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.
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)
- Cross-State Licensing
- Federally Qualified Health Centers (FQHC)
- Informed Consent
The location where services are being delivered by the physician or licensed practitioner at the time the service is provided.
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:
- Live Video
- Origination Site (patient, remote, rural, spoke site) The location where services are being delivered by the physician or licensed practitioner at the time the service is provided.
- Store-and-Forward (asynchronous)
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.
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:
- 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:
- Rural Healthcare Centers (RHC)
- Transmission/Facility Fees
- FQHC and RHC Reimbursements
Currently, thirty-four states reimburse transmission and/or facility fees.
The following states allow FQHC and RHC reimbursements: