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.
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.
States and payers may traditionally limit the types of visits available for telehealth care.
States and payers may have laws or payment policies that limit payment for telehealth care by provider titles.
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.
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.
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.
Billing and Payment
American Academy of Pediatrics