Does My County/city Qualify As An Hpsa Under Medicare Guidelines
The Health Resources and Services Administration determines HPSAs, and the Census Bureau determines MSAs. You can access HRSAs Medicare Telehealth Payment Eligibility Analyzer
to determine a potential originating sites eligibility for Medicare telehealth payment. More information is available online at the CMS Medicare Learning Network, including proper CPT codes to use when billing for specific Medicare telehealth interactions.
When Can You Use Telehealth
Since COVID-19
Since March 6, 2020, Medicare has covered telehealth appointments for all Medicare beneficiaries for office, hospital visits and other services that typically take place in person.
Its still unclear exactly what telehealth benefits will be covered once the COVID-19 pandemic is over. CMS has proposed a permanent expansion of telehealth coverage to make it easier and more convenient for people receiving Medicare to access care, especially those living in rural areas.4
Before COVID-19
Prior to the coronavirus pandemic, Medicare only covered and paid for telehealth services for seniors in rural areas who left their home to have a virtual appointment at a nearby clinic, hospital or other medical facility.
Many appointments were with specialists that patients otherwise would not have been able to meet with in person due to distance.
Medicare limited the eligible facilities where seniors could have their appointments to:5
- speech language pathologists
- audiologists
While this public health emergency lasts, Medicare wont check that patients have an established relationship with practitioners theyre connecting with via telehealth, which was previously a requirement for a telehealth visit.8
Medicaid Reimbursement Regarding Remote Patient Monitoring & More
Live video is the most effective reimbursed form of telehealth services offered. Although live videos are most accepted, there are some restrictions in Medicaid reimbursements, including the type of provider offering the service, the setting, and types of telehealth service, such as consultations or office visits. Store-and-forward services are generally reimbursed for real-time delivery only yet may still face some limitations. Store-and-forward is being initiated in various states via CPT and CTBS codes to fit the description to be eligible for reimbursement.
Remote patient monitoring garners forms of reimbursement in 29 out of 50 states. However, most states that extend RPM have many restrictions, including limitations on the information to be collected, the type of monitoring devices utilized, which types can monitor symptoms, and only offering reimbursement to home health agencies. Although there are many restrictions regarding Medicaid reimbursements, there have been some expansions regarding reimbursement eligibility for telephone, audio-only, and email telehealth services, mainly due to the pandemic.
As mentioned above, CTBS codes, which CMS established, are still widely employed by many states, including remote evaluation of pre-recorded information, virtual check-ins, remote physiological monitoring codes, and audio-only service codes. Much of Medicaid grants CTBS codes recognizable under telehealth but garner Medicares coding for reimbursement eligibility.
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State Actions To Expand Medicaid Telehealth Coverage And Access
The Centers for Medicare and Medicaid Services has released a COVID-19 FAQ document which notes the broad flexibility states have to cover telehealth through Medicaid and addresses flexibilities for telehealth payment rates, reporting, and managed care organizations , among others. To further guide states in establishing new telehealth policies to increase access during the pandemic, CMS released a State Medicaid & CHIP Telehealth Toolkit on April 23, 2020. The toolkit identifies key areas of telehealth for state consideration:
As referenced in the toolkit, states can broaden access to telehealth using Medicaid emergency authorities, which require CMS approval. As of June 15, 2020, 51 states are using Section 1135 waivers to allow out-of-state providers with equivalent licensing in another state to provide care to Medicaid enrollees. Twelve states are using Disaster-Relief SPAs to authorize telehealth payment variation and/or to include ancillary telehealth delivery costs. States are also using Section 1915 Waiver Appendix K strategies to amend home and community-based services to broaden access to telehealth: 47 states are permitting virtual eligibility assessments and service planning meetings and 44 states are allowing electronic service delivery.
In addition to the steps noted above, states are also issuing guidance to broaden telehealth access for specific services, including:
Medicare Telemedicine Health Care Provider Fact Sheet
Medicare coverage and payment of virtual services
INTRODUCTION:
Under President Trumps leadership, the Centers for Medicare & Medicaid Services has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. These policy changes build on the regulatory flexibilities granted under the Presidents emergency declaration. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans particularly those at high-risk of complications from the virus that causes the disease COVID-19 are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.
Prior to this waiver Medicare could only pay for telehealth on a limited basis: when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service.
TYPES OF VIRTUAL SERVICES:
There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries summarized in this fact sheet: Medicare telehealth visits, virtual check-ins and e-visits.
KEY TAKEAWAYS:
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Cms Approach To Reviewing Telemedicine Spas
- States are not required to submit a SPA for coverage or reimbursement of telemedicine services, if they decide to reimburse for telemedicine services the same way/amount that they pay for face-to-face services/visits/consultations.
- States must submit a reimbursement SPA if they want to provide reimbursement for telemedicine services or components of telemedicine differently than is currently being reimbursed for face-to-face services.
- States may submit a coverage SPA to better describe the telemedicine services they choose to cover, such as which providers/practitioners are where it is provided how it is provided, etc. In this case, and in order to avoid unnecessary SPA submissions, it is recommended that a brief description of the framework of telemedicine be placed in an introductory section of the State Plan and then a reference made to telemedicine coverage in the applicable benefit sections of the State Plan. For example, in the physician section it might say that dermatology services can be delivered via telemedicine provided all state requirements related to telemedicine as described in the state plan are otherwise met.
Going Backward With Telehealth
While requiring in-person visits to establish the doctor-patient relationship was a part of many states telehealth medicare laws in years past, the trend has been moving towards allowing providers to see new clients via telehealth for the first visit. Enter COVID-19 and the emergency measures put in place to allow for greater coverage and access to healthcare. Many mental health providers closed their brick-and-mortar offices and have guided their new and existing clients to telehealth use to reduce the spread of the virus.
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Restrictions On Medicare Telehealth Coverage
In the past, Medicare has placed some restrictions on telehealth coverage.
For example, Medicare formerly covered telehealth services in only certain circumstances, including when a person lived in a rural area and was staying in a facility such as a skilled nursing home or hospital-based dialysis facility.
However, Medicare lifted many restrictions due to the Coronavirus Preparedness and Response Supplemental Appropriations Act, which became law in March 2020.
In the past, changes to the coverage of telehealth services were effective for a calendar year. The emergency legislation and coverage expansion in 2020 does not clearly state whether the changes are permanent.
As a result, a person may want to check with their healthcare professionals office if they want to continue to use telehealth for the foreseeable future.
New Medicare Law Requires In
In December 2020, the Consolidated Appropriations Act of 2020, section 123 includes language that requires behavioral health providers to have seen their client in person during the prior six months before a telehealth visit will be covered by Medicare. Further, providers must have in-person visits on a regular interval to be determined by the Health and Human Services Department for telehealth visits to be covered by Medicare.
As discussed in the blog by Nate Lacktman, a partner at Foley & Lardner who chairs the Telemedicine and Digital Health Industry team the in-person exam requirement is at odds with a direction that telehealth policy has moved over the last decade. It disrupts Medicares historical approach which is to defer to state laws on professional practice requirements and clinical standards of care.
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Don’t Have A Smartphone
Sunshine Health is proud to work with SafeLink Wireless® to offer you this cell phone program at no cost.
Approved members get a free smartphone and these free, monthly benefits:
- 3 GB of data
- 3 Telehealth calls per month and written prescriptions to a local pharmacy through Doc.com
- Unlimited text messages
- Free calls to Sunshine Health Member Services
- Some limitations may apply.
- Visit SafeLink’s website to apply online.
Managed Care: Face To Face Visits
Service coordination visits
Effective immediately MCOs may allow service coordination visits to be completed in person when requested by the member receiving services. Telehealth should be the primary modality for service coordination visits if in-person is not feasible. Beginning September 1, 2021 MCOs must offer service coordination visits in person when requested by the member receiving services.
For all members, including those with levels of care and ISPs that have been extended, MCOs and MMPs must continue to conduct service coordination and service planning telephonic or telehealth visits to ensure members are receiving needed services.
MCOs and MMPs are required to conduct the same number of contractually required annual outreach contacts, at this time. This applies to facility and community members.
All MCOs and MMPs may use telehealth or telephonic processes to:
- Coordinate discharge planning for members transitioning from hospitals.
- Conduct joint meetings with Local Intellectual and Developmental Disability Authorities , Case Management Agencies and Direct Service Agencies.
- Allow providers to provide mental health targeted case management services.
- Conduct Screening and Assessment Instruments and Individual Service Plans for STAR Kids members not in the Medically Dependent Childrens Program .
Extended enrollment MDCP and STAR+PLUS HCBS
Telehealth Assessments
Beginning September 1, 2021 MCOs must offer waiver assessments in person when requested by the member.
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Providing Noncovered Audiology And Speech
Medicares temporary coverage of telehealth services means that audiologists andSLPs may no longer enter into a private pay arrangement with Medicare beneficiaries for thoseservices that are now included on Medicares telehealth list. Clinicians may continue to accept private payments from Medicare beneficiaries for services not included on the telehealth list. However, if Medicare adds more services to the approved telehealth list, enrolled Medicare providers must reimburse their patients for those services and submit claims to Medicare for payment. Unenrolled providers must also reimburse their patients, but may not submit claims to Medicare for reimbursement and may not enter into private pay agreements with Medicare beneficiaries for covered services.
School And Health Related Services
School Health and Related Services are provided to students with a disability to ensure individuals benefit from special education programs.
During any temporary closure of schools for in-person classroom attendance, schools may continue to provide instruction using alternative methods of delivery. Read the TMHP Bulletin posted April 24 for more details.
Beginning July 1, 2021, SHARS providers will no longer get the Certification of Funds letter through email in addition to the mailed letter. Read the TMHP Bulletin posted on June 14 for details.
If schools are unable to provide instruction using alternative methods of delivery, providers can work with MCOs to ensure clients have access to needed services during this time.
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Medicaid & Telemedicine: Top 10 Faqs
At eVisit, we get a lot of interest from healthcare providers who want to offer better care access to their Medicaid patients. And why not? Telemedicine can be a great way to make sure even your Medicaid patients who live far away or have trouble getting into the office get all the care they need.
The good news is that in most states, Medicaid does cover telemedicine services in some form. But like with Medicare, there are some basic guidelines and restrictions youll need to follow, depending on what state youre in.
Here are the top questions about how telemedicine works with Medicaid answered!
Clinical Ethical And Legal Considerations
ASHA guidelines state that the use of telehealth must be equivalent to the quality of in-person services and must adhere to the ASHA Code of Ethics, audiology or speech-language pathology scope of practice, state and federal laws, and ASHA policy.
Clinicians must also consider their own skill/experience and the patients needs and capabilities before beginning telehealth services. To ensure compliance, you should do the following:
- Check whether your state allows telehealth by audiologists or SLPs on ASHAs state-by-state pages.
- Follow best practice and legal requirements for telehealth, including using Health Insurance Portability and Accountability Act -compliant technology. Learn more through ASHAs Practice Portal on telepractice, the Center for Connected Health Policy, and the American Telemedicine Association.
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Why Gao Did This Study
To respond to the COVID-19 pandemic, states have expanded their coverage of telehealth in Medicaid, a jointly financed federal-state health care program for low-income and medically needy individuals.
The CARES Act includes a provision for GAO to report on the federal response to the pandemic. In addition, GAO was asked to examine the use of Medicaid flexibilities in response to COVID-19. This report describes selected states’ telehealth use before and during the pandemic, and experiences with and plans for telehealth. It also evaluates, among other things, CMS’s telehealth oversight of quality of services.
GAO analyzed state-reported data on telehealth use in six states selected, in part, based on variation in geography, Medicaid program size, and percentage of population living in rural areas. GAO reviewed federal oversight documents, interviewed state and federal Medicaid officials, and assessed CMS oversight against CMS guidance on using data to identify disparities in health care and target improvements.
What Is The Difference Between Telehealth Vs Telemedicine
Telehealth is the broad scope of care that includes telemedicine. Telemedicine includes clinical services. Whereas telehealth consists of both clinical and non-clinical services.
For example, doctor training and administrative meetings would fall under telehealth. And, a virtual follow up doctors visit would be telemedicine. To make things more complicated, the World Health Organization uses the term telematics to describe health activities that take place via communication technology. Telematics is both telemedicine and telehealth.
So, all telemedicine is telehealth. But not all telehealth is telemedicine. And, telematics is both.
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Coding And Billing Guidelines
Audiologists and SLPs providing telehealth services should report the same CPT codes and follow the same coding guidelines as they would for in-person services, including same-day billing rules and time requirements. For example, a brief check-in via telecommunication technology should not be reported with an evaluation or treatment CPT code and is not considered a Medicare telehealth service.
Medicare telehealth services are reimbursed at the same rate as in-person services paid under the Medicare Physician Fee Schedule for Part B services.
Legal And Regulatory Foundation
Although CMS has temporarily waived certain telehealth laws, allowing audiologists and SLPs to provide some telehealth services during the public health emergency, Section 1834 of the Social Security Act precisely defines telehealth as a service provided by a physician or practitioner under the Medicare benefit. The SSA currently classifies audiologists and SLPs as suppliers. This means standing Medicare law doesnt recognize audiologists and SLPs for reimbursement for telehealth services. This statutory exclusion eliminates such services from Medicare service delivery requirements and shifts financial liability for paying for the services to beneficiaries at the discretion of the patient. As a result, audiologists and SLPs may provide non-covered telehealth services to Medicare beneficiaries and enter into private pay contracts to receive reimbursement, if the patient agrees. This interpretation is supported by a series of direct communications with CMS staff, engagement with external experts familiar with Medicare law, and in consultation with other professional associations.
Section 50.3.2 of Chapter 30 of the Medicare Claims Processing Manual also makes it clear that when services are statutorily excluded from coverage, Medicare policy does not apply, there is no Medicare reimbursement, and the use of an ABN is voluntary.
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Appeals And Fair Hearings
Appeals
In response to COVID-19, HHSC requires all MCOs, DMOs and MMPs to extend the timeframes for the number of days members, legally authorized representatives or authorized representatives can request an appeal through January 31, 2022:
- Normally 60 days to request an MCO internal appeal, now 90 days.
The timeframe to request continuation of benefits upon receipt of the adverse benefit determination was extended to 30 days through June 30, 2021. Effective July 1, 2021, MCOs, DMOs and MMPs must enforce the normal, regular and established timeframes that members have to request for continuation of benefits, which is the later of 10 days from the date the MCO notice of adverse benefit determination is mailed or the date services will change.
HHSC also requires all MCOs, DMOs and MMPs to accept oral requests for appeals without the member having to provide a written request through January 31, 2022.
Fair Hearings
In response to COVID-19, HHSC is also extending the timeframes for the following through January 31, 2022:
- Number of days members, legally authorized representatives or authorized representatives have to request a fair hearing.
- Normally 120 days to request a fair hearing after the internal MCO appeal, now 150 days.If the timeframe for a member to request a fair hearing would have expired in January 2022, they will have an extra 30 days from that expiration date to request a fair hearing.
