Maine

MASTER MEDICAID TELEHEALTH LAWS
WITH THE HELP FROM GD

Summary

Maine Medicaid (MaineCare) reimburses for live video telehealth under certain conditions, and remote patient monitoring for patients with certain risk factors. Although their definition of telehealth is broad enough to include of store-and-forward, there is no mention of store-and-forward reimbursement within their policies.

 

Definitions

Telehealth services are the use of information technology by a Health Care Provider to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment. Telehealth Services may be either telephonic or interactive (combined video/audio).

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 3 (Apr. 9, 2018) & Code of ME Rules 10-144-101, Ch. 1, Sec. 4. (Accessed Apr. 2019).

 

Telehealth as it pertains to the delivery of health care services, means the use of interactive real-time visual and audio or other electronic media for the purpose of consultation and education concerning and diagnosis, treatment, care management and self-management of a patient’s physical and mental health and includes real-time interaction between the patient and the telehealth
provider, synchronous encounters, asynchronous encounters, store-and-forward transfers and remote patient monitoring. “Telehealth” includes telephonic services when interactive telehealth services are unavailable or when a telephonic service is medically appropriate for the underlying covered service.

Source: ME Statute Sec. 22:855.3173-H. (Accessed Apr. 2019).

Live Video

Policy

If the Member is eligible for the underlying covered service and providing it via telehealth is medically appropriate as determined by the health care provider, and is of comparable quality if it had been delivered in-person, the telehealth service is eligible for reimbursement.
No reimbursement for communication between health care providers when the member is
not present at the originating site.

 

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 2 & 6. (Accessed Apr. 2019).
Eligible Services / Specialties

There is a specific list of codes provided in the manual.
Non-Covered services include:
• Medical equipment
• Personal care aide
• Pharmacy services
• Assistive technology services
• Non-emergency medical transportation
• Ambulance services
• Services that require physical contact
• Any service medically inappropriate for telehealth services
See manual for full list of exclusions.

 

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 5-6. (Accessed Apr. 2019).
Eligible Providers

A health care provider must also be:
• Acting within the scope of his or her license
• Enrolled as a MaineCare provider; and
• Otherwise eligible to deliver the underlying Covered Service

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03., p. 3. (Accessed Apr. 2019).

 

If approved by HRSA and the state, a FQHC, RHC, or IHC may serve as the provider site and bill under the encounter rate.

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 10. (Apr. 9, 2018). (Accessed Apr.2019).
Eligible Sites

FQHCs, RHCs or IHCs may be originating sites.

 

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4., p. 10. (Apr. 9, 2018). (Accessed Apr.2019).
Facility/Transmission Fee

NA facility fee is provided to a health care provider at the originating site.
An originating facility fee may only be billed in the event that the originating site is in a healthcare provider’s facility.
When an FQHC or RHC serves as the originating site, the facility fee is paid separately
from the center or clinic all-inclusive rate.
The Department does not reimburse a transmission fee.

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. p. 1, 6, 10. (Apr. 9, 2018). (Accessed Apr.2019).

 

Remote Patient Monitoring

Policy

ME Medicaid provides coverage for telemonitoring services (which may or may not take place in real-time) under certain circumstances.
Covered telemonitoring services include:
• Evaluation of the member to determine if telemonitoring services are medically necessary;
• Evaluation of Member to ensure cognitively and physically capable of operating equipment;
• Evaluation of residence to determine suitability for telemonitoring services;
• Education and training;
• Remote monitoring and tracking of data by a RN, NP, PA or physician and response with appropriate clinical interventions;
• Monthly telephonic services;
• Maintenance of equipment; and
• Removal/disconnection of equipment.

 

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.04. p. 4-5. (Accessed Apr. 2019).

 

Home and Community Benefits for the Elderly and for Adults with Disabilities
Real time remote support monitoring is covered under Home and Community Benefits for the Elderly and for Adults with Disabilities. Services may include a range of technological options including in-home computers, sensors and video camera linked to a provider that enables 24/7 monitoring and/or contact as necessary.

Source: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 13 (Jan. 7, 2019). (Accessed Apr. 2019).
Conditions

In order to be eligible for telemonitoring a member must:
• Be eligible for home health services;
• Have a diagnosis of a health condition requiring monitoring of clinical data at a minimum of five times per week, for at least one week;
• Have documentation in the patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room or have continuously received Telemonitoring Services during the past calendar year and have a continuing need
for such services, as documented by an annual note from a health care provider;
• Have telemonitoring services included in the Member’s plan of care;
• Reside in a setting suitable to support telemonitoring equipment; and
• Have the physical and cognitive capacity to effectively utilize the telemonitoring equipment or have a caregiver willing and able to assist with the equipment.

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.02. p. 2-3. (Accessed Apr. 2019).

 

Home and Community Benefits for the Elderly and for Adults with Disabilities Final approval must be obtained from the Department, Office of Aging and Disability Services while considering:
• Number of hospitalizations in the past year;
• Use of emergency room in the past year;
• History of falls in the last six months resulting from injury;
• Member lives alone or is home alone for significant periods of time;
• Service access challenges and reasons for those challenges;
• History of behavior indicating that a member’s cognitive abilities put them at a significant risk of wandering; and
• Other relevant information.

Source: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 13 (Jan. 7, 2019). (Accessed Apr. 2019).
Provider Limitations

In order to be reimbursed for services, Health Care providers:
• Must be enrolled as MaineCare providers in order to be reimbursed for services;
• Be a certified Home Health Agency pursuant to the MaineCare Benefits Manual
Ch. II Section 40 (“Home Health Services”);
• The Provider ordering the service must be a Provider with prescribing privileges
(physician, nurse practitioner or physician’s assistant);
• Must document that they have had a face-to-face encounter with the member before a physician may certify eligibility for services under the home health benefit. This may be accomplished through interactive telehealth services, but not by telephone or e-mail.

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.01. (Accessed Apr. 2019).
Other Restrictions

Department required to adopt regulations that comply with the following:
• May not include any requirement that a patient have a certain number of ER visits
or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s
eligibility for telemonitoring services;
• Must include qualifying criteria for a patient’s eligibility of telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an ER;
• Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth; and
• Must include requirements for individual providers and the facility or organization in which the provider works for providing telehealth and telemonitoring services.

Source: ME Statute Sec. 3173-H. (Accessed Apr. 2019).

 

A health care provider must document that a face-to-face encounter with the member occurred before they are eligible for a home health benefit. This can occur through interactive telehealth services, but not by telephone or e-mail.

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03. p. 4 (Accessed Apr. 2019).

 

ME established the ME Telehealth and Telemonitoring advisory group to evaluate difficulties related to telehealth and telemonitoring services and make recommendations to the department to improve it statewide.

Source: ME Statute Sec. 3173-I. (Accessed Apr. 2019).

 

Home and Community Benefits for the Elderly and for Adults with Disabilities
Use of remote monitoring requires sufficient Back Up Plans and the SCA will be responsible for ensuring that the member has at least two adequate back-up plans prior to making a referral for this service.

Source: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 13 (Jan. 7, 2019). (Accessed Mar. 2019).

Store-and-Forward

Policy

Provider manual indicates coverage of “telehealth services” which is inclusive of storeand-forward, however the manual only discusses interactive telehealth, and remote patient monitoring in detail. Additionally, the manual only discusses the use of the GT modifier (live interactive video), and does not mention the GQ modifier (asynchronous).

 

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Accessed Apr. 2019).
Eligible Services / Specialties

No reference found.

 

Email / Phone / Fax

Telephonic services may be reimbursed if the following conditions are met:
• Interactive telehealth services are unavailable; and
• A telephonic service is medically appropriate for the underlying covered service.
Services may not be delivered through electronic mail.
Interprofessional telephone/internet assessment are among the listed reimbursable procedure codes.

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. p. 4, 7, 12. (Accessed Apr. 2019).

 

For Indian Health Services, a second tier consultation can utilize direct email communications or telephone consultation.

Source: MaineCare Benefits Manual, Indian Health Services, 10-144 Ch. II, Sec. 9, p. 5 (March 21, 2012). (Accessed Apr. 2019).

 

Telephone is also covered for:
• Targeted Case Management Services for purposes of monitoring and follow up activities
can take place over the telephone.
• Telephone can be used in under the Home and Community Benefits for the Elderly and for Adults with Disabilities for purposes of monitoring.
• Behavioral Health Services for purposes of crisis resolution services when at least one face-to-face contact is made with the member within seven days prior to the first contact related to the crisis resolution service.

Source: MaineCare Benefits Manual, Targeted Case Management Services, 10-144 Ch. 101, Sec. 13, p. 6 (Mar. 20, 2014).; MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 15 (Jan. 7, 2019).; & MaineCare Benefits Manual, Behavioral Health Services, 10-44 Ch. II, Sec. 65, p. 10 (Feb. 11, 2019). (Accessed Apr. 2019).
Consent

Providers must deliver written educational information to patients at their visit.
This information should be in a format and manner that the Member is able to understand and include the following:
• Description of the telehealth services and what to expect;
• Explanation that the use of telehealth for this service is voluntary and that the member is able to refuse the telehealth visit at any time without affecting the right to future care or treatment or loss or withdrawal of MaineCare benefit;
• Explanation that MaineCare will pay for transportation to a distant appointment if needed;
• Explanation that the Member will have access to all information resulting from the telehealth service provided by law;
• The dissemination, storage or retention of an identifiable Member image or other information shall comply with federal and state laws and regulations requiring confidentiality;
• Informed of all parties who will be present at the receiving and originating site and have the right to exclude anyone from either site; and
• Member has the right to object to videotaping or other recording of consult.

 

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. p. 8. (Accessed Apr. 2019).

Member’s record must document consent for RPM.

Source: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec.
19, p. 13 (June. 1, 2017). (Accessed Apr. 2019).
Out of State Providers

Healthcare Providers must be licensed or certified in the state of Maine.

 

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.01. p. 1, (Accessed Apr. 2019).
Miscellaneous

MaineCare will pay for transportation to a distant appointment if needed.

 

Source: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.06. (Apr. 9, 2018). (Accessed Apr. 2019).

The Department is required to report on the utilization of telehealth and telemonitoring services within the MaineCare program annually.
The Department is required to conduct educational outreach to providers and MaineCare members on telehealth and telemonitoring.

Source: ME Statute Sec. 3173-H. (Accessed Mar. 2019).

Tele-pharmacy is allowed.
Tele-pharmacy is a method of delivering prescriptions dispensed by a pharmacist to a remote site.
Pharmacies using tele-pharmacy must follow all applicable State and Federal regulations, including use of staff qualified to deliver prescriptions through tele-pharmacy.
Providers may dispense prescriptions via tele-pharmacy; pre-authorization is required.

Source: MaineCare Benefits Manual, Pharmacy Services, 10-144 Ch. 2, Sec. 80 p. 5 & 30. 80.01 & 07 (Sept. 1, 2017) (Accessed Apr.
2019).

Private Payer Laws

Definitions

“Telemedicine, as it pertains to the delivery of health care services, means the use of interactive audio, video or other electronic media for the purpose of diagnosis, consultation or treatment. ‘Telemedicine’ does not include the use of audio-only telephone, facsimile machine or e-mail.”

 

Source: ME Revised Statutes Annotated. Title 24, Sec. 4316. (Accessed Apr. 2019).
Requirements

A health plan may not deny coverage on the basis that the coverage is provided through telemedicine if the health care service would have been covered through an in-person consultation between a covered person and a health care provider. Coverage must be determined in a manner consistent with coverage for services provided through in-person consultation.

 

Source: ME Revised Statutes Annotated. Title 24 Sec. 4316 (2012). (Accessed Apr. 2019).

Parity

Payment Parity

Coverage must be determined in a manner consistent with coverage for services provided through in-person consultation.

 

Source: ME Revised Statutes Annotated. Title 24 Sec. 4316 (2012). (Accessed Apr. 2019).
Service Parity

A health plan may not deny coverage on the basis that the coverage is provided through telemedicine if the health care service would have been covered through an in-person consultation between a covered person and a health care provider.

 

Source: ME Revised Statutes Annotated. Title 24 Sec. 4316 (2012). (Accessed Apr. 2019).

Professional Regulation /
Health & Safety

Online Prescribing

Board of Licensure in Medicine & Board of Osteopathic Licensure
Prior to providing treatment, including issuing prescriptions, electronically or otherwise, a licensee who uses telemedicine in providing health care shall interview the patient to collect the relevant medical history and perform a physical examination, when medically necessary, sufficient for the diagnosis and treatment of the patient. An internet questionnaire that is a static set of questions provided to the patient, to which the patient responds with a static set of answers, in contrast to an adaptive interactive and responsive online interview, does not constitute an acceptable medical interview and physical examination for the provision of treatment, including issuance of prescriptions, electronically or otherwise, by the licensee.
A valid physician-patient relationship may be established between a licensee who uses telemedicine in providing health care and a patient who receives telemedicine services through consultation with another licensee or through a telemedicine encounter if the standard of care does not require an in-person encounter and in accordance with evidence-based standards for practice and telemedicine practice guidelines that address the clinical and technological aspects of telemedicine.

 

Source: ME Regulation Sec. 02-373-6 & 02-383-6. (Accessed Apr. 2019).
Consent

Board of Licensure in Medicine & Board of Osteopathic Licensure
A licensee who uses telemedicine shall ensure the patient provides appropriate informed consent for the health care services provided, including consent for the use of telemedicine, which must be documented in the patient’s medical record.

 

Source: ME Regulation Sec. 02-373-6 & 02-383-6. (Accessed Apr. 2019).
Miscellaneous

Professional Board Telehealth-Specific Regulations
• AL Board of Optometrists (Source: AL Admin Code 630-X-13-.02). (Accessed Mar. 2019).
• AL Board of Nursing (Source: AL Admin Code 610-X-6-.16). (Accessed Mar. 2019).

 

Definitions

Board of Licensure in Medicine & Board of Osteopathic Licensure
“Telemedicine” means the practice of medicine or the rendering of health care services using electronic audio-visual communications and information technologies or other means, including interactive audio with asynchronous store-and-forward transmission, between a licensee in one location and a patient in another location with or without an intervening health care provider. Telemedicine includes asynchronous store-and-forward technologies, remote monitoring, and real-time interactive services, including teleradiology and telepathology. Telemedicine shall not include the provision of medical services only through an audio-only telephone, e-mail, instant messaging, facsimile transmission, or U.S. mail or other parcel service, or any combination thereof.

 

Source: ME Regulation Sec. 02-373-6 & 02-383-6. (Accessed Apr. 2019).
Cross-State Licensing

Member of the Interstate Medical Licensure Compact.

Source: Interstate Medical Licensure Compact. The IMLC. (SP 467-2017). (Accessed Apr. 2019).

 

Member of Nurse Licensure Compact.

Source: Nurse Licensure Compact. Current NLC States and Status. NCSBN. (Accessed Apr. 2019).

 

A physician who is not licensed in Maine can practice medicine in Maine through interstate telemedicine if they are licensed in the state they are providing telemedicine from, their license is in good standing, the physician does not open an office, meet patients or receive calls in the state and agrees to provide only consultative services as requested by other physicians, APRNs or PAs, and the physician annually registers with the board and pays a fee.

Source: 32 MSRA Sec. 3300-D. (Accessed Apr. 2019).

 

The Board may issue an interstate telemedicine consultation registration to an applicant who:
• Submits an administratively complete application on forms approved by the Board;
• Pays the appropriate licensure application fee;
• Demonstrates that the applicant is a physician and is fully licensed without restriction to
practice medicine in the state from which the physician provides telemedicine services;
• Meets the examination requirement;
• Has not had a license to practice medicine revoked or restricted in any state or jurisdiction; and
• Has no cause existing that may be considered grounds for disciplinary action or denial of licensure as provided by law.
A physician registered for the interstate telemedicine consultation shall not:
• Open an office in this State;
• Meet with patients in this State;
• Receive calls in this State from patients; and
• Shall provide only consultative services as requested by a physician, advanced practice registered nurse or physician assistant licensed in this State who retains ultimate authority over the diagnosis, care and treatment of the patient.

Source: ME Regulation Sec. 02-373 Ch. 1, p. 13-14. (Accessed Apr. 2019).

Professional regulation with telehealth specific standards
• Board of Licensure in Medicine (Source: ME Regulation Sec. 02-373-6) (Accessed Apr. 2019).
• Board of Osteopathic Licensure (Source: ME Regulation 02-383-6) (Accessed Apr. 2019).

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