Medicaid Regulations Overview
- Currently, 49 states and the District of Columbia (DC), Puerto Rico, and the Virgin Islands have defined telehealth, telemedicine, or both.
- All 50 states and DC reimburse for live video sessions.
- Twenty-one states reimburse for remote patient monitoring (RPM)
- Only 11 states reimburse for store-and-forwards services
- Only 14 states reimburse to the home (DE, CO, MD, MI, MN, MT, NH, NV, NY, SC, TX, VT, WA, and WY)
- Thirty-eight states and DC have included informed consent as part of regulations, policy, and law.
- Currently, nine state boards issue licenses relating to telehealth services that allow an out of state provider to deliver care.
The Rural Health Clinic Modernization Act of 2019 aims to expand the services offered by rural health clinics to improve coverage gaps and increase access to care in underserved areas nationwide. According to a 2018 census by the CMS Quality, Certification & Oversight Reports (QCOR), there are more than 4,300 rural health clinics in the U.S. Currently these clinics are reimbursed by Medicare and Medicaid, however, guidelines haven’t been updated since 1988.
According to the Telehealth Advancement Act of 2011, ”telehealth is the mode of delivering healthcare services and public health utilizing information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health while the patient is at the originating site and the healthcare provider is at the distant site”.
According to CMS, “telemedicine is the use of medical information exchanged from one site to another using interactive telecommunications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time, interactive communication between the patient and physician or practitioner at the distant site to improve a patient’s health”.
Most Commonly Used Telehealth Terms and Information for Reimbursement
Critical Access Hospital (CAH)
Distant Site (hub, specialty, referral site)
The location where services are being delivered by the physician or licensed practitioner at the time the service is provided.
Federally Qualified Health Centers (FQHC)
Currently, thirty nine states require a form of informed consent in order to be reimbursed for recieving services via telehealth depending on how each state regulation is written. The following states are:
- District of Columbia
- Minnesota (alcohol & abuse program)
- New Hampshire
- New Jersey
- New Mexico (behavioral health services)
- New York
- Oregon (Physical Therapy & Community Treatment)
- Rhode Island
- South Carolina
- West Virginia
Every state reimburses telehealth services via live video. The reimbursement policies differ from state to state. Many states have restrictions for the type of services that can be reimbursed such as office visits and inpatient consultations. Furthermore, the type of healthcare provider and location where services are rendered can be affected when it comes to reimbursement.
Origination Site (patient, remote, rural, spoke site)
The location of the patient at the time the service is being rendered via telecommunication.
The transmission of digital or still medical images and/or data due to the transfer of data taking place over a period of time from one site to another. The most common services provided through this route are dermatology, ophthalmology, pathology, radiology, and wound care. These services are services that are not in real-time and are restricted for reimbursements in 39 states. The states that include these services are:
- New Mexico
- District of Columbia*
- New Jersey*
- New York*
* denotes legislation recently passed, however not implemented yet
Remote Patient Monitoring (RPM)
As of 2019, there are twenty-one states that reimburse for RPM. The most common restriction to these states is that reimbursements are made to home health agencies, which limits the type of monitoring device used to collect data and limits on what clinical conditions for symptoms can be monitored. The type of patient monitoring that transmits data in real-time includes devices such as glucose meters, heart monitors and blood pressure monitors. The following states accept a type of RPM:
- South Carolina
- District of Columbia*
- New Jersey*
- New York*
- South Dakota*
* denotes legislation recently passed, however not implemented yet
Rural Healthcare Centers (RHC)
Currently, thirty-four states reimburse transmission and/or facility fees.
FQHC and RHC Reimbursements
The following states allow FQHC and RHC reimbursements:
- Arkansas (RHC)
- District of Columbia (FQHC & RHC)
- Georgia (FQHC & RHC)
- Idaho (FQHC & RHC)
- Illinois (FQHC & RHC)
- Indiana (FQHC & RHC)
- Maine (FQHC & RHC)
- Maryland (FQHC)
- Missouri (RHC)
- Ohio (FQHC)
- Pennsylvania (FQHC & RHC) – Behavioral Health only
- Utah (FQHC & RHC)
- Virginia (FQHC & RHC)
- Wisconsin (FQHC & RHC)
State Telehealth Regulations
The provider manual in Alabama does not have a specific definition for telemedicine; however, it states that services rendered must be administered through interactive audio and visual telecommunications system that allows two-way communication between the distant site and the origination site. This does not include telephone, email, or fax.
All providers with an Alabama medical license are able to participate in the telemedicine program for eligible services that are necessary to the patient. For all services provided via telemedicine, a properly trained staff member must be familiar with the patient or a treatment plan must immediately be available in-person.
Currently, there are no regulations to reimburse for origination site or transmission fees. Furthermore, Alabama does not reimburse for store-and-forward services; however, RPM with in-home monitoring through the Patient’s 1st program is reimbursed for live video encounters for patients with a diagnosis of diabetes and chronic heart failure.
The following EPs are eligible to participate in the telemedicine program:
- Physicians enrolled with Alabama Medicaid with a specialty type of 931
- Physicians must submit the telemedicine Service Agreement/Certification form
- Physicians must obtain prior consent from the patient before any encounters
- The services rendered counts toward the annual visit limit of 14 encounters
For nursing assessment and care, the following EPs are eligible:
- Licensed Registered Nurse
- Licensed Practical Nurse
- Certified Nursing Assistant
- MAC worker
The following services are reimbursed:
- Office or outpatient visits
- Individual psychotherapy
- Psychiatric diagnostic services
- Neurobehavioral status exams
- *Nursing assessment and care and rehabilitative services
*only when certain conditions are met
For rehabilitative services, certain conditions must be present in order for the provider to be reimbursed for services rendered. Furthermore, the originating site must be located in Alabama at:
- Physician’s office
- Community mental health center
- Public health department
The distant site may be located outside of the state of Alabama as long as the provider has an Alabama state medical license and enrolled in the Medicaid program. For cross-state licensing, a special purpose license allows providers licensed in other states to perform care via telehealth services.
For prescription medication, the provider should examine the patient in-person when possible. There are certain exceptions where telemedicine is suitable for e-prescribing. For controlled substances, providers must abide by federal and state laws.
Currently, the state of Alabama does not have any parity laws.
Alaska’s definition of telemedicine is, “Telemedicine means the practice of health care delivery, evaluation, diagnosis, consultation, or treatment, using the transfer of medical data through audio, video, or data communications that are engaged in over two or more locations between providers who are physically separated from the patient or from each other.”
Services rendered are reimbursed when delivered in the following manner:
- Interactive method
- The encounter between the provider and patient must be in realtime using video and/or dedicated audio conference equipment.
- Store-and-forward method
- One provider transmits data such as imaging, sound, or previously recorded video to a consulting provider in a different location. The consulting provider must report the analysis of information received after it has been reviewed.
- Self-monitoring method
- The provider is indirectly involved with medical services from one location via telemedicine while the patient being monitored from home is in another location.
Alaska’s Medicaid program reimburses for covered medical services via telemedicine applications for live video if the service provided is:
- Covered under traditional methods that are not via telemedicine
- From a consulting, treating, referring or presenting provider
- Suitable for provisions via telemedicine
Office consultations that are medically necessary may be covered only if a second opinion is used by a provider of a different specialty than the requesting provider.
The following services are reimbursed:
- Initial or one subsequent followup visit
- A consultation is made to confirm a diagnosis
- Diagnostic, therapeutic or interpretive services
- Psychiatric or substance abuse assessments
- Psychotherapy or pharmacological management services
The following services are not reimbursed:
- Home and community-based waiver services
- Durable medical equipment
- Direct-entry midwife
- Accommodation services
- Visual care, dispensing or optician services
- Personal care assistants
- End-stage renal disease
- Technological equipment associated with telemedicine applications
- Private duty nursing
- Telephone when not part of a dedicated conference system
Furthermore, documentation requirements may apply. The following required forms of documentation fo Alaska’s Medicaid program for telemedicine consultations include:
- A state from the providers that a telemedicine application was used during the encounter
- The patient’s address
- The provider’s address
- The method of the telemedicine application used during the encounter
- The name for every provider and patient that was part of the encounter during the telemedicine session.
- An inquiry from the requesting provider
- The report from the consulting provider back to the requesting provider
Office consultations from providers within the same organization and specialty are not reimbursed. The department will only pay for services rendered via telemedicine, but will not cover expenses for the application or equipment used to provide services. The rate at which payment is reimbursed to the provider is limited for the evaluation and management of an established patient. Providers that use telemedicine to deliver services are reimbursed in the same manner as a traditional office visit.
For community-based health services, reimbursements will be made for the provider facilitating the use of telemedicine sessions if:
- The provider supplies telemedicine communication equipment
- Interrupted sessions occur due to the lapse in internet connection, but the provider reestablishes the telemedicine session before the intended session ends
- The patient’s clinical record is summarized
Regarding encounters, a physician is not subject to disciplinary actions for establishing a diagnosis, treatment or prescribing medication for the patient if there is a procedure set for follow up care. Furthermore, the physician must request consent from the patient to send copies of all records of the encounter and date of service to the patient’s PCP. Physicians cannot prescribe medication based on a patient who supplied their past medical history received by telephone, fax, or electronic format.
Currently, the state of Alaska has a proposed parity bill.
Arizona’s state Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS), has its own definition of telemedicine and telehealth.
Telemedicine is “the practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the member, including audio or video communications sent to a health care
provider for diagnostic or treatment consultation”.
Telehealth (or telemonitoring) is, “the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance. Telehealth includes such technologies as telephones, facsimile machines, electronic mail systems, and remote member monitoring devices, which are used to collect and transmit member data for monitoring and interpretation. While they do not meet the Medicaid definition of telemedicine they are often considered under the broad umbrella of telehealth services. Even though such technologies are not considered telemedicine, they may nevertheless be covered and reimbursed as part of a Medicaid coverable service”.
Furthermore, the definition of store-and-forward is the transfer of medical information from one site to another through the use of a camera or similar device that can record and store an image that is sent and forwarded via telecommunication for a consultation.
Arizona’s state Medicaid program also participates in teledentistry, which is “the acquisition and transmission of all necessary subjective and objective diagnostic data through interactive audio, video or data communications by an AHCCCS registered dental provider to a distant dentist for triage, dental treatment planning, and referral”. Teledentistry includes provisions for preventative and other approved services by the Affiliated Practice Dental Hygienist when the provider renders dental hygiene services under an affiliated relationship with a dentist. In addition, non-Arizona licensed providers can provide consultation services if it is specific to the patient in the AHCCCS program, the provider is registered with AHCCCS and the provider is licensed in the state where the consultation occurs. Early and Periodic Screening, Diagnostic and Treatment (EPSDT) aged members are covered by AHCCCS as well as services for enrollees under the age of 21. Comprehensive, limited and periodic dental examinations are not replaced by teledentistry and cannot be billed for the services rendered via telecommunications.
Telemedicine can be delivered in two methods. The first method is real-time which is an interactive, two-way transfer of medical information and data that occurs at two sites at the same time, which are referred to as the hub site and spoke site. The second method is via interactive audio, video and/or communication systems for diagnostic, consultation and treatment services.
Live video is reimbursed for medically necessary services rendered at specific originating sites by certain providers. If live video recording is enabled during the session, a consent form must be obtained. In addition, providers must document and obtain written or oral consent before delivering services. The patient’s PCP, attending physician, or other healthcare professional employed by the PCP who is familiar with the patient’s condition may be present during the time the services are rendered. Regarding medication, physicians are restricted from e-prescribing medication to patients without having a physical or mental health status exam that establishes a provider and patient relationship. These examinations can occur via real-time telemedicine encounters.
Eligible providers include:
- Registered Nurse Practitioner
- Physician Assistant
- Certified Nurse Midwife
- Clinical Psychologist
- Licensed Clinical Social Worker
- Licensed Marriage and Family Therapist
- Licensed Professional Counselor
Other healthcare professionals include:
- Registered Nurses
- Licensed Practical Nurses
- Clinical Nurse Specialists
- Registered Nurse-Midwives
- Physical, Occupational, Speech, and Respiratory Therapists
- Trained tele-presenter that is familiar with the patient’s medical history and condition
Eligible specialties include:
- Home Health
- Infectious Diseases
- Pain Clinics
- Pediatrics and pediatric sub-specialties
- Behavioral health
Behavioral health services are covered for AHCCCS and KidsCare patients if services rendered are in real-time. These services include:
- Diagnostic consultation and evaluation
- Psychotropic medication adjustment and monitoring
- Individual and family counseling
- Case management
Additional services that are covered are:
- Inpatient consultation
- Medical Nutrition Therapy (MTN)
- Office, outpatient, and surgery follow-up consultations
- Pain Management
- Pharmacy Management
Eligible facilities for Indian Health Services or tribal providers include:
- Indian Health Service Clinics
- Physician or other provider offices
- Urban Clinic for Native Americans
- Tribally-governed facility
Reimbursements are made for store-and-forward services for specific specialties. The following specialties are covered by AHCCCS:
Asynchronous telemedicine applications are not considered reimbursable, but the applications can be used to deliver services that are necessary. However, out-of-state providers are able to render care and bill for spoke and/or hub site services. Furthermore, behavioral health is not covered by AHCCCS. There are exceptions for services rendered that are reimbursable but are not considered to be a telemedicine service. The following exceptions are when:
A provider is a tele-presenter and delivers care through separately billing applicable services such as an EKG or X-Ray, but tele-presenting is not covered.
Reimbursement for dermatology, radiology, ophthalmology, and pathology is subject to review by AHCCCS when a consulting provider is at a distant site that does not require real-time interaction with a patient.
A consulting neurologist provides assistance in determining thrombolytic therapy when a patient in a rural area presents the onset symptoms of a stroke.
As for RPM, services rendered are reimbursed for patients with chronic heart failure (CHF). The following criteria must be met to determine if these services are able to be reimbursed:
A patient with a primary or secondary discharge diagnosis of CHF after an observation/inpatient admission occurs within the past two months, or the patient is readmitted within the past six months.
A symptom of CHF is identified by one of the specified ICD-10 codes through the New York Heart Association at a class level of 2 or more.
Private payers have a different definition of telemedicine. Under the Arizona Administrative Code, Department of Insurance, and Health Care Services Organizations (HCSO), “telemedicine means diagnostic, consultation, and treatment services that occur in the physical presence of an enrollee on a real-time basis through interactive audio, video, or data communication”. HSCOs are allowed to provide access to services via telemedicine, telephone, and email, but this requirement is not mandated. Coverage via telemedicine must be provided if the same service was provided through an in-person consultation; however, there may be limitations due to contracts between healthcare providers in the HSCO provider network.
There are no parity laws in the state of Arizona. Telehealth coverage is applied to the following:
- Substance abuse
- Pain Medicine
- Neurologic diseases
- Mental health disorders
- Infectious diseases
- Burn victims
- Urology (Jan 1st, 2020)
Regarding cross-state licensing, Arizona is engaged with the inter-jurisdictional Compact of the Association of State and Provincial Psychology Boards (PSYPACT). EPs must either be members of the Interstate Medical Licensure Compact, Nurse Licensure Compact, or Physical Therapy Compact.
Regulations pertaining to abortions are strictly prohibited using telemedicine services.
According to the Arkansas Medicaid program, telemedicine is defined as “the use of electronic information and communication technology to deliver healthcare services including without limitation, the assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient. Telemedicine includes store-and-forward technology and remote patient monitoring”.
Medicaid reimburses for live video sessions when the service and coverage are comparable to in-person encounters. This includes store-and-forward and RPM; however, reimbursement conditions may vary.
In order for telemedicine services to be reimbursed in the state of Arkansas, a provider and patient relationship must be established. A professional relationship can be established through telemedicine by face to face encounters using realtime audio and visual technology only if the standards of care do not require an in-person visit.
In comparison, a professional relationship cannot be established solely through:
- Email or text message
- Audio only communications
- Medical history generated by the patient
- Internet questionnaires
- Telephone or internet consult
Providers at the distant site are prohibited from using telemedicine services unless an existing provider and patient relationship already exist. There are certain exceptions below:
- In emergency situations where the patient’s health or life is in jeopardy
- Provide patient education not specific to a patient
Services through telemedicine such as interactive audio, facsimile, text messaging, or email may be used; however, the use of these methods is not reimbursed through Arkansas State Medicaid. Private payers may opt to reimburse services with the methods used above, but it is not required. Likewise, private health plans cannot prohibit providers from charging patients for the methods used above; however, there is no requirement to reimburse for services provided via telemedicine that is not comparable to an in-person visit. A private health plan cannot restrict beneficiaries from:
- Annual or lifetime reimbursement coverage provided through telemedicine.
- Deductibles, copays, coinsurance, benefit limitations that are not equally treated upon services rendered for in-person visits
- Prior authorizations that exceed requirements for services rendered for in-person visits
Furthermore, providers must abide by state and federal regulations regarding informed consent, the privacy of PHI, the confidentiality of medical record-keeping and fraud and abuse. In addition, providers must be fully licensed or certified to practice in Arkansas in order to treat patients through telemedicine; however, it is not required for providers who are geographically located in another area where they provide care for occasional consultations. Providers located out-of-state can provide care via electronic methods if the initial service was rendered in Arkansas and their interpretation can affect the diagnosis or treatment.
The facility fee for the distant site is not authorized for reimbursement under the Telemedicine Act. However, payment will be made to originating sites for a facility fee in the provider or covered entity is enrolled in Arkansas State Medicaid. HCPCS code Q3014 must be used for a telemedicine claim. In addition, outpatient behavioral health services are also covered as a telemedicine service. For these services, POS code 22 should be used by the distant provider.
For RHCs, in order to be reimbursed by Medicaid for telemedicine services, the provider and the patient must be able to see and hear each other in real-time (live video). Two secondary services are covered as well (fetal echography and echocardiology). To be considered a telemedicine service, the physician must view the echography or echocardiography output in real-time while the procedure is occurring. For billing purposes, in addition to CPT and HCPCS codes, the provider at the distant site must use a GT modifier and POS 02. For FQHCs and telemedicine billing services, procedure code T1014 must be used.
Regarding e-prescriptions, telemedicine cannot be used for providers to prescribe controlled substances under schedule II through V drug classifications unless the provider was on call or cross-coverage situations occurred. Furthermore, the patient must have already been seen in person or was referred to the provider. For abortion-inducing medication, the initial drug must be administered in the physical presence of the provider and telemedicine cannot be used for prescirbed any abortion-related circumstances for medication. Arkansas prohibits providers from writing medical marijuana certifications through telemedicine.
Med-Cal uses “telemedicine” to make a distinction from “telehealth”. Medi-Cal reimburses for live video across various specialties. Reimbursements are made for select services via live video when billed with modifiers GT or 95. The live video session can be used to deliver face-to-face encounters related to the primary reason a recipient requires home health services or durable medical equipment items. Psychiatrists are EPs that can bill for services in accordance with the Medicaid state plan. Providers must document and obtain informed consent from a patient that is oral or written. As of January 2019, HCPCS codes G0071, G2010, and G2012 will be reimbursed.
G0071 – Payment for communication technology-based services for 5 minutes or more of a virtual communication between a RHC or FQHC practitioner and RHC or FQHC patient, or 5 minutes or more of remote evaluation of recorded video and/or images by an RHC or FQHC practitioner, occurring in lieu of an office visit; RHC or FQHC only.
G2010 – Remote evaluation of recorded video and/or images submitted by an established patient, including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
G2012 – Brief communication technology-based service, virtual check-ins, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment, followed by 5-10 minutes of medical discussion.
The following criteria must be met in order to be eligible for reimbursement for the codes G2010 and G2012 above:
- The patient must be an established patient within the past three years of the billing physician or quality care health plan (QCHP).
- HCPCS G2010 and G2012 are not billable if the evaluation is performed by a non-qualified practitioner to furnish E/M services.
- The provider must obtain informed consent from the patient either verbally or electronically. This must be documented in the patient’s chart.
- Practices must collect the required co-pays as part of Medicare Part B Fee-for-Services.
- If the remote evaluation of the image takes place during an in-person visit, within seven days after an in-person visit, or triggers an in-person visit within 24 hours, the evaluation is NOT billable. Payment is to be bundled into the relevant in-office E/M code.
- A follow-up discussion is required with the patient that lasts 5-10 minutes.
Medi-Cal will reimburse the originating and distant site facility fees for live video transmission costs. Transmission fees are not reimbursed for store-and-forward services. Furthermore, services rendered via telephone, email or facsimile are not reimbursable; however, asynchronous methods are reimbursed for certain specialties. These specialties include:
Medi-Cal reimburses telehealth services for the California Children’s Services Program (CCS), Genetically Handicapped Person’s Program (GHPP) and Child Health and Disability Prevention Program (CHDP).
CCS uses CPT/HCPCS codes 16-1217 and 09-0718. These codes include tele-speech, tele-auditory-verbal therapy, tele-auditory habilitation, and tele-auditory rehabilitation services in-home care with a parent or guardian working with a speech therapist at a distant site.
For Denti-Cal, live video sessions are only billable if the patient requests the service. Allied dental professionals are not permitted to bill for teledentistry.
Private payers cannot restrict telehealth services to the condition that in-person encounters occur before being reimbursed. Furthermore, services provided cannot be limited geographically subject to terms and conditions of California’s regulatory requirements.
Drug Medi-Cal certified providers may receive reimbursement for individual counseling provided through telehealth services. In accordance with the Administrative Procedure Act, the Department of Health Care Services must adopt regulations by July 1st, 2022 in order for providers to be reimbursed. Healthcare providers are prohibited from prescribing or dispensing medications or devices through the internet without prior encounters. Remote dispensing site pharmacies are authorized to dispense or provide medication in medically underserved locations. Furthermore, telepharmacy services must be provided to the remote dispensing site under conditions that the pharmacy is not geographically located more than 150 miles.
According to Colorado state statutes and worker’s compensation, telehealth and telemedicine are used separately when describing services provided.
“Telehealth is a mode of delivery of health care services through telecommunications systems,
including information, electronic, and communication technologies, to facilitate the assessment,
diagnosis, consultation, treatment, education, care management, and/or self-management of an
injured worker’s health care while the injured worker is located at an originating site and the provider is located at a distant site. The term includes synchronous interactions and store-and-forward
transfers. The term does not include the delivery of health care services via telephone with audio-only function, facsimile machine, or electronic mail systems.
Telemedicine means two-way, real-time interactive communication between the injured worker and the provider at the distant site. This electronic communication involves, at minimum, audio, and
video telecommunications equipment. Telemedicine enables the remote diagnoses and evaluation
of injured workers in addition to the ability to detect fluctuations in their medical condition(s) at a
remote site in such a way as to confirm or alter the treatment plan, including medications and/or
For live video services delivered via telehealth, Colorado State Medicaid reimburses direct member services that can involve collaborating providers and the beneficiary. The originating provider does not have to be present under the circumstances that telecommunication equipment facilities are available between the distant site provider and beneficiary. Reimbursements are made for select services via live video when billed with modifier GT, which adds $5.00 to the CPT code to cover costs of the transmission fee.
A PCP or behavioral health provider is eligible to be reimbursed as the originating provider; however, certain conditions apply for reimbursement of a distant provider. For distant providers, the PCP must be able to deliver patient care in-person if treatment is necessary for the patient.
An exception to the Colorado State Medicaid requirement that a provider and the patient relationship must be established before telemedicine services are rendered, can be waived for treating a patient for the first time. In order for the exception to take effect, informed consent is needed for all of the following written statements that are signed by the patient or patient’s legal guardian:
- Confidentiality protections apply to all services
- The patient and legal guardian must have access to all medical information obtained via telemedicine
- The patient may refuse the delivery of care provided via telemedicine without affecting his or her rights to future treatment or benefits
Regarding worker’s compensation, the patient is required to provide consent for treatment. Furthermore, the use of telehealth services can establish a professional relationship between a provider and patient via live video and audio services.
For store-and-forward services delivered via telehealth, the services must be the same as an in-person visit in order to be reimbursed; however, in-person visits are not required for providers to make an official diagnosis, development of a treatment plan, or instruction for delivering services for therapeutic restoration procedures. Reimbursements are limited for interim therapeutic restoration in teledentistry. Furthermore, services provided via telephone and fax are not reimbursed.
EPs are eligible for facility fee reimbursements under the conditions the provider is a:
- Physician Assistant
- Nurse Practitioner
The Colorado State Medicaid Program reimburses RPM services at a flat rate. In order to be reimbursed for RPM, the originating site can be located at the beneficiary’s home if there is no originating provider present, but the delivery of telemedicine services must include appropriate lighting and auditory levels.
The patient must receive services for at least one of the conditions:
- Congestive heart failure
- Chronic obstructive pulmonary disease
The state also requires remote monitoring at least five times weekly to manage the patient’s condition or disease that was diagnosed by a physician or podiatrist. Likewise, the patient or caretaker cannot miss five monitoring events in a 30-day period. In addition, the patient’s home must have the space necessary for telemedicine equipment and transmission capability. Another requirement for reimbursement is that the patient must have been hospitalized twice or more times in the last 12 month period for conditions related to their diagnosis. In relation, if the patient has received care in their home for less than six months, has been hospitalized at least once in a three month period and experienced symptoms of a qualifying diagnosis that requires telemonitoring, or experiences a new onset of a qualifying disease that requires ongoing monitoring, then this meets the criteria for reimbursement. Acute and long-term home health agencies are reimbursed for the installation and education of telehealth. Agencies can bill for every day they receive and review pertinent patient clinical information. Prior authorizations are not required for these services.
Home health services that are eligible for reimbursement, if all of the following criteria are met:
- Services are rendered for treatment of an illness, injury or disability that may include mental disorders
- The services are essential to the patient’s overall well being
- The frequency, duration, and amount of encounters are reasonable
- A plan of care must be defined and implemented during services
- The services provided are on a periodic basis
- The patient’s medical records justify that care shall be provided in their home rather than a physician office, clinic, or other outpatient environments
Managed care organizations may or may not reimburse telemedicine costs. Providers that deliver telemedicine services, must implement procedures that safeguard all ePHI. These procedures include, but are not limited to:
- Ensuring a procedural system is in place to limit access to individuals or staff members not qualified to view or share ePHI
- Ensure that members that do have specific access to ePHI, create unique and strong passwords when logging into the practice’s preferring EHR
- Ensure a procedural system is in place to routinely track and permanently record medical information
- Advise patients of their rights to privacy and they are able to select the location of where they receive telemedicine services
Private health plans shall not restrict or deny coverage to patients solely because services are delivered through telehealth communication technology or applications; however, insurers can find other reasons to deny coverage if the service provided does not meet their standards of care. Payers shall give reasonable compensation to the originating site for telehealth transmission costs, except when the originating site is a private residence. Private healthcare insurers must treat the services rendered via telemedicine the same as they would for an in-person encounter.
Costs incurred from telemedicine visits at FQHCs are not billable encounters because they are included in the cost report.
Pharmacies are prohibited from dispensing prescription medication if a pre-existing provider and patient relationship has not been established.
Regarding cross-state licensing, Colorado is engaged with the inter-jurisdictional Compact of the Association of State and Provincial Psychology Boards (PSYPACT). EPs must either be members of the Interstate Medical Licensure Compact, Nurse Licensure Compact, or Physical Therapy Compact.
According to Connecticut State Medicaid, telehealth and telemedicine are used separately when describing services provided. When referring to the Telemedicine Demonstration Program for FQHCs, “telemedicine means the use of interactive audio, interactive video or interactive data communication in the delivery of medical advice, diagnosis, care or treatment. Telemedicine does not include the use of facsimile or audio-only telephone.
Telehealth means the mode of delivering health care or other health services via information and
communication technologies to facilitate the diagnosis, consultation, and treatment, education, care
management and self-management of a patient’s physical and mental health, and includes an interaction between the patient at the originating site and the telehealth provider at a distant site, and synchronous interactions, asynchronous store-and-forward transfers or remote patient monitoring. Telehealth does not include the use of a facsimile, audio-only telephone, texting or electronic mail.”
Connecticut State Medicaid is required to provide coverage for services delivered via telehealth that the commissioner determines the services provided are clinically relevant, cost-effective, and expanding access to services for where there is a shortage of healthcare providers. Connecticut’s Medical Assistance Program will not reimburse for services provided electronically or via telephone.
For reimbursement purposes, a telehealth provider shall provide telehealth services if the provider:
- Communicates through real-time, interactive, two-way communication technology or store-and-forward services
- Has access to pertinent ePHI and the patient’s PCP information
- Applies the same standards of care through telehealth services as in-person services, except when the care of the patient requires the use of diagnostic testing and a physical examination
- Gives the patient information on the telehealth provider’s license number and contact information.
Telephone services are allowed by the state for case management behavioral health care for patients that are 18 years old and younger.
Regarding consent, the provider must inform the patient pertaining to treatment methods and limitations of treatment provided via telehealth applications for their first telehealth interaction with a patient. This shall be documented in the patient’s health record. Likewise, if the patient withdraws their consent, documentation is necessary for ePHI. Consent must also be obtained by the parent or patient’s legal guardian.
For store-and-forward services, provider to provider communication for specialty care is the only eligible service.
FQHCs, outpatient office, hospital and clinic settings, can be reimbursed for electronic consults for specialty care. eConsults are permitted for physician-to-physician email consultations as well as store-and-forward services for reimbursement.
As of 2019, RPM services are not reimbursed.
EP’s that may provide telehealth services include:
- Any physician licensed under chapter 370 of Connecticut’s state statute
- Physical therapist
- Occupational therapist
- Registered nurse or advanced practice registered nurse
- Physician assistant
- Marital and family therapist
- Clinical social worker or master social worker
- Alcohol and drug counselor
- Professional counselor
- Speech and language pathologist
- Respiratory care practitioner
Consistent with federal law, no telehealth provider can prescribe any schedule I, II, or III controlled substances via telehealth. Exceptions to this rule are that schedule II and III controlled substances other than opioids can be prescribed for the treatment of a patient with psychiatric disability or substance use disorder, including but not limited to MAT.
For cross-state licensing, the Department of Public Health may establish procedures for accepting a provider’s license from another state and issue the provider a license to practice in the state of Connecticut without a physical examination if specific conditions are met.
District of Columbia
Bill HB 23 was passed on April 29th, 2019 and will take effect on Jul 1st, 2019. This bill ultimately removes parity laws that reimburse telehealth services at the same rate as in-person care. Payers and providers are now able to negotiate their own rates for virtual care, which also requires providers to initiate different rates for virtual care and in-person care. This is a step backward for providing telehealth services as private payers believe these services should be less expensive than in-person care. The bill creates new definitions for telehealth services that include asynchronous platforms, but do not include telephony, e-mails, or faxes.
Florida’s First Family telehealth legislation is helping thousands of public school students dealing with behavioral health from the damages Hurricane Michael caused in the Florida panhandle in 2018. Plans have been announced to create a telemental health network for more than 35,000 students that would have on-demand access to virtual care when they return to school this fall.
As of 2018, Kansas has approved telehealth and prescription laws as the same as in-person visits.
As of June 13, 2019, legislation has been passed that establishes regulations and guidelines for telehealth by private payers. This essentially lets providers utilize RPMs on a broader scale, as well as telephonic and store-and-forward services (asynchronous). Private health plans must treat telehealth services that are offered, are equally treated as an in-person visit. Furthermore, co-pays, deductibles, and coinsurance shall not exceed any fees as an in-person visit.
The qualifications for coverage must meet six criteria in order to be reimbursed:
- The service rendered is covered under the patient’s health plan
- The service delivered via telehealth is of similar quality as in-person treatment
- Prior authorizations (PA) is required for telehealth encounters only if a PA is required for the corresponding service that is covered. Furthermore, an in-person consultation is not required to receive telehealth services.
- The geographic location and distance for travel are not limited in any way for telehealth coverage.
- The carrier requires a clinical evaluation either in-person or through telehealth before a provider can write a prescription.
- The carrier shall provide coverage and treatment of two or more patients that are enrolled in a health plan at the same time through telehealth, which includes counseling for substance abuse disorders involving opioids.
The new law prohibits payers from requiring providers to use a specific telemedicine platform as a condition of coverage.
Massachusetts is the only state that requires private insurers to reimburse for services provided via telehealth. Recently the state began to reimburse for mental and behavioral health services delivered via telehealth.
Will only reimburse of telepsychiatry services
Currently, the only EPs that are reimbursed are physicians, certified registered nurse practitioner and certified nurse-midwives.
Bill SP 670 is closer to being enacted into law which removes previous burdens for providing telehealth services. Medicaid payers can’t deny coverage for connected care because the service isn’t offered in person. The bill would enable providers to explore the use of RPM and asynchronous telehealth programs.
Amendments from current laws for telehealth and telemedicine would:
- Repeal provisions that mandate facilities use a specific minimum requirement for technology used during encounters
- Amend language in the current bill that the commission encourages providers to provide telemedicine and telehealth services
- Remove the requirement that the commission encourages STAR Health program providers to use telemedicine and increase medical services in underserved areas.
Managed Care Organizations (MCO) are to reimburse providers at the same rate as in-person encounters and prevent MCOs from limiting the use of certain telehealth platforms. Furthermore, FQHCs will be added to the list of facilities that are able to use telepharmacy services and the definition of “telemedicine and telehealth” will be added to the definition of “direct primary care”.
Bill SB 71 was signed into law on June 4th, 2019 to create a statewide telehealth network to connect remote healthcare providers with Sexual Assault Nurse Examiners (SANEs), who are trained to collect evidence and provide testimonies in court. Many nurses in rural areas have limited or no experience in testifying, so the Sexual Assault Forensic Examination Telehealth (SAFE-T) Center that connects Pennsylvania’s program to provide virtual simulations to healthcare providers in Texas.
Live video, store-and-forward, and RPM are reimbursed under certain conditions and .restricted to specific specialties. Plans must be participating in the Medicare-Medicaid Demonstration Waiver in order to use store-and-forward and RPM in rural and urban areas.
Allows medication-assisted therapy (MAT) through telehealth.
Department of Veterans’ Affairs (Could be a blog)
It helps veterans in rural areas with HIV to improve their care management via telehealth programs. Studies recently conducted by Micahel E. Ohl, MD, MSPH, an investigator in the Center for Access and Delivery Research and Evaluation at the VA Medical Center in Iowa City and his associate found that viral suppression improved in patients using telehealth services when compared to in-person care. There were improvements in documented viral suppression due to more frequent viral load testing during care leading to fewer patients missing viral loads. Increased monitoring of viral loads can be a significant impact on telemedicine and may lead to the overall improvement of viral suppression due to patients being more apt to using telehealth platforms at the comfort of their home and other factors that may be personal.
Medication and Pharmacy
Most states do not consider the use of online questionnaires to establish a patient and provider relationship. Several states require that an in-person visit and/or physical exam must occur before the patient can be prescribed medication online. In contrary to the above, some states specifically allow the use of telehealth services to prescribe medication. However, the use of e-prescribing controlled substance is prohibited for the majority of states. For states that allow controlled substances to be prescribed: