GOVERNMENT PAYOR COVERAGE FOR

TELEHEALTHApril 2017

OVERVIEW Discussion of Specific Services, Expansion of Coverage Medicare Medicaid (Kansas, Missouri) Proposals in the Pipeline

MEDICARE TELEHEALTH SERVICES Criteria for Medicare Coverage:

Interactive telecommunications Physician or other authorized practitioner

Physician assistants Nurse practitioners Nurse midwives CNS Psychologists, social workers Dieticians or nutrition professionals

Eligible telehealth individual Eligible originating site Qualifying telehealth service

1834(m)(4)(F)(i), 42 U.S.C. 1395m Professional consultations, office visits, office psychiatry services Updated annually

MEDICARE TELEHEALTH SERVICES1. Interactive telecommunications

Audio and visual, two-way, real-time Not phone, fax, email

2. Physician or other authorized practitioner

3. Eligible telehealth individual

4. Eligible originating site Geography, site of service requirements

5. Qualifying telehealth service Category 1: Services similar to professional consultations, office visits, and office psychiatry services Category 2: Dissimilar services – review whether services demonstrate clinical benefit to patient

Submission of clinical studies; medical necessity; copies of published peer reviewed articles

MEDICARE TELEHEALTH SERVICESQualifying telehealth service

Psych diagnostic evaluations Psychotherapy End stage renal disease services Nutrition services Office visits Subsequent hospital visits Subsequent nursing facility visits Prolonged office/outpatient, inpatient services Tobacco use cessation Transitional care management Advanced care planning Diabetes management Alcohol/substance use intervention Medicare IPPE/AWV

MEDICARE TELEHEALTH SERVICES

Psychiatry/Psychology Services Diagnostic evaluation with/without medical services

History Mental Status Recommendations Communication with family, other sources Review/order diagnostic studies “Medical services”: other physical exam elements as indicated, medications May include interactive complexity, but interactive complexity not covered via

telehealth

MEDICARE TELEHEALTH SERVICES

Psychiatry/Psychology Services Psychotherapy

Physician or other qualified health care professional Definitive therapeutic communication Alleviate emotional disturbance Reverse or change maladaptive patterns Encourage personality growth and development May include someone other than the patient Individual services, family services Does not include psychotherapy for crisis

MEDICARE TELEHEALTH SERVICES

End Stage Renal Disease Outpatient services Physician or other qualified health professional Establish the dialyzing cycle Management of dialysis visits Phone calls Patient management during dialysis

MEDICARE TELEHEALTH SERVICESNutrition Services

Clinical staff other than physicians and other qualified health care professionals Primarily RD, licensed nutritional professionals

Outpatient Managing acute or chronic condition or disease Usually multiple encounters Nutritional diagnostic therapy Review screening and/or relevant clinical data

Labs Meds Signs and symptoms Nutrition-oriented physical exam

Determine nutritional diagnosis Identify appropriate interventions Counseling

Behavioral, therapeutic, lifestyle changes Food/meal purchasing, activity level, readiness to learn

Nutrition monitoring and evaluation of goals

MEDICARE TELEHEALTH SERVICES Office visits

Subsequent hospital visits

Subsequent nursing facility visits

Prolonged office/outpatient, inpatient services

MEDICARE TELEHEALTH SERVICES Tobacco use cessation

Physician or other qualified health care professional No specific illness, but the behavior is considered an illness itself

Alcohol/substance use intervention Structured assessment and intervention

Diabetes management Outpatient Self-management training

Advanced care planning Physician or other qualified health care professional With patient and/or surrogate Advance directives, health care proxy, DPOA, living will

MEDICARE TELEHEALTH SERVICES Medicare Initial Preventive Physical Exam, Annual Wellness Visit

Not a well woman/well male exam PMFSH

Medications Diet Activities

Risk factors for depression and mood disorders Functional ability

Hearing impairment ADLS

Level of safety Fall risk Home safety

Exam Vitals Visual acuity

End of life planning Education, counseling, referrals Screening schedule

MEDICARE TELEHEALTH SERVICES Chronic care management

Not approved telehealth service, but no face to face required “Regular” or complex Two or more chronic conditions expected to last at least 12 months, or until death of patient No list of diagnoses Comprehensive care plan established, implemented, revised, or monitored At least 20 minutes of clinical staff time in a calendar month Directed by physician or other qualified health care professional Complex:

60 minutes Moderate or high complexity decision-making

MEDICARE TELEHEALTH SERVICES

KS MEDICAID TELEHEALTH SERVICES Office visits Individual psychotherapy Providers cannot prescribe drugs based on internet questionnaire/consult, phone

consult only. Must have valid pre-existing patient-prescriber relationship. Remote monitoring

Prescribed by physician Medically necessary Signed consent for telehealth services Skilled nursing service Does not exceed two visits per week for non-home and community based services Services must be provided by a registered nurse or licensed practical nurse

KS MEDICAID TELEHEALTH SERVICES Remote monitoring under HCBS Frail/Elderly program:

Patient education Counseling Nursing supervision Baseline review Survey responses Vitals RN/LPN with RN supervision Two or more hospitalizations (including ER visits) in previous year related to disease

MO MEDICAID TELEHEALTH SERVICES 2016 Legislation allows a physician-patient relationship to be established by a

telemedicine encounter, consistent with standard of care A questionnaire completed by the patient, whether via the internet or telephone,

does not constitute an acceptable medical interview and examination for the provision of treatment by telehealth

MO MEDICAID TELEHEALTH SERVICES

Originating SitesMedicare MO Medicaid

Provider office Provider office

Hospital Hospital

Critical access hospital Critical access hospital

Rural health clinic Rural health clinic

Federally qualified health center Federally qualified health center

Skilled nursing facility Long-term care facility

Community mental health center Community mental health center

Hospital-based renal dialysis center Dialysis center

Missouri state habilitation center or regional office

Missouri state mental health facility

Missouri state facility

Missouri residential treatment facility w/ children’s division (limitations apply)

Comprehensive substance treatment and rehab program

School

*Recipient’s home

Pharmacy

Child assessment center

MO MEDICAID TELEHEALTH SERVICES Consultation Evaluation and management Diagnosis, therapeutic, or interpretive service Individual psychiatric or substance abuse assessment Diagnostic interviews Individual psychotherapy

MO MEDICAID TELEHEALTH SERVICES Home telemonitoring, with risk factors:

Pregnancy Diabetes Heart disease Cancer Chronic obstructive pulmonary disease Hypertension Congestive heart failure Mental illness or serious emotional disturbance Asthma Myocardial infarction; or Stroke

MO MEDICAID TELEHEALTH SERVICES Home telemonitoring, with risk factors:

Two or more hospitalizations in the prior twelve-month period; Frequent or recurrent emergency department admissions; A documented history of poor adherence to ordered medication regimens; A documented history of falls in the prior six-month period; Limited or absent informal support systems; Living alone or being home alone for extended periods of time; A documented history of care access challenges; or A documented history of consistently missed appointments with health care

providers

PROPOSALS IN THE PIPELINE HR 1148, S431

Exceptions to Medicare’s originating site geographic restrictions Related to stroke Similar to companion bills that failed in 2016 S. 431 would allow any site administering acute stroke care to be added as an eligible

site with no geographic restrictions, but exclusively limited to providing services to treat acute stroke for Medicare patients

H.R 1148 is more limited in its allowances, permitting only hospitals or mobile units to qualify as an eligible site when delivering strictly defined “telehealth-eligible stroke services”

PROPOSALS IN THE PIPELINE HR 1152: Would allow VA providers to be able to treat VA patients in any state

using telemedicine, even if neither the provider nor the patient is physically located in a facility owned by the federal government

HR 766: Establishes a pilot program to expand telehealth options under the Medicare program for individuals living in public housing

HR 2012, S356: Establishes a telehealth services demonstration program to provide telehealth services or to expand existing telehealth service programs located at school based health centers

QUESTIONSRichelle Marting, JD, MHSA, RHIA, CPC, CEMC, CPMA, CPC-I

rmarting@forbeslawgroup.com

Forbes Law Group, LLC

6900 College Blvd, Ste 840

Overland Park, KS 66211

(913) 341 – 8600