Washington

MASTER MEDICAID TELEHEALTH LAWS
WITH THE HELP FROM GD

Summary

Washington Medicaid (Apple Health) reimburses for live video, store-and-forward, and remote patient monitoring under some circumstances. Client must be present and participating in telemedicine visit. Clients under the Family Planning, TAKE CHARGE, First Steps, and School-Based Health Care Service program are eligible for telemedicine through fee-for-service.
For patients with managed care plan coverage, telehealth services will not be reimbursed separately. All services must be arranged and provided by primary care providers. It is not mandatory that the plan pay for telehealth services

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 87 (Apr. 2019); (Accessed Apr. 2019).

 

Telemedicine is covered by the Department.

Source: WA Admin. Code Sec. 182-531-0100. (Accessed Apr. 2019).
Definitions

“Telemedicine is when a health care practitioner uses HIPAA-compliant interactive real-time audio and video telecommunications (including web-based applications) or store-and-forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.”

Source: WA Admin. Code Sec. 182-531-1730. WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 87 (Apr. 2019); School Based Health Care Services, p. 31 (Jan, 1, 2019) (Accessed Apr. 2019).

 

Home Health Services
“Telemedicine means the use of tele-monitoring to enhance the delivery of certain home health skilled nursing services through:
• The collection of clinical data and the transmission of such data between a patient at a distant location and the home health provider through electronic processing technologies.
Objective clinical data that may be transmitted includes, but is not limited to, weight, blood pressure, pulse, respirations, blood glucose, and pulse oximetry; or
• The provision of certain education related to health care services using audio, video, or data communication instead of a face-to-face visit.”

Source: WA Admin. Code Sec. 182-551-2010. (Accessed Apr. 2019).

Live Video

Policy

Live video is covered for patients with fee-for-service coverage when it is medically necessary. The referring provider is responsible for determining and documenting medical necessity.

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 87 & 88 (Apr. 2019). (Accessed Apr. 2019).
Eligible Services / Specialties

Applied Behavior Analysis (ABA) for Clients Age 20 and Younger
Eligible telemedicine services:
• Program supervision when the child is present
• Family training, which does not require the child’s presence
See ABA fee schedule for telemedicine billing instructions.

Source: WA State Health Care Authority, Medicaid Provider Guide, Applied Behavior Analysis for Clients 20 and Younger, p. 35-36 (Jan. 2019) & WAC 182-531A-1200. (Accessed Apr. 2019).

 

Behavioral Health
Behavioral health organizations who have a contract with the department shall reimburse a provider for behavioral health services provided to a covered person who is under 18 years old through telemedicine or-store-and-forward if:
• The organization provides coverage for behavioral health services when provided
in-person; and
• The service is medically necessary.

Source: Revised Code of WA Sec. 71.24.335(1). (Accessed Apr. 2019).

 

Teledentistry
Teledentistry can be delivered through a synchronous or asynchronous method. The agency covers teledentistry as a substitute for an in-person, face-to-face, hands-on encounter
when medically necessary.
A dentist or authorized dental provider may delegate allowable tasks to dental hygienists and Expanded Function Dental Assistants through teledentistry. Delegation of tasks must be under general supervision.

Source: WA State Health Care Authority, Medicaid Provider. Dental-Related Services, p. 84. (Jul, 2018). (Accessed Apr.2019).

Eligible Providers

Rural Health Clinics (RHCs)
RHCs are authorized to serve as an originating site for telemedicine services.

Source: WA State Health Care Authority, Medicaid Provider Guide, p. 43, Apr. 2019. (Accessed Apr. 2019).

 

Source: AL Medicaid Management Information System Provider Manual, (105-60) (Accessed Mar. 2019).
Eligible Sites

Eligible Originating Sites:
• Clinics;
• Dental offices;
• Home or any location determined appropriate by the individual receiving the service;
• Hospitals—inpatient or outpatient;
• Neurodevelopmental centers;
• Schools;
• Rural health clinic;
• Federally qualified health center;
• Physician’s or other health care provider’s office;
• Community mental health center/chemical dependency settings;
• Skilled nursing facility; or
• Renal dialysis center (included in statute, and administrative code, but not in
provider manual).
Originating site providers are responsible for determining and documenting that telemedicine is medically necessary.

Source: RCW 41.05700(3) & WAC 182-531-1730.(3) & WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 87-88 (Apr. 2019). (Accessed Apr. 2019).

 

When the originating site is a school, the school district must submit a claim on behalf of both the originating and distant site.

Source: WA State Health Care Authority, Medicaid Provider Guide, School Based Health Care Services, p. 33 (Jan. 1,2019), (Accessed Apr. 2019).
Geographic Limits

An urban or rural distinction must not be placed on the originating site.

Source: Revised Code of WA Sec. 41.05700(5) (Accessed Apr. 2019).
Facility/Transmission Fee

Facility fees are available for originating sites, except inpatient hospitals, skilled nursing facilities, homes or other locations determined appropriate by the individual receiving service, but not specified as an eligible originating site.

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 89 (Apr. 2019). (Accessed Apr. 2019).

Store-and-Forward

Policy

Washington Medicaid reimburses for some store-and-forward services.

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 91 (Apr. 2019). & WA State Health Care Authority, Medicaid Provider. Dental-Related Services, p. 84-85. (Apr.2019) (Accessed Apr. 2019).

 

WA Medicaid pays for store-and-forward when all of the following conditions are met:
• There is an associated office visit that can be done either in-person or via asynchronous telemedicine.
• The transmission of information is HIPAA compliant.
• Written informed consent is obtained.
If the consultation results in a face-to-face visit in-person or via telemedicine with the specialist within 60 days of the store-and-forward consult, the agency does not pay for the consult.

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 91-92 (Apr. 25, 2018). (Accessed Apr. 2019).
Eligible Services / Specialties

WA Apple Health pays for store-and-forward teledermatology. Teledermatology services via store-and-forward must be billed with GQ modifier and 02 POS Code from the distant site. The sending provider bills as usual with the E&M code and no modifier.

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 91-92 (Apr. 2019). (Accessed Apr. 2019)

 

Teledentistry
Teledentistry can be delivered through a synchronous or asynchronous method. The agency covers teledentistry as a substitute for an in-person, face-to-face, hands-on encounter
when medically necessary.

Source: WA State Health Care Authority, Medicaid Provider. Dental-Related Services, p. 84. (Apr. 2019) (Accessed Apr.2019).

 

Behavioral Health Organizations
Store-and-forward reimbursable only for covered services specified in the negotiated
agreement between the behavioral health organization and health care provider.

Source: RCW 71.24.335(2(b)) (Accessed Apr. 2019).
Transmission Fee

The originating site for store-and-forward is not eligible to receive an originating site fee.

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 91 (Apr. 2019). (Accessed Apr. 2019).
Email / Phone / Fax

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

 

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 87 (Apr. 2019). (Accessed Apr. 2019).
Consent

Written consent must be obtained for store-and-forward.

 

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 91 (Apr. 2019). (Accessed Apr. 2019).
Miscellaneous

“Use place of service (POS) 02 to indicate that a billed service was furnished as a telemedicine service from a distant site. Distant site practitioners billing for telemedicine services under Critical Access Hospital (CAH) optional payment method must use the GT modifier. Add modifier 95 if the distant site is designated as a nonfacility.”

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 90 (Apr. 2019). (Accessed Apr. 2019).

 

Additional Documentation Requirements for Telemedicine:
• Verification that the service was provided via telemedicine
• The location of the client and a note of any medical personnel with the client
• The location of the provider
• The names and credentials (MD, ARNP, RN, PA, CNA, etc.) of all people involved in the
telemedicine visit, and their role in the encounter at both the originating and distant sites

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 88
(Apr. 2019). (Accessed Apr. 2019).

 

“If a provider from the originating site performs a separately identifiable service for the client on the same day as telemedicine, documentation for both services must be clearly and separately identified in the client’s medical record.

Source: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 89 (Apr. 2019). (Accessed Apr. 2019).

Private Payer Laws

Requirements

Insurers (including employee health plans and Medicaid Managed Care) must reimburse a provider for services delivered through telemedicine or store-and-forward if:
• The plan provides coverage when provided in-person;
• The health care service is medically necessary;
• The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act (ACA);
• The health care service is determined to be safely and effectively provided through
telemedicine or store-and-forward technology according to generally accepted health
care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information.

Source: RCW 48.43.735.(1) (Accessed Apr. 2019).

 

Eligible Originating Sites
• Hospital
• Rural health clinic
• Federally qualified health center
• Physician’s or other health care provider’s office
• Community mental health center
• Skilled nursing facility
• Renal dialysis center, except an independent renal dialysis center
• Home or any location determined appropriate by the individual receiving the service
• Originating sites may not distinguish between rural and urban originating sites

Source: RCW 48.43.735.(3) (Accessed Apr. 2019).

 

An originating site (other than a home) can charge a facility fee, but it is subject to a negotiated agreement between the originating site and the health plan.

Source: RCW 48.43.735.(4) (Accessed Apr. 2019).

 

If the services are provided via store-and-forward, there must be an associated office visit between the patient and referring health care provider.

Source: RCW 48.43.735.(2(a)) (Accessed Apr. 2019).
Definitions

“Telemedicine” means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment. For purposes of this section only, “telemedicine” does not include the use of audio-only telephone, facsimile, or email.

Source: WA Rev. Code Sec. 48.43.735.(8(g)) (Accessed Apr. 2019).

Parity

Payment Parity

No explicit payment parity.

 

Service Parity

Services must be considered an essential health benefit under the ACA and be determined to be safely and effectively provided through telemedicine or store-and-forward.

Source: RCW 48.43.735.(1(c)) (Accessed Apr. 2019).

Professional Regulation /
Health & Safety

Definitions

“Telemedicine means the delivery of health care (or behavioral health) services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.
For purposes of this section only, ‘telemedicine’ does not include the use of audio-only telephone, facsimile, or email.”

Source: RCW 70.41.020(13) & WAC 246-335-610.(21) (Accessed Apr. 2019).

 

Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) to deliver covered services that
are within his or her scope of practice to a client at a site other than the site where the provider is located.

Source: WAC 182-531-1730.(1) (Accessed Apr. 2019).

 

Hospice
“Telehealth” means a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technology. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services.
“Telemedicine” means the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment.

Source: WAC 246-335-610.(20) & (21) (Accessed Apr. 2019).

 

Physical and Occupational Therapy
“Telehealth means providing physical therapy [or occupational therapy] via electronic communication where the physical [occupational] therapist or physical [or occupational] therapist assistant and the patient are not at the same physical location.”

Source: WAC 246-915-187(3(a)) & 246-847-176.(1) (Accessed Apr. 2019).
Consent

Patient consent should be obtained and documented prior to the telemedicine encounter.

Source: Washington Medical Quality Assurance Commission, Guidelines for Appropriate Use of the Internet in Medical Practice
(Accessed Apr. 2019).
Cross-State Licensing

Member of the Interstate Medical Licensure Compact.

Source: The IMLC. (Accessed Apr. 2019).

 

Member of Physical Therapy Compact.

Source: PT Compact. Compact Map. (Accessed Apr. 2019).
Miscellaneous

Source: WAC 284-43-204. (Accessed Apr. 2019).

 

Source: WSB 6163 -2018. (Accessed Apr. 2019).
Source: SB 6399 – 2018. (Accessed Apr. 2019).

 

Online Prescribing

The WA Medical Quality Assurance Commission has issued guidelines on the use of the Internet in medical practices. A guideline does not have the force of law, but can be considered by the Commission to be the standard of practice in the state.
A documented patient evaluation, including history and physical evaluation adequate to establish diagnoses and identify underlying conditions and/or contra-indications to the treatment recommended/provided, must be obtained prior to providing treatment, including issuing prescriptions, electronically or otherwise.
Treatment and consultation recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in in-person settings.
Treatment, including issuing a prescription, based solely on an online questionnaire or consultation does not constitute an acceptable standard of care.

 

Source: Washington Medical Quality Assurance Commission, Guidelines for Appropriate Use of the Internet in Medical Practice (Accessed Apr. 2019).

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