Utah

MASTER MEDICAID TELEHEALTH LAWS
WITH THE HELP FROM GD

Summary

Utah Medicaid reimburses for live video. Store-and-forward is not reimbursable as telehealth is required to be a “two-way, real-time interactive connection.”

Source: Utah Medicaid Provider Manual: Section I: General Information, P. 44 (Apr. 2019). (Accessed Apr. 2019).

 

Home telemetry for outpatient long-term cardiac monitoring is allowable with prior authorization under certain conditions.

Source: Utah Medicaid Provider Manual: Physician Manual, p. 19 (Jul. 2018). (Accessed Apr. 2019).
Definitions

Telemedicine “is two-way, real-time interactive communication between the member and the physician or authorized provider at the distant site. This electronic communication uses interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”

Source: Utah Medicaid Provider Manual: Section I: General Information, p. 44 (Apr. 2019). & R414-42-1. (Accessed Apr. 2019).

 

Home Health Services
Telehealth or Telemedicine is a technological method of providing auditory and visual connection between the skilled home health care nurse at a Telehealth site and the patient living in a rural Utah area.

Source: Utah Medicaid Provider Manual: Home Health Agencies, p. 16 (Apr. 2019). (Accessed Apr. 2019).

Live Video

Policy

Providers are eligible for reimbursement for telemedicine services under Utah’s Medical Assistance Program.

Source: UT Code Annotated Sec. 26-18-13. (Accessed Apr. 2019).

 

Utah Medicaid covers medically appropriate services delivered via telemedicine.
Limitations:
• Must be HIPAA compliant
• Must comply with Utah Health Information Network Standards for Telehealth

Source: Utah Medicaid Provider Manual: Section I: General Information, p. 44-45 (Apr. 2019). (Accessed Apr. 2019).

 

Covered services may be delivered by means of telemedicine, as clinically appropriate, including consultation, evaluation and management services, mental health services, substance use disorder services and telepsychiatric consultations. Must comply with Utah Health Information Network standards for telehealth.
The Department pays the lesser of the amount billed or the rate on the fee schedule.

Source: UT Admin. Code R414-42-3, R414-42-4, & R414-42-5 (Accessed Apr. 2019).
Eligible Services / Specialties

Eligible services include but are not limited to:
• Consultation services
• Evaluation and management services
• Mental health services
• Substance use disorder services
• Telepsychiatric consultations
See manual for high level list of services that can be delivered via telemedicine.
Rural health clinic and federally qualified health clinic services may be delivered via telemedicine.

Source: Utah Medicaid Provider Manual: Section I: General Information, p. 44-47 (Apr. 2019) & Utah Medicaid Provider Manual: Rural Health Clinics and Federally Qualified Health Centers Services. p.3 (Jan. 2019). (Accessed Apr. 2019).

 

The Medicaid program is required to reimburse for personal mental health therapy office visits provided through telemedicine services and telepsychiatric consultations at a rate set by the Medicaid program (includes managed care plans). Also see Misc. section.

Source: UT Code 26-18-13.5.(3) (Accessed Apr. 2019).

 

Telepsychiatric consultations between a physician and a board-certified psychiatrist are a covered service. See Medicaid Information Bulletin for specific CPT codes to bill

Source: Medicaid Information Bulletin. Jul. 2018. Sec. 18-67. (Accessed Apr. 2019).

 

Rehabilitative Mental Health and Substance Use Disorder
Rehabilitative behavioral health services include the following:
• Psychiatric Diagnostic Evaluation
• Mental Health Assessment by a Non-Mental Health Therapist
• Psychological Testing
• Psychotherapy with Patient and/or Family Member
• Family psychotherapy with Patient Present and Family Psychotherapy without Patient Present
• Group Psychotherapy and Multiple Family Group Psychotherapy
• Psychotherapy for Crisis
• Psychotherapy with Evaluation and Management (E/M) Services
• Evaluation and Management (E/M) Services (Pharmacologic Management)
• Therapeutic Behavioral Services
• Psychosocial Rehabilitative Services
• Peer Support Services
• SUD Services in Licensed SUD Residential Treatment Programs
• Assertive Community Treatment (ACT)
• Mobile Crisis Outreach Teams (MCOT)

Source: Utah Medicaid Provider Manual: Rehabilitative Mental Health and Substance Use Disorder Services. P. 8-9 (Apr. 2019) (Accessed Apr. 2019).
Eligible Providers

Rural health clinic and federally qualified health clinic services may be delivered via telemedicine.

Source: Utah Medicaid Provider Manual: Section I: General Information, p. 45 (Jul. 2018). (Accessed Apr. 2019).
Facility/Transmission Fee

The provider at the originating site receives no additional reimbursement for the use of telemedicine.

 

Source: Utah Medicaid Provider Manual: Section I: General Information, p. 45 (Apr. 2019). & R414-42-4.(3). (Accessed Apr. 2019).

Store-and-Forward

Policy

Utah Medicaid defines telemedicine as “two-way, real time interactive communication” excluding store-and-forward from the definition.

Source: Utah Medicaid Provider Manual: Section I: General Information, p. 44 (Apr. 2019). (Accessed Apr. 2019).

 

Remote Patient Monitoring

Policy

Bulletin indicates The Skilled Nursing Pilot Project has been removed from manual, however it is still listed in the Home Health Services manual, as of their last update in Aug. 2017. See Home Health Services Manual for details.

Source: Medicaid Information Bulletin January 2018 & Home Health Services Manual, Aug. 2017. (Accessed Apr. 2019).

 

Home telemetry for outpatient long-term cardiac monitoring is allowed with prior authorization. Criteria include:
• Must be ordered by a neurologist
• Member must have had a stroke or TIA with no identifiable cause
• Member should have already had 24-hour monitoring done previously
• Member should not be currently taking anti-coagulated or Warfarin for any other
reason
• Member should not have a known contraindication for Warfarin
• Outpatient long-term cardiac monitoring may only be authorized for the 30-day
test
• Data from the test must be reviewed and interpreted by a cardiologist

Source: Utah Medicaid Provider Manual: Physician Manual, p. 19 (Jul. 2018). (Accessed Apr. 2019).

 

Conditions

Only for patients with a long-term cardiac health issue.

Source: Utah Medicaid Provider Manual: Physician Manual, p. 19 (Jul. 2018). (Accessed Apr. 2019).
Provider Limitations

Test must be ordered by a neurologist and reviewed and interpreted by a cardiologist.

Source: Utah Medicaid Provider Manual: Physician Manual, p. 19 (Jul. 2018). (Accessed Apr. 2019).

Private Payer Laws

Requirements

All health insurance plans must disclose whether the insurer provides coverage for telehealth services in accordance with section 26-18-13.5 and terms associated with that coverage.

Source: UT Code 31A-22-613.5(2)(e). (Accessed Apr. 2019).

 

Recently Passed Legislation (Effective: Jan. 1, 2019)
A health benefit plan that offers coverage for mental health services shall: Provide coverage for telepsychiatric consultation during or after an initial visit between the patient and a referring in-network physician;
• Provide coverage for a telepsychiatric consultation from an out-of-network board certified psychiatrist if the consultant is not made available to a physician within seven business days after the initial request is made by an in-network provider; and
• Reimburse for the services at the equivalent of the in-network or out-of-network rate set by the benefit plan after taking into account cost-sharing that may be required under the health benefit plan.
An insurer can also meet the requirement to cover telepsychiatric consultation for a patient by providing coverage for behavioral health treatment (see statute for details).

Source: UT Code, 31A-22-647 (HB 139 – 2018). (Accessed Apr. 2019).
Definitions

“Digital health service means the electronic transfer, exchange, or management of related data for diagnosis, treatment, consultation, educational, public health, or other related purposes.”

Source: UT Code, 26-9f-102. (Accessed Apr. 2019).

 

“Telehealth services” means the transmission of health-related services or information through the use of electronic communication or information technology.
“Telemedicine services” means telehealth services including:
• Clinical care;
• Health education;
• Health administration;
• Home health; or
• Facilitation of self-managed care and caregiver support; and
Must be provided by a provider to a patient through a method of communication that:
• Uses asynchronous store-and-forward transfer; or
• Uses synchronous interaction; and
Meets industry security and privacy standards, including compliance with:
• The federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-
191, 110 Stat. 1936, as amended; and
• The federal Health Information Technology for Economic and Clinical Health Act, Pub. L. No. 111-5, 123 Stat. 226, 467, as amended.

Source: Utah Code, 26-60-102. (Accessed Apr. 2019).

Professional Regulation /
Health & Safety

Online Prescribing

Before providing treatment or prescribing a prescription drug, provider must:
• Obtain and document patient’s relevant clinical history and current symptoms

Source: UT Code, 26-60-103(b). (Accessed Apr. 2019).

 

Providers must first obtain information in the usual course of professional practice that is sufficient to establish a diagnosis, to identify conditions, and to identify potential risks to the proposed treatment.

Source: UT Code, 58-1-501(2(m)). (Accessed Apr. 2019).
Miscellaneous

If a hospital participates in telemedicine, it shall develop and implement policies governing the practice of telemedicine in accordance with the scope and practice of the hospital.
These policies shall address security, access and retention of telemetric data, and define the privileging of all health professionals who participate in telemedicine.

Source: UT Admin. Code R432-100-33. (Accessed Apr. 2019).
Cross-State Licensing

An out-of-state physician may practice without a Utah license if:
• The physician is licensed in another state, with no licensing action pending and at least 10 years of professional experience;
• The services are rendered as a public service and for a noncommercial purpose;
• No fee or other consideration of value is charged, expected or contemplated, beyond an amount necessary to cover the proportionate cost of malpractice insurance;
• The physician does not otherwise engage in unlawful or unprofessional conduct.

Source: UT Code Annotated Sec. 58-67-305(7). (Accessed Apr. 2019).

 

A mental health therapist licensed in another state and in good standing can provide short term transitional mental health therapy remotely if:
• The mental health therapist is present in the state where he/she is licensed;
• The client relocates to Utah, and was a client immediately before the relocation;
• The therapy or counseling is provided for a maximum of 45 days after the client relocates;
• Within 10 days of the client’s relocation, the mental health therapist provides a written notice to the Division of Occupational and Professional Licensing of their intent to provide therapy/counseling remotely; and
• The mental health therapist does not engage in unlawful or unprofessional conduct.

Source: UT Code, 58-61-307(k) (Accessed Apr. 2019).

 

Utah is a member of the Interstate Medical Licensure Compact.

Source: Interstate Medical Licensure Compact. (Accessed Apr. 2019).

 

Member of Psychology Interjurisdictional Compact.

Source: Physical Therapist Compact. (Accessed Apr. 2019).

 

Member of the Nurse Licensure Compact.

Source: Nurse Licensure Compact (Accessed Apr. 2019).

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