Tribal lands, or is associated 
with a Tribe, or part of the Indian Health Service.
     Description of the anticipated level of broadband service 
required for the proposed project, including the necessary speeds/
technologies and relevant service characteristics (e.g., 10/1 Mbps, or 
4G).
     Detailed estimated break-down of the total estimated costs 
for the broadband internet access services and any other eligible 
costs.
     Estimated total ineligible costs and description of the 
anticipated sources of financial support for the project's ineligible 
costs.
     Description of how the participating health care provider 
will ensure compliance with the Health Insurance Portability and 
Accountability Act (HIPAA) and other applicable privacy and 
reimbursement laws and regulations, and applicable medical licensing 
laws and regulations, and how it will safeguard the collected patient 
information against data security breaches.
     Description of the health outcome metrics that the 
proposed project will measure and report on, and how those metrics will 
demonstrate whether the supported connected care services have improved 
health outcomes.
     Description of how the health care provider intends to 
collect and track the required Pilot program data.
    42. Is there any additional information that the Commission should 
require health care providers to submit in the application? What types 
of information or documentation should the Commission require health 
care providers to include in their applications to demonstrate that the 
supported services would enhance the health care provider's access to 
advanced telecommunications and information services? Is there a 
minimum number of patients that a project must serve to provide 
statistically significant data? Is the proposed application information 
sufficient to determine whether projects have processes in place to 
ensure compliance with the applicable medical licensing laws and 
regulations, HIPAA and any other applicable privacy laws, and guard 
against data security breaches? Is there anything in HIPAA or privacy 
laws and regulations that would limit the Commission's ability to 
structure the Pilot program or collect data needed to evaluate the 
Pilot's success?
    43. Should the Commission require health care providers to submit a 
self-certification regarding their patient care and telehealth 
qualifications with their applications? Moreover, should the Commission 
require applicants to certify that they are financially qualified? If 
so, what information should the Commission rely on to make that 
determination? Is there any supporting documentation the Commission 
should require to demonstrate that applicants are financially 
qualified? Likewise, should the Commission require health care 
providers to submit a self-certification that specifies that they will 
be able to meet patients' long-term care needs as well as provide the 
appropriate technology to help meet those needs? Should the Commission 
require applicants to certify that they have the capacity to conduct a 
valid clinical trial? If so, are there specific criteria the Commission 
should rely on to make such a showing? Should the Commission require 
applicants to certify that all information in their application is true 
and accurate?
    44. The Commission intends to establish a deadline for submitting 
applications for the Pilot program. If the Commission ultimately issues 
an order establishing the proposed Pilot program, would requiring that 
applications be submitted within 120 days from the release of such an 
order give health care providers sufficient time to develop and submit 
a meaningful application for the Pilot program?
    45. The Commission proposes to direct the Wireline Competition 
Bureau (Bureau) to review applications in coordination with the FCC's 
Office of Economics and Analytics, Office of Managing Director, Office 
of General Counsel, and the Connect2Health Task Force. The Commission 
proposes that it will then make any final selection decisions. To 
facilitate the review and selection of proposals, should the Commission 
also seek advice from other expert health care entities with telehealth 
expertise? For example, should the Commission consult with the 
federally designated Telehealth Resource Centers or Telehealth Centers 
of Excellence? Are there other organizations with whom the

[[Page 36873]]

Commission should consult during the application and selection process?
    46. Evaluation of Proposals and Selection of Projects. The 
Commission seeks comment on the factors to evaluate the applications 
and select Pilot program projects. At a minimum, the Commission 
proposes considering whether each project would serve the Pilot program 
goals and whether the applicant is able to successfully implement, 
operate, and evaluate the outcomes of the project. The Commission also 
proposes considering the cost of the proposed project compared to the 
total Pilot program budget. What other objective factors should be used 
to evaluate the proposals and what should be the relative importance of 
each objective evaluation factor? For example, should a project's 
ability to further the goals of the Pilot program be more important 
than the estimated cost of the project compared to the total Pilot 
program budget? Should the Commission decline to consider proposals 
that do not have a plan for how participating patients will obtain the 
necessary connected care medical devices, end user devices (e.g., 
smartphones or tablets), or connected care applications? Should the 
Commission decline to consider projects that cannot provide 
statistically sound evaluations of their proposed interventions?
    47. To promote the selection of a diverse range of projects, the 
Commission proposes awarding additional points to proposed projects 
that would serve geographic areas or populations where there are well-
documented health care disparities (Tribal lands, rural areas, or 
veteran populations) or that treat certain health crises or chronic 
conditions that significantly impact many Americans and are documented 
to benefit from connected care, such as opioid dependency, diabetes, 
heart disease, mental health conditions, and high-risk pregnancy. For 
all of the additional point factors the Commission proposes in the 
following, to seek comment on the relative importance of these factors 
compared to each other and compared to the other standard objective 
evaluation factors. Are there any other factors for which additional 
points should be awarded to a particular project?
    48. It is well documented that there are significant health care 
shortages in rural areas and Tribal lands. In addition, the Department 
of Health and Human Services' Health Resources and Services 
Administration (HRSA) designates areas that are Healthcare Provider 
Shortage Areas (HPSA) or are Medically Underserved Areas (MUA)--these 
areas can be urban or rural. Given the significant health care 
disparities in these areas and potential benefits of increasing the 
adoption of connected care in these areas, the Commission proposes 
awarding extra points during the evaluation process to proposals that 
satisfy the following factors: (a) The health care provider is located 
in a rural area; (b) the project would primarily serve patients who 
reside in rural areas; (c) the project would serve patients located in 
five or more Health Professional Shortage areas (for primary care or 
mental health care only) or Medically Underserved Areas as designated 
by HRSA by geography; (d) the health care provider is located on Tribal 
lands, is affiliated with a Tribe, or is part of the Indian Health 
Service; or (e) the health care provider would primarily serve patients 
who are veterans. How should the relative importance of these 
additional factors be compared to each other and to the other proposed 
standard objective factors for evaluating proposals? Should projects 
receive additional points for each factor that they satisfy? What 
criteria should determine whether a health care provider is located in 
a rural area for purposes of these additional points? Would the 
definition of ``rural area'' in section 54.600 of the Rural Health Care 
program rules or the definition of ``urban area'' in section 
54.505(b)(3)(i) of the E-Rate rules be appropriate for determining 
whether a project qualifies for additional points based on rurality? Is 
there another definition of ``rural area'' that the Commission should 
consider and, if so, what geographic level (e.g., Census block, Census 
tract, Census block group) should the Commission use to determine 
eligibility for extra points based on rurality? How should this 
proposal apply to consortia?
    49. The Commission also seeks comment on the criteria that should 
be used to determine whether a project would primarily serve patients 
who reside in rural areas. The Commission believes that relying on 
individual patient addresses for this purpose would be too complex to 
administer because of the potential volume of individual patient 
addresses. Are there other, non-patient address measures that could be 
used instead? For example, should the Commission use a metric that 
estimates average patient travel distance to the health care provider's 
facility?
    50. The Commission proposes relying on the health care provider's 
certification that it is located on Tribal lands, affiliated with a 
Tribe or is part of the Indian Health Service. The Commission seeks 
comment on this proposal. For purposes of the additional points, should 
the Commission apply the definition of Tribal lands in section 
54.400(e) of the Lifeline rules? Is there another definition that the 
Commission should consider? To receive the extra Tribal points, should 
the Commission require that the health care provider be located in a 
rural area as defined for the Pilot program? If so, how should rurality 
be defined? Should the Commission use the same definition for ``rural'' 
areas as that found in section 54.505(b)(3)(i) of the Commission's 
rules, or instead use a population density measure for a given 
geographic unit?
    51. Similarly, the Commission seeks comment on the criteria that 
should be used to determine whether a project would primarily serve 
veterans. What threshold would be appropriate? For example, the 
Commission seeks comment on whether a project ``primarily serves'' 
veterans if more than 50% of its patient base are veterans. What 
documentation, if any, is appropriate to define a veteran population? 
Many veterans receive disability compensation from the VA, for 
instance, or cost-free health care based on certain factors. Would 
receipt of these benefits be sufficient to identify veteran status for 
purposes of the application?
    52. The Commission seeks comment on awarding additional points for 
projects that are primarily focused on treating certain chronic health 
conditions or conditions that are considered health crises, such as 
opioid dependency, high-risk pregnancies, heart disease, diabetes, or 
mental health conditions. Opioid dependency is a well-documented 
epidemic in America and has had a particularly devastating impact in 
rural America where there are fewer opioid treatment centers. The 
Notice of Inquiry explains that connected care services have been 
frequently used to treat opioid dependency; thus, the Commission 
believes that it would be appropriate to award extra points for 
proposals that seek to use connected care to treat opioid dependency. 
Maternal mortality is also a crisis in America--the maternal mortality 
rate in the U.S. is higher than most other high-income countries and 
has increased over the last few decades. This crisis impacts both rural 
and urban areas and is particularly acute in rural areas where there is 
a significant shortage of hospitals and health care providers offering 
obstetric care, and also disproportionately impacts low-income, 
African-American women. In December 2018, Congress took action to

[[Page 36874]]

address the maternal mortality crises by passing the Preventing 
Maternal Deaths Act to create a federal infrastructure and resources 
for collecting and analyzing data on every maternal death in the United 
States. Accordingly, the Commission believes that it would be 
appropriate to award additional points for projects focused on treating 
high-risk pregnancy. Connected care has been used to treat heart 
disease and diabetes--two of the leading causes of death in America 
that are also associated with very high costs for patients and the 
health care system. Therefore, the Commission believes that it would 
also be appropriate to award additional points to proposals that seek 
to treat these conditions. Some organizations also have indicated that 
there is a mental health crisis in America--many Americans need mental 
health care but lack access or the ability to find it, particularly 
Americans who are low-income or reside in rural areas. Therefore, the 
Commission also believes that it would be appropriate to award 
additional points to proposals that seek to treat mental health 
conditions. The Commission seeks comment on these proposals. Are there 
any other health conditions that would warrant awarding additional 
points to specific project proposals during the selection process? 
Should the Commission expressly limit eligible health conditions in 
advance of receiving applications for Pilot projects?
    53. Are there any other criteria the Commission should consider in 
the evaluation and selection of pilot projects? For example, the 
Commission seeks comment on whether to permit a project to serve a 
patient population that is primarily, but not entirely low-income? If 
so, should the Commission require health care providers to conduct a 
project where more than 50% of the patients are low-income? Or 75%? 
Similarly, how would the Commission evaluate whether a project includes 
low-income individuals? Should the Commission, for example, rely on the 
health care provider to identify patients for their project who are 
enrolled in Medicaid, receive cost-free health care from the VA, or who 
are uninsured or underinsured?
    54. Consistent with the Commission's other universal service 
support programs, it is critical that the Commission ensures that the 
Pilot program funds are spent wisely and appropriately and that the 
Commission guards the Pilot program from waste, fraud, and abuse. At 
the same time, the Commission seeks to minimize the administrative 
burdens on service providers and health care providers participating in 
the Pilot program. In this section, the Commission proposes and seeks 
comment on potential requirements for Pilot program participants, 
including requirements for the vendor selection for Pilot-eligible 
costs, requesting funding, and requesting disbursements. For the 
Healthcare Connect Fund program, the Commission has developed robust 
rules and processes that are designed to minimize waste, fraud, and 
abuse. To promote the efficient and cost-effective use of Pilot program 
funds and guard against waste, fraud, and abuse, the Commission 
proposes extending many of these rules and processes to the proposed 
Pilot program.
    55. Selecting Service Providers. The Commission proposes that 
participating health care providers, and not the participating 
patients, procure the services and equipment that could be funded 
through the Pilot program. The Commission believes that having 
participating health care providers select the service provider would 
be a better approach because health care providers are in the best 
position to know the specific service and performance requirements 
necessary to provide the specific connected care services supported by 
their particular Pilot project. In addition, aggregating eligible 
subscribers and streamlining benefit payments may lead to cost 
efficiencies and/or better service arrangements. The Commission seeks 
comment on this approach.
    56. Consistent with the Commission's other universal service 
support programs, it is important that the Commission ensures the cost-
effective, efficient use of Pilot program funds. To appropriately 
tailor the vendor selection requirements to the marketplace, the 
Commission requests additional information on how health care providers 
typically purchase broadband internet access service connections for 
connected care efforts. Do health care providers typically select and 
contract directly with a broadband service provider for patient 
broadband internet access service, or is the broadband service provider 
typically determined by a connected care service vendor, such as a 
remote patient monitoring service provider? Is the broadband internet 
access service for connected care, whether purchased as a stand-alone 
product or as part of a package, a commercially available product that 
is purchased at publicly-available rates? Are these rates typically 
negotiable? What is the typical contract term (e.g., month-to-month, 
annual contract or multi-year contract) for these services? Are the 
health care provider costs for connectivity services for connected care 
determined on a per patient basis? Where health care providers purchase 
services for connected care as part of a complete package or suite of 
services, can the costs for the individual components be broken out 
separately? For example, for such a package or suite of services, is it 
possible to isolate the costs for the included software, or the 
broadband internet access service?
    57. For all of the costs that could potentially be supported 
through the Pilot program, the Commission proposes requiring the 
participating health care providers to conduct a competitive bidding 
process, and select the most cost-effective service, as is required by 
the Healthcare Connect Fund program. For the E-Rate and Rural Health 
Care support programs, the Commission has traditionally required 
schools and libraries and health care providers to competitively bid 
for the supported services and equipment, with limited exemptions. 
These competitive bidding requirements are designed to ensure that 
applicants select the most cost-effective method of providing the 
requested service, ensure that service providers have sufficient 
information to submit a responsive proposal, seek the most cost-
effective pricing for eligible services, and guard against waste, 
fraud, and abuse.
    58. If the Commission requires health care providers to 
competitively bid any services and equipment that could be funded 
through the Pilot program, should the Commission use the existing 
Request for Services Form (Form 461) for the Healthcare Connect Fund 
program and, if so, what modifications would the Commission need to 
make to that form for purposes of the Pilot program? The Commission 
also proposes requiring the lead health care provider for projects 
involving multiple health care providers to secure a Letter of Agency 
from all participating providers before submitting a request for 
services. The Commission seeks comment on these proposals. Should the 
Commission allow exemptions from competitive bidding rules, as done in 
other USF programs? For example, should the Commission allow an 
exemption in the Pilot program if the health care provider is 
requesting commercially available services purchased at publicly-
available rates and/or the total cost of the eligible services or 
equipment is below a specific monetary threshold (e.g., total annual 
cost under $10,000 or monthly per-patient cost of $50 or below)? The 
Commission seeks comment on whether the other exemptions to the 
competitive bidding requirements for the Healthcare Connect Fund 
program should also be

[[Page 36875]]

extended to the Pilot program. Are there any other competitive bidding 
exemptions or alternatives to competitive bidding that the Commission 
should consider applying to the Pilot program?
    59. Where an exemption to competitive bidding applies, are there 
public resources or entities that could help health care providers 
identify potential vendors or service providers? Should the Commission 
require ETCs to indicate their interest in participating in the Pilot 
program and their service areas, and make this information publicly 
available before the application deadline for the Pilot program? How 
can the Commission share similar interests to participate in the Pilot 
program from telecommunications providers that are not ETCs?
    60. The Commission also proposes prohibiting gifts from 
participating service providers to participating health care providers. 
Are there any aspects of the competitive bidding requirements for the 
Healthcare Connect Fund program that would not work for the Pilot 
program and, if so, why not? If the Commission requires competitive 
bidding for the Pilot program, the Commission proposes requiring 
participating health care providers to submit the same competitive 
bidding information, make the same certifications, and use the same 
processes that are required for the Healthcare Connect Fund program, 
including any changes that may be made as a result of the 2017 
Promoting Telehealth Order and Notice (FCC 17-164).
    61. Requesting Funding. The Commission further seeks comment on the 
most efficient methods for Pilot program participants to request 
funding. Should the Commission require selected Pilot projects to 
request funding under the Pilot program using the same forms and 
processes and making the same certifications that are required for the 
Healthcare Connect Fund program, including any changes that may be made 
as a result of the 2017 Promoting Telehealth Order and Notice? 
Requiring health care providers to submit funding requests for the 
Pilot program would allow USAC to ensure that the Pilot projects only 
request funding for eligible services and that the health care 
providers requesting funding are in fact eligible. What modifications 
to the Healthcare Connect Fund funding request form, if any, are 
necessary to use for the Pilot program? Are there other HCF 
certifications or processes to import to the Pilot program as well? And 
how should the Commission modify these requirements, if at all? Would 
these modifications vary depending on the legal authority on which the 
Pilot program is based? If competitive bidding is required for the 
Pilot program, the Commission proposes requiring selected projects to 
submit a copy of their contract and supporting competitive bidding 
documentation with their funding request, as is currently required for 
the Healthcare Connect Fund program.
    62. For purposes of administrative efficiency and to ensure that 
Pilot projects are not unreasonably delayed, the Commission proposes 
requiring Pilot program applicants who are selected to submit funding 
requests within six months of the date of their respective selection 
notices for the Pilot program. The Commission anticipates that USAC 
would promptly review funding requests of selected Pilot program health 
care providers on a rolling basis, irrespective of when they submit 
their funding requests within the six-month window. Would this proposed 
deadline for submitting the initial funding request give participating 
health care providers sufficient time to select a vendor and submit a 
funding request? Should the Commission require participating health 
care providers to submit a new funding request for each year of the 
Pilot program?
    63. The Commission also proposes requiring selected projects to 
certify that the provided funding will only be used for the eligible 
Pilot program purposes for which the support is intended. Should the 
Commission also require participating health care providers to certify 
that the supported services and equipment will only be used for 
purposes reasonably related to the provision of health care services or 
instruction that the health care provider is legally authorized to 
provide under law? Additionally, the Commission proposes requiring 
projects involving multiple health care providers to identify the name 
and contact information for the organization that will be legally and 
financially responsible for the activities supported through the Pilot 
(e.g., submitting funding requests, submitting invoicing and 
disbursement forms, submitting competitive bidding forms (if 
required)), as is required for consortia participating in the 
Healthcare Connect Fund program. This requirement would identify the 
responsible party if disbursements must be recovered for violations of 
program rules or requirements. The Commission seeks comment on these 
proposals.
    64. Disbursements. The Notice of Inquiry sought comment on how 
disbursements should be issued for the Pilot program. Few commenters 
specifically addressed the issue of how often disbursements should be 
issued and which entity should receive disbursements through the Pilot 
program. One commenter supported monthly disbursements. Another 
commenter asserted that disbursements should be issued to service 
providers to minimize health care providers' administrative burdens, 
while two other commenters asserted that the disbursements should be 
issued directly to health care providers. Another commenter recommended 
issuing disbursements in the form of vouchers directly to participating 
patients, but other commenters argued that this approach would 
complicate the administration of the Pilot program, create unnecessary 
consumer burdens, and raise potential program integrity concerns.
    65. The Commission proposes issuing disbursements to the service 
provider, as is the current practice for the RHC programs, for the 
purchase of connectivity or other eligible items pursuant to its legal 
authority. In practice, this would equate to monthly discounts paid 
towards the cost of service or eligible equipment purchased by the 
health care provider. The Commission seeks comment on this proposal and 
any alternatives that commenters may provide. The Commission also 
proposes requiring that all reimbursement requests for any health care 
provider-purchased services funded through the Pilot program be 
submitted within six months of the date of receipt of the eligible 
service or network equipment, and allow for extensions to this deadline 
where good cause exists. Based on the Commission's experience with the 
existing RHC programs, establishing deadlines for submitting invoices 
would facilitate effective administration of the Pilot program.
    66. For all services supported through the Pilot program, should 
the project's compliance with the data reporting requirements discussed 
in the following be a requirement for issuing each disbursement to the 
service provider? Since the purpose of Pilot program is to collect data 
and test the efficacy of a connected universal service support 
mechanism, would delay or failure to comply with data reporting 
requirements create sufficient reason to hold disbursements until the 
error is corrected? The Commission seeks comment on the best methods to 
ensure participants are regularly reporting useful and required program 
data including whether and how to tie the data submission requirement 
to the

[[Page 36876]]

reimbursement of Pilot program support.
    67. Ensuring Effective and Responsible Use of Funds. Consistent 
with the other existing universal service support programs, to ensure 
the fiscally responsible use of Pilot program funds and guard against 
waste, fraud, and abuse, the Commission proposes adopting document 
retention and production requirements for health care providers and 
service providers participating in the Pilot program, and also proposes 
making individual projects subject to random compliance audits. 
Specifically, the Commission proposes applying to the Pilot program (1) 
section 54.648(a) of the Healthcare Connect Fund program rules, which 
makes participating health care providers and service providers subject 
to random compliance audits, and (2) section 54.648(b)(1)-(3) of the 
Healthcare Connect Fund program rules, which require participating 
health care providers and service providers to retain documentation 
sufficient to establish compliance with the rules and requirements for 
the Pilot program for at least five years and produce such documents to 
the Commission, any auditor appointed by the Administrator or the 
Commission, or any other state or federal agency with jurisdiction. Are 
there any other rules or requirements for the RHC support programs, the 
E-Rate program, or the Lifeline program not specifically mentioned in 
the NPRM that the Commission should apply to the Pilot program?
    68. With respect to audits, the Office of the Managing Director and 
the Bureau would have the authority to direct USAC to conduct targeted 
audits as necessary to ensure Pilot program funds are being used 
consistent with the program. The Commission believes that a five-year 
document retention period after the final disbursement is made would 
provide sufficient time to conduct audits and any other investigations 
related to the Pilot program. The Commission seeks comment on this 
proposal.
    69. The Notice of Inquiry sought comment on several potential goals 
for the Pilot program. In addition, the Notice of Inquiry proposed 
several metrics and methodologies for gathering data and measuring 
progress towards the proposed goals. The Commission proposes to focus 
on four primary program goals and seeks comment on this approach: (1) 
Improving health outcomes through connected care; (2) reducing health 
care costs for patients, facilities, and the health care system; (3) 
supporting the trend towards connected care everywhere; and (4) 
determining how USF funding can positively impact existing telehealth 
initiatives. Further, the Commission seeks comment on appropriate 
metrics and methodologies to measure Pilot projects' progress towards 
these goals.
    70. The Commission believes these constitute sound goals for the 
Pilot program and they are consistent with our statutory obligation to 
promote universal service. Section 254(c)(1), for example, directs the 
Commission to keep in mind when establishing the definition of services 
supported by USF ``the extent to which such telecommunications services 
are essential to education, public health, or public safety.'' 
Moreover, section 254(h)(2)(A) directs the Commission to establish 
rules to enhance access to advanced telecommunications and information 
services for health care providers. Additionally, section 254(b)(3) 
provides that ``[c]onsumers in all regions of the Nation, including 
low-income consumers and those in rural, insular, and high cost areas, 
should have access to advanced telecommunications and information 
services . . . that are reasonably comparable to those services 
provided in urban areas and that are available at rates that are 
reasonably comparable to rates charged for similar services in urban 
areas.'' The Commission believes the proposed goals will help advance 
these principles, and seeks comment on that conclusion.
    71. Proposed Program Goals. First, the Commission intends that the 
Pilot will help improve health outcomes through connected care. Several 
comments in the record expressed support for including this as a 
program goal. For example, Hughes stated that the ``provision of 
telehealth services expands access to high-level care and closes 
geographic barriers experienced by patients.'' TruConnect stated that 
the ``use of telemedicine applications on smartphones and devices 
benefits those who use them and will especially help rural patients who 
must travel great distances to health care providers.'' According to 
the American Heart Association, a ``strong and growing body of evidence 
identifies telehealth and remote patient monitoring as cornerstones of 
advanced healthcare systems.''
    72. Commenters also identified several specific ways in which 
broadband access can improve health outcomes. For example, the Medical 
University of South Carolina (MUSC) and Gila River Telecommunications, 
Inc. (GRTI) both note that greater access to telehealth can enable 
health care providers to more easily engage their patients in the daily 
management of chronic conditions. Commenters also note that broadband 
access for telehealth purposes increases the likelihood that patients 
will seek out medical care, and also increases the likelihood that 
patients will follow a prescribed course of treatment. Commenters 
stated that telehealth can reduce emergency room visits and hospital 
admissions and readmissions, and can lead to increased contact with 
specialists. The Commission agrees with these assessments and therefore 
proposes to include improvement of health outcomes through connected 
care as a goal of the Pilot program.
    73. The Commission also believes the Pilot program can ultimately 
help reduce health care costs for patients, facilities, and the health 
care system, and proposes to adopt that program goal. The Commission 
seeks comment on this proposal. In the Notice of Inquiry, the 
Commission asked how the Pilot program could help identify effective 
means of improving health care affordability for patients, including by 
reducing the burden of out-of-pocket expenses like transportation costs 
for rural and remote patients. Similarly, the Commission stated that 
the Pilot program could help identify the circumstances in which 
support for telehealth services could create savings for health care 
providers and the Medicaid program.
    74. Many commenters noted the potential for the Pilot program to 
greatly reduce travel time for rural and remote patients, significantly 
reducing out-of-pocket costs for patients, in addition to reducing the 
need to miss work or school to see a health care provider. Commenters 
also noted that reduction in travel times could lower costs for 
physicians and health care providers. The University of Arkansas for 
Medical Sciences stated that insurers will ``witness cost savings when 
fewer beneficiaries experience long-term, costly morbidities.'' The 
Medical Home Network described the ability of telemedicine to increase 
communication between a primary care physician and a specialist, 
``expediting wait times for patient appointments, and reducing 
unnecessary referrals and emergency room visits.'' In particular, 
Hughes, citing to videoconferencing capabilities at the University of 
California, Davis, found that ``patients avoided nearly 5 million miles 
of travel and $3 million in travel expenses by being able to 
videoconference the treatment center in Sacramento.'' CHRISTUS Health 
provided data on a remote monitoring pilot in partnership with a 
carrier and vendor in Texas, and found that after

[[Page 36877]]

one year of study, the pilot program reduced the cost of care by an 
estimated $236,000 per year for congestive heart failure patients 
enrolled in the pilot. Thus, based on the record, the Commission 
believes the program could help reduce health care costs for patients, 
facilities, and the health care system overall and seeks comment on 
this program goal.
    75. Next, the Commission proposes to establish a goal of supporting 
the trend toward bringing health care directly to the consumer. The 
Notice of Inquiry observed that there is a trend away from relying on 
connectivity solely within and between physical health care centers and 
towards a ``connected care everywhere'' model--a trend that has shown 
promising results for patients, communities, and the health care 
system. The Notice of Inquiry sought comment on using the Pilot program 
to support the current movement towards direct-to-consumer health care 
to ensure that low-income Americans can realize the benefits of this 
trend.
    76. Commenters broadly support making this a program goal for the 
Pilot. GRTI, for example, noted that the Commission ``has an 
opportunity to support the trend towards greater use of connected care 
and the benefits of such a policy,'' and supports the goal of 
evaluating success of the Pilot program based in part on how it 
furthers this trend. The American Heart Association, commenting on the 
benefits and costs of the move towards ubiquitous connected care, noted 
the ability of telehealth to provide ``instant healthcare at a fraction 
of the cost regardless of the patient's health care status or 
geographic location,'' but also noted potential ethical issues, 
including questions of trust, confidentiality, privacy, and informed 
consent. MUSC stated that as part of the movement towards connected 
care everywhere, the Pilot program should support the participation of 
rural and underserved consumers in the direct-to-consumer health care 
market. The Commission seeks comment on adopting this program goal. The 
Commission encourages commenters to specifically address how making USF 
dollars available to support the connectivity that enables telehealth 
applications can promote access to health care services for patients 
outside of the confines of brick-and-mortar medical facilities.
    77. Finally, the Commission anticipates that the Pilot will help to 
determine how USF funding can positively impact existing telehealth 
initiatives, and the Commission proposes to include this as a goal of 
the Pilot program. In the Notice of Inquiry, the Commission stated that 
it sought ``to ensure that the pilot program enhances existing 
telehealth initiatives by the Commission and other federal agencies.'' 
The Commission observed that it currently has several initiatives to 
assist with the expansion of health care connectivity in rural and 
underserved areas including through the Rural Health Care programs and 
the Connect2Health Task Force. In addition, the Commission noted 
various other telehealth programs established by other federal 
agencies, for example, the VA's Home Telehealth Program and several 
initiatives run by the Department of Health and Human Services (HHS).
    78. Numerous commenters assert that the Commission should consider 
working with HHS, in particular CMS, the National Coordinator for 
Health Information Technology (ONC), the Health Resources and Services 
Administration (HRSA), and the Indian Health Service. The Virginia 
Telehealth Network similarly proposed that the Commission consider 
collaborating with private sector entities that are providing broadband 
internet access service to vulnerable populations that might benefit 
from connected care services.
    79. The Commission seeks comment on this proposed goal. How can the 
funding of connectivity for telehealth through the Connected Care Pilot 
complement other Commission initiatives, such as the Rural Health Care 
Program and the Connect2Health Task Force? How can the Pilot program 
complement other Commission programs to provide connectivity to low-
income consumers, like the Lifeline Program, and rural and remote 
consumers, like the High Cost Fund? Other than the VA's Home Telehealth 
program, what existing federal programs, if any, specifically fund 
connectivity for patients to enable the provision of telehealth? How 
can the Commission best collaborate with other federal agencies 
pursuing this goal?
    80. Metrics. The Commission seeks comment on the best metrics and 
methodologies for measuring progress towards its proposed program 
goals. For example, are there specific ways in which broadband-enabled 
telehealth applications can improve health outcomes that could be 
demonstrated through the Pilot program? In the Notice of Inquiry, the 
Commission proposed several metrics: Reductions in emergency room or 
urgent care visits in a particular geographic area or among a certain 
class of patients; decreases in hospital admissions or re-admissions 
for a certain patient group; condition-specific outcomes such as 
reductions in premature births or acute incidents among sufferers of a 
chronic illness; and patient satisfaction as to health status. Are 
there other metrics for measuring this goal? For example, commenters 
suggested measuring adherence to medication and care plans as a 
possible metric, because of the correlation with reducing morbidity and 
mortality. How can the Commission best measure whether and to what 
extent telehealth can promote adherence to medication and care plans? 
Similarly, how can the Commission measure patient satisfaction as to 
health status?
    81. The Commission also encourages commenters to explain the 
specific ways itmeasures how universal service support for connectivity 
will improve health outcomes through telehealth. Do low-income 
consumers face budget constraints that are not adequately addressed by 
existing programs that prevent them from adopting connected care 
services via broadband internet access service? In such cases, what 
alternatives do those consumers use to obtain medical care, and do 
those alternatives result in poorer health outcomes? Do health care 
providers face budgetary shortfalls with respect to funding broadband 
internet access connections for connected care services, or other 
information services or equipment that health care providers need to 
provide connected care services such that the Fund can help serve a 
crucial funding need? In what other ways will universal service funding 
for connectivity promote improved health outcomes through telehealth?
    82. The Commission also asks commenters to provide, where 
available, data and other information to help evaluate the potential 
for cost savings through telehealth. In addition to the specific areas 
of cost savings discussed in this document, in what other ways can the 
provision of telehealth produce cost savings for patients, facilities, 
and the health care system? The Commission further asks commenters to 
provide information on the specific way in which universal service 
support for connectivity to enable telehealth will produce cost 
savings. And the Commission seeks comment on the best metrics to 
evaluate progress towards this goal. How can the Commission best 
measure the savings from, for example, reduction in travel miles and 
travel time for patients and physicians? How can the Commission measure 
the effect of healthier patients on costs faced by health care 
providers and insurers? To what extent do these measures depend on 
accurate metrics on the health outcomes of the patients of pilot 
programs? What metrics exist to determine the cost savings from a

[[Page 36878]]

reduction in hospital admissions or re-admissions, or a reduction in 
emergency room visits?
    83. How can the Commission measure its progress in supporting the 
trend toward bringing health care directly to the consumer? Will that 
funding enable access for patients and providers that would not 
otherwise have access to telehealth, perhaps by bringing telehealth 
into new geographic areas or attracting new funding for existing 
telehealth services? Will funding connected care pilots draw attention 
to, and increase the effectiveness of, future connected care 
applications, thereby promoting the development of connected care? 
Would it help incent more health care providers to purchase broadband, 
in order to bring connected care services to more patients? The 
Commission also seeks comment on any potential costs of ubiquitous 
connected care, including the ethical issues raised by the American 
Heart Association. How should these issues impact whether the 
Commission sets increased use of connected care as a goal of the Pilot 
program?
    84. Finally, the Commission seeks comment on how it can determine 
whether the Pilot program supports existing Commission and federal 
efforts to promote telehealth. How can the Commission avoid duplicating 
existing efforts or otherwise overlap with programs that promote 
connectivity for telehealth? The Commission proposes to require Pilot 
program proposals to identify non-USF sources of funding or support, 
and to also require reporting from Pilot program participants to help 
the Commission identify how USF support for connected care broadband 
connectivity can leverage existing or new efforts to support other 
components of successful telehealth services. The Commission seeks 
comment on this approach.
    85. For the Commission to evaluate the success of the Pilot 
program, it is critical to establish tools and procedures to gather 
data from the Pilot program participants on progress toward achieving 
the stated Pilot program goals. In addition, this information will 
allow the Commission to evaluate the progress of each project and 
ensure that Pilot program funds are being used efficiently and 
effectively. Ultimately, this data will determine the success of the 
Pilot program and will help inform the Commission about the long-term 
viability of a connected care program.
    86. Reporting Intervals. The Commission proposes requiring 
participating health care providers to submit regular reports with 
anonymized, aggregated data that will enable the Commission to monitor 
the progress of each project and ultimately evaluate the Pilot program, 
as a condition of receiving the proposed support. The Commission seeks 
comment on the required reporting intervals (e.g., quarterly, annually) 
and the information that should be included in the reports. For 
example, TeleHealthCare America proposed quarterly reports, and the 
Commission seeks comment on whether quarterly intervals would be 
sufficient. Is there a shorter or longer reporting interval that would 
be more appropriate when analyzing outcomes from clinical trials? Do 
clinical trials commonly report interim results before completion of 
the trial? What types of information are reported on an interim basis 
and would such results provide reliable information? Or should the 
Commission delay reporting of health outcomes until the study is 
completed? What is the standard practice in medical research? Could 
such reports create difficulties for blinding protocols?
    87. Clinical Trials. The Commission seeks comment on the 
appropriate methods for measuring the health effects of the connected 
care Pilot projects. Should all projects be required to conduct 
randomized controlled trials to determine the effect of the treatments 
on patients' health? Are there alternative, less costly methods that 
are statistically sound and can accurately measure the effect of the 
treatment? Are these alternative methods generally accepted in the 
scientific and medical communities? If the proposed treatment in a 
Pilot project has already been extensively studied and the health 
benefits are generally accepted by the medical community, and the 
pilot's purpose is to uncover other effects, such as the impact on the 
costs of providing health care or the broader impacts of subsidized 
access to broadband internet access services for connected care, is 
there any need to require the reporting of health outcomes?
    88. Would different clinical trials be better served by different 
reporting requirements and, if so, could these be judged as part of the 
proposed project methods? Should the Commission require participants to 
file a detailed annual report, and shorter reports on a quarterly 
basis? The Commission is mindful of the burden that reporting can 
create for participants, particularly those that do not regularly 
report information to the Commission and seek to minimize this burden 
while still providing a mechanism for participants to provide valuable 
information. The Commission encourages commenters to discuss the 
burdens and the best methods to alleviate them.
    89. Data Fields. The Commission proposes that the regular reports 
from each participating project include information on a number of data 
fields that will enable the Commission to monitor the progress of each 
project towards the overall goals of the Pilot program. The Commission 
seeks comment on the data Pilot program participants should provide in 
regular reports to enable measuring progress towards these goals. The 
Commission proposes several data fields that should be part of regular 
reporting from Pilot participants. These fields include: The number of 
patients participating in the pilot project each month; the number of 
patients participating in the pilot project being treated for specific 
health conditions; the types of connected care services provided for 
each condition; average frequency of patient use of each type of 
connected care service; health outcomes for patients; and average cost-
savings per patient. The Commission seeks comment on the proposed use 
of these data fields. Are there other types of information the 
Commission should require Pilot program participants to report on a 
regular basis? Should the Commission require pilot beneficiaries to 
submit raw health data on study participants or is it sufficient for 
beneficiaries to provide estimates of the effect of the treatment? 
Should the Commission require any type of certification as to the 
accuracy of the information provided?
    90. To obtain information regarding patient experience, the 
Commission proposes requiring health care providers to conduct regular 
surveys of participating patients. The purpose of these surveys is to 
collect information regarding data such as patient cost savings, saved 
travel miles, patient satisfaction and comfort with the provided 
connected care services. Given the additional time and expense in 
administering patient surveys, reviewing data, and reporting it to the 
Commission, should health care providers conduct these surveys on a 
quarterly basis, or on a longer timeframe, such as after the completion 
of the clinical trial?
    91. The Commission also proposes collecting additional information 
from Pilot program patient participants at the time of enrollment to 
better understand the impact of the Pilot program on the goals 
identified in this document, including whether the patient already has 
a mobile and/or home broadband connection, the speed, technology and 
broadband data usage for any broadband connection the patient already 
has, and

[[Page 36879]]

what devices the patient uses to connect to the internet. What other 
information might be important to know at the time of enrollment to 
help establish a baseline for measuring the impact of the Pilot 
program? Which party would be in the best position to collect this 
information from participants?
    92. As noted in this document, the Commission proposes that all 
data provided by Pilot program participants should be anonymized and 
aggregated, and if that is impossible, for example, because there are 
so few participants within a reporting area their data could be used to 
identify individuals, then masked. Should the regular reports from each 
pilot project be made publicly available? If so, is the Commission's 
website, or USAC's website, the best place to host this information? 
Should the Commission allow project participants to request delay of 
publication until the project is completed if publication might impact 
the experiment? The Commission anticipates that these reports would not 
raise any HIPAA or other privacy concerns because the proposed required 
data would be submitted on an aggregated, anonymized basis. The 
Commission seeks comment on this conclusion. Further, are there other 
privacy or security measures that the Commission and USAC should take 
to ensure proper receipt, storage, and use of the data? The Commission 
is acutely aware of the data protections and sensitivities surrounding 
health data and seeks comment on the best ways to ensure proper 
handling of this information.
    93. The Commission also proposes that Pilot program participants 
provide information regarding their experience with the Pilot program. 
For example, the Commission is interested in measuring the costs that 
Pilot program participants experience in designing their programs, 
submitting applications to the Commission, and ensuring ongoing 
compliance with the Pilot's rules and procedures. The Commission 
proposes to ask on a regular basis for these types of cost and time 
estimates to evaluate whether the Pilot program is an administratively 
feasible method of distributing funding for connected care services. 
This information will be critical if, following the Pilot, the 
Commission chooses to make a connected care program permanent, and 
seeks to minimize applicant burdens in so doing.
    94. Forms. In addition, the Commission seeks comment on the forms 
that participants will use to provide this information. Are there 
existing Commission forms from other USF programs, in particular the 
Rural Health Care program, that can be used to report data for the 
Pilot program? Should the Commission establish new forms for the 
purposes of the Pilot program?
    95. The Commission's stewardship of the universal service support 
mechanisms and determinations concerning the services that are eligible 
for universal service funding are bound by section 254 of the Act, as 
amended by the 1996 Act. The Notice of Inquiry sought comment on the 
Commission's legal authority to establish the Pilot program. In the 
following, the Commission proposes and seeks comment on itssources of 
legal authority for the Pilot program. The Commission seeks comment on 
the potential impact of its legal authority on the structure, 
administrability, and effectiveness and efficiency of the Pilot 
program. Are there any additional potential sources of legal authority 
that the Commission should consider?
    96. Based on review of the record and reading of the statute, the 
Commission believes that the Commission's rural health care legal 
authority in section 254(h)(2)(A) of the Act supports the proposed 
Pilot program. Section 254(h)(2)(A) directs the Commission to 
``establish competitively neutral rules, (A) to enhance, to the extent 
technically feasible and economically reasonable, access to advanced 
telecommunications and information services for all public and non-
profit . . . health care providers. . . .'' The Commission has 
previously explained that it has ``broad discretion regarding how to 
fulfill this statutory mandate.'' The Commission seeks comment on 
whether to rely on the rural health care legal authority in section 
254(h)(2)(A) as its authority to create the proposed Pilot program, and 
how relying on this legal authority would impact the structure of the 
Pilot program.
    97. Several commenters argued that section 254(h)(2)(A) provides 
the Commission with legal authority to establish the proposed Pilot 
program. The Commission previously relied on this statutory provision 
as its legal authority for the RHC Pilot program and the Healthcare 
Connect Fund program, which were designed to develop dedicated health 
care provider networks and fund broadband internet access services used 
directly by health care providers, and network equipment necessary to 
make the supported services functional. The Commission has not 
previously relied on this statutory provision to provide support for 
connectivity between patients and health care providers, however. The 
Commission believes the most feasible way to structure the Pilot 
program would be to have the health care provider purchase the 
broadband internet access service needed by the patient to access 
connected care services from a broadband carrier or a connected care 
company (e.g., a remote patient monitoring company) and then provide 
the telehealth service, including the underlying internet broadband 
access service, to the patient directly. The Commission therefore seeks 
comment on whether and how section 254(h)(2)(A) could be interpreted to 
authorize the creation of a Pilot program that would support patient 
broadband internet access service connections for connected care.
    98. The Commission requests information on how providing health 
care providers support for patient-centered connected care enhances 
health care provider ``access to advanced telecommunications and 
information services'' consistent with section 254(h)(2)(A). Is there 
an argument that patient broadband internet access service falls within 
section 254(h)(2)(A) when it is purchased by a health care provider and 
used for medical purposes? Is the legal argument for supporting 
connectivity underlying technologies such as remote patient monitoring 
under section 254(h)(2)(A) stronger where the health care provider 
purchases the residential broadband internet access service as part of 
a complete solution or package and provides the connected care services 
to the patient? Does the fact that a health care provider cannot serve 
a patient at the patient's location through connected care unless the 
patient has a broadband internet access connection provide a basis for 
relying on the rural health care authority in section 254(h)(2)(A)? Is 
there an argument that individual patient broadband connections for 
connected care services fall within the scope of section 254(h)(2)(A) 
because they extend the health care provider's network by allowing the 
health care provider to send and receive communications to its patients 
wherever the patients are located, and thus would enhance access to 
advanced service ``for'' the health care provider, as required by 
section 254(h)(2)(A)?
    99. The Commission also seeks comment on whether section 
254(h)(2)(A) would also authorize the Commission to provide funding 
under the Pilot program for health care provider purchases of 
services--other than patient connectivity--that are used to provide 
connected care services but that are not already eligible for support

[[Page 36880]]

through the Healthcare Connect Fund program. For example, companies may 
offer cloud-based solutions, finished service packages, or complete 
suites of services that allow health care providers to provide 
telehealth, including connected care. Are these services ``information 
services'' under section 254(h)(2)(A), for which the Commission is 
required to develop competitively neutral rules to enhance access for 
health care providers? Are there other types of services that qualify 
as ``information services'' under section 254(h)(2)(A)? The Commission 
seeks additional information about, and examples of, these services and 
the components of these services, including any network equipment 
required to make these services functional. The Commission also seeks 
specific information and data that would help it to determine whether 
these types of services could qualify as supportable information 
services under section 254(h)(2)(A). Finally, the Commission seeks 
information on how these types of services help health care providers 
provide connected care services, and whether health care providers have 
difficulty affording these types of services without USF support.
    100. The Commission believes that the universal service principles 
in sections 254(b)(1) and (b)(3) of the Act, and section 254(j) of the 
Act provide additional statutory support for a Pilot program that would 
provide USF support to enable health care providers to provide 
connected care technologies to eligible low-income consumers. Sections 
254(b)(1) and (b)(3), provide, respectively, that the Commission's 
universal service policies must be based on the principles that 
``[q]uality services should be available at just, reasonable, and 
affordable rates'' and ``[c]onsumers in all regions of the Nation, 
including low-income consumers . . . should have access to 
telecommunications and information services . . . that are reasonably 
comparable to those services provided in urban areas and that are 
available at rates that are reasonably comparable to those services 
provided in urban areas.'' Section 254(j) ensures the continuation of 
the Lifeline program through any subsequent changes to the Universal 
Service Fund. In addition, section 154(i) also authorizes the 
Commission to ``perform any and all acts, make such rules and 
regulations, and issue such orders, not inconsistent with this chapter, 
as may be necessary in the execution of its functions.''
    101. The Commission believes that using a discrete, time-limited 
Pilot program to obtain additional data about the benefits of 
broadband-enabled connected care services, and how universal service 
funds could better support the adoption of broadband-enabled connected 
care services, as well as broadband internet access service more 
generally, is consistent with these statutory provisions. The 
Commission notes that it has previously relied on sections 254(b)(1) 
and (b)(3) and 154(i) to establish the limited Lifeline Broadband Pilot 
program, which provided participating low-income consumers support for 
bundled broadband service or stand-alone broadband service to test the 
impact of Lifeline support on broadband adoption. The Commission seeks 
comment on relying in part on the low-income legal authority for the 
proposed Pilot program and how relying on the low-income legal 
authority would impact the structure of the Pilot program. For example, 
would relying on the low income legal authority require the Commission 
to limit Pilot projects to those serving exclusively low-income 
individuals?
    102. The Commission also seeks comment on whether it should rely on 
its low-income legal authority to provide support for broadband 
internet access connections for connected care services through the 
Pilot program, and rely on its rural health care legal authority to 
provide support for information services not already funded through the 
Healthcare Connect Fund program that health care providers use to 
provide connected care services. How would this approach impact the 
structure and administrability of the Pilot program? Would it result in 
a Pilot program structure that incentivizes participation from eligible 
health care providers, service providers, and patients better than 
under the other proposed legal authorities?
    103. For example, if a health care provider contracts with a remote 
patient monitoring solution provider for a package that includes 
broadband connectivity for patients, patient remote monitoring 
equipment, and software for the health care provider to process data 
received by the patient's remote monitoring equipment, could the 
Commission fund some parts of that overall package via its Rural Health 
Care legal authority and other parts through its low-income legal 
authority? If the health care provider needed additional broadband 
capacity to its location to support that remote monitoring service, 
could the Commission also support that additional capacity through this 
Pilot program?
    104. Are there other services the Commission should consider 
supporting consistent with its legal authority? For example, in the 
Commission's Rural Health Care Pilot Program, participants were 
permitted to purchase equipment integral to running their broadband 
networks, such as servers, routers, firewalls, and switches, or to 
upgrade their existing equipment and increase bandwidth. The Commission 
seeks comment on its legal authority to fund such services here.

III. Procedural Matters

A. Initial Paperwork Reduction Act Analysis

    105. This document contains proposed information collection 
requirements. The Commission, as part of its continuing effort to 
reduce paperwork burdens, invites the general public and the OMB to 
comment on the information collection requirements contained in this 
document, as required by the Paperwork Reduction Act of 1995, Public 
Law 104-13. In addition, pursuant to the Small Business Paperwork 
Relief Act of 2002, Public Law 107-198, see 44 U.S.C. 3506(c)(4), the 
Commission seeks specific comment on how to further reduce the 
information collection burden for small business concerns with fewer 
than 25 employees.
    106. Ex Parte Rules--Permit-But-Disclose. The proceeding the NPRM 
initiates shall be treated as a ``permit-but-disclose'' proceeding in 
accordance with the Commission's ex parte rules. Persons making ex 
parte presentations must file a copy of any written presentation or a 
memorandum summarizing any oral presentation within two business days 
after the presentation (unless a different deadline applicable to the 
Sunshine period applies). Persons making oral ex parte presentations 
are reminded that memoranda summarizing the presentation must (1) list 
all persons attending or otherwise participating in the meeting at 
which the ex parte presentation was made, and (2) summarize all data 
presented and arguments made during the presentation. If the 
presentation consisted in whole or in part of the presentation of data 
or arguments already reflected in the presenter's written comments, 
memoranda, or other filings in the proceeding, the presenter may 
provide citations to such data or arguments in his or her prior 
comments, memoranda, or other filings (specifying the relevant page 
and/or paragraph numbers where such data or arguments can be found) in 
lieu of summarizing them in the memorandum. Documents shown or given to 
Commission staff during ex parte meetings are deemed to

[[Page 36881]]

be written ex parte presentations and must be filed consistent with 
rule 1.1206(b). In proceedings governed by rule 1.49(f) or for which 
the Commission has made available a method of electronic filing, 
written ex parte presentations and memoranda summarizing oral ex parte 
presentations, and all attachments thereto, must be filed through the 
electronic comment filing system available for that proceeding, and 
must be filed in their native format (e.g., .doc, .xml, .ppt, 
searchable .pdf). Participants in this proceeding should familiarize 
themselves with the Commission's ex parte rules.
    107. Initial Regulatory Flexibility Analysis. As required by the 
Regulatory Flexibility Act of 1980, as amended, the Commission has 
prepared an Initial Regulatory Flexibility Analysis (IRFA) for the 
NRPM, of the possible significant economic impact on a substantial 
number of small entities by the policies and rules proposed in the 
NPRM. Written public comments are requested on this IRFA. Comments must 
be identified as responses to the IRFA and must be filed by the 
deadlines for comments on the NPRM. The Commission will send a copy of 
the NPRM, including this IRFA, to the Chief Counsel for Advocacy of the 
Small Business Administration. In addition, the NPRM and IRFA (or 
summaries thereof) will be published in the Federal Register.
    108. Need for, and Objectives of, the Proposed Rules. The 
Commission is required by section 254 of the Communications Act of 
1934, as amended, to promulgate rules to implement the universal 
service provisions of section 254 and ``to establish competitively 
neutral rules--(A) to enhance to the extend technically feasible and 
economically reasonable, access to advanced telecommunications and 
information services for all public and nonprofit . . . health care 
providers . . . .'' The Commission is also required to base policies 
for the preservation and advancement of universal services on 
principles including ``[q]uality rates should be available at just, 
reasonable, and affordable rates'' and ``[c]onsumers in all regions of 
the Nation, including low-income consumers . . . should have access to 
telecommunications service and information services . . . that are 
reasonably comparable to those services provided in urban areas and 
that are available at rates that are reasonably comparable to rates 
charged for similar services in urban areas.'' In the NPRM, the 
Commission proposes a Connected Care Pilot program (Pilot) that will 
assist in satisfying these requirements by providing support for 
eligible health care providers to provide connected care to low-income 
patients, including veterans and those in medically underserved 
communities. The Commission seeks comment on whether the Pilot program 
should fund broadband internet access services or other information 
services used by health care providers to provide connected care 
services and network equipment necessary to make the supported services 
functional. The Commission expects that the data gathered from the 
Pilot program will help to understand how and whether USF funds could 
be used to promote health care provider and low-income patient adoption 
and use of connected care services.
    109. The Commission proposes four goals for the proposed Pilot 
program and also propose a three-year duration and budget of $100 
million for the Pilot program. The Commission also proposes and seeks 
comment on the application process and the objective criteria for 
selecting projects among the applications the Commission receives for 
the Pilot program, and proposes and seeks comment on awarding 
additional points during the evaluation process for proposed projects 
that would primarily serve veterans or rural or Tribal areas or 
populations or primarily treat diabetes, heart disease, opioid 
addiction, mental health conditions, or high-risk pregnancy. The 
Commission should be able to fund a range of diverse projects 
throughout the country. The Commission proposes the specific 
requirements for health care providers, including vendor selection 
requirements, requirements for requesting funding and reimbursements, 
and audit and document retention requirements, and data reporting 
requirements. Finally, the Commission proposes specific requirements 
for participating service providers including indicating interest in 
participating in the Pilot program, requesting disbursements, and 
document retention and audit requirements. Participating consumers may 
also be required to complete consumer surveys.
    110. Legal Basis. The legal basis for the Notice of Proposed 
Rulemaking is contained in sections 1 through 4, 201, 254, and 403 of 
the Communications Act of 1934, as amended by the Telecommunications 
Act of 1996, 47 U.S.C. 151 through 154, 201, 254, and 403.
    111. Description and Estimate of the Number of Small Entities to 
Which the Proposed Rules Will Apply. The RFA directs agencies to 
provide a description of and, where feasible, an estimate of the number 
of small entities that may be affected by the proposed rules, if 
adopted. The RFA generally defines the term ``small entity'' as having 
the same meaning as the terms ``small business,'' ``small 
organization,'' and ``small governmental jurisdiction.'' In addition, 
the term ``small business'' has the same meaning as the term ``small 
business concern'' under the Small Business Act. A small business 
concern is one that: (1) Is independently owned and operated; (2) is 
not dominant in its field of operation; and (3) satisfies any 
additional criteria established by the Small Business Administration 
(SBA). Nationwide, there are a total of approximately 29.6 million 
small businesses, according to the SBA. A ``small organization'' is 
generally ``any not-for-profit enterprise which is independently owned 
and operated and is not dominant in its field.''
    112. Small Businesses, Small Organizations, Small Governmental 
Jurisdictions. The Commission's actions, over time, may affect small 
entities that are not easily categorized at present. The Commission 
therefore describes here, at the outset, three broad groups of small 
entities that could be directly affected herein. First, while there are 
industry specific size standards for small businesses that are used in 
the regulatory flexibility analysis, according to data from the SBA's 
Office of Advocacy, in general a small business is an independent 
business having fewer than 500 employees. These types of small 
businesses represent 99.9% of all businesses in the United States which 
translates to 29.6 million businesses.
    113. Next, the type of small entity described as a ``small 
organization'' is generally ``any not-for-profit enterprise which is 
independently owned and operated and is not dominant in its field.'' 
Nationwide, as of August 2016, there were approximately 356,494 small 
organizations based on registration and tax data filed by nonprofits 
with the Internal Revenue Service (IRS).
    114. Finally, the small entity described as a ``small governmental 
jurisdiction'' is defined generally as ``governments of cities, 
counties, towns, townships, villages, school districts, or special 
districts, with a population of less than fifty thousand.'' U.S. Census 
Bureau data from the 2012 Census of Governments indicates that there 
were 90,056 local governmental jurisdictions consisting of general 
purpose governments and special purpose governments in the United 
States. Of this number there were 37,132 general purpose governments 
(county,

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municipal and town or township) with populations of less than 50,000 
and 12,184 special purpose governments (independent school districts 
and special districts) with populations of less than 50,000. The 2012 
U.S. Census Bureau data for most types of governments in the local 
government category show that the majority of these governments have 
populations of less than 50,000. Based on this data the Commission 
estimates that at least 49,316 local government jurisdictions fall in 
the category of ``small governmental jurisdictions.''
    115. Small entities potentially affected by the proposals herein 
include eligible non-profit and public health care providers and the 
service providers offering them services, including telecommunications 
service providers, internet Service Providers (ISPs), and vendors of 
the eligible services and equipment that would be supported by the 
Pilot program.
    116. Description of Projected Reporting, Recordkeeping, and Other 
Compliance Requirements for Small Entities. In the NPRM, the Commission 
seeks comment on a proposed Connected Care Pilot program with a $100 
million budget and three-year duration, that would provide support for 
eligible low-income patients to receive discounts on residential 
broadband service for purposes of connected care.
    117. To participate in the Pilot program, the Commission proposes 
that health care providers satisfy the definition of an eligible health 
care provider under section 254(h)(7)(B) of the Act and submit an 
application by the application deadline that the Commission ultimately 
adopts for the Pilot program. The NPRM proposes specific information 
that health care providers would be required to submit in an 
application for each pilot project proposal, including, but not limited 
to, information on the participating health care provider(s), 
description of the project and how it would further the goals of the 
Pilot program, estimated project budget, patient populations and the 
geographic areas to be served and health conditions to be treated. The 
NPRM also proposes that the applications be made publicly available.
    118. The NPRM proposes requirements for participating health care 
providers to select service providers for the supported services and 
other potential Pilot-program supported items, including the 
possibility of requiring health care providers to competitively bid the 
supported services. In addition, the NPRM proposes requiring health 
care providers for participating projects to submit funding requests 
and invoices for services and other items that are eligible for support 
through the Pilot program, and reports at regular intervals that would 
allow the Commission to monitor the status of each project and how each 
project is using the funding and seeks comment on the appropriate 
interval and contents of those reports. Participating service providers 
may also have requirements related to requesting disbursements. The 
NPRM also proposes that participating health care providers and service 
providers be subject to random compliance audits, and a three or five-
year document retention period.
    119. Steps Taken to Minimize the Significant Economic Impact on 
Small Entities, and Significant Alternatives Considered. The RFA 
requires an agency to describe any significant, specifically small 
business, alternatives that it has considered in reaching its proposed 
approach, which may include the following four alternatives (among 
others): ``(1) the establishment of differing compliance or reporting 
requirements or timetables that take into account the resources 
available to small entities; (2) the clarification, consolidation, or 
simplification of compliance and reporting requirements under the rule 
for such small entities; (3) the use of performance rather than design 
standards; and (4) an exemption from coverage of the rule, or any part 
thereof, for such small entities.''
    120. The Commission does not expect the requirements for the Pilot 
program to have a significant economic impact on eligible service 
providers or eligible health care providers because service providers 
and health care providers have a choice of participating. The 
Commission also does not expect small entities to be disproportionately 
impacted. The Bureau will consider whether the proposed projects will 
promote entrepreneurs and other small businesses in the provision and 
ownership of telecommunications and information services, consistent 
with section 257 of the Communications Act, including those that may be 
socially and economically disadvantaged businesses. All eligible health 
care providers that choose to participate may be required to collect 
and submit data at regular intervals during the Pilot program and at 
the end of the Pilot program to USAC and the Commission, as described 
in section III(E) of the NPRM. The collection of this information is 
necessary to evaluate the impact of the Pilot program, including 
whether the Pilot program achieves its goals. The benefits of 
collecting this information outweigh any costs.
    121. The NPRM proposes an application process that would encourage 
a wide variety of eligible health care providers and eligible service 
providers to participate, including small entities. The Commission 
seeks to strike a balance between requiring applicants to submit enough 
information that would allow the selection of high-quality, cost-
effective projects that would best further the goals of the Pilot 
program, but also minimizing the administrative burdens on entities 
that seek to apply.
    122. The Commission proposes awarding additional points during the 
application process for projects that are located in a rural area, 
would primarily serve rural patients or veterans, would serve five or 
more Medically Underserved Areas and Healthcare Provider Shortage 
Areas, as designated by the Health Resources and Services 
Administration by geography, or are located on Tribal lands, associated 
with a Tribe, or part of the Indian Health Service. This recognizes the 
disparities in health care in rural areas and Tribal areas, and areas 
that are designated as Medically Underserved Areas and Healthcare 
Provider Shortage Areas and is aimed at increasing the likelihood 
projects serving these areas will be selected.
    123. The reporting requirements, compliance audit requirements, and 
document retention requirements the Commission proposes are tailored to 
ensure that Pilot program funding is used for its intended purposes and 
so that the Commission can obtain meaningful data to evaluate the Pilot 
program and inform its policy decisions. The proposed compliance audit 
and document retention requirements the Commission proposes are the 
same measures that apply to health care providers and service providers 
that participate in the Healthcare Connect Fund program. The proposed 
reporting requirements are tailored to ensure that the Commission 
receive regular, meaningful data about each project. The Commission 
finds that ensuring that participating health care providers and 
service providers, including small entities, are accountable in the use 
of Pilot program funds and that participating health care providers 
submit regular, meaningful information about their projects outweighs 
the burdens associated with these requirements.

IV. Ordering Clauses

    124. It is ordered that, pursuant to the authority contained in 
sections 1

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through 4, 201, 254, and 403 of the Communications Act of 1934, as 
amended by the Telecommunications Act of 1996, 47 U.S.C. 151 through 
154, 201, 254, and 403 the Notice of Proposed Rulemaking is adopted.
    125. It is further ordered that, pursuant to applicable procedures 
set forth in sections 1.415 and 1.419 of the Commission's rules, 47 CFR 
1.415, 1.419, interested parties may file comments on the NPRM on or 
before August 29, 2019, and reply comments September 30, 2019.

Federal Communications Commission.
Marlene Dortch,
Secretary.
[FR Doc. 2019-16077 Filed 7-29-19; 8:45 am]
BILLING CODE 6712-01-P