TELEHEALTH LAWS IN THE UNITED STATES

Let’s explore the
State Telehealth Laws & REIMBURSEMENT Policies

General Devices has been a referent in offering telehealth services for years. All this experience empowers us to share with you all you need to know about telehealth laws in different States.

According to the Center for Connected Health Policy (CCHP), States continue to pursue their own unique set of telehealth policies as more and more legislation is introduced each year. Some states have incorporated policies into law, while others have addressed issues such as definition, reimbursement policies, licensure requirements, and other important issues in their Medicaid Program Guidelines.

While this guide focuses primarily on Medicaid fee-for-service policies, information on managed care is noted in the report if it was available. The report also notes particular areas where we were unable to find information. Recently passed legislation and regulation have also been included in this information with their effective date noted in the report (if applicable). This information is brought to you in an effort from GD to make it more accesible and easier to find.

While many states are beginning to expand telehealth reimbursement, others continue to restrict and place limitations on telehealth delivered services. Although each state’s laws, regulations, and Medicaid program policies differ significantly, certain trends are evident. Live video Medicaid reimbursement, for example, continues to far exceed reimbursement for store-and-forward and remote patient monitoring (RPM). However, over the past year there has been a slight uptake in RPM reimbursement, although generally on a limited basis. Store-and-forward reimbursement remains limited with many states only reimbursing for teleradiology (which CCHP does not count as store-and-forward) or other very specific specialties or forms of store-and-forward. For example, Connecticut is allowing for store-and-forward reimbursement for physician-to-physician email consults (known as eConsult) exclusively, while Virginia has store-and-forward and RPM reimbursement, but limited it to specific specialties. Other noteworthy trends include the addition of the home and schools as an eligible originating site in some states, and the inclusion of teledentistry and substance use disorder services as a specialty qualifying for Medicaid reimbursement and/or required to be reimbursed by private insurers.

Additionally, some state Medicaid programs have begun incorporating specific documentation and/or confidentiality, privacy and security guidelines within their manuals for telehealth specifically. On the private payer side, some states have passed wide ranging laws to require telehealth reimbursement (most recently Kansas), while others limit reimbursement to specific specialties, such as Massachusetts (telepsychiatry only). Laws and regulations allowing practitioners to prescribe medications through live video interactions have also increased, as well as a few states even allowing for the prescription of controlled substances over telehealth within federal limits.

A few additional significant findings include:
• Fifty states and Washington DC provide reimbursement for some form of live video in Medicaid fee-for-service.
Massachusetts’ Medicaid recently began reimbursing for mental and behavioral health delivered via telehealth.
• Eleven state Medicaid programs reimburse for store-and-forward. However, five additional jurisdictions (D.C., HI, MS, NJ and NY) have laws requiring Medicaid reimburse for store-and-forward but as of the creation of this edition, yet to have any official Medicaid policy indicating this is occurring.
• Twenty state Medicaid programs provide reimbursement for RPM. As is the case for store-and-forward, four Medicaid programs (D.C., HI, NY and NJ) have laws requiring Medicaid reimburse for RPM but at the time this report was written, did not have any official Medicaid policy. Kentucky Medicaid is also required to create an RPM pilot, but CCHP has not seen any evidence that the pilot has been established. Iowa will begin an RPM program for Medicaid managed care plans on July 1, 2019.
• Six state Medicaid programs (Alaska, Arizona, Maryland, Minnesota, Virginia and Washington) reimburse for all three, although certain limitations apply.

Telehealth policies are organized into three categories that address Medicaid reimbursement, private payer law and professional regulation/health & safety. Within those category areas, topic focuses include modality of reimbursement (for Medicaid), requirements and parity (for private payer law), licensing, consent and online prescribing (for professional regulation/health & safety). In many instances the specific policy is found in law and/or regulations and administrative policy, but that is not always the case. This report primarily addresses the individual state’s policies that govern telehealth use when seeking Medicaid coverage for service. However, we have also included a specific category that describes whether a state has established any specific policies that require private insurers to pay for telehealth services.

 

 

This project was partially funded by The California HealthCare Foundation and The National Telehealth Policy Resource Center program is made possible by Grant #G22RH30365 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS.

A Comprehensive Scan of the 50 States:
Findings and Highlights

CCHP examined state law, state administrative codes, and Medicaid provider manuals as the report’s primary resources.

Additionally, other potential sources such as releases from a state’s executive office, Medicaid notices, transmittals or Agency newsletters were also examined for relevant information. In some cases, CCHP directly contacted state Medicaid personnel in order to clarify specific policy issues. Most of the information contained in this report specifically focuses on fee-for-service; however, information on managed care plans has also been included if available from the utilized sources.
Newly approved regulations related to specific telehealth standards for various professions are noted in the “Miscellaneous” section of the state’s Professional Regulation/Health & Safety category area.

The survey focused on three primary areas for telehealth policy including Medicaid reimbursement, private payer laws and professional regulation/health & safety requirements. Within the larger categories listed above, information is organized into various topic and subtopic areas, based upon the frequency they have appeared in discussions and questions around telehealth reimbursement and laws. These topic areas include:

• Medicaid Reimbursement:
• Definition of the term telemedicine/telehealth
• Reimbursement for live video
• Reimbursement for store-and-forward
• Reimbursement for remote patient monitoring (RPM)
• Reimbursement for email/phone/fax
• Consent issues
• Out-of-state providers
• Private payer laws
• Definitions
• Requirements

No two states are alike in how telehealth is defined and regulated. While there are some similarities in language, perhaps indicating states may have utilized existing verbiage from other states, noticeable differences exist. These differences are
to be expected, given that each state defines its Medicaid policy parameters, but it also creates a confusing environment for telehealth participants to navigate, particularly when a health system or practitioner provides health care services in
multiple states. In most cases, states have moved away from duplicating Medicare’s restrictive telehealth policy, with some reimbursing a wide range of practitioners and services, with little to no restrictions.

As noted previously, even if a state has enacted telehealth policies in statute and/or regulation, these policies may not have been incorporated into its Medicaid program. In the findings below, there are a few cases in which a law has passed requiring Medicaid reimbursement of a specific telehealth modality or removal of restrictions, but Medicaid policies have yet to reflect this change. CCHP has based its findings on current Medicaid policy according to those listed in their program regulations, manuals or other official documentation. Requirements in newly passed legislation will be
incorporated into the findings section of future editions of CCHP’s report once they are implemented in the Medicaid program, and CCHP has located official documentation confirming this.

Below are summarized key findings in each category area contained in the report.

States alternate between using the term “telemedicine” or “telehealth”. In some states both terms are explicitly defined in law and/or policy and regulations. ”Telehealth” is sometimes used to reflect a broader definition, while “telemedicine” is used mainly to define the delivery of clinical services. Additional variations of the term, primarily utilizing the “tele”
prefix are also becoming more prevalent. For example, the term “telepractice” is being used frequently as it relates to physical and occupational therapy, behavioral therapy, and speech language pathology. “Telepsychiatry” is also a term commonly used as an alternative when referring specifically to psychiatry services. Many professional boards are also adopting definitions of telehealth specific to their particular profession, in some cases, creating many different definitions for the term within a state’s administrative code. For example, Wyoming passed legislation encouraging each Board to adopt their own definition of the term “telehealth”. This has the potential to add to the already complex telehealth policy environment.

Some states put specific restrictions within the definitions, which often limit the term to “live” or “interactive”, excluding store-and-forward and RPM from the definition and subsequently from reimbursement. The most common restriction states place on the term telemedicine/telehealth is the exclusion of email, phone, and/or fax from the definition. Fortynine states and the District of Columbia have a definition in law, regulation, or their Medicaid program for telehealth, telemedicine, or both. Only Alabama lacks a definition for either term.

All 50 states and the District of Columbia have some form of Medicaid reimbursement for telehealth in their public program. However, the extent of reimbursement for telehealth delivered services is less clear in some states than others. For example, Iowa’s Medicaid program issued a broad regulatory statement confirming that they do provide reimbursement for telehealth in 2016. This policy change came as a result of IA Senate Bill 505 which required the Department of Human Services to adopt formal rules regarding their longstanding (although unwritten) policy to provide reimbursement for telehealth. However, the rule that was adopted simply states that “in-person contact between a provider and patient is not required for payment for services otherwise covered and appropriately provided through telehealth as long as it meets the generally accepted health care practices and standards prevailing in the applicable professional community.” Neither the legislation nor the rule provides a definition of telehealth, which leaves the policy vague and up for interpretation. Therefore, it is unclear whether store-and-forward or RPM services would fall under the umbrella of this telehealth policy.

Thirty-nine jurisdictions include some sort of informed consent requirement in their statutes, administrative code, and/or Medicaid policies. This requirement can sometimes apply to the Medicaid program, a specific specialty or all telehealth encounters that occur in the state, depending on how and where the policy is written. States with informed consent
policies include:
1. Alabama
2. Arizona
3. Arkansas
4. California
5. Colorado
6. Connecticut
7. District of Columbia
8. Delaware
9. Georgia
10. Idaho
11. Indiana
12. Kansas
13. Kentucky
14. Louisiana
15. Maine
16. Maryland
17. Michigan
18. Minnesota (alcohol &
abuse program)
19. Mississippi
20. Missouri
21. Nebraska
22. New Hampshire
23. New Jersey
24. New Mexico (behavioral
health services)
25. New York
26. Ohio
27. Oklahoma
28. Oregon (Physical Therapy
& Community Treatment)
29. Pennsylvania
30. Rhode Island
31. South Carolina
32. Tennessee
33. Texas
34. Vermont
35. Virginia
36. Washington
37. West Virginia
38. Wisconsin
39. Wyoming

Nine state medical (or osteopathic) boards issue special licenses or certificates related to telehealth. The licenses could allow an out-of-state provider to render services via telemedicine in a state where they are not located, or allow a clinician to provide services via telehealth in a state if certain conditions are met (such as agreeing that they will not open an office in that state). States with such licenses are:
1. Alabama
2. Louisiana
3. Maine
4. Nevada
5. New Mexico
6. Ohio
7. Oregon
8. Tennessee (Osteopathic Board only)
9. Texas

Twenty-nine states and one jurisdiction (D.C.) have adopted the Federation of State Medical Boards (FSMB)’s Interstate Medical Licensure Compact (IMLC) in its place. The Compact allows for an Interstate Commission to form an expedited licensure process for licensed physicians to apply for licenses in other states. Jurisdictions that have adopted the IMLC

Compact language include:

1. Alabama
2. Arizona
3. Colorado
4. District of Columbia
5. Georgia (Implementation delayed)
6. Idaho
7. Illinois
8. Iowa
9. Kansas
10. Kentucky (Implementation delayed)
11. Maine
12. Maryland
13. Michigan (Implementation delayed)
14. Minnesota
15. Mississippi
16. Montana
17. Nebraska
18. Nevada
19. New Hampshire
20. North Dakota (Implementation
delayed)
21. Oklahoma (Implementation delayed)
22. Pennsylvania (Implementation
delayed)
23. South Dakota
24. Tennessee (Implementation delayed)
25. Utah
26. Vermont
27. West Virginia
28. Washington
29. Wisconsin
30. Wyoming
Besides the IMLC, there are also three additional Compacts to be aware of that are currently active or soon to be active, including:
• The Nurses Licensure Compact which currently has 31 state members.
• The Physical Therapy Compact which currently has 25 members.
• The Psychology Interjurisdictional Compact which currently has 9 members.
Still other states have laws that don’t specifically address telehealth and/or telemedicine licensing, but make allowances for practicing in contiguous states, or in certain situations where a temporary license might be issued provided the specific state’s licensing conditions are met.

No two states are alike in how telehealth is defined and regulated. While there are some similarities in language, perhaps indicating states may have utilized existing verbiage from other states, noticeable differences exist. These differences are
to be expected, given that each state defines its Medicaid policy parameters, but it also creates a confusing environment for telehealth participants to navigate, particularly when a health system or practitioner provides health care services in
multiple states. In most cases, states have moved away from duplicating Medicare’s restrictive telehealth policy, with some reimbursing a wide range of practitioners and services, with little to no restrictions.

As noted previously, even if a state has enacted telehealth policies in statute and/or regulation, these policies may not have been incorporated into its Medicaid program. In the findings below, there are a few cases in which a law has passed requiring Medicaid reimbursement of a specific telehealth modality or removal of restrictions, but Medicaid policies have yet to reflect this change. CCHP has based its findings on current Medicaid policy according to those listed in their program regulations, manuals or other official documentation. Requirements in newly passed legislation will be
incorporated into the findings section of future editions of CCHP’s report once they are implemented in the Medicaid program, and CCHP has located official documentation confirming this.

Below are summarized key findings in each category area contained in the report.

Currently, thirty-nine states and DC have laws that govern private payer telehealth reimbursement policies. Kansas, Iowa and Utah laws went into effect January 1, 2019. Additionally, only a few private payer laws require that the reimbursement amount for a telehealth-delivered service be equal to the amount that would have been reimbursed had the same service been delivered in-person. Because so many states now have private payer reimbursement bills, the more common policy change in relation to private payers, is to amend a law to expand its applicability to additional specialties or policy types. For example, Michigan recently expanded the applicability of their private payer law to include dental coverage. Utah, on the other hand, who recently passed their first private payer bill, singles out telepsychiatry services. While they are not the only state to limit private payer telehealth reimbursement requirements to a specific specialty (see Arizona and Alaska), they are the first state to make a distinction between in-network and out-of-network providers in their law.  Under the new law (effective Jan. 1, 2019), a health benefit plan is required to cover mental health services for in-network physicians, or out-of-network psychiatrists only if an in-network consultant is not made available within seven business days after the initial request.

In the Kansas law, a provision was included that ensures insurers are not requiring patients to utilize telemedicine in lieu of receiving in-person services from an in-network provider. This type of provision may become more common in private payer laws, as policymakers look to build in protections for patients.

To learn more about state telehealth related legislation, visit CCHP’s interactive map at cchpca.org.

Want to learn more? Contact us


[recaptcha]

*Required

Answer, Consolidate, Record, Replay & Analyze all communications from any media including; radios, phones, fax, email, data, vitals & apps consolidated into a single, fully featured, easy to use, FDA listed and HIPAA secure solution accessible from anywhere.

Secure, all-in-one, feature rich and highly configurable solution that makes it easy for all your emergency and non-emergency teams to streamline protocols and workflows.

 

Your Hospital, EMS & MIH/CP

Average Return on Investment, Money & Time savings with consolidation & streamlined multi-team workflows

30% faster time to treatment

50%+ shorter hand-off time

30% fewer unnecessary transports

15% reduced ED overcrowding

36% EMS frequent user decrease

30%+ less false lab activations @ $8k-$12k each

25%+ reduced re-admissions @ $12k-$15k each

The Spring 2019 release of the Center for Connected Health Policy’s (CCHP) report of state telehealth laws and Medicaid reimbursement policies is the seventeenth updated version of the report since it was first released in 2013. Like its previous iterations, the report is updated on a biannual basis, in spring and fall. An interactive map version of the report is available on CCHP’s website, cchpca.org. Due to constant changes in laws, regulations, and policies, CCHP will continue to update the information in both PDF and map formats twice a year to keep it as accurate and timely as possible.
It should be noted that even if a state has enacted telehealth policies in statute and/or regulation, these policies may not have been incorporated into its Medicaid program. Throughout the report, CCHP has notated changes in law that have not yet been incorporated into the Medicaid program, as well as laws and regulations that have been approved, but not yet taken effect.