State Medicaid & CHIP Telehealth Toolkit, COVID-19 Version: Supplement #1 (CMS, December 6, 2021)
Summary
Supplement #1, dated December 6, 2021, to the State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth, COVID-19 Version, which the Centers for Medicare and Medicaid Services (CMS) released on April 23, 2020. The introduction refers to nearly 73 million Medicaid and Children's Health Insurance Program (CHIP) beneficiaries. The table of contents lists an updated Appendix A of Frequently Asked Questions (benefit, financing, workforce, managed care and health information exchange flexibilities, T-MSIS coding guidance, and quality reporting), an updated Appendix B of Resources, and further appendices on telehealth modalities, an action plan, communication strategies, and state experience profiles.
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“State Medicaid & CHIP Telehealth Toolkit, COVID-19 Version: Supplement #1 (CMS, December 6, 2021).”
Original at www.medicaid.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/cms-www-medicaid-gov-medicaid-benefits-downloads-medicaid-chip-telehealth-toolkit-supplement1-pdf-www-medicaid/
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State Medicaid & CHIP Telehealth Toolkit
Policy Considerations for States Expanding Use of Telehealth
COVID-19 Version: Supplement #1
December 6, 2021
Table of Contents
Introduction ......................................................................................................................................1
Updated Appendix A: Frequently Asked Questions ........................................................................2
Benefit Flexibilities..................................................................................................2
Financing Flexibilities .............................................................................................9
Workforce Flexibilities ..........................................................................................10
Managed Care Flexibilities ....................................................................................10
Health Information Exchange Flexibilities ............................................................12
T-MSIS Coding Guidance .....................................................................................12
Quality Reporting...................................................................................................12
Updated Appendix B: Resources ...................................................................................................14
Appendix C: Common Telehealth Modalities ...............................................................................17
Appendix D: State Medicaid Telehealth Assessment/Action Plan ................................................24
Appendix E: Comparison Tool – Fee-for-Service /Managed Care Telehealth Policies ................34
Appendix F: State Medicaid Telehealth Communication Strategies .............................................46
Appendix G: COVID-19 State Telehealth Experience Profiles ....................................................57
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Introduction
This document serves as supplement to the State Medicaid & CHIP Telehealth Toolkit: Policy
Considerations for States Expanding Use of Telehealth, COVID-19 Version released by the
Centers for Medicare and Medicaid Services (CMS) on April 23, 2020. The purpose of the
original toolkit was to assist states in general considerations for telehealth expansion in response
to the COVID-19 Public Health Emergency (PHE) on behalf of the nation’s nearly 73 million
Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries. States seeking to
facilitate adoption of telehealth services are encouraged to review this toolkit.
The focus of this supplement is to provide additional support to state Medicaid and CHIP
agencies in their adoption and implementation of telehealth. This supplement explores
terminology, communication strategies, telehealth operations and implementation tools, and
shared experiences and examples from states and territories across the nation. It includes updates
to Frequently Asked Questions (FAQs) and Resources for states to consider as they expand
telehealth and begin to plan beyond temporary flexibilities. While this supplement frequently
references Medicaid programs, the tools and resources contained throughout this Supplement are
generally also applicable to CHIP programs, though it should be noted that there is some
guidance specific to CHIP in the Updated Appendix A: Frequently Asked Questions.
While telehealth has become a resourceful way to provide select services while maintaining
social distance and reducing the risk of in-person COVID-19 transmission, it also has potential
as an additional access pathway for services when social distancing is no longer required. Based
on their own documented successes, many states are considering implementing policies for
continued telehealth flexibilities following the PHE and on a more permanent basis.
Implementing policy and service changes with managed care plans (MCPs), providers and
beneficiaries continues to require a careful and well-thought-out process. Additionally, providing
timely information in a consumable format is critical to enabling stakeholders to effectively
utilize telehealth. States may use this supplemental toolkit to help think through how they will
explain and clarify which policies are temporary or permanent, when flexibilities will expire,
which services can be accessed through telehealth, which providers may deliver those services,
the modality they may use to deliver telehealth services, and the circumstances under which
telehealth can be reimbursed.
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Updated Appendix A: Frequently Asked Questions
* Indicates newly added FAQ at end of question
Benefit Flexibilities
1. What flexibilities are available to provide care via telehealth for individuals who are
quarantined or self-isolated to limit risk of exposure?
States have broad flexibility to cover telehealth through Medicaid, including the methods
of communication (such as telephonic or video technology commonly available on smart
phones and other devices) to use. Telehealth is important not just for people who are
unable to go to the doctor but also for when it is not advisable to go in person. No federal
approval is needed for state Medicaid programs to reimburse providers for telehealth
services in the same manner or at the same rate that states pay for face-to-face services. A
state plan amendment (SPA) would be necessary to accommodate any revisions to
payment methodologies to account for telehealth costs.
With regard to 1915(i) face-to-face assessments, the use of telemedicine or other
information technology medium is authorized under federal regulations at 42 C.F.R. §
441.720(a) under certain conditions. With regard to 1915(c) waivers, the state can
complete an Appendix K to allow case management to be done via telephone or other
information technology medium and, where personal care services only require verbal
cueing and/or instruction, the personal care service can be expanded to permit
information technology medium as a resource.
2. Are there any available flexibilities in implementing the requirement for face-to-
face encounters under Medicaid home health? Can telehealth be utilized?
Yes. For initiation of home health services, face-to-face encounters may occur using
telehealth as described at 42 C.F.R. §440.70(f)(6). A physician, nurse practitioner or
clinical nurse specialist, a certified nurse midwife, a physician assistant, or attending
acute or post-acute physician for beneficiaries admitted to home health immediately after
an acute or post-acute stay may perform the face-to-face encounter. The allowed non-
physician practitioner must communicate the clinical findings of the face-to-face
encounter to the ordering physician. Those clinical findings must be incorporated into the
beneficiary’s written or electronic medical record. Additionally, the ordering physician
must document that the face-to-face encounter occurred within the required timeframes
prior to the start of home health services and indicate the practitioner who conducted the
encounter and the date of the encounter. A SPA would only be necessary to revise
existing state plan language that imposes telehealth parameters that would restrict this
practice. As is discussed above and at
https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html, states are not
required to submit separate SPAs for coverage or reimbursement of telehealth services if
they decide to reimburse for telehealth services in the same manner or at the same rate
paid for face-to-face services. A SPA would be necessary to accommodate any revisions
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to payment methodologies to account for telehealth costs.
3. Can Pre-Admission Screening and Resident Review (PASRR) Level 1 and Level 2
evaluations be conducted remotely as opposed to through a face-to-face visit?
Yes. The PASRR statutory provisions require all applicants to and residents of Medicaid-
certified nursing facilities (NFs) be screened for mental illness and intellectual disability,
and, if necessary, be provided specialized services while in the NF.
Federal regulations do not prohibit PASRR Level 1 and Level 2 evaluations from being
conducted by telephone or through another electronic medium. Unless the state has a
specific requirement that PASRR Level 2 evaluations be conducted in a face-to-face
interview, there is no need to amend language in the state plan.
States can also request an 1135 waiver to temporarily suspend pre-admission screening
and resident review Level 1 and Level 2 for 30 days.
4. How do the Medicaid flexibilities around use of telehealth as a service delivery mode
interact with Medicare and commercial third party liability (TPL) requirements,
which may be less flexible around telehealth? For example, a Medicare or
commercial payer may require a face-to-face physician visit to order care or
supplies.
Please note that Medicare has recently increased flexibilities related to telehealth due to
the public health emergency, as summarized in the fact sheet available at
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-
fact-sheet. While Medicare and commercial payers have increased flexibilities for
telehealth, there may still be instances where coordination of benefits is necessary.
Medicaid payment allows for state plan flexibilities in the event Medicare or a
commercial insurer denies payment. If the third party denied the claim for a substantive
reason (e.g., service not covered) and the service is covered under the Medicaid state
plan, Medicaid would review for payment accordingly. If at a later time, the state is made
aware of a third party’s coverage for these specific services, the state, as it currently does,
would chase recovery of payment accordingly. Therefore, in the example above, once
Medicare or a commercial payer reviews a claim and denies for a substantive reason,
such as face-to-face physician visit requirement, Medicaid would review and pay
according to the state plan. If telehealth is permitted under the Medicaid state plan,
Medicaid would pay accordingly.
5. How can states ensure continuity of coverage for Medicaid services ordinarily
delivered to children in schools while schools are closed due to COVID-19? *
The use of telehealth can assist states in continuing to deliver Medicaid-covered services
to eligible children. As a reminder, the Early and Periodic Screening, Diagnostic, and
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Treatment (EPSDT) benefit requires states to make available to eligible children under
age 21 all medically necessary services included under section 1905(a) of the Act in order
to correct or ameliorate defects and physical and mental illnesses or conditions. If the
state establishes that a Medicaid service can be delivered via telehealth, states may
generally use existing state plan methodologies to cover and pay for the service when
delivered via telehealth, or to reimburse additional costs that are incurred by the provider
because of telehealth delivery. If the state plan contains restrictions that would prevent an
otherwise covered service from being provided via telehealth, the state may use the
Medicaid Disaster SPA template issued on March 22, 2020, to temporarily remove such
restrictions during the period of the public health emergency. If the state needs
flexibilities beyond the period of the public health emergency, CMS is available for
technical assistance to determine if a SPA is needed. If telehealth is used, covered entities
must provide effective communication to individuals with disabilities as per Section 1557
of the Affordable Care Act, Section 504 of the Rehabilitation Act and Title II of the
Americans with Disabilities Act. For further information on Medicaid coverage and
reimbursement of services delivered via telehealth, please refer to the Medicaid.gov web
page: https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html. This page
includes the State Medicaid & CHIP Telehealth Toolkit Policy Considerations for States
Expanding Use of Telehealth COVID-19 Version and a link to Medicaid State Plan Fee-
for-Service Payments for Services Delivered Via Telehealth.
The Office for Civil Rights in the Department of Health and Human Services is
exercising enforcement discretion to waive potential penalties for Health Insurance
Portability and Accountability Act of 1996 (HIPAA) Privacy, Security, and Breach
Notification Rules violations against health care providers that in good faith provide
patient care through remote communications technologies during the COVID-19 public
health emergency. Additional guidance is available explaining how covered health care
providers can use remote video communication products and offer telehealth to patients
responsibly. See: https://www.hhs.gov/hipaa/for-professionals/special-topics/hipaa-
covid19/index.html.
States may also refer to the guidance issued by the Office of Special Education
Programs (OSEP) in the Department of Education for further information on the IDEA
and other federal civil rights laws:
https://www2.ed.gov/about/offices/list/ocr/frontpage/faq/rr/policyguidance/Supple%20
Fact%20Sheet%203.21.20%20FINAL.pdf. For other updates on the Department of
Education website, see: https://www.ed.gov/coronavirus.
Additionally, see “Section 1557: Ensuring Effective Communication with and
Accessibility for Individuals with Disabilities,” https://www.hhs.gov/civil-rights/for-
individuals/section-1557/fs- disability/index.html; “Disability Resources for Effective
Communication,” https://www.hhs.gov/civil-rights/for-individuals/special-
topics/hospitals-effective- communication/disability-resources-effective-
communication/index.html; and “ADA Requirements,” https://www.ada.gov/effective-
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comm.htm.
6. Would an Individualized Education Program (IEP), an Individualized Family
Service Plan (IFSP), Section 504 plan, or other plan that identifies Medicaid-
covered services for a Medicaid-enrolled child need to expressly indicate that
services can be delivered via telehealth as a pre-condition for receipt of Medicaid
reimbursement for the services? *
No. Medicaid considers telehealth to be a service delivery method, not a service.
Services included in an IEP, IFSP, Section 504 plan, or other plan, can be covered by
Medicaid only if they are Medicaid services provided to a Medicaid-enrolled child by
a Medicaid qualified practitioner. If these requirements are met, and there is an
approved payment methodology for the services in the state Medicaid plan, then
Medicaid can reimburse for the services, including when they are delivered via
telehealth.
Generally, states need to have current Medicaid state plan 4.19-B pages that set forth
the reimbursement methodology for any covered Medicaid services that would be
included in the child’s IEP, IFSP, section 504 plan, or other plan of services for a
child. States do not need to refer to telehealth reimbursement methodologies in their
state plans unless the reimbursement rate or methodology for a service provided via
telehealth is different from the rate or methodology that applies when the same service
is provided face to face.
Please also refer to the Medicaid.gov and the OSEP and Department of Education
links noted above.
7. Can early intervention services (EIS) under the Individuals with Disabilities
Education Act (IDEA) be reimbursed by Medicaid when the services are delivered
via telehealth? *
If the state establishes that a Medicaid-covered service can be delivered via telehealth,
states may generally use existing state plan methodologies to cover and pay for the
service when delivered via telehealth, or to reimburse additional costs that are incurred
by the provider because of telehealth delivery. If the state plan contains restrictions that
would prevent an otherwise covered service from being provided via telehealth, the state
may use the Medicaid Disaster SPA template issued on March 22, 2020 to temporarily
remove such restrictions during the period of the public health emergency. States can
cover and reimburse for EIS that are Medicaid-covered services provided to a Medicaid-
enrolled child by a qualified Medicaid provider. As explained previously in the CMS
telehealth FAQs (Section III. Benefits, Item B. Telehealth, Question 1) updated May 5,
2020, states have broad flexibility to cover services provided via telehealth under
Medicaid, and also have flexibility regarding the methods of communication used to
provide services via telehealth (such as telephonic, video technology commonly
available on smart phones and other devices). Telehealth is important not just for people
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who are unable to go to the doctor, but also for when it is not advisable to go in person.
No federal approval is needed for state Medicaid programs to reimburse providers for
Medicaid services provided via telehealth in the same manner or at the same rate that
states pay for those same Medicaid services when provided face-to-face. A SPA would
be necessary to accommodate any revisions to payment methodologies to account for
telehealth costs. The updated FAQs can be found here: https://www.medicaid.gov/state-
resource-center/downloads/covid-19-faqs.pdf. Providers of EIS who are not being
reimbursed for delivery of services via telehealth should contact their state Medicaid
agency. Additional information may be found at the OSEP guidance noted above and on
the Department of Education website at https://www.ed.gov/coronavirus.
8. Is Medicaid coverage available for evaluations to determine the need for EIS under
the IDEA if providers conduct the evaluation via telehealth? *
Yes. If a state establishes that evaluations for EIS that Medicaid would otherwise
cover can be delivered via telehealth, Medicaid qualified practitioners can bill for their
time spent in conducting evaluations via telehealth as an applicable practitioner
service.
9. Can pediatric clinicians receive Medicaid reimbursement for well-child visits
delivered via telehealth? *
Yes. Well-child visits are coverable under EPSDT, and states may elect to cover visits
conducted via telehealth. Generally speaking, states can establish the same rate for
Medicaid services delivered via telehealth that is paid when the same services are
delivered face-to-face, but states may establish different rates. Each state has the
discretion to set payment rates that are consistent with section 1902(a)(30)(A) of the Act.
Accordingly, states may pay a different rate for services delivered via telehealth to
account for differences between the cost of delivering the services face-to-face and the
costs of delivering them via telehealth. If states choose to pay different rates for services
when they are delivered via telehealth, a SPA submission would be necessary to describe
and receive CMS approval for the new payment methodology.
10. During the PHE, may states cover clinic services under 42 C.F.R. § 440.90 if the
services are provided via telehealth and neither the patient nor clinic practitioner is
physically onsite at the clinic? *
Yes, but only if CMS provides the state with time-limited waiver authority pursuant to
section 1135(b)(1)(B) of the Act. Under that provision, CMS can modify the requirement
in 42 C.F.R. §440.90 that clinic services be provided “by a facility that is not part of a
hospital but is organized and operated to provide medical care to outpatients,” to permit
services under 42 C.F.R. § 440.90 to be provided via telehealth when patients and clinic
practitioners are in their respective homes or in another location. 42 C.F.R. § 440.90(a)
requires that services covered under that benefit be provided “at the clinic” — that is,
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within the four walls of the clinic facility, with an exception at 42 C.F.R. § 440.90(b) for
services furnished outside the clinic to people who are homeless. While states generally
have broad flexibility to cover and pay for services provided via telehealth in their
Medicaid program, unless states have a waiver of federal requirements applicable to
specific Medicaid benefits, they must adhere to those federal requirements, including
when benefits are provided via telehealth. Historically, states have covered clinic
services under 42C.F.R. § 440.90 that were provided via telehealth only if either the
patient or the clinic practitioner was physically onsite at the clinic facility. However,
under section 1135 of the Act, CMS could modify the “facility” requirement in 42 C.F.R.
§ 440.90 to permit the state and clinic to temporarily designate a clinic practitioner’s
location as part of the clinic facility. This, in turn, would permit clinic services to be
provided via telehealth when neither the patient nor practitioner is physically onsite at the
clinic, because it would permit services provided via telehealth in clinic practitioners’
homes (or another location) to be considered to be provided at the clinic for purposes of
42 C.F.R. § 440.90(a). Such a waiver would help to ensure continued Medicaid coverage
for clinic services during the PHE, and would also facilitate the urgent need for states to
employ all measures to prevent the spread of COVID-19 during the PHE. To submit a
section 1135 waiver request, a state should send the request via email to its State Lead
and to Jackie Glaze at Jackie.Glaze@cms.hhs.gov.
11. Can Money Follows the Person (MFP) programs use alternative communication
methods such as telephone calls or video chat for transition activities that would
normally be conducted on an in-person basis during the COVID-19 public health
emergency? *
MFP programs may leverage MFP demonstration flexibility and resources to make
temporary programmatic changes that are consistent with their states’ and local
communities’ responses to COVID-19. States may choose to implement strategies using
alternative communication methods such as video chat or telephone calls for transition
activities that would normally be conducted on an in-person basis. CMS encourages
states to consider telehealth options as a flexibility in combating the COVID-19
pandemic and increasing access to care. Further guidance on telehealth/telemedicine may
be found on Medicaid.gov:
https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-telehealth-services.pdf
and https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html.
MFP grantees should notify their MFP Project Officer as soon as possible if they need to
make programmatic changes, but states do not need to receive CMS approval before
implementing programmatic changes to their MFP program’s Operational Protocol if
those changes are directly related to their response to COVID-19 and are otherwise
allowable.
Please note that this pre-approval to implement MFP programmatic changes does not
supersede any requirements that apply to section 1915(c) waivers or other Medicaid
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HCBS authorities. States should follow the applicable rules and processes of those
authorities if they are making changes to an HCBS program that operates under section
1915(c) of the Act or another Medicaid authority, regardless of whether any of the
service costs are funded under MFP. States should reach out to their CMS HCBS lead
and request the Appendix K for the section 1915(c) waiver application if they need to
request changes to a section 1915(c) waiver program or have any questions about how to
request approval under another Medicaid authority.
12. In what ways might states use the Medicaid disaster relief SPA template to increase
payments to providers during the PHE? *
States can use the Medicaid disaster relief SPA template to increase payments to
providers during the emergency period. This includes, but is not limited to: increasing
payments to providers that are seeing an influx in Medicaid patients as a result of the
PHE; recognizing additional costs incurred through the provision of Medicaid services to
COVID-19 patients; increasing payments to recognize additional cost incurred in
delivering Medicaid services, including additional staff costs and/or personal protective
equipment; adjusting payments to providers to account for decreases in service utilization
but an increase in cost per unit due to allocation of fixed costs or an increase in patient
acuity as a result of the PHE; or increasing payments for Medicaid services delivered via
telehealth to ensure that Medicaid services are delivered in a safe and economical
manner. The payment increases can take the form of dollar or percentage increases to
base payment rates or fee schedule amounts, rate add-ons, or supplemental payments,
depending on the applicability to the state’s payment methodology for the provider and
service categories. Payments must comport with all applicable requirements, including
those under section 1902(a)(30)(A) of the Act. SPA approvals and other COVID-19
related waiver documents may be found here: https://www.medicaid.gov/resources-for-
states/disaster-response-toolkit/coronavirus-disease-2019-covid-19/index.html.
13. Does federal Medicaid law and policy allow states to cover and reimburse for
Medicaid services delivered using audio-only telehealth technologies?
Yes. States have broad flexibility to cover and pay for Medicaid services delivered via
telehealth, including to determine which telehealth modalities may be used to deliver
Medicaid-covered services. Nothing in federal Medicaid law or policy prevents states
from covering and paying for Medicaid services that are delivered via audio-only
technologies. This broad flexibility to cover and pay for Medicaid services delivered via
telehealth, including via audio-only technologies, was in place prior to the COVID-19
PHE, has not changed during the COVID-19 PHE, and will continue to be available to
states after the end of the COVID-19 PHE.
14. Are SPAs necessary to specify when states will cover and pay for Medicaid services
that are delivered using telehealth?
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Generally, a SPA is not necessary to describe when the state will cover and pay for
already-covered Medicaid services when they are delivered via telehealth, if there are no
changes to the benefit descriptions, limitations, or payment methodologies that are
already in the state plan. However, a SPA would generally be necessary if states want to
cover or pay for services delivered via telehealth differently than they do for services
delivered face-to-face, such as when states reimburse differently for covered services
delivered via telehealth than they do for covered services delivered face-to-face. States
may elect to submit SPAs to more comprehensively document coverage and payment for
services delivered via telehealth, but are not required to do so unless the state is covering
and paying for services differently if they are provided via telehealth. Additional
information about Medicaid telehealth policy can be found at
https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html. .
Financing Flexibilities
15. Are “telephonic services” provided by federally qualified health centers (FQHCs) or
rural health clinics (RHCs) eligible for Federal Financial Participation (FFP) during
and immediately following a declared state of emergency?
Yes, FFP is available for telephonic services. If a state’s approved state plan excludes
FQHC/RHC services from being provided telephonically, CMS can work with the state
to expedite processing of a SPA to lift this restriction.
16. Do states need to a submit a SPA if they pay the same PPS rate for telephonic
services provided by FQHCs or RHCs as they pay for services delivered in-person?
No SPA is needed if the state plan does not specifically define a visit for the purpose of
reimbursing FQHC services as a “face to face encounter” with an eligible provider type.
If it does, and states would like to reimburse telephonically delivered services at the PPS
rate, they would need to submit a SPA amending the definition of a visit.
17. Can states pay FQHCs and RHCs an amount less than the PPS rate on a FFS basis
with an approved SPA or waiver? Additionally, if a service is provided
telephonically, can the state pay the provider an amount lower than Prospective
Payment System (PPS) rate for the telephonic service delivered via telehealth?
If a service is covered within the scope of the FQHC/RHC benefit, section 1902(bb) of
the Act requires a state to pay a provider using the state plan prospective payment system
(PPS) rate or an alternative payment methodology (APM) that pays at least the PPS rate.
For services that are not covered as part of the FQHC/RHC benefit, a state may pay
providers using the state plan fee- for-service payment methodology established for that
service. Rates for those services may be lower than the PPS or an APM paid for
FQHC/RHC services, provided the rate is consistent with all other applicable
requirements, including section 1902(a)(30)(A) of the Act. This policy applies whether a
service is delivered face-to-face or telephonically.
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18. Healthcare Common Procedure Coding System (HCPCS) code G0071 is
reimbursable to FQHC and RHCs for virtual communication activities, including
telephone calls. Do states need to submit a SPA to activate that code?
States do not need to submit a SPA to activate HCPCS code G0071 unless the state
decides to pay a rate for that code that is different from the face-to-face encounter rate
approved in the Medicaid state plan.
Workforce Flexibilities
19. What options are available if a state experiences a shortage of health care workers
because of COVID-19?
To address provider shortages for individuals receiving 1915(c) waiver services, states
can use Appendix K to expand provider qualifications (e.g., where a provider must be 21
years old, states could modify the age requirement to 18); add additional providers
(including allowance of payment to family members and legally responsible relatives);
add services, such as a live-in care giver; and temporarily adjust rates to entice more
individuals into the workforce.
For state plan services, a SPA can increase the types of providers a state authorizes to
deliver services. As always, states should be mindful of state-level requirements that
might impact provider flexibility in delegation of authority.
Additionally, states have broad ability to cover telehealth through Medicaid, and no
federal approval is needed for state Medicaid programs to reimburse for telehealth
services in the same manner or at the same rate paid for face-to-face services, visits, or
consultations. A SPA is necessary to accommodate any revisions to payment
methodology to account for telehealth costs.
To address state staff shortages, the Appendix K process can also be utilized for case
managers under 1915(c) to permit the use of telehealth or telephonic consultations in
place of typical face- to-face requirements. Under 1915(i), existing regulatory flexibility
at 42 C.F.R. § 441.720(a) permits use of telehealth in place of face-to-face assessments
when certain conditions are met.
Managed Care Flexibilities
20. How can states implement or update Medicaid or CHIP managed care telehealth
policies, including allowing remote monitoring and reimbursement of telehealth
services at the in-person clinical services rate?
The available telehealth flexibilities allow Medicaid beneficiaries to receive a wide range
of healthcare services from their providers without having to travel to a health care
facility so that they can limit risk of exposure and spread of the virus. In fee-for-service,
states are not required to submit separate SPAs for coverage or reimbursement of
telehealth services if they decide to reimburse for telehealth services in the same manner
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or at the same rate paid for face-to-face services. Medicaid guidelines require all
providers to practice within the scope of their State Practice Act, and states may have
laws and regulations that govern the scope of telemedicine coverage. In fee-for-service, a
SPA would be necessary to accommodate any revisions to payment methodologies to
account for telehealth costs.
If a benefit is covered under the state plan or Medicaid waiver (e.g., section 1915(b) or
1915(c)) or a state demonstration (e.g., section 1115), CMS encourages states to amend
managed care contracts (if the services are not already included in the contract) to extend
the same telehealth flexibilities authorized under their state plan, waiver, or
demonstration to services covered under the managed care contract. Absent coverage
under the state plan or otherwise authorized through a Medicaid waiver or demonstration,
services furnished under telehealth through managed care could also be provided as:
1. In-lieu of services (42 C.F.R. §438.3(e)(2) and 42 C.F.R. §457.1201(e)). Under these
regulations, alternate services or services furnished in an alternative setting that the
managed care plan or entity voluntarily agrees to cover in lieu of state plan-covered
services must be: (i) authorized by the state as being a medically appropriate and cost-
effective substitute for the covered service or setting under the state plan; (ii)
authorized and identified in the managed care contract; and (iii) not required to be
used by the enrollee in lieu of the state plan-covered service. In addition, there are
specific rate development rules used when a managed care contract authorizes use of
in-lieu of services.
2. Additional services, beyond those in the contract, voluntarily provided by managed
care plans (commonly referred to as value-added services). No contract amendment is
needed; however, the cost of value-added services cannot be included when
determining the capitation rates (per 42 C.F.R. §438.3(e)(1)(i) and 42 C.F.R.
§457.1201(e)).
Regarding Medicaid managed care payment, under 42 C.F.R. §§438.3(c)(1)(ii) and
438.4, final capitation rates must be actuarially sound and based only upon services
covered under the state plan or waiver authority and represent a payment amount
adequate to allow the managed care organization (MCO), prepaid inpatient health
plan (PIHP) or prepaid ambulatory health plan (PAHP) to efficiently deliver covered
services to Medicaid-eligible individuals in a manner compliant with contractual
requirements. If a state determines a retroactive adjustment to capitation rates under
one or more of its managed care contracts is necessary for costs eligible for
reimbursement, such as telehealth-related infrastructure costs, retroactive adjustments
must be certified by an actuary in a revised rate certification and submitted as a
contract amendment in accordance with 42 C.F.R. §438.7(c)(2). The rate certification
must describe the rationale for the adjustment, and the data, assumptions and
methodologies used to develop the magnitude of the adjustment. For additional
information about telemedicine, visit:
https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html. For CHIP,
11
rates must be based on public or private payment rates for comparable services for
comparable populations, consistent with actuarially sound principles, as described in
42 C.F.R. §457.1203(a). States that update their CHIP capitation payments due to
telehealth related costs would not need to submit a rate certification.
Health Information Exchange Flexibilities
21. How can states establish, implement, and enhance telehealth technologies through
the process described in 45 C.F.R. § 95.624 (emergency funding requests) as part of
the COVID-19 response effort and in support of their Medicaid provider and
beneficiary populations?
CMS is available to provide technical assistance regarding approaches to rapidly scale
telehealth technologies. If states are granted waivers under section 1135 for federal
requirements related to provider location or provider enrollment
(https://www.cms.gov/files/document/covid19-emergency-declaration-health-care-
providers-fact-sheet.pdf), complementary technology investments may be appropriate.
CMS advises states to leverage existing infrastructure and technology. States should
discuss any patient-facing telehealth proposals with their Medicaid Enterprise Systems
(MES) State Officer. Please reach out to your MES State Officer for information on
submitting an FFP request under 45 C.F.R. § 95.624.
T-MSIS Coding Guidance
22. How should telehealth-related services be reported in the Transformed Medicaid
Statistical Information System (T-MSIS)?
States should ensure that providers are educated on the correct submission of telehealth
claims. States should report COVID-19 telehealth services to T-MSIS as they are billed
on the claim form, identified through the procedure code and procedure code modifier
fields. Please contact your CMS State Systems Officer with further questions. For general
information on Medicaid telehealth, see Medicaid for Services Delivered via Telehealth.
Quality Reporting
23. In what ways will the COVID-19 pandemic affect FFY 2020 reporting for the
Medicaid and CHIP Child Core Set and Adult Core Set? *
While all Core Set reporting continues to be voluntary on the part of states, CMS
encourages states that can collect and submit this information safely to continue doing so.
To this end, however, CMS recommends temporarily suspending the types of
measurement activities that could present a health risk to state employees or contractors,
such as conducting on-site medical chart reviews. In addition, CMS expects that the
COVID-19 pandemic could affect the accuracy of Core Set reporting in a number of
ways. For example, state performance on preventive care Core Set measures may decline,
since individuals have generally been advised not to seek in- person routine or preventive
care unless medically necessary at this time. Moreover, these services offered through
telehealth may not be captured in the measure unless the measure specifications allow for
12
telehealth. All of these factors can affect not only the ability of states to collect and
submit Core Set data to CMS on time but can also limit the accuracy of that information
and the ability for CMS to trend state performance rates over time. To the extent those
Core Set measures are also included in the Medicaid and CHIP Scorecard, state
Scorecard performance and the ability to trend that information will also be affected.
24. How can states minimize the impact of the COVID-19 pandemic on quality
measurement activities? *
CMS encourages states to rely as much as possible on quality data that can be submitted
and validated electronically to enable quality measurement and reporting activities to
continue while minimizing the public health impacts of COVID-19.
Where preventive and elective services can be provided through telehealth, CMS
encourages states to do so and to include those visits in their Core Sets data submissions
where technical specifications allow for them (please refer to the COVID-19 State
Medicaid & CHIP Telehealth Toolkit and FAQ # III.B.1, regarding the delivery of
telehealth services).
25. Can well-child screenings provided through telehealth be included in the Form
CMS- 416, which provides a count of EPSDT services? *
The American Academy of Pediatrics (AAP) issued guidance to address the delivery of
well- child screenings during the public health emergency, including the use of telehealth.
To the extent it is clinically appropriate to conduct well-child screenings through
telehealth and they can be provided according to the state’s periodicity schedule, these
screenings can be included in the count of EPSDT services on the Form CMS-416.
No federal approval is needed for state Medicaid programs to reimburse providers for
telehealth services provided in the same manner or at the same rate that states pay for
face-to-face services. A SPA would be necessary to implement any revisions to payment
methodologies to account for telehealth costs (please refer to the COVID-19 State
Medicaid & CHIP Telehealth Toolkit and for example, please refer to FAQ Section
III.B.1. regarding the delivery of telehealth services).
13
Updated Appendix B: Resources
* Indicates newly added resources
Focus Area Resources
Medicaid • Policy Options for Paying Medicaid Providers
COVID-19 https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-
telehealth-services.pdf
• COVID-19 FAQs (See pp.7, 8,10, 11, 14, 19, 23, 32, and 33)
https://www.medicaid.gov/state-resource-center/Downloads/covid-
19-faqs.pdf
Medicaid • Medicaid Telemedicine Landing Page
https://www.medicaid.gov/medicaid/benefits/telemedicine/index.ht
ml
• Disaster Toolkit
https://www.medicaid.gov/resources-for-states/disaster-response-
toolkit/index.html
• Managed Care Adequacy and Access Toolkit (See page 53)
https://www.medicaid.gov/medicaid/downloads/adequacy-and-
access-toolkit.pdf
Medicare • Medicare Telemedicine Toolkit
https://www.cms.gov/files/document/general-telemedicine-
toolkit.pdf
• Medicare Learning Network definition of telehealth services
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf
Recent Related • CMS Interim Final Rule containing various telehealth-related
Federal coverage flexibilities, released March 31, 2020 (CMS-1744-IFC
Regulation and https://www.govinfo.gov/content/pkg/FR-2020-04-06/pdf/2020-
Legislation 06990.pdf
• CARES Act of 2020 (“Stimulus bill”) containing several telehealth
coverage flexibilities, signed into law March 27, 2020
https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf
• CMS’s expansion of access for Medicare telehealth under the
Secretary’s 1135 waiver authority, dated March 17, 2020
https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-
health-care-provider-fact-sheet
14
Focus Area Resources
Office for Civil • Notification of Enforcement Discretion for Telehealth Remote
Rights Communications During the COVID-19
https://www.hhs.gov/hipaa/for-professionals/special-
topics/emergency-preparedness/notification-enforcement-discretion-
telehealth/index.html
• Guidance: FAQs on HIPAA and Telehealth
https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf
(English), https://www.hhs.gov/sites/default/files/telehealth-faqs-
508.pdf (Spanish)
• Bulletin: Civil Rights, HIPAA, and the Coronavirus Disease 2019
(COVID-19), dated March 28, 2020
https://www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf
Office of • COVID-19 Policy Statement re Reducing or Waiving Cost Sharing
Inspector Obligation - Physicians and Other Practitioners will not be subject to
General Administrative Sanction
https://oig.hhs.gov/fraud/docs/alertsandbulletins/2020/policy-
telehealth-2020.pdf
MACPAC • MACPAC Chapter on Telehealth in Medicaid
https://www.macpac.gov/wp-content/uploads/2018/03/Telehealth-
in-Medicaid.pdf
Technical • Office of the National Coordinator for Information Technology
Assistance for https://healthit.gov
Providers
• National Consortium of Telehealth Resource Centers
– Resources
https://www.telehealthresourcecenter.org/resources/
– Toolkit
https://www.telehealthresourcecenter.org/resource-documents/
– Contacts
https://www.telehealthresourcecenter.org/wpcontent/uploads/2
019/08/08.23.19-2019-contact-sheet.pdf
Guidance on • Substance Abuse and Mental Health Services Administration
treating guidance on telehealth for medication assisted treatment
substance use https://www.samhsa.gov/sites/default/files/programs_campaigns/me
disorder via dication_assisted/telemedicine-dea-guidance.pdf
telehealth
15
Focus Area Resources
• Drug Enforcement Authority guidance on telemedicine
https://www.samhsa.gov/sites/default/files/programs_campaigns/me
dication_assisted/dea-information-telemedicine.pdf
Health • Telehealth Resources Centers
Resources and https://www.hrsa.gov/rural-health/telehealth/resource-centers
Services
Administration* • Telehealth Programs
https://www.hrsa.gov/rural-health/telehealth
• Training and Technical Assistance Hub
https://www.hrsa.gov/library/telehealth
Center for • Telehealth Coverage Policies in the time of COVID-19
Connected https://www.cchpca.org/resources/covid-19-telehealth-coverage-
Health Policy* policies
• COVID-19 Related State Actions
https://www.cchpca.org/covid-19-related-state-actions
• Current State Laws & Reimbursement Policies
https://www.cchpca.org/telehealth-policy/current-state-laws-and-
reimbursement-policies#
• Telehealth Resources
https://www.cchpca.org/resources/search-telehealth-resources
16
Appendix C: Common Telehealth Modalities
Achieving clarity on telehealth and telehealth policies can be a challenge for state Medicaid
programs in part because of confusion about what services can be delivered using which
technologies. Ultimately for Medicaid programs, however, the goal of the policy should be to
clarify for stakeholders, such as providers, consumers, and payors, whether and how a range of
communication technologies can be used to support care delivery in instances when a person’s
visit would already be covered. As a result of the COVID-19 PHE, there is new urgency for
states to clarify what technologies can be used, and how, to maintain continuity of care for
vulnerable individuals without exposing patients and providers to unnecessary risks.
This document is intended to describe each of the major communication technology types and
how they are currently being used to support care delivery. Examples are drawn primarily from
Medicaid, but are also germane to state CHIP programs, too. Because much of the language
around telehealth is imprecise, this Appendix will describe a technology’s capabilities and will
place under this framework common terms that are used to describe similar capabilities. It
should be kept in mind that not all services are billable by all providers under all circumstances
in all states. State Medicaid agencies have broad flexibility to determine which types of
telehealth are covered under their programs. States seeking to facilitate adoption of telehealth
services should review the State Medicaid & CHIP Telehealth Toolkit: COVID-19 Version,
which can be used to help identify policy obstacles, and to make telehealth definitions more
consistent within their state.
In addition, the act of sending information—regardless of the modality—is not itself a billable
visit. The billable component is the clinical decision making which should then be documented
in line with the standard of care for an in-person visit. The service is NOT using technology
itself; the service is the evaluation, management, diagnosis, etc. that is enabled by the
technology.
In the context of COVID-19, all forms of telehealth are directly involved in reducing risk of
transmission by maintaining distancing between patients, and between patients and providers.
Telehealth can be an important tool to speed access to scarce provider resources.
17
Modality Description Uses Limitations
2-Way Audio- A real-time, interactive Most commonly, 2-way interactive audio Providers generally cannot bill for every service
Video technology, 2-way audio-video is video is used to connect patients and that is delivered via 2-way audio-video telehealth,
likely what most people think providers. but states handle these limitations differently.
about when they consider Some states explicitly list those services or
telehealth. It requires a working Sometimes the 2-way audio-video is Current Procedural Terminology (CPT) codes that
camera, microphone, and supplemented with information from are eligible for reimbursement when delivered via
speakers/headphones for sensors or other peripheral devices at the 2-way audio-video; others rely on the provider
individuals on both sides of the patient site. This could include, for scope of practice (and documentation
conversation to function at full example, a scale, blood pressure cuff, or requirements) to ensure that only those services
capability. Most consumers can a glucometer, which can help inform a that, in the professional estimation of the health
already support this through a diagnosis or a treatment approach. care provider, can be delivered in a clinically
smartphone, or a tablet, laptop, or Additional information could also include appropriate way are delivered via this form of
desktop computer with the pictures or other still images; however, in telehealth.
necessary components. It also most cases this would only enhance an
requires enough internet bandwidth existing 2-way audio-video visit without Although smartphone adoption and use in the
to support the upload/download of making it materially different. adult Medicaid population is roughly equivalent to
data for audio and moving video the general adult population 1, there may be
images. Depending on the state, the provider, and challenges within specific communities that
device/sensor in question, it may enable include broadband availability, and/or fully-
Of all telehealth modalities, 2-way billing additional evaluation and funded data plans for mobile technologies.
audio-video is most widely management (E&M) codes.
available for providers of different In addition to patient-to-provider visits, a In addition, the Office for Civil Rights (OCR)
types. If a provider cannot less common use of 2-way audio-video within the Department of Health and Human
perform or bill for a visit using 2- telehealth is to support provider-to- Services (HHS)—the office that enforces the
way audio-video, they likely provider consults. In these instances, a HIPAA Privacy and Security Rules—issued
cannot receive reimbursement or provider reaches out to another provider guidance effective for the period of the PHE
perform other forms of telehealth. to get counsel on how to treat a patient. allowing enforcement discretion for providers
Note: Medicaid reimbursement for using non-public facing “audio or video
consultations between professionals communication” 2 in a good faith manner.
1
https://www2.deloitte.com/us/en/insights/industry/public-sector/mobile-health-care-app-features-for-patients.html Accessed 8/3/2020
2
https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html Accessed
8/7/2020)
18
Modality Description Uses Limitations
regarding treatment for a patient may be
available when these costs are
incorporated into the rate a state pays a
provider for a covered service for a
beneficiary
Audio-Only Audio-only is a real-time Although states have broad flexibility At the start of the COVID-19 PHE, many states
interactive voice-only discussion, under federal Medicaid law and policy to expanded Medicaid coverage of and payment for
usually between a patient and a cover and pay for Medicaid services services delivered via telehealth to include
provider, and generally only when those services are delivered via services delivered via “audio-only” technologies.
requires a working phone. This telehealth, including via audio-only After the COVID-19 PHE ends, states can still opt
includes older-style “flip” phones, technologies, many states explicitly to cover and pay for Medicaid telehealth services
or a traditional “land-line” phone excluded audio-only technologies from provided via audio-only technologies.
that only supports an audio-based the definition of telehealth prior to the
communication. COVID-19 PHE. As noted above under the “2-Way Audio-Video”
section, OCR has issued enforcement discretion
Care delivered via audio-only This means that even though they could with regard to provider use of an audio or video
technology is explicitly excluded choose to do so, not all states decided to communication platform during the COVID-19
from the definition of “telehealth” cover or pay for Medicaid services when PHE. As a result of OCR’s enforcement
in several states. Even so, the delivered via audio-only technologies, or discretion, a covered health care provider that
American Medical Association has at least did not opt to do so for all wants to use audio or video communication
defined several codes related to providers in all situations. For example, technology to provide telehealth to patients during
audio-only communication that are several states do not cover or pay for the COVID-19 PHE can use any available non-
included in the CPT code set. Medicaid services delivered via audio- public facing audio or video communication
These audio-only CPT codes are only technologies when provided by technology in connection with the good faith
used for specific time increments certain provider types (e.g. physical provision of telehealth to patients without risk of
(5 minutes to 30 minutes) of therapists, among others). OCR imposing a penalty on the provider for
reimbursable “phone-based violating applicable HIPAA Privacy, Security, and
consultations” between a provider Audio-only technologies may be more Breach Notification Rules (the HIPAA Rules).
and a patient. appropriate for individuals who do not The OCR Notification of Enforcement Discretion
have access to sufficient bandwidth or will remain in effect until the HHS Secretary
technology to support 2-way audio-video. declares that the PHE no longer exists, or upon the
Thus, states report that defining expiration date of the declared PHE, whichever
telehealth to include “audio-only” occurs first. OCR will issue a notice to the public
when it is no longer exercising its enforcement
19
Modality Description Uses Limitations
technologies has expanded health care discretion based upon the triggering of one of
access for lower-income individuals. these events. When the PHE ends, covered entities
may continue to provide services via telehealth in
Medicare pays for services delivered via compliance with the applicable HIPAA Rules, as
audio-only communications with they could before the Notification went into effect.
restrictions on how close the audio-only
communication is relative to an in-person
visit.
Asynchronous Also called, “Store and Forward”, Like other forms of telehealth, States’ Medicaid programs differ in both how
Communications of all forms of “telehealth” asynchronous communications can asynchronous or “store and forward” technology
technology, asynchronous support billable communication between can be used, and in how to use it as part of a
communications are the most a patient and a provider (sometimes call billable service.
heterogeneous and reflect the most eVisits), or between a provider and
complex range of capabilities, another provider (sometimes called an Different forms of asynchronous
coverage, and applicability to communication—narrative only, narrative with
different providers. These image, etc.—can support diagnoses or evaluation
communications involve contact of a condition—but the degree to which this is the
between two parties (patient-to- case is highly dependent on state regulations and
provider or provider-to-provider) policies.
in a way that does not require real-
time interaction. For example, a To a greater degree than 2-way audio-video,
patient sends a message to a asynchronous communications are often limited to
provider, who reads the message certain providers either by explicit regulation, or
several hours later and replies to on the basis of a provider’s scope of practice.
the message. However, these
communications could be a
narrative (text-based) description,
an image, a video recording, an
audio recording, or responses to a
20
Modality Description Uses Limitations
survey, among other items. In most eConsult). 3 States should provide more
cases, the electronic system detailed information on which providers
functioning as the conduit of the may use this modality, using which
information should be a HIPAA- form(s) of asynchronous communication,
compliant technology that supports for which kind(s) of service.
encrypted communication from
one party to another. For example, some state Medicaid
programs—such as Texas--allow a
Finally—and critically—not all physician to bill for an office visit only
forms of asynchronous when a narrative-based message from a
communication are billable. States patient is accompanied by an
that explicitly allow for synchronous audio conversation, an
asynchronous communication image (including a moving image), or a
often require a narrative medical record. 4
description with an image, so a
simple text message would not In Medicare, an asynchronous
suffice. Other states do not have communication is called an “E-Visit”
an operational definition of when a Medicare patient initiates a
asynchronous communication even communication with a provider via a
though it is not explicitly patient portal, 5 but it is called a “Virtual
prohibited; as a result, it is rarely Check in” when using other
used. communication methods like a secure
email.
Other examples of asynchronous
communication include:
3
Medicaid reimbursement for consultations between professionals regarding treatment for a patient may be available when these costs are incorporated into the
rate a state pays a provider for a covered service for a beneficiary.
4
See §3.2.2 of the Texas Medicaid Provider Procedures Manual: Telecommunications Services Handbook
(http://www.tmhp.com/Manuals_PDF/TMPPM/TMPPM_Living_Manual_Current/2_Telecommunication_Srvs.pdf) Accessed 7/31/2020
5
Other conditions apply. See https://www.medicare.gov/coverage/e-visits Accessed 8/13/20
21
Modality Description Uses Limitations
• A detailed questionnaire response
sent from a patient to a provider
o The provider evaluates the
questionnaire response and
provides a diagnosis and
treatment.
• Images of a skin infection that are
sent from a patient to a provider with
a narrative of when it began and how
it has progressed;
o The provider evaluates the
images, provides a diagnosis,
and prescribes a medication; or
• A primary care provider submits a
clinical question as a recorded voice
memo along with the patient
information through a secure
platform to an endocrinologist for an
evaluation and recommendations.
o The endocrinologist provides an
asynchronous consultation to aid
diagnosis and treatment by the
primary care provider.
22
Modality Description Uses Limitations
Remote Patient Although Remote Patient In an outpatient setting, a patient with Medicare and several states do not consider RPM
Monitoring Monitoring (RPM) could take hypertension uses a web-enabled blood a type of telehealth.
many forms, it typically involves pressure cuff to take readings several
the deployment and use of times a day. This information is shared As with asynchronous communications, RPM is
technology to capture biometric securely with a provider who regularly not widely reimbursed across different Medicaid
information about the patient that reviews readings and, as needed, follows programs, or there may be billing rules that
is automatically shared with a up with the patient to support diet and specify which providers are permitted to bill. In
remote provider. The provider can other behavior changes to reduce blood 2018, the American Medical Association added
then review the data and determine pressure. several CPT codes to facilitate billing for RPM,
the appropriate course of action. but these have not been widely adopted in
RPM typically involves the use of Providers can oversee many patients Medicaid programs.
“peripheral devices” that are simultaneously using remote patient
designed to capture patient monitoring technologies that help Several states only allow remote patient
biometric information such as identify individuals who have readings monitoring under specific circumstances for:
weight, blood pressure, blood that fall outside established parameters patients in home health settings; specific clinical
oxygen levels, etc. and therefore warrant follow-up. conditions; certain provider types.
Billing for RPM can be complex and may not
cover the cost of RPM hardware. In State
Medicaid programs that are more advanced in the
use of value-based contracting with providers,
there may be more leeway and/or incentive to
cover remote monitoring technologies that help
patients maintain a healthy lifestyle.
Generally, RPM is only for established patients
who are under the active care of a provider.
23
Appendix D: State Medicaid Telehealth Assessment/Action Plan
Introduction
Although telehealth services have been available in many states for decades, the recent PHE
resulting from COVID-19 has accelerated the interest in this model of service delivery. CMS has
actively supported states in expanding their use of telehealth in Medicaid for physical health
services, behavioral health services, and long-term services and supports as well as in CHIP
during this unprecedented PHE. Early in the PHE, CMS issued guidance to state policy makers
related to state efforts to expand the use of telehealth services. See State Medicaid & CHIP
Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth. This new
Assessment/Action Plan is intended as a supplement to the previous toolkit.
Background
States continue to have a great deal of flexibility with respect to covering Medicaid and CHIP
services provided via telehealth. States have the option to determine whether (or not) to utilize
telehealth; what types of services to cover; where in the state it can be utilized; how it is
implemented; what types of practitioners or providers may deliver services via telehealth, as long
as such practitioners or providers are enrolled in the Medicaid program and qualified according
to federal and state statute and regulation; and how services delivered via telehealth are
reimbursed. States have full discretion to select from a variety of Healthcare Common Procedure
Coding System (HCPCS) / CPT codes and modifiers in order to identify, track and reimburse for
these services.
States are not required to submit a SPA to pay for services delivered via telehealth if payments
for services furnished via telehealth are made in the same manner as when the service is
furnished in a face-to-face setting. States may submit a coverage SPA to describe services
delivered via telehealth. A state would need an approved state plan payment methodology (and
thus, might need to submit a SPA) to establish rates or payment methodologies for telehealth
services that differ from those applicable for the same services furnished in a face-to-face setting.
Medicare Telehealth Policy Implications
There is no requirement that State Medicaid and CHIP telehealth policies follow Medicare
guidance. State Medicaid programs have the flexibility to decide their own telehealth policies
keeping in mind the best interests of their Medicaid and CHIP beneficiaries. Concurrent with
state Medicaid telehealth initiatives, Medicare has expanded access to telehealth services.
Clinicians providing services to Medicare beneficiaries can now provide more services via
telehealth, enabling more Medicare beneficiaries to readily access necessary care while
maintaining physical distancing where appropriate. As states adjust their telehealth policies, it
makes sense to take into consideration the telehealth policy changes Medicare and other payers
have made during this PHE. There are advantages to states, their providers and beneficiaries in
considering potential alignments across payers. It makes adherence easier for providers and
beneficiaries when there can be some consistency across payers.
24
Use of Assessment/Action Plan
The following Assessment/Action Plan Template supplement outlines a list of potential policy
areas to consider in addressing the appropriate use of telehealth for Medicaid and CHIP
populations after the PHE expires. The list can be used to capture telehealth policies related to
your Medicaid and/or CHIP program which were in place prior to the COVID-19 PHE and
which policy changes were adopted during the COVID-19 PHE. As the PHE eases, the
Assessment/Action Plan will also help focus and capture discussions of which telehealth policies
can/should be continued in your state; which could be modified, better defined, or eliminated;
and which should be given further consideration. These decisions will be affected by your
experience with telehealth during the PHE and the feedback you have received from your
stakeholders.
As it will be critical to update policies and communicate with MCPs, providers and beneficiaries
in a timely manner to encourage adoption and reduce confusion moving forward, the
Assessment/Action Plan provided below will also support Medicaid policy makers in facilitating
discussions within the state Medicaid agency, with decision makers and with other stakeholders.
It will also prompt states to consider what, if any, SPAs, legislative authorities or other external
approvals may be needed to implement and promote adoption.
On the next page are two versions of the State Medicaid Telehealth Assessment/Action Plan
template. (Please note that additional rows can be added to reflect state policies not specifically
noted in the prepopulated list; likewise, items on the list can be removed if not considered
relevant to state policy considerations):
1. Blank Version: The first template is a blank version configured for state telehealth
policy and operations teams to use in summarizing your current and proposed plans
related to telehealth. Note that this blank version not only provides space to capture
descriptive information (See columns D through F), but also allows for the opportunity to
capture specific decision points, dates and action items (see columns G through I). The
Potential State Coverage Policies cited in the template on Column A are not exhaustive
and states are encouraged to include any additional, relevant, and state-specific policies
they consider to be appropriate to capture in the document or remove any policies that do
not apply.
2. Sample Version: The second table includes policy-specific samples of how a state might
complete each of the fields in the template depending on the telehealth policies in place
in your state prior to COVID-19, during the PHE period, as well as how you plan to use
telehealth in your Medicaid and CHIP programs going forward.
25
State Medicaid Telehealth Assessment/Action Plan
Blank Version
Ref A. Potential State B. Pre- C. D. Description of Temporary Policy E. Date F. Continue COVID-19 G. Follow Up Action H. Affected I. Proposed
# Coverage Policies COVID COVID-19 (Differentiating between Physical Temp Policy or Consider Needed 6 Stakeholders 7 Effective
-19 Temp Health, Behavioral Health, and Policy Modifying Policy Date of
(List to be used as reference Policy Policy Long-term Services and Supports as Expires (Differentiating between Change
in documenting state applicable) Physical Health, Behavioral
policies; states’ own policies Yes/No Yes/No Health, and Long-term
may vary) Services and Supports as
applicable)
Yes, Yes with modifications -
explain, No
1.0 General policies --- --- --- --- --- --- --- ---
1.1 Patient consent for the service --- --- --- --- --- --- --- ---
1.2 Established patient-provider
relationship required prior to --- --- --- --- --- --- --- ---
telehealth
1.3 Add additional policies to be
--- --- --- --- --- --- --- ---
evaluated
2.0 State-level
Originating/Distant Site --- --- --- --- --- --- --- ---
Policies 8
2.1 Originating site permitted to
--- --- --- --- --- --- --- ---
be the patient’s residence
2.2 Originating site permitted to
--- --- --- --- --- --- --- ---
be in an urban area
2.3 Originating site: any
--- --- --- --- --- --- --- ---
limitations
6
Such as legislation, regulation, state Medicaid policy change, state plan amendment (SPA), system change, managed care organization (MCO) contract amendment
7
Such as providers, beneficiaries, state licensing agencies, MCOs
8
State-level policies will be listed here because originating and distant sites are not defined by federal policy or regulations.
26
Ref A. Potential State B. Pre- C. D. Description of Temporary Policy E. Date F. Continue COVID-19 G. Follow Up Action H. Affected I. Proposed
# Coverage Policies COVID COVID-19 (Differentiating between Physical Temp Policy or Consider Needed 6 Stakeholders 7 Effective
-19 Temp Health, Behavioral Health, and Policy Modifying Policy Date of
(List to be used as reference Policy Policy Long-term Services and Supports as Expires (Differentiating between Change
in documenting state applicable) Physical Health, Behavioral
policies; states’ own policies Yes/No Yes/No Health, and Long-term
may vary) Services and Supports as
applicable)
Yes, Yes with modifications -
explain, No
2.4 Distant site: Clinicians
permitted to provide care via
--- --- --- --- --- --- --- ---
telehealth while outside of the
clinical setting
2.5 Distant site: Federally
Qualified Health Centers
(FQHC) and Rural Health --- --- --- --- --- --- --- ---
Clinics (RHC) permitted as
distant sites
2.6 Add additional policies to be
--- --- --- --- --- --- --- ---
evaluated
3.0 Payment, cost-sharing, &
--- --- --- --- --- --- --- ---
billing
3.1 Payment parity for telehealth
--- --- --- --- --- --- --- ---
services
3.2 Originating site payments
--- --- --- --- --- --- --- ---
made to providers suspended
3.3 Beneficiary cost-sharing for
all telehealth services --- --- --- --- --- --- --- ---
suspended
3.4 Providers required to use a
telehealth-specific ‘place of
--- --- --- --- --- --- --- ---
service’ code on all telehealth
claims
27
Ref A. Potential State B. Pre- C. D. Description of Temporary Policy E. Date F. Continue COVID-19 G. Follow Up Action H. Affected I. Proposed
# Coverage Policies COVID COVID-19 (Differentiating between Physical Temp Policy or Consider Needed 6 Stakeholders 7 Effective
-19 Temp Health, Behavioral Health, and Policy Modifying Policy Date of
(List to be used as reference Policy Policy Long-term Services and Supports as Expires (Differentiating between Change
in documenting state applicable) Physical Health, Behavioral
policies; states’ own policies Yes/No Yes/No Health, and Long-term
may vary) Services and Supports as
applicable)
Yes, Yes with modifications -
explain, No
3.5 Providers billing for
telehealth services must use a
--- --- --- --- --- --- --- ---
telehealth-specific ‘modifier’
code on all telehealth claims
3.6 Add additional policies to be
--- --- --- --- --- --- --- ---
evaluated
4.0 Service Coverage Policies --- --- --- --- --- --- --- ---
4.1 Coverage parity for telehealth
services relative to in-person --- --- --- --- --- --- --- ---
services
4.2 Telehealth for Evaluation &
Management services --- --- --- --- --- --- --- ---
(standard office visits)
4.3 Emergency medical services --- --- --- --- --- --- --- ---
4.4 Telehealth for Gynecological
--- --- --- --- --- --- --- ---
Services
4.5 Telehealth for Pediatric
--- --- --- --- --- --- --- ---
services
4.6 Telehealth for Behavioral
--- --- --- --- --- --- --- ---
Health Services
4.7 Telehealth for Physical
--- --- --- --- --- --- --- ---
Therapy
4.8 Telehealth for Occupational
--- --- --- --- --- --- --- ---
Therapy
28
Ref A. Potential State B. Pre- C. D. Description of Temporary Policy E. Date F. Continue COVID-19 G. Follow Up Action H. Affected I. Proposed
# Coverage Policies COVID COVID-19 (Differentiating between Physical Temp Policy or Consider Needed 6 Stakeholders 7 Effective
-19 Temp Health, Behavioral Health, and Policy Modifying Policy Date of
(List to be used as reference Policy Policy Long-term Services and Supports as Expires (Differentiating between Change
in documenting state applicable) Physical Health, Behavioral
policies; states’ own policies Yes/No Yes/No Health, and Long-term
may vary) Services and Supports as
applicable)
Yes, Yes with modifications -
explain, No
4.9 Telehealth for Speech
--- --- --- --- --- --- --- ---
Pathology
4.10 Telehealth for Home Health
--- --- --- --- --- --- --- ---
services
4.11 Telehealth for Hospice
--- --- --- --- --- --- --- ---
services
4.12 Telehealth for Personal Care
and Home and Community- --- --- --- --- --- --- --- ---
based Services 9
4.13 Telehealth Visits for
Medication Assisted --- --- --- --- --- --- --- ---
Treatment (MAT)
4.14 Telehealth
Prescription/Prescribing
Authority Limits/Restrictions --- --- --- --- --- --- --- ---
for Opioids or Other
Controlled Substances
4.15 Add additional services to be
--- --- --- --- --- --- --- ---
evaluated
5.0 Eligible providers --- --- --- --- --- --- --- ---
5.1 Primary care physicians --- --- --- --- --- --- --- ---
9
States may add lines to this section if they wish to delineate specific home and community-based services in addition to personal care.
29
Ref A. Potential State B. Pre- C. D. Description of Temporary Policy E. Date F. Continue COVID-19 G. Follow Up Action H. Affected I. Proposed
# Coverage Policies COVID COVID-19 (Differentiating between Physical Temp Policy or Consider Needed 6 Stakeholders 7 Effective
-19 Temp Health, Behavioral Health, and Policy Modifying Policy Date of
(List to be used as reference Policy Policy Long-term Services and Supports as Expires (Differentiating between Change
in documenting state applicable) Physical Health, Behavioral
policies; states’ own policies Yes/No Yes/No Health, and Long-term
may vary) Services and Supports as
applicable)
Yes, Yes with modifications -
explain, No
5.2 Behavioral Health service
--- --- --- --- --- --- --- ---
providers
5.3 Occupational therapists --- --- --- --- --- --- --- ---
5.4 Physical therapists --- --- --- --- --- --- --- ---
5.5 OBGYN --- --- --- --- --- --- --- ---
5.6 Add additional providers to
--- --- --- --- --- --- --- ---
be evaluated
6.0 Modalities --- --- --- --- --- --- --- ---
6.1 Audio-only visits --- --- --- --- --- --- --- ---
6.2 Audio-video visits --- --- --- --- --- --- --- ---
6.3 Virtual Check-ins (brief
patient-provider two-way --- --- --- --- --- --- --- ---
audio-video correspondence)
6.4 E-visits (online portal) --- --- --- --- --- --- --- ---
6.5 Store and Forward (emails of
--- --- --- --- --- --- --- ---
text)
6.6 E-consults (inter-professional
--- --- --- --- --- --- --- ---
consultations)
6.7 Remote Patient Monitoring --- --- --- --- --- --- --- ---
6.8 Direct-to-consumer telehealth
--- --- --- --- --- --- --- ---
provider contracted
30
Ref A. Potential State B. Pre- C. D. Description of Temporary Policy E. Date F. Continue COVID-19 G. Follow Up Action H. Affected I. Proposed
# Coverage Policies COVID COVID-19 (Differentiating between Physical Temp Policy or Consider Needed 6 Stakeholders 7 Effective
-19 Temp Health, Behavioral Health, and Policy Modifying Policy Date of
(List to be used as reference Policy Policy Long-term Services and Supports as Expires (Differentiating between Change
in documenting state applicable) Physical Health, Behavioral
policies; states’ own policies Yes/No Yes/No Health, and Long-term
may vary) Services and Supports as
applicable)
Yes, Yes with modifications -
explain, No
6.9 Add additional modalities to
--- --- --- --- --- --- --- ---
be evaluated
7.0 Other Related Policies --- --- --- --- --- --- --- ---
7.1 Licensure of clinicians:
Permits out-of-state clinicians
to practice in-state --- --- --- --- --- --- --- ---
(physicians, nurses, social
workers) via telehealth
7.2 Licensed professionals
permitted to bill for telehealth --- --- --- --- --- --- --- ---
visits
7.3 MCPs must incorporate all
Medicaid FFS telehealth --- --- --- --- --- --- --- ---
requirements
7.4 State Medicaid Telehealth
--- --- --- --- --- --- --- ---
Provider Training Provided
7.5 Telehealth Specific Fraud and
--- --- --- --- --- --- --- ---
Abuse Policies
7.5 Add additional policies to be
--- --- --- --- --- --- --- ---
evaluated
31
State Medicaid Telehealth Assessment/Action Plan
Sample Version
Ref A. Potential State B. Pre- C. D. Description of Temporary E. Date F. Continue COVID-19 G. Follow Up Action H. Affected I. Proposed
# Coverage Policies COVID COVID Policy (Differentiating between Temp Policy or Consider Needed Stakeholders Effective Date
-19 -19 Physical Health, Behavioral Policy Modifying Policy of Change
(List to be used as Policy Temp Health, and Long-term Services Expires (Differentiating between
reference in documenting Policy and Supports as applicable) Physical Health, Behavioral
state policies; states own Yes/No Health, and Long-term
policies may vary) Yes/No Services and Supports as
applicable)
Yes, Yes with modifications -
explain, No
1.0 General policies --- --- --- --- --- --- --- ---
1.1 Patient consent for the Regardless of category, services
service that allow for a temporary Regulation, policy, SPA,
All providers and
telehealth option require Waiver Amendment, MCP Already
Yes Yes 10/23/20 Yes beneficiaries;
documented consent from the agreement, provider Implemented
MCPs
beneficiary agreeing to this as a agreements
service delivery option
2.0 Originating/Distant Site
--- --- --- --- --- --- --- ---
Policies
2.5 Distant site: Federally Yes with modifications: Allow
Allow any site within the US or Legislation change, Providers,
Qualified Health Centers FQHCs & provider residences
territories to be a distant site, regulation, policy, SPA, beneficiaries, Upon passage
(FQHC) and Rural Health No Yes 10/23/20 as distant sites; post-PHE, any
including FQHCs & provider systems, MCP agreement, MCPs, of legislation
Clinics (RHC) permitted as distant site must be within the
residences provider agreements legislature
distant sites state
3.0 Payment, cost-sharing, & --- --- --- --- --- --- --- ---
billing
4.0 Service Coverage Policies --- --- --- --- --- --- --- ---
4.2 Telehealth for Evaluation & Providers,
Allow telehealth for any clinically Regulation, policy, SPA,
Management services beneficiaries,
No Yes appropriate, medically necessary 10/23/20 Yes systems, MCP agreement, 10/23/20
(standard office visits) MCPs, licensing
covered service provider agreements
board/ agency
5.0 Eligible providers --- --- --- --- --- --- --- ---
32
Ref A. Potential State B. Pre- C. D. Description of Temporary E. Date F. Continue COVID-19 G. Follow Up Action H. Affected I. Proposed
# Coverage Policies COVID COVID Policy (Differentiating between Temp Policy or Consider Needed Stakeholders Effective Date
-19 -19 Physical Health, Behavioral Policy Modifying Policy of Change
(List to be used as Policy Temp Health, and Long-term Services Expires (Differentiating between
reference in documenting Policy and Supports as applicable) Physical Health, Behavioral
state policies; states own Yes/No Health, and Long-term
policies may vary) Yes/No Services and Supports as
applicable)
Yes, Yes with modifications -
explain, No
5.5 OBGYN Providers,
OBGYNs may bill for telehealth in Regulation, policy, SPA,
beneficiaries, Already
No Yes place of in-office visits. Specific to 10/23/20 Yes systems, MCP agreement,
MCPs, licensing implemented
state plan physical health services provider agreements
board/ agency
6.0 Modality --- --- --- --- --- --- --- ---
6.2 Audio-video visits Providers,
Temporarily allow two-way audio Yes: After PHE, allow audio- Regulation, policy, SPA,
beneficiaries,
Yes Yes only telehealth visits for all 10/23/20 only telehealth for limited systems, MCP agreement, 10/23/20
MCPs, licensing
telehealth services services provider agreements
board/ agency
7.0 Other Related Policies --- --- --- --- --- --- --- ---
33
Appendix E: Comparison Tool – Fee-for-Service /Managed Care Telehealth Policies
State Medicaid and CHIP agencies seeking to track the variation in telehealth coverage across the Fee-For-Service (FFS) and managed care programs in their state may benefit from
using a standardized evaluation tool which enables a clear simplified view of the coverage across these Medicaid/CHIP service delivery options. In the current environment,
telehealth coverage is likely to include a complex array of permanent and temporary telehealth coverage policies that may differ across FFS and managed care. The matrix below
offers a method for consolidating and evaluating this information.
The matrix below allows for a comparison of Medicaid/CHIP FFS telehealth policy with the telehealth policies of up to three MCPs 10 but can be modified or expanded depending
on the number of MCPs to be considered. The matrix also provides space to capture descriptive information about FFS and MCPs’ telehealth policies. It includes some completely
blank rows in each of the policy sections to enable states to add telehealth policies to the matrix that are unique to their state; states can also remove policies that do not apply.
Following the matrix is also a brief example of how the matrix can be completed.
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- MCP 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
1.0 General Policies --- --- --- --- --- --- --- --- --- --- --- ---
1.1 Patient consent for the service --- --- --- --- --- --- --- --- --- --- --- ---
1.2 Established patient-provider --- --- --- --- --- --- --- --- --- --- --- ---
relationship required prior to
telehealth
1.3 Add additional policies to be --- --- --- --- --- --- --- --- --- --- --- ---
evaluated
2.0 Originating/Distance Site --- --- --- --- --- --- --- --- --- --- --- ---
Policies 11
2.1 Originating site permitted to be the --- --- --- --- --- --- --- --- --- --- --- ---
patient’s residence
10
A managed care plan can be a Managed Care Organization (MCO), Prepaid Inpatient Health Plans (PIHP), or Prepaid Ambulatory Health Plan (PAHP), as defined in 42 CFR 438.2.
11
State-level policies will be listed here because originating and distant sites are not defied by federal policy or regulations.
34
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- MCP 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
2.2 Originating site permitted to be in --- --- --- --- --- --- --- --- --- --- --- ---
an urban area
2.3 Originating site: any limitations --- --- --- --- --- --- --- --- --- --- --- ---
2.4 Distant site: Clinicians permitted to --- --- --- --- --- --- --- --- --- --- --- ---
provide care via telehealth while
outside of the clinical setting
2.5 Distant site: Federally Qualified --- --- --- --- --- --- --- --- --- --- --- ---
Health Centers (FQHC) and Rural
Health Clinics (RHC) permitted as
distant sites
2.6 Add additional policies to be --- --- --- --- --- --- --- --- --- --- --- ---
evaluated
3.0 Payment, Cost Sharing and --- --- --- --- --- --- --- --- --- --- --- ---
Billing
3.1 Payment parity for telehealth --- --- --- --- --- --- --- --- --- --- --- ---
services
3.2 Originating site payments made to --- --- --- --- --- --- --- --- --- --- --- ---
providers waived
3.3 Beneficiary cost-sharing for all --- --- --- --- --- --- --- --- --- --- --- ---
telehealth services suspended
3.4 Providers required to use a --- --- --- --- --- --- --- --- --- --- --- ---
telehealth-specific ‘place of
service’ code on all telehealth
claims
3.5 Providers billing for telehealth --- --- --- --- --- --- --- --- --- --- --- ---
services must use a telehealth-
specific ‘modifier’ code on all
telehealth claims
3.6 Add additional policies to be --- --- --- --- --- --- --- --- --- --- --- ---
evaluated
35
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- MCP 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
4.0 Service Coverage Policies --- --- --- --- --- --- --- --- --- --- --- ---
4.1 Coverage parity for telehealth --- --- --- --- --- --- --- --- --- --- --- ---
services relative to in-person
services
4.1 Telehealth for Evaluation & --- --- --- --- --- --- --- --- --- --- --- ---
Management services (standard
office visits)
4.3 Emergency medical services --- --- --- --- --- --- --- --- --- --- --- ---
4.4 Telehealth for Gynecological --- --- --- --- --- --- --- --- --- --- --- ---
Services
4.5 Telehealth for Pediatric services --- --- --- --- --- --- --- --- --- --- --- ---
4.6 Telehealth for Behavioral Health --- --- --- --- --- --- --- --- --- --- --- ---
Services
4.7 Telehealth for Physical Therapy --- --- --- --- --- --- --- --- --- --- --- ---
4.8 Telehealth for Occupational --- --- --- --- --- --- --- --- --- --- --- ---
Therapy
4.9 Telehealth for Speech Pathology --- --- --- --- --- --- --- --- --- --- --- ---
4.10 Telehealth for Home Health --- --- --- --- --- --- --- --- --- --- --- ---
services
4.11 Telehealth for Hospice services --- --- --- --- --- --- --- --- --- --- --- ---
4.12 Telehealth for Personal Care and --- --- --- --- --- --- --- --- --- --- --- ---
Home and Community-based
Services 12
12
States may add lines to this section if they wish to delineate specific home and community-based services in addition to personal care.
36
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- MCP 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
4.13 Telehealth Visits for Medication --- --- --- --- --- --- --- --- --- --- --- ---
Assisted Treatment (MAT)
4.14 Telehealth Prescription/Prescribing --- --- --- --- --- --- --- --- --- --- --- ---
Authority Limits/Restrictions for
Opioids or Other Controlled
Substances
4.15 Add additional services to be --- --- --- --- --- --- --- --- --- --- --- ---
evaluated
5.0 Eligible Providers --- --- --- --- --- --- --- --- --- --- --- ---
5.1 Primary care physicians --- --- --- --- --- --- --- --- --- --- --- ---
5.2 Behavioral Health service providers --- --- --- --- --- --- --- --- --- --- --- ---
5.3 Occupational therapists --- --- --- --- --- --- --- --- --- --- --- ---
5.4 Physical therapists --- --- --- --- --- --- --- --- --- --- --- ---
5.5 OBGYN --- --- --- --- --- --- --- --- --- --- --- ---
5.6 Add additional providers to be --- --- --- --- --- --- --- --- --- --- --- ---
evaluated
6.0 Modality of telehealth --- --- --- --- --- --- --- --- --- --- --- ---
6.1 Audio-only visits --- --- --- --- --- --- --- --- --- --- --- ---
6.2 Audio-video visits --- --- --- --- --- --- --- --- --- --- --- ---
6.3 Virtual Check-ins (brief patient- --- --- --- --- --- --- --- --- --- --- --- ---
provider two-way audio-video
correspondence)
6.4 E-visits (online portal) --- --- --- --- --- --- --- --- --- --- --- ---
6.5 Store and Forward (emails of text) --- --- --- --- --- --- --- --- --- --- --- ---
6.6 E-consults (inter-professional --- --- --- --- --- --- --- --- --- --- --- ---
consultations)
37
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- MCP 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
6.7 Remote Patient Monitoring --- --- --- --- --- --- --- --- --- --- --- ---
6.8 Direct-to-consumer telehealth --- --- --- --- --- --- --- --- --- --- --- ---
provider contracted
6.9 Add additional modalities to be --- --- --- --- --- --- --- --- --- --- --- ---
evaluated
7.0 Other Related Policies --- --- --- --- --- --- --- --- --- --- --- ---
7.1 Licensure of clinicians: Permits --- --- --- --- --- --- --- --- --- --- --- ---
out-of-state clinicians to practice
in-state (physicians, nurses, social
workers) via telehealth
7.2 Licensed professionals permitted to --- --- --- --- --- --- --- --- --- --- --- ---
bill for telehealth visits
7.3. MCPs must incorporate all --- --- --- --- --- --- --- --- --- --- --- ---
Medicaid FFS telehealth
requirements
7.4 State Medicaid Telehealth Provider --- --- --- --- --- --- --- --- --- --- --- ---
Training Provided
7.5 Telehealth Specific Fraud and --- --- --- --- --- --- --- --- --- --- --- ---
Abuse Policies
7.6 Add additional policies to be --- --- --- --- --- --- --- --- --- --- --- ---
evaluated
Sample: Some examples of how the matrix can be used
Cells within the matrix marked with a dash (-) indicate there is no applicable telehealth policy in place, while cells marked with an asterisk (*) indicate the applicable telehealth
policy associated with the MCP is consistent with FFS.
38
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- MCP 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
1.0 General Policies --- --- --- --- --- --- --- --- --- --- --- ---
1.2 Established patient-provider --- Yes Only behavioral --- Yes Applies to all --- Yes * --- Yes *
relationship required prior to health services types covered
telehealth services
2.0 Originating/Distance Site Policies --- --- --- --- --- --- --- --- --- --- --- ---
2.1 Originating site permitted to be the --- Yes Any Medicaid --- Yes * --- Yes * --- Yes *
patient’s residence covered service
3.0 Payment, Cost Sharing and --- --- --- --- --- --- --- --- --- --- --- ---
Billing
3.5 Providers billing for telehealth Yes Yes Use claim Yes Yes * Yes Yes * Yes Yes Use claim
services must use a telehealth- modifier code = modifier code
specific ‘modifier’ code on all ‘95’ = ‘GT’
telehealth claims
4.0 Service Coverage Policies --- --- --- --- --- --- --- --- --- --- --- ---
4.7 Telehealth for Physical Therapy --- --- --- --- --- --- --- Yes Any PT service --- --- ---
5.0 Eligible Providers --- --- --- --- --- --- --- --- --- --- --- ---
5.2 Behavioral Health service --- Yes Psychiatrists --- Yes Adds LCSWs --- Yes * --- Yes Adds LCSWs,
providers and and LCADAC
psychologists
6.0 Modality of telehealth --- --- --- --- --- --- --- --- --- --- --- ---
6.1 Audio-only visits --- Yes Behavioral --- Yes Permitted for all --- Yes Permitted for --- Yes *
health services services all services
only
7.0 Other Related Policies --- --- --- --- --- --- --- --- --- --- --- ---
39
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- MCP 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
7.1 Licensure of clinicians: Permits out- --- Yes Physicians and --- Yes * --- Yes * --- Yes *
of-state clinicians to practice in- nurses
state (physicians, nurses, social
workers) via telehealth
40
Complete Example
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- P 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
1.0 General Policies --- --- --- --- --- --- --- --- --- --- --- ---
1.1 Patient consent for the service - Yes - - Yes * - Yes * - Yes *
1.2 Established patient-provider - Yes Applies only to - Yes Applies to all - Yes * - Yes *
relationship required prior to behavioral types covered
telehealth health providers services
2.0 Originating/Distance Site Policies --- --- --- --- --- --- --- --- --- --- --- ---
2.1 Originating site permitted to be the - Yes Any Medicaid - Yes * - Yes * - Yes *
patient’s residence covered service
2.2 Originating site permitted to be in - Yes Any Medicaid - Yes * - Yes * - Yes *
an urban area covered service
2.3 Originating site: any limitations - Yes Any Medicaid - Yes * - Yes * - Yes *
covered service
2.4 Distant site: Clinicians permitted to - Yes Any Medicaid - Yes * - Yes * - Yes *
provide care via telehealth while covered service
outside of the clinical setting
2.5 Distant site: Federally Qualified - Yes Any Medicaid - Yes * - Yes * - Yes *
Health Centers (FQHC) and Rural covered service
Health Clinics (RHC) permitted as
distant sites
3.0 Payment, Cost Sharing and --- --- --- --- --- --- --- --- --- --- --- ---
Billing
3.1 Payment parity for telehealth - Yes - - Yes * - - Telehealth - Yes *
services services
reimbursed at
80% of in-
person services
3.2 Originating site payments made to - Yes - - Yes * - Yes * - Yes *
providers waived
41
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- P 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
3.3 Beneficiary cost-sharing for all - - - - Yes No cost sharing - - - - Yes No cost-
telehealth services suspended for telehealth sharing for
behavioral health any telehealth
services services
3.4 Providers required to use a Yes Yes Use place of Yes Yes * Yes Yes * Yes Yes *
telehealth-specific ‘place of service code =
service’ code on all telehealth ‘02’
claims
3.5 Providers billing for telehealth Yes Yes Use claim Yes Yes * Yes Yes * Yes Yes Use claim
services must use a telehealth- modifier code = modifier code
specific ‘modifier’ code on all ‘95’ = ‘GT’
telehealth claims
4.0 Service Coverage Policies --- --- --- --- --- --- --- --- --- --- --- ---
4.1 Coverage parity for telehealth - - - - - - - Yes Any Medicaid - - -
services relative to in-person covered service
services
4.2 Telehealth for Evaluation & - Yes - - Yes * - Yes * - Yes *
Management services (standard
office visits)
4.3 Emergency medical services - - - - - - - Yes Any ED service - - -
4.4 Telehealth for Gynecological - Yes - - Yes * - Yes - - Yes *
Services
4.5 Telehealth for Pediatric services - Yes - - Yes * - Yes * - Yes *
4.6 Telehealth for Behavioral Health - - - - - - - Yes * - - -
Services
4.7 Telehealth for Physical Therapy - - - - - - - Yes Any PT service - - -
4.8 Telehealth for Occupational - - - - - - - Yes Any OT service - - -
Therapy
4.9 Telehealth for Speech Pathology - - - - Yes - - - Any SP service - - -
42
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- P 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
4.10 Telehealth for Home Health - - - - Yes Any HH service - - - - - -
services
4.11 Telehealth for Hospice services - - - - Yes Any Hospice - - - - - -
service
4.12 Telehealth for Personal Care and - Yes - - Yes Any Personal - Yes - - Yes -
Home and Community-based Care Services
Services 13
4.13 Telehealth Visits for Medication - Yes - - Yes * - Yes * - Yes *
Assisted Treatment (MAT)
4.14 Telehealth Prescription/Prescribing - Yes - - Yes * - Yes * - Yes *
Authority Limits/Restrictions for
Opioids or Other Controlled
Substances
4.15 Coverage parity for telehealth - Yes - - Yes * - Yes * - Yes *
services relative to in-person
services
5.0 Eligible Providers --- --- --- --- --- --- --- --- --- --- --- ---
5.1 Primary care physicians - Yes - Yes * - Yes * - Yes *
5.2 Behavioral Health service - Yes Psychiatrists - Yes Psychiatrists, - Yes * - Yes Psychiatrists,
providers and psychologists, psychologists,
psychologists and LCSWs LCSWs, and
LCADAC
5.3 Occupational therapists - - - - - - - - - - - -
5.4 Physical therapists - - - - - - - - - - - -
5.5 OBGYN - Yes - - Yes - - Yes - - Yes -
13
States may add lines to this section if they wish to delineate specific home and community-based services in addition to personal care.
43
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- P 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
6.0 Modality of telehealth --- --- --- --- --- --- --- --- --- --- --- ---
6.1 Audio-only visits - Yes Permitted for - Yes Permitted for - Yes Permitted for - Yes Permitted for
behavioral behavioral health behavioral behavioral
health services services and health services health services
evaluation and
management
services
6.2 Audio-video visits Yes Yes Permitted for Yes Yes * Yes Yes * Yes Yes *
all Medicaid
covered
services
6.3 Virtual Check-ins (brief patient- - - - - Yes Evaluation and - - - - - -
provider two-way audio-video management
correspondence) services
6.4 E-visits (online portal) - - - - Yes Evaluation and - - - - - -
management
services
6.5 Store and Forward (emails of text) - - - Yes Yes Dermatology - - - Yes Yes Dental
services services
6.6 E-consults (inter-professional - - - - - - - - - - - -
consultations)
6.7 Remote Patient Monitoring - - - - - - - Yes COVID-19 - Yes Post-surgical
patients cardiac rehab
discharged from patients and
the hospital patients with
multiple
chronic
conditions
6.8 Direct-to-consumer telehealth - - - Yes - Contracts with - - - - Yes Contracts with
provider contracted Telehealth firm Telehealth
to provide urgent firm to
care services provide
44
Ref FFS: Pre- FFS: FFS: Detail MCP 1: Pre- P 1: MCP 1: Detail MCP 2: Pre- MCP 2: MCP 2: Detail MCP 3: Pre- MCP 3: MCP 3:
# COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary COVID-19 Temporary Detail
Potential State Coverage Policy policy for Policy policy for Policy policy for Policy policy for
COVID-19 COVID-19 COVID-19 COVID-19
Policies (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No) (Yes/No)
behavioral
health services
7.0 Other Related Policies --- --- --- --- --- --- --- --- --- --- --- ---
7.1 Licensure of clinicians: Permits - Yes - - Yes * - Yes * - Yes *
out-of-state clinicians to practice
in-state (physicians, nurses, social
workers) via telehealth
7.2 Licensed professionals permitted to - Yes Physicians and - Yes * - Yes * - Yes *
bill for telehealth visits nurses
7.3 MCPs must incorporate all - Yes - - Yes * - Yes * - Yes *
Medicaid FFS telehealth
requirements
7.4 State Medicaid Telehealth Provider - Yes - - Yes * - Yes * - Yes *
Training Provided
7.5 Telehealth Specific Fraud and - Yes - - Yes * - Yes * - Yes *
Abuse Policies
45
Appendix F: State Medicaid Telehealth Communication Strategies
When making new changes to telehealth policy, processes, or procedures, states rely on
communications, training, feedback and support as useful elements of a successful
implementation. Each of these elements create a balanced bi-directional dialogue and a pathway
to close information gaps to make providers and beneficiaries aware of state Medicaid and/or
CHIP requirements. They allow collection of input from stakeholders to implement informed
policy and program improvements on an ongoing basis. They also ensure MCPs, providers and
beneficiaries may pose questions and find answers about services available via telehealth, how
they can be rendered and reimbursed, and how they are accessed under individual state
Medicaid/CHIP programs.
Amidst the COVID-19 PHE, these implementation tools have become critical in broadcasting the
message that telehealth is a viable option for MCPs, providers and beneficiaries in place of in-
office or in-person services. Providers who are able to deliver virtual services receive a clear
message that this is a supported method of service delivery and beneficiaries are able to receive
routine and non-routine care without interruption when these services are not available in person.
The next few pages will outline some successful strategies states may use to implement new or
existing telehealth services. Communications, training, feedback and support will be the focus of
these strategies illustrated through examples from state Medicaid programs that expanded use of
telehealth services before or during the COVID-19 PHE. While these examples demonstrate how
state Medicaid programs used expanded flexibility to quickly implement telehealth during the
PHE, states may also want to consider how these strategies may be used to support more
permanent telehealth policies and services.
Following these strategies, this Appendix recommends the type of information states may
consider in communications and training to providers about the telehealth rules that apply to their
specific clinical area or unique circumstances. This is critical to providers as they assess the
needs of their patient population and make decisions about the extent to which to invest in
telehealth infrastructure. The strategies and recommended information described are not all
inclusive, nor is it suggested that states must utilize all of these options. States are encouraged to
consider using the most appropriate approach based on their individualized implementation
requirements.
Communications
As states develop or update requirements related to telehealth, it is helpful to consider the
functions communications may serve. Communications efforts support:
• alerting MCPs, providers and beneficiaries of telehealth changes or updates,
• educating on the operational and billing requirements being implemented,
• garnering support for providers who are willing to adopt new methods of delivering care
but also may need additional assistance, and
• providing a call to action when there are gaps telehealth may help to fill.
Communication is key to the successful implementation of programs and program changes,
including those related to telehealth initiatives. During the PHE, many best practices related to
46
communication strategies are emerging to potentially support state efforts with the
implementation of these program changes.
For instance, tailoring information to a subset of stakeholders such as those involved in a home
and community-based services (HCBS) waiver program will allow states to create detailed
training materials, billing guidance, and implementation instructions. These kinds of
communications have allowed states to promote telehealth when providers of a certain type seem
to have low telehealth adoption rates or have more questions due to the nature of their specialty.
Targeted communications have also been used to provide specific information to beneficiaries
who are more likely to have a gap in utilizing certain services, such as during a PHE. To reach
all audiences, it is essential for the state to make materials available in alternative and Americans
with Disabilities Act (ADA)-compliant formats and the materials must be translated in multiple
languages. In extenuating circumstances, such as the onset of the PHE, additional consideration
is needed for distributing information to those audiences when crisis-based timeframes may not
allow for rapid development of alternative formats.
Timing, frequency of updates, level of detail, and communication vehicles all impact the
implementation of telehealth policies. For instance, when making announcements, alerts, or
reminders, states may choose to broadcast frequent messages to a wide audience of MCPs,
providers and/or beneficiaries through multiple vehicles to ensure that information is reaching
the intended audience. During a PHE, this is not always feasible. However, as states move
beyond the PHE, there may be opportunities to utilize multiple vehicles to explain what
components of telehealth may be implemented on a more permanent basis. States often alternate
between summary level documents and more comprehensive multi-page guides and manuals.
This varied method allows providers, for example, to consider how they will operationalize
changes quickly, but also to understand more granular billing and services requirements as they
make internal process changes.
Some states regularly leverage partnerships with other stakeholders, such as provider
associations or advocacy organizations, to help promote new initiatives. This approach is
particularly helpful when pushing information out quickly to many providers or broader
populations. For instance, MCPs and associations (hospital and provider) may incorporate
messages into their own newsletters, meetings, e-mail blasts/listservs, etc. These types of
organizations will know how best to convey information to their providers and members.
Engaging with these partners early on is a strategy states have used not only to extend the reach
of communication but also to garner support from these organizations as all parties work toward
a common goal, especially in the wake of a PHE. It also ensures that these organizations are
using the same tone with the same clear and consistent messages. Additionally, while telehealth
coverage may vary between MCPs, communications may be linked on the state website or in a
resource document to direct providers to the appropriate policy reference material.
Deciding Which Information to Share
Amidst the PHE, providers have had to juggle day-to-day changes to direct service provision
amidst a plethora of policy and procedural changes. It can be challenging to stay informed about
the rules and guidance involving Medicaid telehealth for fee-for-service and waiver programs,
and across Medicaid MCPs. Specifically, providers may grapple with locating and identifying
47
telehealth rules that apply to their specific clinical area or unique circumstances. The clarity of
this information is critical for providers as they assess the needs of their patient population and
make decisions about the extent to which to invest in telehealth infrastructure.
In recent months, providers have shared feedback with CMS and states about their experience
with new or changing telehealth requirements. Most notably, providers have expressed that they
have found it easier to search for and comprehend complex and rapidly changing telehealth
policy when the information is organized by clinical area or provider specialty. Additionally,
these communications are useful when they include information on:
• how telehealth policy has changed from the pre-COVID-19 period to the period of the
PHE,
• the expiration date of temporary telehealth policies,
• the specific services providers are permitted to supply via telehealth (by description and
billing code),
• the types of providers permitted to bill for specific services (e.g., physicians, nurse
practitioners, physician assistants, psychologists),
• the rules for billing for telehealth services (e.g., CPT billing codes, modified codes, and
place of service codes),
• the modality of telehealth that is permitted (e.g., audio-video, audio-only, store-and-
forward, remote patient monitoring),
• any originating or distant site limitations that may apply,
• any geographic limitations that may apply (e.g., urban or rural or health professional
shortage area), or
• plans to permanently incorporate telehealth flexibilities added during the PHE
Since the beginning of the PHE, state governments have made clear efforts to generate guidance
and rules as quickly as possible to better serve their patients. During this time, guidance or rules
on various topics have been packaged together to facilitate a faster release of the information.
The packaging of this information has successfully streamlined the rulemaking process and
disseminated information rapidly but may also slow the ability of providers to gather and digest
new guidance and rules. In more recent months, state governments have enhanced their efforts to
convey and communicate information to providers about telehealth coverage and may refine this
process in considering telehealth applications beyond the PHE.
As states collect the information needed, or already shared with providers, beneficiaries and
stakeholders, it can be helpful to create an inventory to ascertain where there are opportunities
for enhancement in both developing and communicating changes. The table below provides a
potential template that states may use to collect and record this information. This table is not all-
inclusive; rather, it is provided as a reference document. States may adapt this list by adding,
changing, or removing items as appropriate for their state-specific implementation and
communications plans. Following the blank version of the template table are a few completed
illustrative example rows (see sample version) to provide insight into how a state may use this
table.
48
Blank Version
Clinical Service Description of Source Expiration date Provider Billing Geographic Billing Changes Other
new rule (regulation or of policy Type/Specialty Codes/Ranges Limits
guidance)
Evaluation and --- --- --- --- --- --- --- ---
management services
Emergency medical --- --- --- --- --- --- --- ---
services
Gynecological services --- --- --- --- --- --- --- ---
Pediatric --- --- --- --- --- --- --- ---
Behavioral health --- --- --- --- --- --- --- ---
Physical therapy --- --- --- --- --- --- --- ---
Occupational therapy --- --- --- --- --- --- --- ---
Speech pathology --- --- --- --- --- --- --- ---
Home health --- --- --- --- --- --- --- ---
Hospice services --- --- --- --- --- --- --- ---
Personal Care and Home --- --- --- --- --- --- --- ---
and Community-based
Services
Medication Assisted --- --- --- --- --- --- --- ---
Treatment
Prescription/Prescribing --- --- --- --- --- --- --- ---
Authority
Limits/Restrictions for
Opioids or Other
Controlled Substances
Add additional rows as --- --- --- --- --- --- --- ---
needed
49
Sample Version
Clinical Service Description of Source Expiration date Provider Billing Geographic Billing Changes Other
new rule (regulation or of policy Type/Specialty Codes/Ranges Limits
guidance)
Behavioral health Licensed www.state.gov/t 10/23/2020 Psychiatrics, List all billing Urban and rural Place of service Audio-only and
Clinical Social elehealth LCSWs, codes = 02 audio-video
Worker psychiatrists permitted
(LCSW) added Modifier = 95
to the list of
eligible
providers
Home and Community- Permits certain www.state.gov/t 10/23/2020 Any type of List all billing Urban and rural Place of service Audio-video
based services aspects of elehealth home and codes = 02 only
services to be community-
conducted via based provider Modifier = 95
telehealth
Emergency medical Nurse www.state.gov/t 10/23/2020 Physicians and List all billing Urban and rural Place of service Audio-video
services practitioners elehealth nurse codes = 02 permitted
added to the list practitioners
of eligible Modifier = 95
providers
Additionally, the list below also describes the vehicles some state Medicaid programs may utilize to communicate to MCPs, providers
and beneficiaries. This list includes the potential utility these vehicles have in disseminating information about telehealth through
implemented state Medicaid examples in practice from an array of states. This list is not all-inclusive. Many states employ a
combination of these vehicles to disseminate information tailored to the purpose of the message they want to convey, their audience,
and the urgency of the broadcast.
• Websites: Many states have developed highly organized websites that summarize information about telehealth rule changes
by clinical specialty or provider type. Organizing website information in this way reduces the amount of time providers
spend searching for information and sorting through policy details that may or may not apply to them. For example,
– The Missouri Department of Social Services has developed a web page which lists all COVID-19 and non-COVID-19
policy updates by subject: https://dss.mo.gov/mhd/providers/pages/provtips.htm, Accessed August 13, 2020
– MassHealth in Massachusetts has developed a web page which lists COVID-19 related policy updates by provider type:
https://www.mass.gov/info-details/masshealth-coronavirus-disease-2019-covid-19-providers, Accessed August 13, 2020
50
– Georgia’s dedicated COVID-19 website for providers includes up to date information
about telehealth, such as guidance that the agency has issued, announcements for
training webinars specific to telehealth, and a Feedback Form to collect provider and
member telehealth experiences and satisfaction: Georgia Medicaid/COVID-19,
Accessed September 22, 2020. Beginning April 9th, Georgia held webinars for
providers that covered policy changes in the areas of originating site, distance site,
provider types allowed to deliver services through telehealth, and billing
requirements. A recorded webinar is available on Georgia’s Medicaid Management
Information System in COVID-19 Reference Materials: COVID-19 Reference
Materials, Accessed September 22, 2020.
• Written guidance, memorandums, or fact sheets: Many states have posted written
guidance or memorandums to their Medicaid websites summarizing new telehealth
policies by clinical area or provider specialty. This method is a helpful supplement when
posting a regulation or executive order enacting new telehealth policies, because the
regulations and orders are written in a legal or regulatory style that can be difficult to
interpret. In addition, by organizing the information by clinical area or specialty,
providers can more rapidly access the information that pertains to their practice. For
example,
– The Louisiana Department of Health releases provider-specific memorandums
detailing policy changes as they occur, such as the following for mental health
providers:
http://ldh.la.gov/assets/docs/BayouHealth/Informational_Bulletins/2020/IB20-4.pdf,
Accessed August 13, 2020.
– The Colorado Department of Health Care Policy and Finance releases provider-
specific guidance clarifying current telehealth policy and current billing rules, such as
the following for dental providers:
https://www.colorado.gov/pacific/sites/default/files/COVID-
19%20Guidance%20for%20Dental%20Providers%203-23-2020.pdf, Accessed
August 13, 2020.
– While not targeted to providers, in response to the COVID-19 pandemic, the
Washington Health Care Authority published telehealth guidance for Apple Health
(Medicaid) beneficiaries: https://www.hca.wa.gov/assets/free-or-low-cost/telehealth-
guidance-apple-health-clients.pdf, Accessed August 13, 2020. This one-page
document includes information about how to request telehealth services, PHI privacy
concerns, coverage, and interpreter availability. The document is also available in 36
languages.
• Frequently Asked Questions: Many states have posted lists of Frequently Asked
Questions (FAQs) to their websites describing the common questions providers ask about
the new telehealth policies and their implementation. These FAQs are most effective
when they are tailored to specific clinical areas (e.g., behavioral health services or home
health) or provider specialties (e.g., family medicine or speech pathologists). The FAQs
often provide insight into providers’ common concerns, implementation problems, and
billing issues. For example,
51
– The Iowa Department of Human Services includes on its web page an FAQ which
details COVID-19-related telehealth policy changes, their expiration date, permitted
modality, and key rules for provider types such as physical therapists:
https://dhs.iowa.gov/ime/providers/faqs/covid19/telehealth, Accessed August 13,
2020.
– The Washington State Health Care Authority includes on its web site an FAQ
document that details the COVID-19-related telehealth policy changes for behavioral
health providers: https://www.hca.wa.gov/assets/billers-and-providers/behavioral-
health-policy-and-billing-COVID-19.pdf, Accessed August 13, 2020.
– Medi-Cal’s Telehealth FAQs ( https://www.dhcs.ca.gov/provgovpart/
Pages/TelehealthFAQ.aspx, Accessed August 13, 2020) includes a link that directs
providers to the California Telehealth Resource Center (CTRC), a robust website
dedicated to providing support to providers who implement and sustain telehealth
programs. The website includes information across payers in one place, including
Medicaid. Supports include: program needs assessment for implementation or
expansion, equipment selection, telehealth presenter training, contracting with
specialists, and billing, and credentialing information. In addition, the CTRC also
produces a Telehealth Program Developer Kit, a step-by-step guide to help providers
develop a telehealth program. The CTRC also provides toolkits, trainings and policy
updates specific to using telehealth to address the COVID-19 PHE:
https://www.caltrc.org/, Accessed August 13, 2020.
– New York’s Medicaid Agency compiled information detailing COVID-19 telehealth
changes in an FAQ document: https://www.health.ny.gov/health_care/
medicaid/covid19/docs/faqs.pdf, Accessed August 13, 2020. It lists services,
applicable provider types, modifiers, POS codes, notes, and more. The table of
contents allows providers to easily click on topics to be directed to information
applicable to specific provider types or services. The Medicaid guidance also includes
links to guidance by the Office of Mental Health (OMH), the Office for People with
Developmental Disabilities (OPWDD), the Office of Children and Family Services
(OCFS), and the Office of Addiction Services and Supports (OASAS) on Medicaid
payment policy for Medicaid members being served under their authorities, so
providers can click on the link rather than researching separately.
• Webinars: Some states have conducted live webinars or stakeholder telephone calls to
educate providers about the various telehealth policy changes. While many of these
events are live and enable providers to ask questions of state officials in real time, states
conducting these events also often maintain recorded versions of these events on their
websites for providers to download and digest as they have time. In addition, some states
also choose to maintain the slide-decks of these events on their websites and edit them as
policy changes. For example,
– The New York Department of Health includes on its website both a webinar and a
slide deck intended to communicate new COVID-19 telehealth policies to providers
in New York State. The webinar is saved through www.YouTube.com:
https://health.ny.gov/health_care/medicaid/covid19/index.htm, Accessed August 13,
2020.
52
– The Washington State Health Care Authority includes on its website an
announcement to a webinar aimed at communicating to behavioral health providers
changes to telehealth policy resulting from the COVID-19 pandemic:
https://www.hca.wa.gov/webinar-use-telehealth-behavioral-health-and-recovery-
services-response-covid-19, Accessed August 13, 2020.
– The Oregon Health Authority includes on its website a link to a webinar they
conducted early in the COVID-19 pandemic to communicate telehealth policy
changes to providers:
https://www.youtube.com/watch?v=h3A7IeTidso&feature=youtu.be, Accessed
August 13, 2020.
– Florida's Medicaid Agency for Health Care Administration (AHCA) leveraged email
blasts (Florida Medicaid Health Care Alerts) to alert ambulatory providers of a free
10-week telemedicine training through a partnership between the U.S. Department of
Health and Human Services, the ECHO Institute at the University of New Mexico,
and the Public Health Foundation’s TRAIN Learning Network. The "Telemedicine
Hack", a virtual, peer-to-peer learning community is offering five teleECHO sessions;
five virtual “office hour” discussion panels; and inter-session peer-to-peer learning
facilitated via virtual discussion boards to support wide adoption of telemedicine,
from July 22–September 23, 2020.
https://echo.zoom.us/webinar/register/WN_c3mWhTm8Q5K3XHDv0zyHuQ,
Accessed August 13, 2020.
• Stakeholder telephone calls, email announcements, or direct mail: For provider
audiences without robust access to online services (e.g., broadband services), state
Medicaid agencies may consider conducting telephone-based stakeholder conference
calls to disseminate information. In addition, to reach these provider audiences, states
may consider conducting targeted communications by emailing new telehealth policy
guidance to them directly. For example,
– The Wisconsin Department of Health Services conducts periodic stakeholder
conference calls for providers to discuss policy changes related to COVID-19
pandemic: https://www.dhs.wisconsin.gov/dms/policycalls/covid-19.htm, Accessed
August 13, 2020.
– The California Department of Health Care Services implemented a system for
electronically notifying providers of ongoing changes to telehealth policy changes.
Providers must sign up for these announcements:
https://www.dhcs.ca.gov/Pages/DHCSListServ.aspx, Accessed August 13, 2020.
• Matrixes: Some states post simplistic matrixes to their websites that clearly summarize
new telehealth policies by clinical area or provider specialty. For example,
– The Wisconsin’s Medicaid program incorporates a matrix on their website for
providers:
https://www.forwardhealth.wi.gov/WIPortal/content/html/news/telehealth_resources.
html.spage, Accessed August 13, 2020.
In essence, providers need to know what they are expected and able to do, when they may do so,
as well as the parameters under which they are able to deliver and receive compensation for
53
services appropriately. Resources such as those above, may help to provide that information.
Providers will also have questions they want to ask, and feedback to contribute as states move
from telehealth implementations during the PHE to more permanent changes. As states are
aware, these exchanges add value and help to inform future messaging, as well as keep the
dialogue open and continuous.
Provider Training
Virtual provider training is especially helpful when it is comprehensive and easily accessible.
Many states ensure providers have adequate training opportunities by offering variable date and
time options and allowing for multiple presentations of the same training to eliminate any
impediments to service delivery. During the PHE, training for providers may be limited or
general. Longer term, states may have more latitude to provide general training for all providers,
as well as targeted training for individual provider types on an ongoing basis so providers have
up-to-date information. This includes training for providers who have not been exposed to
telehealth before, as well as experienced providers who need to be made aware of policy or
reimbursement changes. States may consider multiple vehicles to advertise training, as well as
engaging provider association and MCP partners in sharing information about the training or
hosting training. States may also consider recording webinars and publishing them on websites
with other training materials as a reference for providers.
Training is also an opportunity for providers to ask questions or seek clarification and allows
them to provide feedback about telehealth services, implementation considerations, or even the
training itself. It also is an opportunity to outline the ongoing support and resources available for
providers and their patients.
Beneficiary Training
Many beneficiaries may not have participated in or initiated a telehealth provider visit prior to
the COVID-19 PHE. In order for telehealth to be an effective tool in reducing gaps in services
and maintaining social distancing, beneficiaries may need help understanding the telehealth
options available to them, and using the technology required to conduct a telehealth visit. States
may consider offering training opportunities to beneficiaries on a regular basis in order to keep
beneficiaries apprised of evolving coverage policies. Training can be offered informally, such as
through an update during public meetings (e.g., stakeholder telephone conference calls or virtual
meetings), or more formally through virtual webinars or training videos posted on a website.
These training offerings provide a platform to explain what types of visits or interactions are
covered and may be accessed through telehealth. The trainings may also provide information
about what technologies beneficiaries must possess in order to participate in a telehealth visit.
Similar to trainings aimed at providers, beneficiary trainings may include information about the
ongoing resources available to beneficiaries to support their use of telehealth, as well as
information explaining the process for submitting questions.
Feedback
Feedback is an important part of evaluating the successful delivery of a service through
telehealth and offers information that will ultimately improve the effectiveness of telehealth in
supporting the service-related needs of beneficiaries. Under normal circumstances, vehicles such
as a Request for Information (RFI), formal inquiry, or public comment in response to a posted
54
bulletin or paper are often used when states seek feedback on a specific topic. However, during a
PHE where rapid deployment of flexible service options is essential, the normal channels of
feedback collection may not work. Under these circumstances, states may collect feedback on
telehealth changes or flexibilities through the documentation of day-to-day interactions and
public discussions that may be valuable in making observations about telehealth
implementations. The feedback loop often reveals opportunities for enhancements in providing
support to providers and beneficiaries using or considering telehealth and may help facilitate a
smoother and well-supported implementation.
When feedback needs to be disseminated or operationalized quickly, this can be accomplished in
something as simple as publishing an FAQ document, forming a focus group or committee, or
incorporating topics into a meeting agenda. While not all feedback will result in immediate
changes to the delivery of the service or to support improvement, it is still extremely valuable to
understand how telehealth as a service delivery option is being perceived by stakeholders as a
tool for continuous improvement.
Provider Support
Technical support to providers may take many forms. Some states provide support internally, but
in situations like the current PHE, other states have relied on contracted vendors to help train
providers and troubleshoot billing and technical questions related to delivering telehealth
services. Some states may designate a help desk; others might train or utilize existing provider
services staff who support multiple provider service needs. Solutions may cover on-call
responses or utilize a dedicated or existing email address for troubleshooting and addressing
issues and concerns. Documentation itself may serve as support in supplying links to helpful
resources such as the Health Resources and Services Administration (HRSA), where FQHCs
may access information about grant opportunities and resource centers, or state licensing boards
who may have additional requirements for specific provider types, as well as technical help
desks for technology vendors whose platforms are being used by providers to deliver services. It
is imperative that whatever the mode of support, the pathway is apparent and known to
providers. States may want to consider their provider environment and whether most providers
are familiar with telehealth modalities. Timeliness of the response could present a barrier to
telehealth adoption and service delivery.
States may want to consider establishing a coordinated support process and system for providers
under both Fee-for-Service and managed care. This may include engaging provider associations
and MCPs in unified messaging. Regardless, states may collect and summarize information
about the implementation of telehealth and ensure MCPs and provider associations are
broadcasting messages and providing support to providers to help defray confusion and barriers
in rendering or receiving services. States may also want to consider how they will also support
inquiries from beneficiaries through the vehicles they have available to them, such as hotlines, e-
mail boxes, or FAQs.
Summary of Strategies for Communications, Training, Feedback and Support
State Medicaid programs have implemented several different strategies for communicating
information about new telehealth policies. Programs have developed websites, disseminated
written guidance and memorandums, developed FAQ documents, conducted webinars, training
and stakeholder calls, published matrixes, and for providers without robust access to online
55
services, have conducted outreach to providers via telephone and direct mail. States may
consider some of these examples, seek feedback from providers, beneficiaries and other
stakeholders and further enhance these communications and training materials. States are
encouraged to draw on their experience, and the experience of other states, as they move beyond
the PHE and utilize telehealth to deliver services in the future.
56
Appendix G: COVID-19 State Telehealth Experience Profiles
Introduction
The COVID-19 PHE has accelerated adoption of telehealth throughout the healthcare system,
including behavioral health (BH) and long-term services and supports (LTSS). Through
increased flexibilities, CMS has actively supported states in expanding their use of telehealth in
Medicaid and CHIP. Early in the PHE, CMS issued guidance to state policy makers related to
state efforts to expand the use of telehealth services. CMS is now examining the rapid changes
and flexibilities that were implemented due to the PHE and how this experience may impact
telehealth in Medicaid in the future. As a part of this work, five states with notable telehealth
developments were interviewed. Cross-state trends in responses and unique state highlights are
described below.
Cross-State Response Trends
Telehealth Policy Changes
While there was variability among the five states in telehealth policy prior to the PHE, state
Medicaid agencies, providers, and beneficiaries all embraced telehealth in the face of COVID-
19. In all cases, implementation was swift and expansive, using flexibilities to ensure that
barriers to care were removed and beneficiary and provider safety was prioritized.
Even in states with progressive coverage policies, pre-COVID-19 telehealth utilization was not
high. States reported a sharp increase in utilization in response to the PHE with all states
reporting high satisfaction with the resulting services. Some remarked that skepticism
surrounding certain telehealth modalities (such as audio-only) or use with certain provider types
were assuaged as they saw them in practice. Suspension of HIPAA enforcement by the Office of
Civil Rights (OCR) and the Office of the National Coordinator for Health Information
Technology (ONC) was cited as a key factor by many in the success of telehealth.
State-reported benefits of telehealth included:
• Reduced no-show rates;
• Decrease in non-emergency transportation costs;
• Ability to engage populations that were historically difficult to bring into care; and
• Greater access for beneficiaries with limitations on time off from work or childcare
concerns to attend appointments.
States and providers were aligned in their desire to quickly implement. For states, the push was
ensuring that beneficiaries retained access to services. For providers, transitioning to telehealth
was no longer optional to sustain a revenue stream during the PHE. This was particularly true for
providers whose primary source of funding is Medicaid, such as Home and Community-Based
Services (HCBS) providers. This led to creativity in implementation strategies as well as a
partnership with the state in determining which services could be effectively delivered via
telehealth and how.
In many instances, states looked to providers to define what services could be effectively
delivered. For example, one state reported variability in implementation of telehealth with
Obstetrics providers. Some issued blood pressure cuffs and scales to patients and conducted
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prenatal visits by telehealth. Others continued office-based visits with enhanced infection
control processes.
Communication Strategies
All states interviewed communicated PHE telehealth policy changes using their typical
communication channels, which often included provider notifications and email/fax blasts. These
methods were enhanced by dedicated webpages with PHE-specific content and Frequently
Asked Questions (FAQ) documents. Most states conducted a series of webinars to present the
policy changes, and some held a series of regular provider calls to answer questions and hear of
concerns and successes. Clarifying policy and reassuring providers who were apprehensive that
the relaxed regulations (e.g. verbal consent, audio-only calls permitted, etc.) would not be
honored were primary reasons for strategies that allowed for dialog between providers and the
state.
A close partnership with provider associations and beneficiary advocates was highlighted as an
important component of both communicating policy changes and learning about and quickly
finding solutions to concerns. Although several states had beneficiary focused strategies, all
emphasized the primary role of beneficiary communication through providers.
Several states noted that the volume and detail of changes were difficult for providers to manage
early on. The use of plain language, and clear communications that were succinct and dated was
identified as an important lesson learned.
Innovations
Audio-only visits were repeatedly identified as one of the most important factors of telehealth
success during the PHE. Telephone visits work for beneficiaries in rural and frontier areas with
limited broadband access necessary for audio-visual communication. Moreover, telephone visits
are accessible to a greater number of low-income beneficiaries who cannot afford a data plan or
device such as a smartphone or tablet. One state in particular shared the excitement expressed by
behavioral health providers who have been able to readily engage some consumers who did not
previously come into offices for care.
Implementation of telehealth with HCBS providers was important to states to promote service
continuity while maximizing safety. They examined specific service components to determine
which would effectively be provided via telehealth. Remote coaching for Activities of Daily
Living and virtual assessments and care plan development were common provisions
implemented. Many states are considering retaining some of the changes, most notably the
ability to virtually conduct assessments.
Considerations for Overcoming Barriers
All states identified use in rural areas as a consideration necessary to address for telehealth
success. While rural areas have the greatest potential benefit from maximizing telehealth use,
both in the PHE and in normal operations, they also have the most challenges to implementation.
Many states indicated that they are actively working to increase broadband access in rural
communities.
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Alignment across Medicaid payers was identified as an important success factor. States with
significant managed care operations discussed the need to maximize consistency between FFS
and managed care policies and procedures, as well as between managed care plans. Beyond
Medicaid, several states noted that differences in coverage as well as billing processes with
Medicare and commercial insurers was a deterrent for adoption, particularly among smaller rural
providers. These concerns were further compounded when providers believed the changes to be
temporary, furthering their belief that it was not worth the effort to implement.
States were asked about the impact of telehealth on their value-based purchasing (VBP)
strategies. Three states expressed optimism that telehealth would eventually positively
contribute, either through increased utilization or by encouraging providers to transition to a
higher Alternative Payment Methodology that better allows for creative approaches to service
delivery. In the near term, however, impacts to quality reporting due to service utilization
decreases or measures that require in-person visits, are impacting current VBP programs.
Use of telehealth in certain populations was raised in several interviews. One state noted
challenges with providing services to individuals with Intellectual/Developmental Disabilities.
Others identified the older adult population as notable, although with differing reports. One
experienced low uptake with older adults in rural communities who were technology adverse,
while another state was surprised to learn of the enthusiasm with which older adults embraced
telehealth, particularly the availability of the telephone only option.
Plans Post-Public Health Emergency
Although in various levels of commitment, all states viewed telehealth positively and were
considering extending some or all of the flexibilities adopted during the PHE. The audio-only
modality was the most cited flexibility under consideration, with discussion of the use of
telehealth with previously unused providers and services, such as HCBS, also under
consideration.
States are recognizing the need to more closely examine the effectiveness of these services
delivered via telehealth. While any service was preferable to no service during the PHE, that
approach does not hold true for normal operations going forward. Consideration of quality,
adherence to community standards, and fraud, waste, and abuse potential were all mentioned as
aspects to consider. How to address services that require hands on components, such as
immunizations and recording of height and weight as part of well-child visits were noted as
important considerations to address. Also identified were concerns about confidentiality,
particularly with behavioral health services delivered in the home with other family members
nearby, and written consent that was typically obtained during an initial in-person visit.
With the speed upon which changes were implemented, several states are now taking care to
more carefully address policies and gaps. For example, one state noted that they did not have
coding modifiers in place to indicate a service was rendered via telehealth, limiting their ability
to track telehealth in their own data systems and T-MSIS. Others recognized the need to
coordinate with licensing agencies when considering long-term changes.
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Several states noted that changing the policy that prohibits use of Medicaid funding for purchase
of devices would facilitate telehealth access as a desired change at the Federal level. One state
also noted a desire for consideration of telehealth as an integral part of a broader move to
Hospital at Home approaches to care.
State Profiles
Colorado
Telehealth Feature Pre- PHE Notable Findings
PHE
Payment Parity
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Beneficiary Home • Colorado offered a robust telehealth coverage policy prior to the PHE,
Permitted including parity, allowance of service in the beneficiary’s home, and
delivery by a wide variety of providers.
All Providers within - -
Scope of License • Colorado approached changes in three streams:
o Changes to the FFS benefit
All Services that can - o HCBS for persons with disabilities
be Effectively o Behavioral health services provided by capitated entities.
Delivered • A wide array of HCBS services were identified as appropriate for
telehealth in the PHE and included services such as: Home
FQHC/RHC - Modification and Adaptations, Peer Mentorship, Substance Use
Encounter Billing Counseling, Supported Employment, and Vehicle Modification.
Out-of-State - - • Use of telehealth with BH services such as Day Treatment and
Providers Allowed Assertive Community Treatment for behavioral health, have been
successful.
Audio-Only -
• Multi-site FQHCs were advantaged in transitioning to telehealth due to
Permitted their administrative infrastructure.
Remote Patient • Telehealth use among Indian Health Services providers was low, as
Monitoring was the case with Rural Health Clinics. The IHS benefits manager is
providing proactive outreach to IHS providers to determine why
Store and Forward - - telehealth adoption has been low.
Committed to • Live chat is available as a telehealth modality.
Extending Post-PHE
Idaho
Telehealth Feature Pre- PHE Notable Findings
PHE
Payment Parity • Idaho Medicaid has been a leader in payment parity for telehealth and
had enacted comprehensive coverage policy prior to the PHE, working
Beneficiary Home closely with the behavioral health and dental carve-out vendors to
Permitted align approaches.
• The state, not specific to Medicaid, has established a Telehealth Task
All Providers within -
Force. It is a 12-member body that meets monthly. Twenty-six subject
Scope of License
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All Services that can matter experts are preparing recommendations for the Healthcare
be Effectively Innovations Council.
Delivered • The Medicaid agency worked closely with the Medical Care Advisory
FQHC/RHC Committee and provider associations to communicate changes. A
Encounter Billing sister agency had dedicated focus on supporting telehealth with critical
access hospitals and rural health clinics.
Out-of-State
• Providers are often the primary source to communicate telehealth
Providers Allowed availability to beneficiaries.
Audio-Only - • St. Luke’s Health System reported a 58% reduction in emergency
Permitted department utilization, an 80% reduction in acute hospitalizations, and
reduced readmissions with implementation of Remote Patient
Remote Patient - - Monitoring pre-PHE.
Monitoring
• The Governor created an office in the Department of Commerce to
Store and Forward - - address broadband connectivity statewide.
• The state of Idaho is conducting an evaluation of telehealth needs
Committed to
through an independent consultant. The project includes an
Extending Post-PHE environmental scan, stakeholder focus groups, and key informant
interviews.
Maine
Telehealth Feature Pre- PHE Notable Findings
PHE
Payment Parity • Maine had a comprehensive telehealth coverage policy prior to the
PHE, but utilization was not high. That changed significantly with the
Beneficiary Home - PHE, almost overnight.
Permitted
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All Providers within • There were initial concerns about the use of certain platforms due to
Scope of License security concerns, but those have since resolved.
All Services that can • Maine added a specific code for FQHCs to bill (G0071), which is a five
be Effectively minute checkin visit.
Delivered • MaineCare added codes to enable dental practices to bill for traige and
screening services conducted via telehealth, and is looking to address, at
FQHC/RHC - the service code level, which other dental services are billable through
Encounter Billing telehealth in accordance to the Board of Dental Practice. MaineCare is
working with other state partners to update related statutes to allow
Out-of-State -
these and other changes.
Providers Allowed
• Maine made heavy use of its Medicaid Advisory Committee and
Audio-Only - provider associations as effective communication strategies, as well as
Permitted its relationship with the Northeast Telehealth Resource Center.
Remote Patient • To address beneficiary engagement, Maine contracted with an
Monitoring advertising agency for a comprehenisve campaign that included a
dedicated webpage, television and social media/digital advertisements,
Store and Forward - and direct mailings, emphasizing the availability of the telephone only
option.
Committed to - • The Medicaid agency participated in weekly Town Hall meetings
Extending Post-PHE hosted by the Office of Behavioral Health and Office of Child and
Family Services to support behavioral health providers with telehealth
implementation.
• MaineCare is considering seeking the necessary authorites to extend the
allowance for take-home doses of Medication Assisted Treatment
(MAT).
Massachusetts
Telehealth Feature Pre- PHE Notable Findings
PHE
Payment Parity - • Prior to the PHE, Medicaid coverage of telehealth was limited to BH
and Substance Use Disorder treatment, which began in March 2019.
Beneficiary Home - However, the Medicaid agency was in the process of finalizing a
Permitted comprehensive telehealth strategy when the PHE was declared, that was
founded on principles of equity in access and high-quality care. The
All Providers within - PHE was a vehicle to implement many of the planned policies, which
Scope of License will continue after the PHE ends.
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All Services that can - • Massachusetts created an innovative approach to connecting residents to
be Effectively services, an approach that goes beyond, but is inclusive of, Medicaid.
Delivered Called Buoy, this online symptom tracker allows users to check
symptoms for possible COVID-19 infection. To support safe care,
FQHC/RHC - Buoy connects the user to telehealth providers, which may include a
Encounter Billing contracted telehealth vendor, if care is indicated. Called Telehealth
Network Providers, three vendors are available to care for users who do
Out-of-State - not have a regular source of care.
Providers Allowed
• Telehealth availability was communicated to residents, which include
Audio-Only - Medicaid beneficiaries, through an opt-in statewide texting system.
Permitted Medicaid also sent information as mailer inserts to beneficiaries.
• Massachusetts created a Remote Patient Monitoring (RPM) program
Remote Patient -
specific to COVID-19. For those being discharged from an inpatient
Monitoring unit and those who have tested positive with a high risk of
hospitalization, 7 days of RPM is authorized, which may be
Store and Forward - -
reauthorized. Tools include, minimally, a pulse oximeter and
Committed to thermometer but may include other tools as indicator. Providers assess
Extending Post-PHE data and symptoms daily. Expansion to beneficiaries with chronic
conditions is under consideration.
Wisconsin
Telehealth Feature Pre- PHE Notable Findings
PHE
Payment Parity • Wisconsin passed comprehensive telehealth legislation just prior to the
PHE, which included asynchronous modalities and Remote Patient
Beneficiary Home Monitoring. The PHE became the vehicle to implement provisions
Permitted quickly.
• Focused implementation assistance was provided to behavioral health
All Providers within -
and long-term care providers.
Scope of License
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All Services that can - • Markedly positive results are noted with behavioral health use of
be Effectively telehealth, including reduced no-shows and better therapy outcomes,
Delivered particularly among young people.
FQHC/RHC - • Continued allowance of out-of-state providers could be a key strategy to
addressing critical provider shortages long-term.
Encounter Billing
• Created telephonic check ins for beneficiaries receiving MAT with
Out-of-State multi-day dosing.
Providers Allowed
• The Medicaid agency is working closely with the State Mental Health
Audio-Only - Authority to identify and address regulatory barriers that would allow
Permitted telehealth using SAMHSA funding.
• Some HCBS providers struggled with revenue loss, even with the
Remote Patient opportunity to provide telehealth services. Several managed care
Monitoring organizations supported them with retainer payments out of their
margin.
Store and Forward
Committed to
Extending Post-PHE
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