California Expands Medicaid Tele-Health Policy

The California Department of Health Care Services (“DHCS”) recently revised its Medi-Cal telehealth policy to allow providers increased flexibility in their use of telehealth as a modality for delivering medically necessary services to their patients. The policy is retroactively effective as of July 1, 2019, and fee-for-service providers must submit claims for services provided via telehealth according to the new policy. Updates to the telehealth policy include the following:

• Reimbursable Modalities: Providers now decide what modality (either live video or store-and-forward technology), they want to use to deliver eligible services to a Medi-Cal enrollee as long as (i) the service is covered by Medi-Cal and meets all other Medi-Cal guidelines and policies, (ii) can be properly provided via telehealth and (iii) meets the procedural and definition components of the appropriate CPT or HCPCS code.
• Telehealth from Home: An “originating site” now includes the home and there is no requirement that a provider be with the patient at the time of the telehealth interaction.
• E-Consults: Providers may now engage in e-consults, defined to mean “asynchronous health record consultation services that provide an assessment and management service in which the patient’s treating health care practitioner (attending or primary) requests the opinion and/or treatment advice of another health care practitioner (consultant) with specific specialty expertise to assist in the diagnosis and/or management of the patient’s health care needs without patient face-to-face contact with the consultant. E-consults between health care providers are designed to offer coordinated multidisciplinary case reviews, advisory opinions and recommendations of care. E-consults are permissible only between health care providers.”
• Provider Requirements: The Policy now includes specific requirements for providers to be eligible to receive reimbursement for telehealth provided services. Specifically, providers must meet all of the following criteria: (i) Provider must be licensed in CA, (ii) enrolled as a Medi-Cal rendering provider or non-physician medical practitioner and (iii) affiliated with an enrolled Medi-Cal provider group. The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

It is important to note that the Policy now explicitly excludes patient initiated electronic transmissions, including through mobile phone applications, from the definition of “asynchronous store-and-forward” technologies for which reimbursement is available.

In addition to the fee for service Medi-Cal telehealth changes, DHCS also revised telehealth policies in the Provider Manuals for Federally Qualify Health Centers/Rural Health Clinics; Indian Health Services Memorandum of Agreement 638 Clinics; and Family Planning, Access, Care, and Treatment with information about telehealth. DHCS also published All Plan Letter 19-009 regarding telehealth services in managed care health plans.

Key Takeaways

DHCS’s changes portend growing use of telehealth tools to provide health care services to patients who may not be able to physically access their health care providers. Enabling providers to decide whether and when to use either live video or store-and-forward technology will likely increase the use of the latter which, at least anecdotally, tends to be more convenient for patients and results in more patients actually seeking and receiving the care they need. Health care providers who choose to use store and forward technologies to provide care should be mindful to ensure they are meeting all applicable standards of practice when doing so. Copyright © 2019, Sheppard Mullin Richter & Hampton LLP.