Telehealth Benefits to Change for Texas Medicaid June 1, 2017

Information posted April 14, 2017 Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client’s specific MCO for details. Effective for dates of service on or after June 1, 2017, telehealth benefits will change for Texas Medicaid.

Overview of Benefit Changes

Major changes to this medical benefit policy include the following:

• Clarification of initial visit requirements
• Addition of patient health information security guidelines
• Documentation requirements
• Procedure code updates

Initial Visit Requirements

Before receiving a telehealth service, the client must receive an initial evaluation for the same diagnosis or condition by a physician or other qualified health-care professional licensed in Texas. A required initial evaluation must be performed in-person or as a telemedicine visit that conforms to Title 22 Texas Administrative Code (TAC) 174 (relating to Telemedicine). If the client is receiving the telehealth services to treat a mental health diagnosis or condition, the client is not required to receive an initial evaluation by a physician or other qualified health-care professional licensed in Texas.

A client receiving telehealth services must be evaluated at least annually by a physician or other health-care professional that is licensed in Texas and qualified to determine if the client has a continued need for services. The evaluation must be performed in-person or as a telemedicine visit that conforms to 22 TAC 174. This evaluation requirement does not apply to a patient receiving telehealth services for the treatment of a mental health diagnosis or condition from a qualified behavioral health provider licensed in Texas.

Patient Health Information Security

If a patient site presenter is not required for the telehealth visit, the software system used by the distant site provider must allow secure authentication of the distant site provider and the client.

If a patient site presenter is required for the telehealth visit, the software system used by both the distant and patient site providers must allow secure authentication of the distant site provider and the client.

The physical environments of the client and the distant site provider must ensure that the client’s protected health information remains confidential. A parent or responsible adult may be physically located in the patient site or distant site environment during a telehealth visit with a child.

A parent or responsible adult must provide written or verbal consent to the distant site provider to allow any other individual, other than the distant site provider, the patient site presenter, or a representative of the distant site provider or patient site presenter, to be physically present in the distant or patient site environment during a telehealth visit with a child.

An adult client must also provide written or verbal consent to the distant site provider to allow any other individual, other than the distant site provider, the patient site presenter, or a representative of the distant site provider or patient site presenter, to be physically present in the distant or patient site environment during a telehealth visit.

Providers of telehealth services must maintain the confidentiality of protected health information (PHI) as required by Federal Register 42, Code of Federal Regulations (CFR) Part 2, 45 CFR Parts 160 and 164, Chapters 111 and 159 of the Texas Occupations Code, and other applicable federal and state law.

Providers of telehealth services must also comply with the requirements for authorized disclosure of PHI relating to clients in state mental health facilities and residents in state supported living centers, which are included in, but not limited to, 42 CFR Part 2, 45 CFR Parts 160 and 164, Texas Health and Safety Code §611.004, and other applicable federal and state law.

All client health information generated or utilized during a telehealth visit must be stored by the distant site provider in a client health record using software that complies with Health Insurance Portability and Accountability Act (HIPAA) confidentiality and data encryption requirements, as well as with the United States Health and Human Services (HHS) rules implementing HIPAA.

Documentation Requirements

Both the distant site provider and the patient site presenter must maintain the records created at each site unless the distant site provider maintains the records in an electronic health record format.

Procedure Code Benefits

The following procedure codes will be added as a benefit for distant-site telehealth providers, when billed with modifier 95: