New York

MASTER MEDICAID TELEHEALTH LAWS
WITH THE HELP FROM GD

Summary

New York Medicaid offers live video reimbursement and some reimbursement for store-and-forward and home health services. The New York State Department of Health released a Medicaid telehealth expansion in 2019. The guidance states that other state offices will be updating guidances and regulation to reflect the changes made, however no other office has released updates at
the time of this report.

 

Definitions

“Telehealth is defined as the use of electronic information and communication technologies to deliver health care to patients at a distance.”

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 1. (Accessed Apr. 2019).

 

Live Video

Policy

Reimbursement policy applies to fee-for-service (effective Jan. 1, 2019) and Medicaid Managed Care plans (effective Mar. 1, 2019).
New York reimburses for two-way electronic audio-visual communications to delivery clinical health care services to a patient at an originating site by a telehealth provider located at a distant site. The communication must be of an amount and nature sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.
Telehealth should not be used by a provider if it may result in any reduction to the quality of care required to be provided to a Medicaid member or if such service could adversely impact the member.
New York Medicaid does not reimburse the acquisition, installation, and maintenance of
telecommunication devices or systems.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 1-3. (Accessed Apr. 2019).

 

Eligible Services / Specialties

NY Medicaid does not reimburse for telehealth used solely for the convenience of the practitioner when a face-to-face visit is more appropriate and/or preferred by the member.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 1-3. (Accessed Apr. 2019).

 

TFederally Qualified Health Centers (FQHCs)
FQHCs that have “Opted Into” Ambulatory Patient Groups (APGs): should follow the billing guidance outlined for sites billing under APGs. FQHCs that have not opted into APGs:
• FQHC Originating Sites: When services are provided via telemedicine to a patient
located at an FQHC originating site, the originating site may bill only the FQHC
offsite services rate code (4012) to recoup administrative expenses associated with
the telemedicine encounter. When a separate and distinct medical service, unrelated to the telemedicine encounter, is provided by a qualified practitioner at the FQHC
originating site, the originating site may bill the Prospective Payment System (PPS)
rate in addition to the FQHC offsite services rate code (4012). If a provider who is
onsite at an FQHC is providing services via telemedicine to a member who is in
their place of residence or other temporary location, the FQHC should bill the FQHC
off-site services rate code (4012) and report the applicable modifier (95 or GT) on
the procedure code line.
• If the FQHC is providing services as a distant site provider, the FQHC may bill their
PPS rate.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 11. (Accessed Apr. 2019).

 

Telepsychiatric services must meet certain conditions to be eligible for Medicaid reimbursement

Source: NY Regulations Title 14 NYCRR Section 596.7. (Accessed Apr. 2019.
Eligible Providers

Providers who may deliver telemedicine services include:
• Licensed physician
• Licensed physician assistant
• Licensed dentist
• Licensed nurse practitioner
• Licensed registered professional nurse
• Licensed podiatrist
• Licensed optometrist
• Licensed psychologist
• Licensed social worker
• Licensed speech language pathologist or audiologist
• Licensed midwife
• Physical Therapists
• Occupational Therapists
• Certified diabetes educator
• Certified asthma educator
• Certified genetic counselor
• Hospital (including residential health care facilities serving special needs populations)
• Home care services agency
• Hospice
• Physical or occupational therapist
• Credentialed alcoholism and substance abuse counselor
• Providers authorized to provide services and service coordination under the early
intervention program
• Clinics licensed or certified under Article 16 of the MHL
• Certified and non-certified day and residential programs funded or operated by the
OPWDD
• Or any other provider as determined by the Commissioner.

Source: NY Public Health Law Article 29 – G Section 2999-cc.& NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 5-6. (Accessed Apr. 2019).

 

Telepsychiatric services must meet certain conditions to be eligible for Medicaid reimbursement.

Source: NY Regulations Title 14 NYCRR Section 599.17.(Accessed Apr. 2019).

 

Home Telehealth
Subject to the approval of the state director of the budget, the commissioner may authorize the payment of medical assistance funds for demonstration rates or fees established for home telehealth services and shall not exclude from the payment of medical assistance funds the delivery of health care services through telehealth as defined in Section 2999-cc.

Source: NY Statute, Social Services Law SOS §367-u. (Accessed Apr. 2019).
Eligible Sites

The distant site is any secure location within the fifty United States or United States’ territories where the telehealth provider is located while delivering health care services by means of telehealth.
Specific distant sites listed include:
• Outpatient departments and clinics
• Emergency room
• Private practitioner’s office
• Skilled Nursing Facility
• Federally Qualified Health Centers

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 3 & 8-11. (Accessed Apr. 2019).

 

Facility/Transmission Fee

Outpatient departments, clinics, emergency rooms, and private practitioner’s offices serving as originating sites may only bill a facility fee under Ambulatory Patient Groups to recoup administrative expenses associated with the telemedicine encounter.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 8-10. (Accessed Apr. 2019).

 

The originating site can bill for administrative expenses only when a telepsychiatric connection is being provided and a physician or NP is not present at the originating site with the patient at the time of the encounter.

Source: NY Code of Rules and Regs. Title 14, Sec. 596.7(e) (Accessed Apr. 2019).

 

Only one clinic payment will be made when both the originating site and the distant site are part of the same provider billing entity. In such cases, only the originating site should bill Medicaid for the telemedicine encounter.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 8. (Accessed Apr. 2019).

Store-and-Forward

Policy

NY Medicaid is authorized to establish fees to reimburse the cost of telehealth store-andforward technology, per a State Plan Amendment submitted and approved by CMS. Storeand-forward technology may be utilized in the specialty areas of dermatology, ophthalmology and other disciplines, as determined by the Commissioner. Services must reduce the need for on-site or in-office visits.

Source: CMS Approved state plan amendment 16-0015. Attachment 3.1A. (Accessed Apr. 2019).

 

NY Medicaid is authorized to establish fees to reimburse the cost of telehealth store-andforward technology, per a State Plan Amendment submitted and approved by CMS. Storeand-forward technology may be utilized in the specialty areas of dermatology, ophthalmology and other disciplines, as determined by the Commissioner. Services must reduce the need for on-site or in-office visits.

Source: CMS Approved state plan amendment 16-0015. Attachment 3.1A. (Accessed Apr. 2019).

 

Pre-recorded videos and/or static digital images (e.g., pictures), excluding radiology, must be specific to the member’s condition as well as be adequate for rendering or confirming a diagnosis or a plan of treatment.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 4. (Accessed Apr. 2019).

 

Reimbursement for store-and-forward is made to the consulting distant-site practitioner and is paid at 75 percent of the Medicaid fee for the service provided.
The consulting provider must provide the requesting originating-site practitioner with a written report of the consultation and use the GQ modifier in order for payment to be made.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 11. (Accessed Apr. 2019).
Eligible Services / Specialties

For the home telehealth program, store-and-forward services may be reimbursed.

 

Source: NY Public Health Law Article 29 – G Section 2999-dd. (Accessed Mar. 2019).

Remote Patient Monitoring

Policy

NY Medicaid is authorized to establish fees to reimburse the cost of telehealth remote patient monitoring, per a State Plan Amendment submitted and approved by CMS.
Remote patient monitoring (RPM) can include synchronous or asynchronous electronic
information and communication technologies to collect personal health information and
medical data. RPM may be provided by a facility licensed under Article 28 of Public Health Law or by a physician, nurse practitioner, midwife or physician assistant who has examined the patient and with whom has an established relationship.

Source: CMS Approved state plan amendment 16-0015. Attachment 3.1A. (Accessed Apr. 2019).

 

RPM included within definition of “telehealth” in statute requiring Medicaid not exclude from payment the delivery of home health services through telehealth.

Source: Social Services Law Title 11, Article 367-u. (Accessed Apr. 2019).

 

Remote patient monitoring services are billed using CPT code “99091” and should not be billed more than once per member per month. Billing should occur on the last day of each month in which RPM is used. A fee of $48.00 per month will be paid for RPM for a minimum of 30 minutes per month spent collecting and interpreting a member’s RPM data.
FQHCs that have opted out of APGs are unable to bill for RPM services.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 11-12. (Accessed Apr. 2019).

 

A Medicaid member must be present during the remote consultation in order to be reimbursed.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 3. (Accessed Apr. 2019).
Conditions

Medical conditions that may be treated/monitored by means of RPM include, but are not limited to:
• Congestive heart failure
• Diabetes
• Chronic obstructive pulmonary disease
• Wound care
• Polypharmacy
• Mental or behavioral problems
• Technology-dependent care, such as continuous oxygen, ventilator care, total
parenteral nutrition, or enteral feeding

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 4. (Accessed Apr. 2019).
Other Restrictions

The following considerations apply to RPM:
1. Medical conditions that may be treated/monitored by means of RPM include, but
are not limited to, congestive heart failure, diabetes, chronic obstructive pulmonary
disease, wound care, polypharmacy, mental or behavioral problems, and technology-dependent care such as continuous oxygen, ventilator care, total parenteral
nutrition or enteral feeding.
2. RPM must be ordered and billed by a physician, nurse practitioner or midwife, with
whom the member has or has entered into a substantial and ongoing relationship.
RPM can also be provided and billed by an Article-28 clinic, when ordered by one
of the previously mentioned qualified practitioners.
3. Members must be seen in-person by their practitioner, as needed, for follow-up
care.
4. RPM must be medically necessary and shall be discontinued when the member’s
condition is determined to be stable/controlled.
5. Payment for RPM while a member is receiving home health services through a
Certified Home Health Agency (CHHA) is pursuant to PHL Section 3614 (3-c)(a) –
(d) and will only be made to that same CHHA.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 4-5. (Accessed Apr. 2019).

. 2019).

Email / Phone / Fax

No payment for telephone.
No payment for e-mail.
No payment for text messaging.
No payment for facsimile transmissions.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 3. (Accessed Apr. 2019).

 

Telepsychiatry services does not include telephone, video cell phone, or e-mail.

Source: NY Code of Rules and Regs. Title 14, Sec. 596.7(d) (Accessed Apr. 2019).
Consent

Medicaid members must provide consent to participating in services utilizing telehealth. Telehealth sessions/services shall not be recorded without the member’s consent. Documentation in the medical record must reflect that the member was made aware of patient rights policies.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 6-7. (Accessed Apr. 2019).

 

Mental Health
Part of obtaining approval for telepsychiatry services is obtaining informed consent and may be incorporated into the informed consent process for in-person care.

Source: NY Code of Rules and Regs. Title 14, Sec. 596. (Accessed Apr. 2019).
Out of State Providers

A distant site may be located within any of the fifty United States or United States’ territories where a telehealth provider is located when delivering health care services by means of telehealth.
Practitioners providing services via telehealth must be licensed or certified, currently registered in accordance with NYS Education Law or other applicable law, and enrolled in NYS Medicaid.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 3 & 6. (Accessed Apr. 2019).
Miscellaneous

NY Department of Health is encouraging Medicaid Managed Care (MMC) plans to allow for telehealth services. They are allowing MMC plans to request reimbursement of additional cost-effective alternative telehealth services.

Source: NY Department of Health Memorandum, Telehealth Innovation in Medicaid Managed Care, Sept. 18, 2017. (Accessed Apr. 2019)

 

Subject to federal financial participation and the approval of the director of the budget, the commissioner shall not exclude from the payment of medical assistance funds the delivery of health care services through telehealth, as defined in section 2999-cc(4) of the public health law.

Source: Social Services Law Article 367-u. (Accessed Apr. 2019).

 

Culturally competent translation and/or interpretation services must be provided when the member and distant practitioner do not speak the same language.

Source: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 6. (Accessed Apr. 2019).

Private Payer Laws

Requirements

A health plan shall not exclude from coverage services that are provided via telehealth if they would otherwise be covered under a policy, provided that an insurer may exclude coverage of a service by a health care provider where the provider is not otherwise covered under the policy.
An insurer may subject the coverage of a service to reasonable utilization management and quality assurance requirements or copayments, coinsurance and deductibles that are consistent with those established for the same service not delivered via telehealth.

 

Source: NY Insurance Law Article 32 Section 3217-h & NY Insurance Law Article 43 Section 4306-g. (Accessed Apr. 2019).
Definitions

Telehealth means the use of electronic information and communications technologies by a health care provider to deliver health services to an insured individual while such individual is located at a site that is different from the site where the health care provider is located.

 

Source: NY Insurance Law Article 32 Section 3217-h & Article 43 Section 4306-g. (Accessed Apr. 2019).

Parity

Service Parity

A health plan shall not exclude from coverage services that are provided via telehealth if they would otherwise be covered under a policy, provided that an insurer may exclude coverage of a service by a health care provider where the provider is not otherwise covered under the policy.

 

Source: NY Insurance Law Article 32Section 3217-h & NY Insurance Law Article 43 Section 4306-g. (Accessed Apr. 2019).

Professional Regulation /
Health & Safety

Definitions

For the home telehealth program, the term “telehealth” means the use of electronic information and communication technologies by telehealth providers to deliver health care services, which shall include the assessment, diagnosis, consultation, treatment, education, care management and/
or self-management of a patient. Telehealth shall not include delivery of health care services by means of audio-only telephone communication, facsimile machines, or electronic messaging alone, though use of these technologies is not precluded if used in conjunction with telemedicine, storeand-forward technology or remote patient monitoring.
Telemedicine means the use of synchronous, two-way electronic audio visual communications to deliver clinical health care services, which shall include the assessment, diagnosis, and treatment of a patient, while such a patient is at the originating site and a telehealth provider is at a distant site.

Source: NY Public Health Law Article 29 – G Section 2999-cc. (Accessed Apr. 2019).

 

Related to Credentialing and Privileging Health Care Practitioners Providing Telemedicine
“Telemedicine means the delivery of clinical health care services by means of real-time two-way electronic audio-visual communications which facilitate the assessment, diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care, while such patient is at the originating site and the health care provider is at a distant site.”

Source: NY Consolidated Law Service Public Health Article 28 Sec. 2805-u. (Accessed Apr. 2019).

 

Under Public Health, originating sites are limited to:
• Licensed health facilities in Articles 28 (hospitals) and 40 (hospice);
• A facility as defined in Section 1.03, subdivision six of the Mental Hygiene Law;
• Certified and non-certified day and residential programs funded or operated by the office for people with developmental disabilities;
• Private physician’s or dentist’s offices located in New York;
• Public, private and charter elementary and secondary schools, school age childcare programs and child day care centers within the state of New York;
• Adult care facility licensed under title two of article seven of the social services law;
• The patient’s place of residence located within the state of New York or other temporary location located within or outside the state of New York.

Source: NY Public Health Law Article 29 – G Section 2999-cc. (Accessed Apr. 2019).
Online Prescribing

Office of Alcoholism and Substance Abuse Services (OASAS)
OASAS Telepractice Standards outlines practitioner requirements for prescribing buprenorphine.

 

Source: NY Office of Alcoholism and Substance Abuse Services. Telepractice Standards for OASAS Designated Providers. p. 3 (Accessed Apr. 2019).
Miscellaneous

Telepsychiatry shall not be utilized in certain personalized Recovery Oriented Services program or Assertive Community Treatment programs.

Source: NY Code of Rules and Regs. Title 14, Sec. 596.3 (Accessed Apr. 2019).

 

Telehealth shall not include delivery of health care services by means of audio-only telephone communication, facsimile machines, or electronic messaging alone, though use of these technologies is not precluded if used in conjunction with telemedicine, store-and-forward technology or remote patient monitoring.

Source: NY Public Health Law Article 29 – G Section 2999-cc. (Accessed Apr. 2019).

 

Office for People with Developmental Disabilities (OPWDD)
Telehealth is an available mechanism to deliver clinical care.

Source: OPWDD. Emergency/Proposed Regulations. 679.1(c)(4). Regulations are effective through the revision process. (Accessed Apr. 2019).

 

Office of Alcoholism and Substance Abuse Services (OASAS)
Telepractice services may be authorized by the Office of Alcoholism and Substance Abuse Services for the delivery of certain addiction services provided by practitioners employed by or pursuant to a contract or Memorandum of Understanding with a program certified by the Office.

Source: Title 14 NYCRR, §830.5 (Accessed Apr. 2019).

 

OASAS has specific telepractice standards for its providers. See regulation for details.

Source: NY Office of Alcoholism and Substance Abuse Services. Telepractice Standards for OASAS Designated Providers. Aug. 2018. (Accessed Apr. 2019).

 

For the home telehealth program, store-and-forward services may be reimbursed.

Source: NY Public Health Law Article 29 – G Section 2999-dd. (Accessed Apr. 2019).

 

The patient must be present for telepsychiatry services for Medicaid reimbursement. Telepsychiatry is also defined as “real-time”.

Source: NY Code of Rules and Regs. Title 14, Sec. 596. (Accessed Apr. 2019).

 

Demonstration rates of payment or fees shall be established for telehealth services provided by a certified home health agency, a long term home health care program or AIDS home care program, or for telehealth services by a licensed home care services agency under contract with such an
agency or program, in order to ensure the availability of technology-based patient monitoring, communication and health management. Reimbursement is provided only in connection with Federal Food and Drug Administration-approved and interoperable devices that are incorporated as part of the patient’s plan of care.

Source: NY Consolidated Law Service Public Health Sec. 3614-3c. (Accessed Apr. 2019).

 

The Department of Health, Office of Mental Health and Office of Alcoholism and Substance Abuse Services and Office of People with Developmental Disabilities required to coordinate on the issuance of a single guidance document that will:
• Identify any differences in regulations or policies issued by the agencies including reimbursement; and
• Be designed to assist consumers, providers and health plans in understanding and facilitating the appropriate use of telehealth in addressing barriers to care.

Source: NY Public Health Law Article Section 2999-dd (SB 7507, 2018). (Accessed Apr. 2019).

 

Independent Practitioner Services for Individuals with Developmental Disabilities (IPSIDD) are prohibited from being delivered via telehealth.

Source: 14 NYCRR § 635-13.4(c). (Accessed Apr. 2019).

 

Each agency that operates a clinic treatment facility shall provide the Office for People with Developmental Disabilities (OPWDD) information it requests, including but not limited to the following:
services provided by CPT/HCPCS and/or CDT codes, where such services were delivered, including the location of both the provider and the individual when services are delivered via telehealth, (i.e., on-site or at a certified satellite site, or, prior to April 1, 2016, off-site) and revenues by funding source or payee. These data shall correspond to the identical time period of the cost report.

Source: 14 NYCRR § 679.6. (Accessed Apr. 2019).

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