In late 2018, the California Department of Health Care Services (DHCS), which administers California’s Medicaid program (Medi-Cal), released proposed updates to their telehealth policy manuals, including those for fee-for-service, managed care, Indian Health Services, Family Plan, Access, Care and Treatment (Family PACT), dentistry and federally qualified health centers/rural health clinics (FQHC/RHCs). Proposed policy changes included 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 under the new policy. As part of their drafting process, DHCS solicited feedback from telehealth stakeholders on their proposed policy.
On December 17, they conducted a webinar to review and respond to comments and later that week released formal written responses to comment letters, which are currently available on the DHCS telehealth webpage. The following are some of the highlights from their responses, and appear in the order of the frequency the response appeared in the document. See the full excel document for responses that appeared less than five times.
(*Please note, although CCHP paraphrased the comments in a few places for consolidation purposes, CCHP attempted to keep them as close to originally written as possible.)
Provider Enrollment/Eligibility: In response to questions about requirements regarding being an eligible Medi-Cal provider, DHCS reports having changed their originally proposed language in the provider manual to the following: “The health care provider rendering Medi-Cal covered benefits or services via a telehealth modality must be licensed in California, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group. The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.” (Appeared 16 times in responses)
Remote Patient Monitoring: In response to requests DHCS include remote patient monitoring in their reimbursement policy, DHCS responded with the following: “RPM is not part of this policy update but, as always, DHCS will continue to evaluate and assess different modalities for delivery of Medi-Cal covered benefits and services.” (Appeared 9 times in responses)
Informed Consent: In response to feedback that the word “informed” should be removed from the manual, to align with existing California law, DHCS responded by stating: “DHCS has removed the word “informed” from the consent section and revised the section to allow written consent. DHCS has also streamlined and further clarified the consent requirement section to apply clearly and equally across the board for the telehealth modality.” (Appeared 9 times in responses). Additionally, in response to feedback regarding the burden of obtaining informed consent and requests for clarification regarding whether the consent must be obtained and/or maintained at both the originating and distant site, DHCS said the following: “State law requires the health care practitioner initiating the use of telehealth to inform the beneficiary and obtain consent and maintain appropriate documentation. Documentation should be maintained in the beneficiary’s medical record at both the originating and distant site, in the event the health records are not shared. If a health care practitioner or health care group/organization has a general consent protocol that specifically references use of telehealth as a modality, then this would satisfy the consent requirement.” (Appeared 8 times in responses)
E-Consult Codes: In response to feedback related to appropriate billing codes for e-consult, DHCS reports that they have reviewed “the available procedure codes, including those proposed by the federal Centers for Medicare and Medicaid Services (CMS) for the Medicare program. DHCS has revised the store and forward/e-consult policy for additional clarity and selected a single and more appropriate CPT-4 code for billing with the GQ modifier. DHCS believes that these revisions more closely align the store and forward/e-consult policy with current industry practices while still meeting the needs of the Department and our beneficiary population. Moving forward, DHCS will continue to have ongoing discussions around telehealth modalities and will also continue to evaluate, assess, and modify its policy, as needed.” (Appeared 8 times in responses)
Appropriate Services: In response to comments that DHCS clarify the appropriate services that can be delivered via telehealth, DHCS said the following: “DHCS’ proposed policy does not list the types of benefits or services appropriate to be provided via a telehealth modality. Instead, DHCS provides parameters around what benefits or services may be appropriate to provide via a telehealth modality, provides examples of what is not appropriate, and speaks to documentation requirements in the event of an audit. This broadness is intentional to allow the health care practitioner rendering services or benefits sufficient flexibility to make medically appropriate decisions regarding the appropriate delivery modality for a particular beneficiary. That said, DHCS will review the language referenced and make additional edits for clarity, if needed.” (Appeared 6 times in responses)
Store-and-Forward for FQHCs/RHCs/IHS: In response to comments that the definition of a “visit” would eliminate the FQHC/RHC’s ability to be reimbursed for store-and-forward including e-consult, DHCS said the following: “DHCS agrees that these clinics are a vital provider in the health care network. Please note that FQHCs and RHCs may be reimbursed for the visit of an established patient through the use of store and forward technology. FQHCs and RHCs may also be reimbursed for visits conducted via live video. E-Consult is not a reimbursable visit for FQHCs, RHCs or Indian Health Service Providers.” (Appeared 6 times in responses)
Originating Sites: In response to feedback that DHCS consider including other examples of acceptable originating sites for a patient in addition to the home (such as a school) DHCS said the following: “BPC Section 2290.5(a)(4) defines the originating site as the patient’s location or where store and forward originates. DHCS’ proposed policy aligns with state law and does not limit the originating site setting. The definition provides clarity that it may include, but is not limited to, a hospital, medical office, community clinic, or the patient’s home.” (Appeared 5 times in responses)
To see all the responses from DHCS, including those specific for teledentistry, Family PACT and the All Plan Letter, access the full response document via the DHCS webpage on telehealth. The final policy is expected to be released publicly and go into effect in Spring 2019.