Illinois

MASTER MEDICAID TELEHEALTH LAWS
WITH THE HELP FROM GD

Summary

IL Medicaid reimburses for live video telemedicine and telepsychiatry services for specific providers. A recent law change required them to expand reimbursement to other behavioral health professions beginning in Jan. 2019. Although IL definitions of telemedicine and telehealth encompass store-and-forward there is no mention of store-and-forward reimbursement. IL Medicaid will provide reimbursement for home uterine monitoring.

 

Definitions

“Telemedicine” is the use of a telecommunication system to provide medical services for the purpose of evaluation and treatment when the patient is at one medical provider location and the rendering provider is at another location.

 

Source: IL Admin. Code, Title 89,140.403(a)(9) (2012). (Accessed Mar. 2019), Handbook for Podiatrists, F-200, p. 7 (Oct. 2016) (Accessed Mar. 2019).

Telehealth is the use of a telecommunication system to provide medical services between places of lesser and greater medical capability and/or expertise, for the purpose of evaluation and treatment.
Medical data exchanged can take the form of multiple formats: text, graphics, still images, audio and video. The information or data exchanged can occur in real-time (synchronous) through interactive video or multimedia collaborative environments or in near real-time (asynchronous) through “store-and-forward” applications.

Source: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, p. 24, (Dec. 12, 2018). Handbook for Podiatrists, F-200, p. 27 (Oct. 2016) & Handbook for Encounter Clinic Services, pg. 16-17 (Aug. 2016). (Accessed Mar. 2019).

“Telehealth” means services provided via a telecommunication system.

Source: : IL Admin. Code, Title 89,140.403 (2012). (Accessed Mar. 2019).

Live Video

Policy

The Department of Healthcare and Family Services must reimburse psychiatrists, federally qualified health centers, clinical psychologists, clinical social workers, advances practice registered nurses certified in psychiatric and mental health nursing and mental health professionals and clinicians to provide behavioral health services to recipients via telehealth.
The Department can establish by rule the reimbursement criteria, however the Department
cannot require a professional be physically present in the same room as the patient for the entire time during which the patient is receiving telehealth services.

 

Source: SB 3049 (2018), 305 ILCS 5/5-5.25. (Accessed Mar. 2019).

Health insurance providers must include coverage for licensed dietitians, nutritionists, and diabetes educators who counsel senior diabetes patients, via telehealth, in the patients’ homes to remove the hurdle of transportation for patients to receive treatment. Department of Healthcare and Family Services may authorize licensed dietitians, nutritionists, and diabetes educators to counsel senior diabetes patients in the patients’ homes to remove the hurdle of transportation for patients to receive treatment.

Source: HB 5351 (2018) 215 ILCS 5/356z.22 (Accessed Mar. 2019).

Illinois Medicaid will reimburse for live video under the following conditions:
• A physician or other licensed health care professional [or other licensed clinician,
mental health professional or qualified mental health professional, for telepsychiatry] must be present with the patient at all times with the patient at the originating
site*; The distant site provider must be a physician, physician assistant, podiatrist or advanced practice nurse who is licensed by Illinois or the state where the
patient is located. For telepsychiatry, it must be a physician who has completed
an accredited general psychiatry residency program or an accredited child and
adolescent psychiatry residency program;
• The originating and distant site provider must not be terminated, suspended or
barred from the Department’s medical programs;
• Telepsychiatry: The distant site provider must personally render the telepsychiatry
service.
• Medical data may be exchanged through a telecommunication system. For telepsychiatry it must be an interactive telecommunication system;
• The interactive telecommunication system must, at a minimum, have the capability
of allowing the consulting distant site provider to examine the patient sufficiently to
allow proper diagnosis of the involved body system. The system must also be capable of transmitting clearly audible heart tones and lung sounds, as well as clear
video images of the patient and any diagnostic tools, such as radiographs.
• Telepsychiatry: Group psychotherapy is not a covered telepsychiatry service.

Source: IL Admin. Code Title 89, 140.403(b). (Accessed Mar. 2019).

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

Source: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, p. 25, (Accessed Mar. 2019).
Eligible Services / Specialties

Appropriate CPT codes must be billed with the GT modifier for telemedicine and telepsychiatry services and the appropriate Place of Service code, 02, telehealth. See Practitioner Services Handbook Appendices A-10 for telehealth billing examples.

Source: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, p. 25, (Dec. 12, 2018). (Accessed Mar. 2019).

 

There is no reimbursement for group psychotherapy as a telepsychiatry service.

Source: IL Admin. Code Title 89, 140.403. (Accessed Mar. 2019).
Eligible Providers

For telemedicine services, the distant site provider must be a physician, physician assistant, podiatrist, or advanced practice nurse who is licensed by the State of Illinois or by the state where the patient is located.
For telepsychiatry, the distant site provider must be a physician who is licensed by the State of Illinois or by the state where the patient is located who has completed an accredited general psychiatry residency program or an accredited child and adolescent psychiatry residency program.he telemedicine Service Agreement/Certification form.
• Physician must obtain prior consent from the recipient before services are rendered.
This will count as part of each recipient’s benefit limit of 14 annual physician office
visits currently allowed.

 

Source: IL Admin. Code Title 89, 140.403(b). Handbook for Podiatrists, F-200, p. 28 (Oct. 2016); & Handbook for Practitioner Services. Ch. 200, p. 26 (Dec. 2018) (Accessed Mar. 2019).

An encounter clinic serving as the distant site shall be reimbursed as follows:
1. If the originating site is another encounter clinic, the distant site encounter clinic shall receive no reimbursement from the Department. The originating site encounter clinic is responsible for reimbursement to the distant site encounter clinic;
and
2. If the originating site is not an encounter clinic, the distant site encounter clinic
shall be reimbursed for its medical encounter. The originating site provider will
receive a facility fee.
Encounter Rate Clinics, Federally Qualified Health Centers (FQHC), and Rural Health
Clinics, are allowed to render telemedicine services.

Source: IL Admin. Code Title 89, 140.403. IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010. Handbook for Encounter Clinic Services. Ch. 200, pg. 17. Aug. 2016. Handbook for Practitioner Services. Ch. 200 (Dec. 2018). (Accessed Mar. 2019).
Eligible Sites

A physician or other licensed health care professional must be present with the patient at all times with the patient at the originating site.

Source: IL Admin. Code Title 89, 140.403. (Accessed Mar. 2019).

 

For telemedicine services, a physician or other licensed health care professional must be present at all times with the patient at the originating site.

Source: IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. A-200 Policy and Procedures, p. 25, (Dec. 12, 2018). (Accessed Mar. 2019).

 

Eligible originating site providers include:
• Physician’s office
• Podiatrist’s office
• Local health departments
• Community mental health centers
• Outpatient hospitals
An encounter clinic is eligible as an originating site, and responsible for ensuring and documenting that the distant site provider meets the department’s requirements for telehealth and telepsychiatry services since the clinic is responsible for reimbursement to the distant site provider.

Source: IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010 & IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. 200, p. 25, Handbook for Podiatrists, F-200, p. 27 (Oct. 2016). & Handbook for Encounter Clinic Services. Ch. D-200, pg. 17. Aug. 2016. (Accessed Mar. 2019).

 

Local education agencies may submit telehealth services as a certified expenditure.

Source: IL Admin. Code Title 89, 140.403(c)(1)(B). (Accessed Mar. 2019).

 

Nonenrolled providers rendering services as a Distant Site provider shall not be eligible for reimbursement from the department, but may be reimbursed by the Originating Site provider.

Source: IL Dept. of Healthcare and Family Svcs. Handbook for Practitioners. Ch. 200, p. 25, Handbook for Podiatrists, F-200, p. 28 (Oct. 2016) (Accessed Mar. 2019).

Facility/Transmission Fee

There is reimbursement for originating site facility fees.
Eligible facilities include:
• Physician’s office
• Podiatrist’s office
• Local health departments
• Community mental health centers
• Outpatient hospitals

 

Source: IL Handbook for Practitioners Rendering Medical Services, Ch. 200, p. 25 (Dec. 2018), Handbook for Podiatrists, F-200, p. 27 (Oct. 2016). (Accessed Mar. 2019).

Store-and-Forward

Policy

Although store-and-forward is included within the definitions of telehealth in IL Medicaid manuals and administrative code (see descriptions below), there are no details provided on store-and-forward reimbursement and other areas of policy indicate that the GT (live video) modifier is required for telehealth services.

Source: Provider Notice Changes to Professional Claims for Telehealth Services. Jan. 10, 2018. (Accessed Mar. 2019).

 

The Illinois Medicaid definition encompasses store-and-forward. “The information or data exchanged can occur in real-time (synchronous) through interactive video or multimedia collaborative environments or in near real-time (asynchronous) through ‘store-and-forward’ applications.”

Source: IL Dept. of Healthcare and Family Svcs., Expansion of Telehealth Services, Informational Notice, Jan. 1, 2010. & IL Dept. of Healthcare and Family Svcs., Handbook for Practitioners. Ch. 200, p. 24,; Handbook for Podiatrists, F-200, p. 27 (Oct. 2016) & Handbook for Encounter Clinic Services pg. 16-17 (Aug. 2016) (Accessed Mar. 2019).

 

Additionally, IL Admin Code encompasses store-and-forward, addressing that a provider at a distant site can “review the medical case without the patient being present.”

Source: IL Administrative Code, Title 89 ,140.403 (2012). (Accessed Mar. 2019).

Remote Patient Monitoring

Conditions

Pregnancy-Induced Hypertension Monitor
• Covered for diagnosis of pregnancy-induced hypertension, previous pregnancy
induced hypertension or pre-eclampsia
• Hospitalizations for symptoms related to pregnancy induced; i.e., hypertension,
headaches, edema in face, hands and feet
• Blurred vision
• Right upper quadrant pain
• 24-hour urine results greater than 300 mg of total protein
• Antihypertensive medications
• Pre-pregnancy and current blood pressure readings.
Will not be covered for patients with a diagnosis of chronic hypertension.

 

Source: IL Dept. of Healthcare and Family Services, Handbook for Durable Medical Equipment, Chapter M-200, Policy and Procedures for Medical Equipment and Supplies, p. 56 (Sept. 2015). (Accessed Mar. 2019).
Email / Phone / Fax

No reimbursement for email.
No reimbursement for telephone.
No reimbursement for FAX.

 

Source: IL Dept. of Healthcare and Family Services, Handbook for Practitioners Rendering Medical Services, Chapter 200 (Dec 2018). p. 25, Handbook for Podiatrists, F-200, p. 27 (Oct. 2016) & IL Administrative Code, Title 89 ,140.403 (2012). (Accessed Mar. 2019).
Out of State Providers

For medical services, the provider rendering the service at the distant site can be a physician, physician assistant, podiatrist or advanced practice nurse, who is licensed by the State of Illinois or by the state where the patient is located.
For psychiatric services, the provider rendering the service at the distant site must be a physician licensed by the State of Illinois, or by the state where the patient is located, who has completed an approved general psychiatry residency program or a child and adolescent psychiatry residency program.

 

Source: IL Handbook for Practitioners Rendering Medical Services, Chapter 200, p. 26, (Dec. 2018). Handbook for Podiatrists, F-200,
p. 27 (Oct. 2016) & Handbook for Encounter Clinic Services pg. 17-18 (Aug. 2016). (Accessed Mar. 2019).
Miscellaneous

Specific documentation requirements apply for telehealth services. See administrative code for details.

 

Source: IL Administrative Code, Title 89 ,140.403(d) (2012). (Accessed Mar. 2019).

Private Payer Laws

Requirements

If an insurer provides coverage for telehealth services, then it shall not:
• Require in-person contact occur between a health care provider and a patient;
• Require the health care provider to document a barrier to an in-person consultation;
• Require telehealth use when it is not appropriate; or
• Require the use of telehealth when the patient chooses an in-person consultation.

Source: IL Insurance Code. Sec. 356z.22. (Accessed Mar. 2019).

 

If an insurer is providing coverage for telehealth services, it must provide coverage for licensed dietitian nutritionists and certified diabetes educators who counsel senior diabetes patients in the senior diabetes patients’ home to remove the hurdle of transportation for senior diabetes patients to receive treatment.

Source: IL Insurance Code. Sec. 356z.22. (Accessed Mar. 2019).
Definitions

“Telehealth services” means the delivery of covered health care services by way of an interactive telecommunication system.

 

Source: IL Insurance Code. Sec. 356z.22. (Accessed Mar. 2019).

Parity

Service Parity

Payers are not required to cover telehealth services, they are only required to meet certain requirements if they choose to do so (see above).

 

Source: IL Insurance Code. Sec. 356z.22. (Accessed Mar. 2019).

Professional Regulation /
Health & Safety

Definitions

“Telehealth” means the evaluation, diagnosis, or interpretation of electronically transmitted patient-specific data between a remote location and a licensed health care professional that generates interaction or treatment recommendations. “Telehealth” includes telemedicine and the delivery of health care services provided by way of an interactive telecommunications system, as defined in subsection (a) of Section 356z.22 of the Illinois Insurance Code.

 

Source: IL Compiled Statutes, Chapter 225, 150/5. (Accessed Mar. 2019).

Telemedicine means the performance of any of the activities listed in Section 49, including, but not limited to, rendering written or oral opinions concerning diagnosis or treatment of a patient in Illinois by a person in a different location than the patient as a result of transmission of individual patient data by telephonic, electronic, or other means of communication. “Telemedicine” does not include the following:
1. Periodic consultations between a person licensed under this Act and a person outside the State of Illinois;
2. A second opinion provided to a person licensed under this Act;
3. Diagnosis or treatment services provided to a patient in Illinois following care or treatment originally provided to the patient in the state in which the provider is licensed to practice medicine; and 4. Health care services provided to an existing patient while the person licensed under this Act or patient is traveling.

Source: IL Compiled Statutes, Chapter 225, 60/49.5(c). (Accessed Mar. 2019).

Under the Department of Public Health, telemedicine means the provision of clinical services to patients by physicians and practitioners from a distance via electronic communications.

Source: IL Admin. Code, Title 77, Sec. 250.310(a)(8) (Accessed Mar. 2019).
Cross-State Licensing

Member of the Interstate Medical Licensure Compact.

Source: Interstate Medical Licensure Compact. The IMLC. (Accessed Mar. 2019).

 

Member of Psychology Interjurisdictional Compact (takes effect Jan. 1, 2020)

Source: Psychology Interjurisdictional Compact. Legislative Updates. (Accessed Mar. 2019) .

 

Must have an IL medical license. An out-of-state person providing a service to a patient in IL through telemedicine submits himself or herself to the jurisdiction of the courts of IL.

Source: IL Compiled Statutes, Chapter 225, 60/49.5(e) (Accessed Mar. 2019).
Miscellaneous

Health professionals authorized by statute to engage in the practice of telehealth to the extent of his or her scope of practice include physicians, physician assistants, optometrists, advanced practice nurses, clinical psychologists licensed in IL, dentists, occupational therapists, pharmacists, physical therapists, clinical social workers, speech-language pathologists, audiologists, hearing
instrument dispensers, and mental health professionals and clinicians authorized by Illinois law to provide mental health services.

 

Source: IL Compiled Statutes, Chapter 225, 150/5. (Accessed Mar. 2019).

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