More of Telemedicine

Telemedicine, for the purpose of Medicaid,  aims to improve a patient's health by allowing two-way, real-time interactive communication between the patient, and the physician or practitioner at the distant site. This would use interactive telecommunications equipment that includes, at a minimum, audio and video.

It is a cost-effective alternative to the more traditional face-to-face way of providing medical care that states can choose to cover under Medicaid. This definition is modeled on Medicare's definition of telehealth services (42 CFR 410.78).

Note that the federal Medicaid statute does not recognize telemedicine as a distinct service.

Terms used in Telemedicine

Distant or Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via the telecommunications system.

Originating or Spoke site: Location of the Medicaid patient at the time the service being furnished via a telecommunications system occurs. Telepresenters may be needed to facilitate the delivery of this service.

Asynchronous or "Store and Forward": Transfer of data from one site to another through the use of a camera or similar device that records an image that is sent via telecommunication to another site for consultation. Asynchronous or "store and forward" applications would not be considered telemedicine but maybe utilized to deliver services.

Medical Codes: States may select from a variety of HCPCS codes (T1014 and Q3014), CPT codes and modifiers (GT, U1-UD) to identify, track and reimburse for telemedicine services.

Telehealth or Telemonitoring is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance. It includes technologies such as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices, 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, and 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).

Medicaid guidelines on Provider/s

Medicaid requires all providers to practice within the scope of their State Practice Act. Some states have enacted legislation that requires providers a valid state license in the state where the patient is located. Any such requirements or restrictions placed by the state are the binding undercurrent Medicaid rules.

Reimbursement for Telemedicine

The reimbursement for Medicaid covered services (including those with telemedicine applications) must satisfy federal requirements of efficiency, economy, and quality of care. The States are encouraged to use the flexibility essential in federal law to create innovative payment methods.

For example, states may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the originating site. Additional costs such as technical support, transmission charges, and equipment can also be reimbursed. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state. If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service.

The flexibility of the State in Covering/Reimbursing for Telemedicine Services and the Application of General Medicaid Requirements to Coverage of Telemedicine Services

Since Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care, States will have the option to determine whether (or not) to cover telemedicine. 

This would include what types of telemedicine will be covered; where in the state it can be covered; how it is covered; what types of telemedicine practitioners/providers may be covered or reimbursed, as long as such practitioners/providers are "recognized" and qualified according to Medicaid regulation; and how much to reimburse for telemedicine services, as long as such payments do not exceed Federal Upper Limits.

If the state decides to cover telemedicine, but does not cover certain practitioners/providers of telemedicine or its telemedicine coverage is limited to certain parts of the state, then the state is responsible for assuring access and covering face-to-face visits or examinations by these "recognized" practitioners/providers in those parts of the state where telemedicine is not available.

Therefore, the general Medicaid requirements of comparability, state-wideness, and freedom of choice do not apply with regard to telemedicine services.

CMS Approach to Reviewing Telemedicine SPAs

States are not required to submit a (separate) SPA for coverage or reimbursement of telemedicine services, if they decide to reimburse for telemedicine services the same way/amount that they pay for face-to-face services/visits/consultations. 

States must submit a (separate) reimbursement (attachment 4.19-B) SPA if they want to provide reimbursement for telemedicine services or components of telemedicine differently than is currently being reimbursed for face-to-face services. 

States may submit a coverage SPA to better describe the telemedicine services they choose to cover, such as which providers/practitioners are; where it is provided; how it is provided, etc. In order to avoid unnecessary SPA submissions, it is recommended that a brief description of the framework of telemedicine be placed in an introductory section of the State Plan and then a reference made to telemedicine coverage in the applicable benefit sections of the State Plan. For example, in the physician section it might say that dermatology services can be delivered via telemedicine provided all state requirements related to telemedicine as described in the state plan are otherwise met.