DELAWARE

MASTER MEDICAID TELEHEALTH LAWS
WITH THE HELP FROM GD

Summary

Delaware Medical Assistance Program (DMAP) reimburses for live video telemedicine for certain providers and for patients at specific sites. DMAP does not reimburse for store-and-forward and makes no reference to remote patent monitoring

 

Definitions

“Telemedicine” is a cost-effective alternate to face-to-face encounters where access to care is compromised due to the lack of available service providers in the patient’s geographical location.
This definition is modeled on Medicare’s definition for telehealth services located at 42 CFR Sec. 410.78. Note that the Federal Medicaid statute does not recognize telemedicine as a distinct service.
For purposes of DMAP, telemedicine is the use of medical or behavioral health information exchanged from one site to another site via an electronic interactive (two-way, real-time) telecommunications system to improve a patient’s health.

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/2019. Ch. 16 Telemedicine (Accessed Mar.2019).

Telemedicine is the use of medical or behavioral health information exchanged from one site to another via an electronic interactive telecommunications system to improve a patient’s health.
Telemedicine services are provided with specialized equipment at each site including real-time streaming via the use of:
• Video Camera
• Audio Equipment
• Monitor
• The telecommunications must permit real-time encryption of the interactive audio and
video exchanges with the consulting provider

Source: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 14, 2016. Sec. 1.8.
(Accessed Mar. 2019)

Live Video

Policy

DE Medicaid reimburses for live video telemedicine services for up to three different consulting providers for separately identifiable telemedicine services provided to a member per date of service.

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine, Sec. 16.8.2 & Adult Behavioral Health Service Certification, and Reimbursement. Dec. 14, 2016. Sec. 1.8. (Accessed Mar. 2019).

The GT modifier (which indicates the service occurred via interactive audio and video telecommunication system) can be used for Early and Periodic Screening, Diagnostic and Treatment Services through the School-Based Health Services program.

Source: DE School Based Health Services Specific Policy Manual, pg. 57 (Sept. 1, 2016). (Accessed Mar. 2019).

The referring provider is not required to be present at the originating site; however, the recipient of the service must be present.
Reimbursement to the referring provider will only occur when providing a separately identifiable covered service.

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine (Accessed Mar. 2019).

The recipient:
• Must be able to verbally communicate, either directly or through a representative,
with the originating and distant site providers,
• Must be able to receive services via telemedicine, and
• Must have provided consent for the use of telemedicine

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine (Accessed Mar. 2019).
Eligible Services / Specialties

Interactive audio and video telecommunications can be used for Early and Periodic Screening, Diagnostic and Treatment Services through the School Based Health Services program.

Source: DE School Based Health Services Specific Policy Manual, pg. 62 (Sept. 1, 2016). (Accessed Mar. 2019).
Eligible Providers

Eligible distant site providers include:
• Inpatient/outpatient hospitals (including ER)
• Physicians (or PAs under the physician’s supervision)
• Certified Nurse Practitioners
• Nurse Midwives
• Licensed Psychologists
• Licensed Clinical Social Workers
• Licensed Professional Counselors of Mental Health
• Speech Language Therapists
• Audiologists
• Other providers as approved by the DMAP

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine & Adult Behavioral Health Service Certification and Reimbursement. Dec. 14, 2016. Sec. 1.8. (Accessed Mar. 2019).
Eligible Sites

An originating site refers to the facility in which the Medicaid patient is located at the time the telemedicine service is being furnished. It can include a Medical Facility site or Medical Professional Site.
Medical Facility Sites:
• Outpatient Hospitals
• Inpatient Hospitals
• Federally Qualified Health Centers
• Rural Health Centers
• Renal Dialysis Centers
• Skilled Nursing Facilities
• Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
• Intermediate Care Facilities/Institutions for Mental Diseases (ICF/IMDs)
• Outpatient Mental Health/Substance Abuse Centers/Clinics
• Community Mental Health Centers/Clinics
• Public Health Clinics
• PACE Centers
• Assisted Living Facilities
• School-Based Wellness Centers
• Patient’s Home
• Other Sites as approved by DE Medicaid
Medical Professional Sites:
• Physicians (or Physicians Assistants under the supervision of a physician)
• Certified Nurse Practitioners
• Medical and Behavioral Health Therapists

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine & Adult Behavioral Health Service Certification and Reimbursement. Dec. 14, 2016. Sec. 1.8. (accessed Mar. 2019).
Facility/Transmission Fee

A facility fee for the following originating site providers is covered.
Facility fees for the distant site are not covered.
Only one facility fee is permitted per date, per member

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine (Accessed
Mar. 2019).

Store-and-Forward

Policy

Asynchronous or “store-and-forward” applications do not meet the DMAP definition of telemedicine.

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine & Adult Behavioral Health Service Certification and Reimbursement. Dec. 14, 2016. Sec. 1.8. (Accessed Mar. 2019).
Email / Phone / Fax

Telephone, chart review, electronic mail messages, facsimile transmissions or internet services for online medical evaluations are not considered telemedicine

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine (Accessed Mar. 2019).

Federally Qualified Health Centers
Telephone consultations are covered services that are included in the payment made to the FQHC and should not be billed as an encounter.

Source: Delaware FQHC Provider Specific Policy Manual, 8/1/18. Sec. 2.1.2 (Accessed Mar. 2019).
Consent

Recipient must provide written consent to use telemedicine. It must be obtained by either the referring, consulting, or distant provider. An exception is made for involuntary detention and commitment. An exception applies when a DMAP recipient is detained or committed to a facility for care

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine (Accessed Mar. 2019) & Adult Behavioral Health Service Certification and Reimbursement. Dec. 14, 2016. Sec. 1.8. (Accessed Mar. 2019).
Out of State Providers

The Distant site provider must be located within the continental US and enrolled in the DE Medicaid program or in a DE Medicaid Managed Care Organization to be reimbursed for services.

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine pg. 77 & 81. (Accessed: March 2019).
Miscellaneous

Provider manual lays out three different models for prescribing:
• First Model: Distant site provider consults with referring provider about appropriate medication. Referring provider executes prescription.
• Second Model: Consulting provider works with medical professional at the originating
site to provide front line care, including prescription writing.
• Third Model: The consulting provider prescribes and sends/calls-in the initial prescription.
For stimulants, narcotics and refills, hard copy prescriptions can be written and sent via delivery service to the referring site for the consumer to pick up a couple days after the appointment (see manual for more details).

 

Source: DE Medical Assistance Program. Practitioner Provider Specific Manual, 2/1/19. Ch. 16 Telemedicine, p. 83. (Accessed Mar.
2019) & Adult Behavioral Health Service Certification and Reimbursement. Dec. 14, 2016. Sec. 1.8, p. 14. (Accessed Mar. 2019).

Confidentiality, privacy and electronic security standards for telemedicine as well as a contingency plan required of telemedicine sites is listed in the DE Behavioral Health Service Certification and
Reimbursement manual.

Source: DE Medical Assistance Program. Adult Behavioral Health Service Certification and Reimbursement. Dec. 14, 2016. Sec.
1.8. (Accessed Mar. 2019).

Private Payer Laws

Definitions

Group and Blanket Insurance, & Health Insurance Contracts
Also applies to: Physicians, Podiatry, Optometry, Chiropractic, Dentistry, Nursing, Occupational Therapy, Mental Health, Psychology, Dietetic and Nutrition Therapy, Pharmacy, and Clinical Social Work

Telehealth means the use of information and communications technologies consisting of telephone, remote patient monitoring devices or other electronic means which support clinical health care, provider consultation, patient and professional health-related education, public health, health administration, and other services as described in regulation

 

Source: Title 18, Sec. 3370; & Title 18, Sec. 3571R; DE Code Title 24, Sec. 1702, Sec. 502, Sec. 701, Sec. 1101, Sec. 1902, Sec.2002, Sec. 2101, Sec. 2502, Sec. 3002, Sec. 3502, Sec. 2500, & Sec. 3902. (Accessed Mar. 2019).

Group and Blanket Insurance, & Health Insurance Contracts
Telemedicine means a form of telehealth which is the delivery of clinical health care services by
means of real time two-way audio, visual or other telecommunications or electronic communications, including the application of secure video conferencing or store-and-forward transfer technology to provide or support healthcare delivery which facilitate the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care by a health care provider practicing within his or her scope of practice as would be practiced in-person with a patient, and legally allowed to practice in the state, while such patient is at an originating site
and the health care provider is at a distant site.

Source: Title 18, Sec. 3370; & Title 18, Sec. 3571R. (Accessed Mar. 2019).
Requirements

Private payers must provide coverage for the cost of health care services provided through telemedicine, and telehealth as directed through regulations by the Department. Insurers must pay for telemedicine services at the same rate as in-person. Payment for telemedicine must include reasonable compensation to the originating or distant site for the transmission cost.
Private payers may not impose an annual or lifetime dollar maximum on coverage for telemedicine services other than what would apply in the aggregate to all items and services covered under the policy. Additionally, no copayment, coinsurance, or deductible amounts, or any policy year, calendar year, lifetime, or other durational benefit limitation or maximum for benefits or services may be imposed unless equally imposed on all terms and services under the policy.

 

Source: Title 18, Sec. 3370; & Title 18, Sec. 3571R. (Accessed Mar. 2019).

Parity

Payment Parity

Insurers must pay for telemedicine services at the same rate as in-person.

 

Source: Title 18, Sec. 3370; & Title 18, Sec. 3571R. (Accessed Mar. 2019).
Service Parity

A payer must reimburse the provider for the diagnosis, consultation, or treatment of the patient on the same basis as in-person services for telemedicine.

 

Source: Title 18, Sec. 3370; & Title 18, Sec. 3571R. (Accessed Mar. 2019).

Professional Regulation /
Health & Safety

Definitions

Applies to: Physical Therapy “Telehealth, as set forth in the Board’s rules and regulations, means the use of electronic communications to provide and deliver a host of health-related information and healthcare services, including physical therapy and athletic training related information and services, over large and small distances. Telehealth encompasses a variety of healthcare and health promotion activities, including education, advice, reminders, interventions, and monitoring of intervention.”

 

Source: DE Code. Title 24, Sec. 2602. (Accessed Mar. 2019).

Applies to: Physicians, Podiatry, Optometry, Chiropractic, Dentistry, Nursing, Occupational Therapy, Mental Health, Psychology, Dietetic and Nutrition Therapy, Pharmacy, and Clinical Social Work “Telehealth” means the use of information and communications technologies consisting of telephones, remote patient monitoring devices or other electronic means which support clinical health
care, provider consultation, patient and professional health-related education, public health, health administration, and other services as described in regulation.

Source: DE Code. Title 24, Sec. 2002. (Accessed: March 2019).

Applies to: Physicians, Podiatry, Optometry, Chiropractic, Dentistry, Nursing, Occupational Therapy, Mental Health, Chemical Dependency Professionals, Psychology, Dietetic and Nutrition Therapy, Clinical Social Work, and Professional Art Therapists
Telemedicine means a form of telehealth which is the delivery of clinical health care services by means of real-time two-way audio, visual or other telecommunications or electronic communications, including the application of secure video conferencing or store-and-forward transfer technology to provide or support healthcare delivery which facilitate the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care by a licensee practicing within his or her scope of practice as would be practiced in-person with a
patient and with other restrictions as defined in regulation.

Source: DE Code Title 24, Sec. 1702, Sec. 502, Sec. 701, Sec. 1101, Sec. 1902, Sec. 2002, Sec. 2101, Sec. 2502, Sec. 3002, Sec. 3060, Sec. 3502, Sec. 3802, & Sec. 3902. (Accessed Mar. 2019).

Applies to: Mental Health and Chemical Dependency Professionals
“Telemedicine” means a form of telehealth which is the delivery of clinical health-care services by means of real-time 2-way audio, visual, or other telecommunications or electronic communications, including the application of secure video conferencing or store-and-forward transfer technology to provide or support health-care delivery, which facilitate the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care by a licensee practicing within his or her scope of practice as would be practiced in-person with a patient and with other restrictions as defined in regulation.

Source: DE Code Title 24, Chapter 30, Sec. 3002. (Accessed Mar. 2019).
Online Prescribing

Pharmacists are prohibited from dispensing prescription drug orders through an Internet pharmacy if the pharmacist knows that the prescription order was issued solely on the basis of an Internet consultation or questionnaire, or medical history form submitted to an Internet pharmacy through
an Internet site.

 

Source: DE Code, Title 16 Sec. 4744(d)(1)(a). (Accessed Mar. 2019).

APRNs and Physicians
Establishing a proper provider-patient relationship includes:
• Verifying the location of requesting patient;
• Disclosing the provider’s identity and credentials;
• Obtaining consent;
• Establishing a diagnosis through acceptable medical practices, including a physical exam;
• Discuss with patient the diagnosis;
• Ensure availability of distant site provider or coverage of patient for follow up care; and
• Provide written visit summary to patient.
Physician & APRNs
Without a prior patient-provider relationship, providers are prohibited from issuing prescriptions based on internet questionnaire, internet consult or a telephone consult.
Prescriptions through telemedicine and under a physician-patient relationship may include controlled substances, subject to limitations set by the Board.

Source: Title 24, Sec. 1769D(b) (Accessed Mar. 2019) & DE Code Title 24, Sec. 1933(b)(4)(g). (Accessed Mar. 2019).

Physicians
Prior to a diagnosis and treatment, a physician using telemedicine must either provide:
• An appropriate in-person exam;
• Have another DE licensed practitioner at the originating site with the patient at the time of diagnosis;
• Diagnosis must be based using both audio and visual communication; or
• The service meets standards of establishing a patient-physician relationship included as part of evidenced-based clinical practice guidelines in telemedicine developed by major medical specialty societies.
After a relationship has been established, subsequent treatment of the same patient with the same physician need not satisfy the limitations of this section.
This section shall not limit the practice of radiology or pathology.

Source: Title 24, Sec. 1769D(h)(i)(j). (Accessed Mar. 2019).

A remote audio only examination is not an “appropriate in-person examination”.
No opioid prescribing is permitted via telemedicine with the exception of addiction treatment programs offering medication assisted treatment that have received a Division of Substance Abuse and Mental Health (DSAMH) waiver to use telemedicine through DSAMH’s licensure or renewal process. All other controlled substance prescribing utilizing telemedicine is held to the same standards of care and requisite practice as prescribing for in-person visits.
For formation of the physician-patient relationship using audio and visual communications, the audio and visual communications must be live, real-time communications.

Source: DE Admin Code. Sec. 1700. Sec. 19. (Accessed Mar. 2019).
Consent

Informed consent must be obtained to establish a physician-patient relationship over telehealth.

 

Source: Title 24, Sec. 1769D & DE Code Title 24, Sec. 1933. (Accessed Mar. 2019).

Informed consent required by Boards.

Cross-State Licensing

Member of Nurses Licensure compact.

Source: Nurse Licensure Compact. Current NLC States and Status. (Accessed Mar. 2019).
Miscellaneous

Professional regulation with telehealth specific standards
• Physical Therapists and Athletic Trainers (Source: DE Statute Title 24, Sec. 2602) (Accessed Mar. 2019).
• Board of Mental Health and Chemical Dependency Professionals (Source: DE Admin. Code
Title 24, Sec. 3002) (Accessed Mar. 2019)
• Board of Clinical Social Work Examiners (Source: 24 DAC 3902 & 3920) (Accessed Mar. 2019).
• Respiratory Care Practice Advisory Council (Source: 24 DAC 1769D) (Accessed Mar. 2019).
• Board of Examiners in Optometry (Source: 24 DAC 2101) (Accessed Mar. 2019).
• Board of Occupational Therapy Practice (Source: 24 DAC 2002) (Accessed Mar. 2019).
• Board of Speech/Language Pathologists, Audiologists and Hearing Aid Dispensers
(Source: 24 DAC 3706) (Accessed Mar. 2019).
• Board of Dietetics/Nutrition (Source: 24 DAC 3802) (Accessed Mar. 2019).
• Board of Dentistry and Dental Hygiene (Source: 24 DAC 1101) (Accessed Mar. 2019).
• Genetic Counselor Advisory Council (Source: 24 DAC 1799H) (Accessed Mar. 2019).
• Pharmacy (Source: 24 DAC 2500) (Accessed Mar. 2019).

 

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