2018 Telemedicine Policy Update
With most legislative sessions having already concluded or preparing to close, it is a good time to take a look at what changes are in-store for telemedicine.
Thirty-one states and Congress have passed legislation or regulations pertaining to telehealth this past year. Most of those deal with reimbursement or licensure for providers practicing remote care. A few of the new rule changes offer increased availability for the direct-to-patient telemedicine services that SimpleVisit addresses.
While it appears that policy-makers are slow to embrace the full benefits of telehealth, it is clear that these recent changes are moving more rapidly than ever before in attempts to catch up with advancements in telemedicine.
Federal: Bipartisan Budget Act of 2018
- 1/1/2019: Adds hospitals, critical access hospitals, mobile stroke units and any other site determined appropriate by HHS (possibly the home) to list of allowable originating sites for treatment of acute stroke through telemedicine for Medicare; removes any geographic location restriction for those sites in the treatment of acute stroke through telemedicine
- 1/1/19: Allows monthly oversight visits from their home or independent renal dialysis facilities via telehealth, if certain “face-to-face” visit requirements are met, for the treatment of end-stage renal disease (ESRD); removes geographic restriction on these two new originating sites, along with hospital-based or critical access hospital-based renal dialysis centers, for the treatment of ESRD.
- Allows for the provision of free telehealth technologies by a provider of services or a renal dialysis facility to an individual with ESRD who is receiving home dialysis for which Medicare payment is received
- 1/1/2020: Allows Medicare Advantage Plans to offer telehealth services as a “basic benefit” with coverage expanded beyond what is currently allowed under Medicare Part B; allows certain two-sided risk payment model Accountable Care Organizations to include the home as an originating site and remove the geographic location requirement for covered telemedicine services
- Requires reimbursement by private payers for telehealth services for urology, pain management, & substance abuse
- Expands list of providers who can administer telehealth services to include registered nurses and pharmacists; clarifies and modifies patient consent procedures
- Offer telehealth coverage to state employees; authorizes payment through Medicaid for telehealth; establishes practice standards of care for telehealth providers; encourages workers’ compensation plans to include services provided through telehealth.
- Requires Medicaid reimbursement of medically necessary telemedicine services or telehealth services.
- (Pertaining to family and social services) Revises the definition of Medicaid telemedicine services to include interactive audio-using store and forward technology and remote patient monitoring technology; removes the mileage restriction between patient and provider; revises the permissible telemedicine provider and service types to include DME and HME providers, care coordination services without member involvement, and provider to provider consultations, but removes speech therapists and services billed by school corporations from the list of reimbursable telemedicine providers.
- (PARITY) requires private payers, non-profit insurance companies, and Kansas Medical Assistance Program to extend the same coverage to services delivered via telehealth as they do to those same services when delivered “in-person”; includes store-and-forward in the definition of telehealth along with the expected synchronous definition; SLP & audiologist services covered by state medical assistance insurance via telehealth when covered as an in-person service; creates the framework for standards of practice for providers and insurance companies when dealing with telemedicine services.
- Pertaining to state healthcare plans: includes Federally Qualified Health Centers, Rural Health Clinics and Indian Health Centers as allowable sites to deliver covered telehealth services; clarifies that those facilities may serve as the provider site and bill under the applicable encounter rate.
- (Department of Mental Health) Allows the licensing requirement for intensive residential treatment programs that states that there must be a physician on-call at all times after-hours and on weekends to be met by a physician who is available through telehealth, provided they are a maximum physical distance of an hour away; allows the requirement of a physician examination prior to hospitalization for an involuntary three-day hold to be met by a physician reachable only through telehealth if no physician is available on the premises within two hours of physical admission
- Adds Board Certified Behavior Analysts and Board Certified Behavior Analyst-Doctorals as a provider of Autism Spectrum Disorder services to children who are covered under Medicaid via telehealth.
- Adopts the Psychology Interjurisdictional Compact and the EMS Personnel Licensure Interstate Compact.
- (For credentialing and practice regulation) Allows physicians and physician assistants to establish provider-patient relationships via telehealth services, for the purpose of meeting requirement to prescribe medications; includes store-and-forward and remote patient monitoring in telehealth definition
- Includes telehealth services in the “encounter” definition for licensing purposes for Indian Health Services facilities
New Mexico Rules
- Establishes a new, 3-year “telemedicine license” for Osteopathic Physicians outside of the state who wish to treat patients in New Mexico, and establishes regulations and fees pertaining to that license.
- Proposes amendments to existing regulations for medical assistance programs to match the requirements of federal rules; establishes requirements for MCOs utilizing telemedicine.
- Requires chiropractic practitioners to be licensed in the state of Oregon in order to provide services furnished through telehealth.
- Establishes guidelines for credentialing-by-proxy for distant site hospital providers within the state.
- Expands the Board of Occupational Therapy Examiners’ definition of telehealth by removing language defining telehealth as only synchronous audio-video, thereby including any service delivered at a different physical location using telecommunications or information technology, specifies that it only applies to practitioners licensed in the state with that board at the time of services rendered.
- Pertaining to general provisions of licensing and regulations, relates to the definition of indirect and in-person supervision, and stipulates whether or not telepractice/telehealth is able to be used.
- Amends rules pertaining to Speech-Language Pathologists and Audiologists Program related to telehealth.
- Amends established rules and allows telemedicine providers to provide the Board-approved complaint notification statement through alternate means.
- Removes Medicaid originating site and geographic location restrictions (patient can be anywhere and not just a rural site or HPSA) for telehealth services reimbursed through workman’s compensation coverage
- Adopts the Interstate Medical Licensure Compact.
- Extends the duration of the collaborative for the advancement of telemedicine until a reporting and reconsideration period in December 2021.
- Creates a three- to five-year telemedicine payment parity pilot program for the specified scope of coverage: diabetes mellitus, stroke, mental health conditions, opioid dependence, and chronic pain.
- (Pertaining to in-home health services agencies) Includes definition of telehealth and telemedicine and requires applicants or licensees to develop and operationalize policies and procedures that describe, among other elements, their utilization of telehealth or telemedicine for patient consultation purposes or to acquire patient vitals and other health data in accordance with state and federal laws.
- Adds rules related to telehealth for occupational therapists and assistants.
West Virginia Law
- Establishes broad definition of telehealth; allows medication-assisted treatment through telehealth
- Three (3) states passed legislation relating to broadband development, which greatly impacts the ability of providers to offer telemedicine options within their practice, though the text of the laws do not include language specific to telehealth. (GA, MO, WV)
- Creates a definition of telehealth nursing as the practice of distance nursing care using telecommunications technology
- Removes the requirement that state department reports to health and human services committee on application of telemedicine to provide services in the fields of home health care, emergency care and critical and intensive care
- Allows dental hygienists to complete certain procedures through “telehealth supervision” for the purposes of communication with the supervising dentist.
- Clarifies that for physician supervisors, “actively practicing medicine in Colorado” does not include the practice of medicine based primarily on telecommunication devices.
- Specifies that clinical social work may be provided by telemedicine as permitted by regulation and may include participation in telehealth.
- Creates standards and requirements for speech-language pathologists to engage in telepractice
- Allows telehealth to be used for the provision of patient counseling for pharmacists
- Creates standards for the use of telehealth in the practice of genetic counseling
- Defines parameters for teledental services authorized under a previously passed act
- Updates the definition of “telepsychology services”; clarifies and introduces consent standards and requirements specific to psychology services delivered via telehealth
- (PARITY) Requires private payers to extend the same coverage to services delivered via telehealth (synchronous – defined as live two-way audio & video) as they do to those same services when delivered “in-person”.
- Applies to both Medicaid plans and private payers plans (PARITY); requires the regulation of telehealth; sets requirements for the delivery of telehealth services to Medicaid recipients; requires provision of coverage and equivalent reimbursement for telehealth services; prohibits the any coverage requirement to include the following: for providers to be physically present with a recipient, the need for prior authorization, medical review, or administrative clearance if not required for the in-person service, and demonstration of necessity; includes store-and-forward in definition of covered telehealth services.
- Includes services delivered via telehealth in requiring a carrier that is an insurer, a nonprofit health service plan, or a health maintenance organization to ensure its members to local health departments and certain services provided through them.
- Authorizes Maryland to enter into the Interstate Medical Licensing Compact
- Includes psychiatrists in list of providers who can be reimbursed for services delivered via telehealth through Medicaid
- Adds federally qualified health centers to the list of provider sites that may register as distance site providers eligible to deliver services via telehealth; includes physician assistants as permitted providers.
- Allows an evaluation delivered via telehealth to fulfill the requirement of a “bona fide prescriber-patient relationship” before medications can be prescribed in Public Health Code
- Within Medicaid law, in rural/HCPS areas: allows DHHS to fund development and expansion of telehealth services in two speciality areas: children’s special health care services program and telepsychiatry
- Requires the Department of Social Services to reimburse providers for services provided through telehealth at the same rate as in person; allows parents and guardians to authorize for school-based telehealth.
- Adds definitions of “distant site” and “originating site” to the existing telemedicine law; establishes a committee to study health care reimbursement for telemedicine and telehealth.
- Allows synchronous telemedicine services to be used for purposes of direct supervision in the regulation of speech-language pathology.
- Creates a rural home health flexibility program which allows the Commissioner to consider for approval proposals from providers operating under this article and serving rural counties to qualify for home telehealth reimbursement.
- (Pertaining to Medicaid fee-for-service and managed care) Creates the healthcare facility transformation program which would foster participation in value-based payment models intended to improve health information technology infrastructure, including telehealth; adds the following to the list of allowed originating sites: certified and non-certified day and residential programs including residential health care facilities serving special needs populations, credentialed alcoholism and substance abuse counselors, providers authorized to provide services and service coordination under the early intervention program, and clinics licensed or certified under the mental hygiene law; removes restrictions on when the the patient’s home is an allowable originating site and includes it without prejudice for reimbursement; expands the definition of RPM and extends the allowed reimbursable scope of coverage for this telehealth service; requires the Commissioner of Mental Health, Office of Alcoholism and Substance Abuse Services and Office of People with Developmental Disabilities to create a guidance document outlining the differences between the telemedicine reimbursement policies of each agency and state and federal policies
- Adds a new optional service of Telepractice which certified providers with adequate technology may choose to implement for alcoholism and substance abuse services.
South Carolina Law
- Clarifies that Advance Practice Nurses may deliver services via telehealth, to include diagnosing and managing an individual’s health care status
- Requires the state Medicaid program to reimburse for telepsychiatric consultations; requires a health benefit plan offered or renewed in the individual or large group market to provide coverage for the use of physician-to-physician psychiatric consultations using telehealth services.
- Creates a telehealth mental health pilot project grant program.
- Requires fingerprinting for participation in the Interstate Medical Licensure Compact.
- Repeals the Telehealth Pilot Program, removing reporting requirements for certain reports pertaining to telehealth to the Health and Human Services Interim Committee, the Social Services Appropriations Subcommittee, or both committees.
- Establishes general licensing practice standards for telehealth.
- Allows telemedicine providers to prescribe Schedule II through V controlled substances through the use of instrumentation and diagnostic equipment, provided there was a prior “bona fide prescriber-patient relationship” established via an in-person encounter; allows telemedicine providers to establish that relationship through an encounter furnished via telehealth in order to prescribe a Schedule VI controlled substance.
- Defines bona fide veterinarian-client-patient relationship; allows practitioners with veterinarian-client-patient relationship to prescribe controlled substances via telemedicine when a practitioner-provider relationship exists.
- Authorizes Mayor to join Interstate Medical Licensure Compact & establishes Commission;
- Introduces telehealth requirements into DC Medicaid law – codes, scope of coverage, technology requirements, site requirements/definitions, eligible RPM criteria, clarifies all categories of Medicaid recipients are eligible for this program, requires Federal authorization for funding. (Full expansion and specification of telehealth policy for DC)
- Establishes rules specific to telemedicine within the Department of Health regulations: defines telemedicine broadly as any care, treatment or service provided by a licensed provider who is physically in a different location as the patient through the use of health information and technology communications; includes remote patient monitoring as an allowable telehealth service under the definition of “Interpretive Services”; allows telehealth to be used to establish provider-patient relationship if a prior relationship was not establish through in-person delivery of services.
- Creates practice standards for the providing of chiropractic services through telehealth.
- Allows physical therapist assistant supervision to be conducted through telehealth; allows physical therapist to oversee care provided by a physical therapist assistant through telehealth when delivered in a home health, long-term care, or school setting; establishes the definition of “telecommunications” as synonymous with “telehealth” and includes the transfer of data or exchange of educational or related information by means of audio, video, or data communications.
After a full review, we have identified the major legislative changes that will hold the most value for clients in need of what SimpleVisit offers.
The first type of noteworthy changes affects direct-to-patient telemedicine. New York passed a law removing the originating site and geographic restriction from its Medicaid programs. Texas approved a rule waiving the same restrictions for services delivered via telehealth in workman’s compensation cases. The Federal Government removed those restrictions for acute stroke and end-stage renal disease care effective in 2019, and for a large number of specified ACOs effective in 2020.
The second type of legislation enacts new private payer parity laws. Parity laws require insurance companies who offer private or commercial plans to cover and/or reimburse for services delivered via telemedicine in the same manner as they do for the same services delivered via in-person or face-to-face visits. Iowa, Kansas, and Kentucky all passed new laws with language regarding parity for telemedicine services, though in some cases it is unclear whether it is coverage parity or payment parity. Arizona passed a law requiring parity for a short list of specified conditions. The state of Washington also passed a parity pilot program limited to only 5 medical conditions over the next few years.
The last area of interest pertains to those states who passed legislation allowing their state medical boards to enter into the Interstate Medical Licensing Compact, which allows doctors to apply for and receive a license to practice in the other states who are a part of this compact – visit imlcc.org for an interactive map showing the 34 states currently active in or in the process of becoming active in this compact. Washington DC, Maryland, and Vermont all passed such legislation this year. Nebraska also passed legislation allowing applicable licensing boards to enter into an inter-jurisdictional compact for psychologists and an interstate compact for EMS personnel.
Looking ahead to the coming year, we expect to see continued changes in policy and law surrounding telemedicine.
The Bipartisan Budget Act will not complete implementation until 2020, and those providers who work with Medicare are anxiously waiting to see how the expanded telemedicine ACO waiver works in actual practice.
There are currently 221 pieces of proposed legislation and regulatory changes pending concerning telemedicine – many of them address the national Opioid Crisis. Telemedicine has been identified as one of the most promising tools we can use to expand access to otherwise-sparse Addiction Treatment services throughout the nation.
25 of the pending pieces of legislation deal with the location where services are being provided, 23 with private payer regulations, and 19 with cross-state licensing.
We are seeing more providers recognized as able to provide telemedicine services, more diagnoses and medical conditions included in the scope of coverage language, and more states show interest in telemedicine as a whole, as well as seeing just how far innovation through telemedicine can take them and help their population. Notably, there are three bills introduced this past year that would allow VA providers to treat military members anywhere in the country, regardless of licensing concerns and crossing state lines.
There are also multiple bills pushing for exceptions to the originating site and geographic location restrictions in Medicare law. This is important even to providers who do not accept Medicare, as the Federal regulations on telemedicine often serve as a benchmark or a “minimum coverage required” guideline for states who are forming their own telehealth laws. As changes come in that sector, we will see more and more states following suit, relaxing restrictions on the practice of telehealth and incorporating it more and more into our everyday conversations about medicine in its entirety. The future is bright for telehealth.
For more information on the laws and regulations in your state, visit the Center for Connected Health Policy’s laws and reimbursement interactive map and searchable tracker at cchpca.org/state-laws-and-reimbursement-policies
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