Virginia Medicaid has expanded coverage of telemedicine services over time. Currently, 35 states provide Medicaid reimbursement for telemedicine. Virginia Medicaid covers telemedicine statewide for services like consultations and evaluations. Future possibilities include adding coverage for telemedicine in home health and expanding store-and-forward and telepractice coverage. The presentation discusses Virginia Medicaid's telemedicine policies and interests in expanding access to care through telemedicine.
Telemedicine: Expanding Access to Medicaid Services
1. Telemedicine: Expanding
Access to Medicaid
Services
Presentation to:
Virginia Telehealth Summit
Gregg M. Pane, MD, MPA, Director April 5, 2011
Va. Department of Medical Assistance Services Wintergreen, Virginia
2. Federal Guidance on
Medicaid and Telemedicine
Centers for Medicare and Medicaid Services issued
guidance in 2001 on Medicaid and telemedicine. Among the
items discussed:
– No formal definition exists for telemedicine under the
Medicaid program
– Federal Medicaid law does not recognize telemedicine
as a distinct service
– Medicaid reimbursement for services furnished through
telemedicine is available at the state’s option as a cost-
effective alternative to the more traditional ways of 2
providing care
3. Federal Guidance on
Medicaid and Telemedicine (Cont)
Advises that states should consider factors such as the
quality of the equipment, type of services to be provided
and location of providers (such as remote rural sites) when
deciding on the scope of telemedicine coverage
Medicaid reimbursement must satisfy Federal requirements
of efficiency, economy, and quality of care
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4. 35 States Provide Medicaid
Reimbursement for Telemedicine
States With
Medicaid
Reimbursement
Source: Telehealth Alliance of Oregon, 2008 4
5. States’ Telemedicine Policies Vary
Widely; But Commonalities Exist
Medical and psychological consultations/treatments are
most prevalent services
Fee-for-service reimbursement is generally provided to
both the originating site (where the Medicaid recipient is
located) and remote site where the physician or other
provider is located
Primarily physicians but also other providers are eligible for
reimbursement, depending on the state
Coding/billing inconsistencies across the states makes it
difficult to track telemedicine utilization and impact
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6. Virginia Medicaid’s
Interests in Telemedicine Coverage
Improved patient access to medical services
Improved patient compliance with treatment
Medical services rendered at an earlier stage of disease,
improving long-term patient outcomes
Reduction in service expenditures such as hospitalizations
and transportation
Allows for an opportunity to work proactively with physicians
and other providers; has potential to be a “win-win” situation
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7. Virginia Medicaid at a Glance
Approximately 62
percent of recipients
are currently enrolled in
a managed care plan
(MCO). Five MCOs are
under contract to DMAS
serving various parts of
Virginia
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8. Virginia Medicaid at a Glance
Among the services covered by DMAS are:
‒ Inpatient and Outpatient hospital ‒Dental care for persons under age
services 21
‒ Physician and nurse midwife ‒Prescription drugs
services ‒Occupational therapy and other
‒ Laboratories and x-ray services rehabilitation services
‒ Transportation-emergency and ‒Hospice
non-emergency ‒Some mental health services
‒ Nursing facility services ‒Some substance abuse services
‒ Home health ‒Federal waiver programs for
‒ Early and Periodic Screening, recipients with AIDS, Alzheimers,
Diagnosis and Treatment program Developmental Disabilities,
for children Intellectual Disabilities and others
conditions
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9. Virginia Medicaid
Telemedicine Coverage, Early Years
Virginia Medicaid started with a telemedicine pilot project in
1995. Services covered were:
– Some consultations
– One psychotherapy service
– A few clinical services in cardiology and colposcopy
Used Virginia defined billing codes
Only physicians recognized as providers
Reimbursed providers at originating and remote site, using
the existing fee schedule
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10. Virginia Medicaid
Telemedicine Coverage, Early Years
Pilot project was limited to three Virginia localities; one was
for psychiatric care and the other two were for medical
consultations
Virginia Medicaid was one of the first states with
telemedicine coverage
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11. Virginia Medicaid Telemedicine
Coverage Expansion, 2003
Virginia Medicaid expanded telemedicine coverage July 1,
2003 to be statewide.
Governor Mark Warner announced the coverage in July
2003 at a community health event in southwest Virginia
Additional services covered
– Evaluation and management, office visits
– Range of individual psychotherapies
– Full range of consultations
– Select clinical services such as in cardiology and
obstetrics
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12. Virginia Medicaid Telemedicine
Coverage Expansion, 2003
Providers recognized by DMAS for telemedicine:
– Physicians
– Nurse practitioners
– Nurse midwives
– Clinical nurse specialists
– Clinical psychologists
– Clinical social workers
– Licensed professional counselors
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13. Virginia Medicaid
Current Telemedicine Coverage
Originating sites (where the recipient is located) were
expanded in October 2009 to include:
‒Certified Outpatient – Rural Health Centers
Rehabilitation Facilities –Program for All-Inclusive Care
‒ Community Services Boards for the Elderly
‒ Dialysis Centers – Plus physicians and other
providers on previous page
‒ Federally Qualified Health
Centers
‒ Health Department Clinics
‒ Hospitals
‒ Nursing Homes
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14. Virginia Medicaid
Current Telemedicine Coverage
Under fee-for-service, billing telemedicine to DMAS
involves:
– Originating site bills a telemedicine code for presenting
patient
– Remote practitioner bills for services such as
consultation
– Reimbursement is according to Virginia Medicaid fee
schedule
– A procedure modifier for telemedicine is to be entered
on the claim form
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– No telemedicine equipment costs recognized in
reimbursement
15. Virginia Medicaid
Current Telemedicine Coverage
Providers of telemedicine services are expected to fully
comply with service documentation and other coverage
and billing requirements described in the Virginia Medicaid
provider manuals
Providers can only bill for a service using telemedicine,
which DMAS already covers for the providers when
delivered conventionally
Virginia Medicaid telemedicine coverage is similar to
Medicare coverage but is not tied to rural area definitions
for the originating site
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16. Virginia Medicaid
Current Telemedicine Coverage
Coverage was expanded in January 2011 to include diabetic
retinopathy screening. This is the first “store and forward”
telemedicine coverage for DMAS
– For diabetics, digital images of the retina are captured
by community health centers and transmitted to
ophthalmologists
– Ophthalmologists perform an evaluation of the image
and report results
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17. DMAS Telemedicine
Billing Experience
Telemedicine “billing” has been low for Virginia Medicaid with
about 3300 claims and encounters for FY2010. Other Medicaid
programs have reported low billing as well
The predominant service is psychiatric consults, especially
pharmacologic management
Possible explanations as to why telemedicine is not appearing in
data include:
– Providers not using telemedicine billing modifier on claims
form
– Telemedicine as part of the larger bundle of services rendered
to patients with particular diagnoses
– Contracts for services with hospitals/clinics do not break out
telemedicine 17
18. Telemedicine, Virginia Medicaid
Managed Care Organizations
Under the contract with DMAS, MCOs are to cover
telemedicine at least to the extent the select services are
covered for the fee-for-service population
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19. Recent Virginia Legislation
on Telemedicine
Virginia Senate Bill 675 Was Signed Into Law by Governor
McDonnell on April 5, 2010
– Mandates health insurance coverage for telemedicine in
the commercial plans
– The legislation significantly expands the availability of
telemedicine coverage in the Commonwealth
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20. Recent National Legislation with
Reference to Medicaid and Telemedicine
Section 3011 of the American Recovery and Reinvestment
Act of 2009 directs the Secretary of Health and Human
Services to invest in infrastructure necessary to allow for
and promote electronic exchange and use of health
information for individuals, consistent with the strategic
plan developed by the National Coordinator for Health
Information Technology
The Centers for Medicare and Medicaid Services is listed as
one of the participating agencies
Infrastructure and tools for the promotion of telemedicine
are included at 3011(a)(4)
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21. Recent National Legislation with
Reference to Medicaid and Telemedicine
National Health Reform (2010)
– A change under Medicare, which also applies to
Medicaid, allows physicians to use telehealth to certify
the need for home health services and durable medical
equipment also applies to Medicaid
– A “health home” option is available to states for serving
persons with chronic conditions. The state is to include
a proposal for the use of health information technology
in providing health home services and improving
service delivery and coordination across the care
continuum
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22. Future Possibilities for Virginia
Medicaid Telemedicine Coverage
Adding home health services to the telemedicine
coverage. DMAS currently covers home health
services when delivered conventionally
The Medicaid recipient’s home serves as the
telemedicine originating site with an electronic
connection to the home health agency office
Medicaid recipient’s condition is monitored via
telemedicine by the home health agency
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23. Future Possibilities for Virginia Medicaid
Telemedicine Coverage (Cont.)
Telemedicine applications for Medicaid recipients at home
include:
– Post-operative care
– High risk pregnancies
– Asthma
– Diabetes
– Congestive Heart Failure
Use of telemedicine for home health patients depends on the
diagnosis, medical need, permission of the patient, and patient’s
ability to use the equipment
Home health providers are interested in telemedicine because
care is delivered more efficiently. The home health nurse can
serve more patients in a day than when the care is delivered
conventionally 23
24. Future Possibilities for Virginia
Medicaid Telemedicine Coverage (Cont.)
Studies have documented savings particularly due to fewer
hospitalizations and shorter hospital lengths of stay.
Medicaid transportation is reduced
The telemedicine visit is not intended to substitute for
needed physical visits to the home by the nurse
DMAS issue of relatively few recipients have more than a
small number of home health visits, making telemedicine
for home care less viable
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25. Future Possibilities for Virginia Medicaid
Telemedicine Coverage (Cont.)
Expanding DMAS telemedicine
“store and forward” coverage
Store and forward involves electronic
medical information, such as video,
still images, and MRIs, which is
stored and transmitted for review by
a physician or other practitioner at a
later time.
– The patient is not present when
the physician conducts the
evaluation of the image but
findings are reported back to the
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patient’s primary care provider
26. Future Possibilities for Virginia Medicaid
Telemedicine Coverage (Cont.)
Store and forward applications under consideration
include:
– Screening for retinopathy of prematurity
– Dermatology
Store and forward can be inexpensive for the originating
and remote sites because the electronic medical
information, such as a digital picture, simply needs to be
captured and transmitted to the physician or other
practitioner
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27. Future Possibilities for Virginia Medicaid
Telemedicine Coverage (Cont.)
Adding “telepractice” to the DMAS telemedicine coverage, which
is the delivery of speech therapy services using telemedicine.
DMAS currently covers speech therapy in the schools and other
settings
Current pilot project involves a speech therapist at James
Madison University performing telepractice with elementary
school children in Wise County. These sites are approximately
280 miles apart
Pilot made possible by a grant from the Virginia Department of
Education to James Madison University
DMAS in discussion with CMS due to the reimbursement method
required for school services
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28. Questions?
DMAS Website http://dmasva.dmas.virginia.gov/
DMAS telemedicine coverage description (“Provider
Memo”, September 30, 2009) at
https://www.virginiamedicaid.dmas.virginia.gov/ECMPdfWe
b/ECMServlet?memospdf=Medicaid+Memo+2009.09.30.pdf
Contact DMAS staff Jeff Nelson- 804-371-8857 or
jeff.nelson@dmas.virginia.gov
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