AAP Guidance: Telehealth Payer Policy in Response to COVID-19

As the US health care system responds to the COVID-19 crisis, the need for expanded use of appropriate telehealth care has become critically important. To facilitate and expedite the uptake and spread of telehealth care while retaining appropriate linkages to the pediatric medical home, payers (private payers as well state Medicaid/Children’s Health Insurance Programs (CHIP) and their contracted managed care organizations (MCOs)) should take steps now to reduce or eliminate barriers to its expanded use.

The AAP is working at all levels to strongly advocate for changes that will eliminate burdens on pediatricians seeking to begin or expand use of telehealth care. While we continue to push for federal solutions, states and payers can act now on policy changes that will alleviate barriers to expanded telehealth care use. Your state-level advocacy is needed now and can make a big difference!

The questions and answers below are intended to guide pediatricians and AAP chapters in assessing payers’ telehealth coverage and, together, advocating for changes in policy. It is important to understand the specifics of carrier coverage for telehealth care—pediatricians and chapters should review state laws, payer contracts, carrier notifications for updates in telehealth coverage, billing requirements, and payment policies.

With respect to state laws, states are rapidly issuing new telehealth care guidance in response to the COVID-19 crisis—the AAP is cataloging this new state-by-state guidance here. Additional information about existing state telehealth regulation can be found in the Center for Connected Health Policy Compendium, State Telehealth Laws & Reimbursement Policies, Fall 2019, or via state-specific information accessible at this map. The Academy will continue to update our resources with new state COVID-19 telehealth guidance/announcements as they become available.

Also of note, the US Department of Health and Human Services (HHS) has indicated in its March 13 Public Health Emergency action that physician state licensure requirements have been waived for purposes of Medicare, Medicaid, and CHIP. This notably does not change state licensure requirements for physicians and other health care professionals generally, although states are beginning to waive licensure requirements for the purposes of practicing or volunteering in the state too. The Federation of State Medical Boards (FSMB) is maintaining a list of state actions in this regard, here. It’s important to read and understand the nuances of these state actions.

Key considerations for telehealth policy are provided below. AAP chapters, pediatric councils, and members should work with states and payers to ensure telehealth care policies meet the standards outlined below in each question and answer.

With respect to Medicaid managed care, and in conjunction with the newly released FAQ document for Medicaid and CHIP programs from the Centers for Medicare and Medicaid Services (CMS), states should also look to amend existing MCO contracts to extend the same telehealth flexibilities authorized under the state plan, waiver, or demonstration covered under the contracts.

For a handy summary of this Guidance, see the AAP Guidance Checklist on this page.

AAP Guidance Checklist: Telehealth Policy in Response to COVID-19

To summarize this guidance, during this time of crisis Medicaid and all payers should:

☑ Cover all modalities of telehealth care. This includes live video, store-and-forward, remote patient monitoring, telephone care (phone only), electronic consults, virtual check ins, and e-visits.

☑ Allow for the home as an originating (patient) and distant (provider) site.

☑ Waive any geographic restrictions.

☑ Provide telehealth care for new and established patients.

☑ Ensure coverage of both COVID-19 related services and other services. During this time of crisis, all types of clinically appropriate services should be allowed to be treated via telehealth care.

☑ Ensure access to all licensed clinicians available to treat via telehealth as long as the services provided are clinically appropriate. Children must have access to all services they need during this crisis.

☑ Not default to existing telehealth care vendor contracts but ensure coverage to the pediatric medical home as well as pediatric medical subspecialists and surgical specialists.

☑ Follow the March 17 HHS OCR guidance and subsequent FAQ and allow for good faith use of non-HIPAA compliant end-to-end communication apps/platforms.

☑ Eliminate any frequency limitations and communicate clearly with providers as to policy change time frames.

☑ Follow proper billing procedures.

☑ Pay for telehealth care visits at parity with in-person visits.

☑ Provide retroactive payment at parity to the start of the COVID-19 crisis.

☑ Pay a transmission/facility fee or otherwise help compensate practices for associated telehealth care costs.

☑ Waive cost sharing for telehealth visits and ensure payment to providers is inclusive of what would otherwise be a cost sharing amount.

Telehealth Care Modalities Covered

There are several modalities of telehealth care, and payers may currently not cover all types.

What telehealth care modalities are covered under the payer telehealth care policy?

Site Restrictions

An “originating site” refers to the location of the patient during a telehealth care encounter, a “distant site” or “hub” refers to the location of the clinician. States and payers may have existing restrictions on originating or distant sites that would limit payment to encounters that take place within those confines.

What is an acceptable originating or distant site?

There should be no restrictions on originating sites where the patient can be located—in particular during this time of social distancing, states and payers should ensure payment for services that take place at the patient’s home. Clinicians should also be free to provide telehealth care to patients from locations other than their normal clinical settings (office, hospital, etc.), to ensure maximum clinician flexibility (ie, pediatricians thus can treat patients during a time of proactive self-quarantine or other social distancing).

Are there other geographic restrictions to be aware of?

Patient Restrictions

States and payers may traditionally limit the types of visits available for telehealth care.

Is telehealth care available for both new and established patients?

Should telehealth care be only available for COVID-19 related services?

Providers Covered

States and payers may have laws or payment policies that limit payment for telehealth care by provider titles.

Are there any restrictions to the types of providers that can perform telehealth?

Existing Vendor Contracts

State Medicaid programs and payers may have existing contracts with private telehealth care vendors (e.g., Teladoc, MDLive, others) to which they provide preferential or exclusive coverage.

Are enrollees restricted to utilizing these telemedicine vendors or can any in-network provider render telemedicine services?

Platform Restrictions/HIPAA Compliance

HIPAA privacy requirements traditionally bar clinicians from using certain communication apps/platforms for purposes of telehealth care. However, on March 17, the US Department of Health and Human Services (HHS) Office of Civil Rights (OCR) announced that it would exercise its enforcement discretion and not penalize providers who make good faith use of platforms that normally would not meet HIPAA privacy standards to provide telehealth care. A subsequent HHS OCR frequently asked question (FAQ) document provides further details of this discretion and expectations at this time.

What limitations are there on apps/communication platforms for purposes of telehealth care?

During this crisis, states and payers should follow the HHS OCR March 17 guidance and subsequent HHS OCR FAQ and allow for the use of apps and platforms for good faith telehealth care use. Of note, these could include end user-to-end user apps such as FaceTime, Skype, Facebook Messenger, Google Hangouts Video, and others. These notably do not include public facing apps/platforms such as Facebook Live or TikToc. As always, providers should take every effort to protect patient information, and use HIPAA-compliant platforms whenever possible.

Frequency and Time Limits

States and payers may have existing limits that restrict when telehealth care can be provided in the context of other services. In addition, newly released COVID-19 guidance may be time limited.

Are there frequency limitations on when telehealth may be used in relation to face-to-face office visits?

What are the time frames for these new telehealth care rules/ exceptions?

As several carriers have adopted new modifications in response to COVID-19 for a 90-day period, pediatricians are advised to monitor whether timeframes will be extended. Several states have indicated that Medicaid telehealth care policy changes will remain in effect as long as there is a state emergency, but pediatricians and chapters should again monitor notifications for changes.

Billing and Payment

How should telehealth care be billed?

The Academy has created a useful reference for coding and billing with respect to COVID-19. Please see “Coding for COVID-19 and Non-Direct Care” or contact the Academy at [email protected] for targeted consultation.

To the extent possible, states and payers should work together to ensure the same coding/billing requirements so that practices do not have to change administrative procedures for different payers. Please keep in mind that if a payer requires the reporting of a code outside of its intended use, practices should be sure to obtain this requirement in writing from the payer as this will provide documentation in the event of an audit.

Is there telehealth care visit payment parity with a face-to-face visit?

The Academy strongly recommends payment for telehealth care visits be set at parity with payment for in-person visits. In response to the COVID-19 crisis, some states are beginning to adopt such a parity requirement, and many payers may already do so. Telehealth care in pediatrics requires medical judgment and is associated with practice expense and medical liability risk. Particularly during this time of crisis, payers should not be disincentivizing telehealth care by providing less than appropriate payment. To ensure pediatricians can provide telehealth visits to the same extent as in-person visits, payment for telehealth care visits should be set at parity with that of in-person visits AAP chapters, pediatric councils, and members should advocate to achieve such payment parity. Of particular note, Medicaid programs that move to pay for telehealth care at parity can avoid filing a state plan amendment (SPA) to do so.

When should the payment for telehealth care and payment parity start?

Payers should recognize that pediatricians have in many cases already begun providing telehealth care during the COVID-19 crisis and should make payment and payment parity retroactive (ie, to an established start date such as the date of your state’s emergency declaration, January 31 National Public Health Emergency, or March 13 national emergency).

Can other components of telehealth care also be paid?

Should cost sharing be waived for families for telehealth visits?

Yes, during this time of crisis, telehealth care should be delivered without the added burden of cost sharing. Medicaid, CHIP, and private insurance payment amounts for telehealth care visits should be inclusive of what might otherwise be cost sharing amounts, so that waived cost sharing does not become a financial penalty for providers.

For useful reference, the above guidance can also be found in the AAP Guidance Checklist on the first page. As always, the AAP is here to help as chapters and members advocate for changes in telehealth policy. Please continue to contact [email protected] with all related questions.

Last Updated

03/26/2020

Source

American Academy of Pediatrics