The California Department of Health Care Services (DHCS) released two draft proposals impacting telehealth policy in the state’s Medicaid program known as Medi-Cal. The Department is soliciting feedback from interested stakeholders on both proposals.
California State Plan Amendment
The first proposal is a State Plan Amendment (SPA) intended for submission to the Centers for Medicare and Medicaid Services (CMS), that provides clarification as to when services provided outside of the “Four Walls” of a federally qualified health center (FQHC) or rural health center (RHC) is eligible for the prospective payment system (PPS). It is proposed that all such services be paid the PPS when rendered to homebound, migratory, seasonal workers and homeless patients, patients in the hospital, dental services rendered to established patients by a contracted dental provider, and telehealth services provided to its established patients when certain requirements are met.
The proposed SPA lays out several requirements that apply to all of the exceptions listed above for services rendered outside of the Four Walls, and others that apply specifically to telehealth and store-and-forward services. Among the general requirements, is the necessity to document services with the same specificity as would be required when services are provided within the Four Walls; the FQHC or RHC must provide written policies that describe all of the services that will be provided outside of the Four Walls, along with circumstances for which the services will be provided; and all HRSA policies and procedures for approved scope of projects apply. Additionally, the SPA specifies that if the patient is assigned to a managed care plan that is responsible for the services being furnished by the FQHC or RHC, the FQHC or RHC must properly bill the managed care plan first for the services and meet the plan’s applicable credentialing requirements.
The telehealth specific requirements include the following:
- “The telehealth communication system must allow the provider at the distant site to view the patient’s condition directly without the interposition of a third person’s judgement;
- The originating site must have a current written agreement with the distant site to furnish the telehealth services. If the originating site compensates the distant site for the provision of telehealth services, the distant site cannot bill for the services outside the PPS rate.
- The originating site must provide its established patient with specific information, such as the risks, benefits and consequences of telehealth, confidentiality protections, etc. … (See SPA text for complete details).
- The originating site must document in the established patient’s health record the patient’s consent to telehealth services.
- All health information transmitted during the delivery of telehealth services must be maintained by both the originating and distant sites. Additionally, both originating and distant sites must document that the telehealth services were medically necessary with the same specificity required to obtain approved treatment authorization request (TAR); and
- The telehealth services at the distant site must be provided by a licensed health care provider in California.”
Additionally, the SPA lays out specific rules for billing as well as for store-and-forward services provided for ophthalmology, dermatology, and dentistry for its established patients. To learn more about the draft SPA proposal, see the full text.
DHCS has requested that any comments be submitted via e-mail to [email protected] and indicate SPA 18-0055 in the subject line by Nov. 2, 2018 no later than 5 pm.
California DHCS Releases Draft Changes to Telehealth Medicaid Policy
Additionally, DHCS is also proposing to update and clarify its telehealth policy manuals within the Medi-Cal program for:
- Managed Care
- Indian Health Services
- Family Plan, Access, Care and Treatment (Family PACT)
Among the most intriguing and exciting proposals in the draft is allowing the distant site/treating provider to decide when it is appropriate for telehealth to be used and whether it should be via live video or store-and-forward. E-consult (provider to provider consultation), falling under the auspice of store-and-forward, would also be reimbursed through two CPT codes, making California along with Connecticut the only state Medicaid programs in the country reimbursing for that particular service. Under Medi-Cal’s proposed draft policy, the services would still need to be a Medi-Cal reimbursable service and the CPT or HCPCS code definition should allow for technology to be used, but this proposed policy is far more advanced than most any other Medicaid policies seen in the country and follows what CCHP has suggested for many years: let the provider and patient decide whether it is appropriate to use telehealth in that particular moment.
Other intriguing proposals in the draft include expansion of the originating site to include the home and what appears to be other non-clinical locations as well as the aforementioned inclusion of the two e-consult codes.
Items that are missing or raise questions are no reimbursement for remote patient monitoring, confusion on licensing and location requirements of the telehealth provider and how does the proposed change in the manual intersect with the SPA? For example, a “visit” for an FQHC and RHC is defined as occurring “face-to-face” in the proposed Medi-Cal policy manual for FQHC/RHCs, indicating that store-and-forward visits (which do not occur face-to-face) would potentially be excluded from coverage for FQHCs and RHCs. However, the SPA indicates that FQHCs and RHCS may bill the PPS rate for ophthalmology, dermatology and dentistry store and forward services provided to established patients if certain requirements are met (as noted in previous SPA section). It is currently unclear how to reconcile these seemingly conflicting policies between the documents.
Despite these points that need clarification, the proposed draft Medi-Cal telehealth policy represents a remarkable step forward. Since the passage of and enactment of AB 415, the Telehealth Development Act, CCHP has long noted that DHCS had the ability in law to create a more expansive telehealth policy. We are pleased to see such innovative and forward movement by the State.