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New Post-PHE Telehealth Guidance for Medicaid Providers Released

The Department of Health (DOH) has released updated telehealth guidance for Medicaid providers to support the continued use of telehealth services once the federal COVID-19 Public Health Emergency (PHE) ends on May 11th. The new guidance provides for continued coverage of telehealth services, including audio-visual telehealth consultations, teledentistry, store-and-forward technology, remote patient monitoring, virtual check-ins, virtual patient education, and audio-only services. The guidance applies only to Medicaid-covered services; it does not apply to commercial insurers or Medicare services. Noteworthy elements of the guidance for long term care providers include the following:

Audio-only visits are covered for Medicaid beneficiaries only when all of the following conditions are met:

  • Audio-visual telehealth is not available to the patient due to lack of patient equipment or connectivity, or audio-only is the preference of the patient;
  • The provider must make either audio-visual or in-person appointments available at the request of the patient;
  • The service can be effectively delivered without a visual or in-person component, unless otherwise stated in guidance issued by DOH (this is a clinical decision made by the provider); and
  • The service provided via audio-only visits contains all elements of the billable procedures or rate codes and meets all documentation requirements as if provided in person or via an audio-visual visit.

Program-specific guidance will govern Medicaid coverage of telehealth services. For example, telephonic billing for specific Community-Based Long Term Care Services and Supports will be defined in program-specific guidance.

For dually eligible beneficiaries, Medicare must be billed prior to Medicaid. If Medicare covers the telehealth encounter, Medicaid will reimburse the Part B coinsurance and deductible to the extent permitted by state law. Any telehealth restrictions imposed by Medicare apply to dually eligible members unless otherwise stated, as noted on the Centers for Medicare and Medicaid Services (CMS) "List of Telehealth Services" webpage.

Medicaid managed care (MMC) plans are required to cover, at a minimum, services that are covered by fee-for-service (FFS) Medicaid and are included in the MMC benefit package, when determined medically necessary. MMC plans must provide telehealth coverage as described in the guidance. However, they may establish claiming requirements (e.g., specialized coding) that vary from FFS billing instructions set forth in the guidance. Plans must adhere to the payment parity requirements set forth in the guidance. MMC plans may not limit enrollee access to telehealth/telephonic services to solely the in-network telehealth vendors and must cover appropriate telehealth/telephonic services provided by other network providers.

Billing rules for audio-visual telehealth services provided in nursing homes depend on whether the services of the telehealth practitioner are included in the nursing home's rate. When the services of the telehealth practitioner are included in the nursing home rate, the telehealth practitioner must bill the nursing home. If the services of the telehealth practitioner are not included in the nursing home rate, the telehealth practitioner should bill Medicaid as if the practitioner saw the Medicaid beneficiary face to face.

The guidance also includes resources to support access to devices and internet services for Medicaid beneficiaries. Questions about the new guidance may be submitted to DOH here or by calling 518-473-2160.

Contact: Karen Lipson, klipson@leadingageny.org