CMS Updates FQHC, RHC and Mental Health MLN Booklets In mid-March, the Centers for Medicare and Medicaid Services (CMS) announced that they had updated their Medicare Learning Network (MLN) booklets for federally qualified health centers (FQHCs), rural health clinics (RHCs) and mental health services.  The Medicare MLN booklets explain national Medicare policies on coverage, billing and payment rules for specific provider types.  The telehealth related changes incorporate the extensions to pandemic telehealth flexibilities made by the Consolidated Appropriations Act, 2023, as well as changes to policy that were made in the 2024 Final Physician Fee Schedule.  The major telehealth changes for each manual are noted below. Mental Health Coverage Booklet:Indicates that telehealth services provided to people in their homes will be paid at the non-facility PFS rate through December 31, 2024.Specifies that both marriage and family therapist (MFT) services and mental health counselor services are covered, and both can be delivered through telehealth.Instructs providers that beginning in 2025, an in-person visit will be required for mental health services provided by telehealth within 6 months before the initial telehealth treatment as well as subsequently at least every 12 months, although exceptions apply for patients who already get telehealth behavioral health services and have circumstances that prevent in person care, and for groups with limited availability for in person visits.  This would also apply to RHC and FQHCs beginning in 2025.FQHC/RHC BookletsAn allowance for FQHCs and RHCs, starting January 1, 2024, to bill remote physiologic monitoring (RPM), remote therapeutic monitoring (RTC), community health integration (CHI), principal illness navigation (PIN), and PIN-Peer Support (PIN-PS) by billing the general care management code, 0511.  Previously, remote monitoring was considered bundled under the FQHC/RHC’s all-inclusive rate and not reimbursed separately at all.The booklet now specifies that FQHCs/RHCs can provide mental health visits using interactive, real-time telecommunication technology. However, as indicated in the last bullet above, the in-person visit mandated by the CAA, while currently waived, will go into effect Jan. 1, 2025.Other telehealth policies in the FQHC/RHC booklets which were not recent revisions, but still provide needed guidance to FQHCs/RHCs include the allowance during the COVID-19 emergency and until December 31, 2024 for patients to be located anywhere to receive telehealth services without any geographic restrictions.  Likewise, all providers eligible to bill Medicare for professional services, including FQHCs/RHCs, can also provide distant site telehealth. It specifies that practitioners can provide telehealth from any distant site location, including their home during the time they’re working for the FQHC, and they can provide any distant site approved telehealth service under the PFS.  However, they can’t bill the visit’s cost or include it in the cost report.  Both the FQHC and RHC booklets also address virtual communication services for FQHCs/RHCs.  See the booklet for the specific requirements FQHC/RHC practitioners must follow to bill for virtual communications.  For an extensive exploration of billing policies applicable to mental health providers, FQHCs, and RHCs, encompassing telehealth, as well as topics beyond telehealth, consult the complete Medicare MLN booklets dedicated to FQHCs, RHCs, and mental health coverage.OMB Unveils AI Governance Policy for Federal Agencies Responding to President Biden’s executive order on AI, the White House Office of Management and Budget (OMB) has introduced a groundbreaking policy aimed at regulating the use of artificial intelligence (AI) across federal agencies. The policy emphasizes risk management, transparency, responsible innovation, workforce, and governance. Alongside this guidance, the Administration is unveiling a suite of initiatives aimed at fostering the responsible integration of AI within government operations, including the following:OMB will launch a Request for Information (RFI) on Responsible Procurement of AI in Government, gathering insights to shape forthcoming OMB strategies governing AI implementation in Federal contracts.Agencies will enhance their 2024 Federal AI Use Case Inventory reporting, significantly amplifying transparency regarding the Federal Government’s utilization of AI.The Administration pledges to recruit 100 AI professionals by Summer 2024 as part of the National AI Talent Surge.Meanwhile, the National Telecommunications and Information Administration (NTIA) released its “Artificial Intelligence Accountability Policy Report,” outlining safety prioritization strategies and independent audits of AI systems. These initiatives aim to promote responsible AI innovation while effectively managing risks and ensuring equitable outcomes. For more information, read the full OMB Agency Wide Policy in its entirety and the NTIA AI Accountability Policy Report.Latest Policy Developments in CCHP’s Telehealth Policy Finder and Policy Trends Map CCHP’s Telehealth Policy Finder look-up tool and Policy Trend Maps were updated throughout the past month based on the latest information from our ongoing state telehealth policy tracking. The latest states to be updated include California, District of Columbia, Indiana, Kansas, Kentucky, Nevada, New Hampshire, New York, North Carolina, Oklahoma, Oregon, Puerto Rico, Vermont, Virgin Islands, Washington. Although CCHP did not find major policy changes in state telehealth policies over the past few months, a few states made additions or modifications to their Medicaid reimbursement requirements for very specific circumstances, by either issuing a bulletin or changing a section of their provider manual. A few states also made modifications to their licensing and prescribing requirements. California:  California Medicaid updated their Telehealth Provider manual to implement two new telehealth provider requirements:Patient Choice of Telehealth Modality – For Medi-Cal providers that do offer telehealth modalities, they must offer Medi-Cal recipients the ability to choose whether they want to receive covered services through synchronous interactive audio/visual telecommunication systems or synchronous, telephone or other interactive audio-only telecommunications systems. Medi-Cal recipients may freely choose and change at any time their desired modality. Medi-Cal providers are exempt from the requirement to offer both telehealth modalities if the Medi-Cal provider does not have access to broadband, but supporting documentation must be available to DHCS upon request.Right to In-person Services – Medi-Cal providers furnishing services via telehealth must also either offer services in-person or have a documented process in place to link Medi-Cal recipients to in-person care within a reasonable time.District of Columbia:  The Department of Health Care Finance finalized emergency rules that amended billing requirements for Assertive Community Treatment (ACT).  The rules define the services that constitute a contact, when telehealth can be used, and establish standards for the types of contacts that a provider must deliver to receive the monthly payment. The rule does allow needs-based assessments to determine service eligibility to be conducted through telehealth.  Additional emergency rules adopted expands services for persons with developmental disabilities in the Medicaid Home and Community-Based Services programs and allows the use of remote support services that employ technology.  Finally, the Alcoholic Beverage and Cannabis Administration issued a final rule defining and authorizing practitioners to provide telehealth medicine services to qualifying patients, including recommending the use of medical marijuana, consistent with the laws and regulations governing their medical practice.Indiana: In response to Indiana House Enrolled Act 1352 (2023), the Indiana Health Coverage Programs (IHCP) has implemented a new telehealth-only provider enrollment for providers that wish to perform only telehealth services (with no physical site where patients are seen) and that meet the Indiana licensure and other special requirements outlined in this bulletin. This telehealth-only provider enrollment option is currently available on the IHCP Provider Healthcare Portal.Nevada:  Nevada Medicaid updated their Telehealth Manual to remove a limitation on audio only telehealth for behavioral health delivery that limited it to targeted case management and crisis intervention services.  The manual now states that audio only is allowed in circumstances where there is medical necessity and its appropriateness for the recipient is documented in the medical record.New York: Medicaid issued an Update in January announcing that they would reimburse for eConsults effective April 1, 2024.  Additionally, S 8058 was passed which defines gender-affirming care, and added the definition to sections of law applicable to providers prescribing abortion medication to out-of-state patients by means of telehealth.North Carolina:  North Carolina Medicaid updated their Dental Services manual in December to add coverage for both synchronous and asynchronous dental services for specific codes.  See manual for list of requirements.  Additionally, the Traumatic Brain Injury Appendix K Flexibilities were also updated to note that members could access Life Skills Training, Cognitive Rehabilitation, Day Supports, Supported Employment, Supported Living, Community Networking via telehealth.  The guidance specifies that the use of telehealth shall not exceed 25% of the authorized service hours per week (i.e. if an individual is authorized 40 hours a week, the individual may use the real time two-way interactive audio and video telehealth 10 hours per week).Oregon:  Amended a regulation on their Medicare Assistance out-of-state services policy to specify that they do not provide payments for items or services to any financial institution or entity located outside of the United States, which effectively prohibits payments to telemedicine providers and pharmacies located outside of the United States.  A separate regulation was also amended to stipulate that a license is not required of a physician or physician assistant when they are located outside the state and have an established provider-patient relationship with a patient in Oregon temporarily for the purpose of business, education, vacation or work who requires the direct medical treatment by that physician or physician assistant; or in circumstances where a patient located in Oregon requires temporary or intermittent follow-up care from a physician or physician assistant with whom they have an established provider-patient relationship.Washington:  Washington State Health Care Authority (Medicaid) updated their Telehealth Manual to include best practice in conducting telemedicine services to include asking a client if they need assistive devices to participate in virtual care, include accessibility options within a telehealth program and use technology designed with equity in mind.  Washington Medicaid also updated their physical health audio-only procedure code list to remove, revise and add specific codes effective Jan. 1, 2024.  Amendments were made to Medicaid coverage of home health services via telemedicine and SB 5821 was passed to align established relationship requirements related to audio-only access across statute (see State Legislation section of newsletter below).  Likewise, Permanent rules were adopted by the Office of the Insurance Commissioner updating audio-only established relationship requirements.  Additional legislation approved includes: HB 1939which enacts the Social Work Compact in Washington; SB 5481 which provides allowances for out-of-state providers and requires the review of the Uniform Law Commission’s proposal regarding implementing a process for out-of-state provider registration within state boards, and SB 5983 which allows medical assistants with telehealth supervision to provide intramuscular injections for syphilis treatment.Given the nuanced and varied approaches states are taking with their telehealth policies, please reference CCHP’s telehealth Policy Finder to link to additional details and access each states’ policies in their entirety.CMS Covered Entity Tool and Adhering to Standards for Electronic Transactions The Centers for Medicare and Medicaid Services (CMS) recently distributed an email blast clarifying that HIPAA (Health Insurance Portability and Accountability Act) covered entities are mandated to adhere to standards for electronic transactions, in addition to privacy and security provisions.  Their email highlighted the existence of the HIPAA Covered Entity Decision Tool, which CCHP had covered in a previous 2022 newsletter.  As a recap, the Covered Entity Decision Tool is designed to help organizations and individuals find out if they are a covered entity under HIPAA.  By referencing the document, providers, including those providing services via telehealth, can find out if they fall under the HIPAA administrative simplification regulations by answering a series of questions related to how the person/business receives payment for services and handles health information. This can be extremely useful due to the expanding scope of telehealth services making it increasingly ambiguous which entities may qualify as a covered entity under HIPAA and which fall outside of its scope. If it’s determined that the entity does qualify as a covered entity under HIPAA Administrative Simplification, providers should closely review CMS’ Simplification Regulations, including the standards for electronic transactions CMS references in their email blast.  CMS provides an overview of its simplified regulations, which covers issues such as use of business associates, trading partner agreements and direct data entry transactions, among other issues.  While the Covered Entity resource is not specific to telehealth, it should be noted that the CMS Office of Civil Rights (OCR) has released a series of materials tailored to help telehealth providers. This comes in the wake of the end of the COVID-19 public health emergency, which ended enforcement discretion and waived penalties for HIPAA violations that serve patients in good faith through everyday communication technologies, such as FaceTime or Skype.  The OCR telehealth-specific materials include:Educating Patients about Privacy and Security Risks to Protected Health Information when Using Remote Communication Technologies for TelehealthTelehealth Privacy and Security Tips for PatientsGuidance on How the HIPAA Rules Permit Remote Communication Technologies for Audio-Only TelehealthTo find out whether or not you are a covered entity, be sure to reference CMS’ Covered Entity Decision Tool and the accompanying regulations.An Update on Telehealth and Medication Abortion In March the Kaiser Family Foundation (KFF) published an article on the availability and use of medication abortion, highlighting telehealth’s role in medication abortion, as well as the policy barriers that currently exist.  As background and a preface to the KFF article, the KFF article reviews the recent history of medication abortion in the United States.  The article notes that in late 2021 the US Food and Drug Administration (FDA)announced (through an update on its FAQ webpage) that it would be ending a longstanding policy to require the in-person dispensing of mifepristone (a drug used to terminate pregnancy). However, soon after (in June 2022), the Supreme Cout ruled on Dobbs v. Jackson Women’s Health Organization overturning Roe v. Wade allowing states to set their own policies protecting or banning abortion.  Telehealth has emerged as a pivotal tool in providing medication abortion, particularly in light of its capability to extend healthcare services to regions with a sparse presence of clinicians offering abortion care.  Numerous studies have shown telehealth medication abortion is effective, safe and comparable to in-person medication abortion care, including a recent study published in Nature Medicine that spanned 20 states and examined medical records of 6,154 patients (and many additional studies exist).  The growing interest in telehealth as a means to facilitate easier access to medication abortion is underscored by the significant barriers many face in obtaining these services. The advent of an updated FDA label for mifepristone, which accommodates telehealth (as noted above), has introduced a viable option for patients who, due to travel constraints or a preference for privacy, opt for an abortion within their own homes, subject to state legislation.  However, this progress faces obstacles from legislative efforts aimed at curtailing abortion access. This is evident in a US state map featured in the KFF article, showing that telehealth medication abortion is only available in 12 states. In-person medication abortion is available in 24 additional states and DC but telehealth is not allowed in those states.  This legislative landscape highlights a contentious battle over the reach and application of telehealth in facilitating abortion access, positioning it as a critical juncture for both healthcare providers and patients navigating the complex interplay of healthcare innovation and regulatory constraints.  A recent report released by the Society of Family Planning and featured in an mHealthIntelligence article found that since the Dobbs v Jackson decision, abortions provided by virtual-only clinics experienced a striking 72% surge, increasing even in states with abortion bans, indicating individuals are still finding a way around the restrictions.  To learn more about the landscape of medication abortion and the use of telehealth to deliver the service, read the full KFF article.FAIR Health Telehealth Usage for December 2023 A recent article in Managed Healthcare Executive highlights some of the recent data gathered by FAIR Health on telehealth utilization nationwide.  FAIR Health receives voluntarily provided claims data, housing the country’s largest collection of private payer healthcare claims, while also receiving Medicare data, which allows them the ability to produce valuable reports for various government and healthcare entities. The latest data indicates a 3.9% decrease in national telehealth medical claims between November and December 2023. While the western region of the United States experienced the most significant decrease at 9.7%, audio-only telehealth services saw a rise nationally and across all regions. Despite telehealth’s surge in popularity in the initial phases of the COVID-19 emergency, FAIR’s data shows that overall telehealth usage has declined over the years. In fact, FAIR Health previously released an issue brief examining telehealth usage between 2020-2022, and found that while utilization increases coincided with COVID-19 case surges, overall usage remained low with just 5.4% of claims being coded as telehealth in January 2022. This data should help alleviate policymaker concerns about telehealth over-utilization.  For more, read the full article in Managed Healthcare Executive and see FAIR Health’s data tracker.New Study Examines Telehealth’s Role in Supporting Pregnant Individuals with Opioid Use Disorder A new study published in JAMA Network Open evaluates the effectiveness of a low-barrier, telemedicine addiction treatment program for pregnant patients with opioid use disorder (OUD) in the United States. This was a cohort study looking at pregnant individuals enrolled in a telemedicine addiction treatment program and had self-reported in pregnancy problem lists.  Researchers utilized electronic medical records from 2018 to 2022.  Primary and secondary outcomes, including continuous OUD care during pregnancy, telehealth treatment retention, and obstetric outcomes, were assessed through statistical analysis.  Ninety-four individuals meeting inclusion criteria had a mean age of 32.3 years, with most receiving Medicaid and some residing in rural areas. Seventy-five patients received continuous OUD care throughout pregnancy, with those becoming pregnant after initiating treatment showing higher rates of continuous care.  The majority continued telehealth treatment post-pregnancy, with all adhering to buprenorphine treatment and experiencing favorable obstetric outcomes, including a high rate of full-term pregnancies.  The results highlight how telehealth can offer continuous OUD care through pregnancy, with a significant majority maintaining treatment and achieving favorable obstetric outcomes. This latest JAMA study demonstrating the utility of telehealth in supporting individuals with OUD is one among several recent studies exploring the subject.  For example, two additional studies featured in mHealthIntelligence in 2024, including one focused on the University of Pennsylvania Medical Center (UPMC)’s telehealth bridge clinic and another conducted by Stanford researchers, reveals OUD treatment by telehealth and/or the audio-only modality provides just as effective treatment and is cost-effective.  The research underscores the potential of telehealth programs to support individuals with OUD, offering insights into the success of such models compared to traditional care settings. For all the details on the study focused on pregnant women, read the full JAMA article.FEDERAL LEGISLATION Telehealth Modernization Act of 2024 HR 7623 (Rep. Carter, R-GA) – Maintains many of the telehealth expansions in Medicare reimbursement made during the COVID-19 public health emergency.  It would allow the home as an originating site for all services, eliminate the geographic requirement, and allows the secretary to consult with stakeholders and expand the types of practitioners who may furnish telehealth services to include any health care professional eligible under the program.  It also provides clarification that FQHC or RHC services furnished through telehealth to an outpatient individual would be payable under the prospective payment system (PPS) or other payment methodology established for FQHCs/RHCs.  Costs would be considered allowable for purposes of PPS.  The bill also would require Medicare provide coverage and payment for certain telehealth services that are furnished via an audio-only communication system. (Status: 2/15/24 – Referred to the House Committee on Energy and Commerce) Primary and Virtual Care Affordability Act HR 7681 (Rep. Wenstrup R-OH) – Amends the Internal Revenue Code of 1986 to extend the exemption for telehealth services from certain high deductible health plan rules, to establish a safe harbor for high deductible health plans with no deductible for certain primary care services, and to direct the Comptroller General of the United States to conduct a study on the effects of such safe harbor. (Status: 3/13/24 – Referred to the House Committee on Ways and Means) Healthcare Enhancement And Learning Through Harnessing Artificial Intelligence Act “HEALTH AI Act” HR 7381 (Rep. Lieu D-CA) – Requires the Director of the National Institutes of Health to establish a grant program to facilitate research regarding the use of generative artificial intelligence in health care.  Research may include efforts to improve the ability of health care practitioners to record comprehensive notes, reduce administrative or documentation burden, expedite health insurance claims, improve efficiency and quality, or otherwise improve health care, as determined appropriate by the Director.  See language for eligible entities. (Status: 2/15/24 – Referred to the House Committee on Energy and Commerce) Advancing Access to Telehealth Act HR 7711 (Rep Dingell D-MI) – Amends title XVIII of the Social Security Act to make permanent certain telehealth flexibilities under the Medicare program.  (Status: 3/19/24 – Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means.)   Telehealth Modernization Act S 3967 (Sen Scott R-SC) – The Telehealth Modernization Act which would amend title XVIII of the Social Security Act to make permanent certain telehealth flexibilities under the Medicare program. (Status:  3/19/24 – Read twice and referred to Committee on Finance.)~~~STATE LEGISLATIONCALIFORNIA AB 2566 – Enters California into the Interstate Counseling Compact, which allows a professional counselor licensed in another Compact Member State to be authorized to practice professional counseling in any other Member State, as long as they go through the Compact’s application process. (Status: 3/4/25 – Referred to Committee on Business and Professions) COLORADO SB 24-168 – Requires that beginning July 1, 2025, the department of health care policy and financing provide reimbursement for the use of telehealth remote monitoring for outpatient services and continuous glucose monitors and related supplies for certain Medicaid members. The bill also creates the telehealth remote monitoring grant program to provide grants to an outpatient health-care facility located in a designated rural county or designated provider shortage area to assist the outpatient health-care facility clinic with the financial cost of providing telehealth remote monitoring for outpatient clinical services. (Status: 3/20/25 – Referred to Committee on Health & Human Services which Referred Amended to Appropriations) CONNECTICUT HB 5198:  Amends the definition of a ‘telehealth provider’ to include additional professions, such as a physician assistant, genetic counselor, nurse-midwife (see bill for full list).  Specifies that no telehealth provider shall provide services unless the provider has determined whether or not the patient has health coverage for such services and requires that the telehealth provider either: (1) accept as payment for their services an amount that is equal to the amount that Medicare reimburses if the provider determines that the patient does not have health coverage for such services; (2) the amount that the patient’s health coverage reimburses; (3) or if the telehealth provider determines the patient is unable to pay, the provider shall offer to the patient financial assistance if the provider is required to offer to the patient such financial assistance under any applicable state or federal law.  See bill for additional requirements. (Status: 3/26/24 – Given File No. 124) FLORIDA SB 7016 – Enacts the Interstate Medical Licensure Compact in Florida which allows physicians to become licensed in multiple states that participate in the Compact, creating another pathway for physician licensure. The Compact requires the physician to be under the jurisdiction of the state medical board where the patient is located.  State medical boards retain the ability to impose an adverse action against a Compact licensee. (Status:3/22/24 – Approved by Governor. Chaptered.) KENTUCKY SB 255 – Establishes requirements and standards for the provision of social work services via telehealth.  For example, it requires a social worker that uses telehealth to obtain informed consent, ensure confidentiality of medical information, disclose to the client the potential risks to privacy and confidentiality of information due to the use of technology, assess the appropriateness of telehealth, and adhere to the same or appropriate standards of care as in person.  Beginning on July 1, 2024, social workers would be required to complete a board-approved two-hour training course on telehealth.  See bill’s language for all requirements.  (Status: 3/28/24 – Delivered to Governor) WASHINGTON SB 5821 – Amends a requirement to provide audio-only coverage (which requires an established relationship) for certain payers by changing the definition of an established relationship to remove a requirement for certain services that the provider have an in-person or interactive video visit within the previous two years or have been referred by another provider that had an in person or interactive video visit. Such visits are still required by statute within the previous three years. (Status: 3/19/24 – Governor signed, effective 6/6/24)