Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient) that states can choose to cover under Medicaid. Note that the federal Medicaid statute does not recognize telemedicine as a distinct service.

Telehealth includes such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices, which are used to collect and transmit patient data for monitoring and interpretation. While they do not meet the Medicaid definition of telemedicine, they are often considered under the broad umbrella of telehealth services. Even though such technologies are not considered "telemedicine," they may nevertheless be covered and reimbursed as part of a Medicaid coverable service, such as laboratory service, x-ray service or physician services (under section 1905(a) of the Social Security Act).

Billing and Reimbursement

Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient). As such, states have the option/flexibility to determine whether (or not) to cover telemedicine; what types of telemedicine to cover; where in the state it can be covered; how it is provided/covered; what types of telemedicine practitioners/providers may be covered/reimbursed, as long as such practitioners/providers are "recognized" and qualified according to Medicaid statute/regulation; and how much to reimburse for telemedicine services, as long as such payments do not exceed federal upper limits.

HHO will continue to reimburse services for appropriate providers delivered via telemedicine at the same rates as in-person delivered services .

Coverage for telehealth and telemedicine are limited to the types of services already considered a covered benefit under Highmark Health Option plans and reimbursement for those services are based on that benefit determination. Coverages and reimbursements for telehealth services are limited to those services performed between a licensed clinician and a member/patient.

When a covered benefit, evaluation and management and consultation services delivered through telehealth may be reimbursed under the following conditions:

• Professional services rendered via an interactive telecommunication system are only eligible for reimbursement to the provider rendering the telemedicine services. A provider rendering face-to-face care should report the appropriate codes for the in-person services.
  
• The patient must be present at the time of all billed services. If state law requires a face-to-face examination PRIOR to the delivery of telemedicine services, the face-to-face services must be concluded and documented in the medical record prior to the initiation of any related telehealth visits.
• The referring, consulting, or distant provider should obtain written valid consent from the member agreeing to participate in services delivered via the means of telemedicine. The member has the right to refuse these services at any time and must be made aware of any alternatives, including any delays in service, need to travel, or risks associated with not having services provided via telemedicine.
• ·All services provided must be medically appropriate and necessary.
• Prior authorization for telehealth-delivery is not required, but the Distant Site provider must obtain prior approval for any other covered services which would normally require prior authorization. This applies for participating and non-participating providers.
• The consultation/evaluation and management service must take place via an interactive audio and/or video telecommunications system (unless exceptions are allowed by applicable laws). Interactive telecommunications systems must be multi-media communication which, at minimum, includes audio and video equipment permitting real-time (synchronous) consultation among the patient and practitioner at the Originating Site and the practitioner at the Distant Site.
• Thorough, appropriate documentation of telemedicine services and other communications relevant to the ongoing medical care of the patient should be maintained as part of the patient's medical record.
• Services billed which indicate telemedicine as the mode of service delivery but are not substantiated by either the claim form or written medical records are subject to disallowances in the course of an audit.
• ·Please note that valid consent is required to assure that the member agrees to receive service via Telehealth delivered service and to assure that the member retains a voice in their treatment. The member must be informed and given an opportunity to request an in-person assessment before receiving a Telehealth service. The member’s verbal consent must be documented in the member’s record. The Contractor shall not require written consent for the provision of Telehealth services.

Limitations

• HHO will reimburse up to three different consulting providers for separately identifiable telemedicine services provided to a member per date of service and only one originating facility fee is permitted per date, per member.
• ·HHO will not reimburse the referring provider at the originating facility on the same date of service unless the referring provider is billing for a separate identifiable covered service. Medical records must document that all of the components of the service being billed were provided to the recipient.
• Chart reviews, electronic mail messages, facsimile transmissions or internet services for online medical evaluations are not covered telehealth services.
• HHO shall not pay a facility fee for the Distant site- at a minimum, HHO shall pay for telehealth services delivered via telephone that meet the States guidelines (2023 MSA).

Eligible Providers

Providers performing and billing telemedicine services must be eligible to independently perform and bill the equivalent face-to-face service. Providers must be located in the United States to provide these services.

 For services delivered through telehealth, healthcare practitioners must:

• Act within their scope of practice.
• Be licensed for the service for which they are providing to members.
• Be a participating provider with HHO or engaged in the process to become a participating provider.
• Be located within the continental United States.
• Provider at originating site and the provider at distant site must be licensed in Delaware or in the state in which the provider is located, if allowed under Delaware law to provide Telehealth services without a Delaware license through the Interstate Medical Licensure Compact or otherwise must be enrolled with DMAP.

Behavioral Health

Examples of eligible Behavioral Health Telehealth services include (not an all-inclusive list):

• Evaluation and Management
• Behavioral Health
• Substance Abuse

Member and Provider Education and Training

Members and providers should be educated about the availability of Telehealth, considerations for using Telehealth versus in person visits, applicable requirements and how to access Telehealth options. Members and providers should be ensured that Telehealth does not replace provider choice and/or member preference for in-person service delivery (2023 MSA).