13-003 Code Vt. R. 13-174-003-X

Current through April, 2024

Section 13 174 003 - MEDICAID BENEFIT DELIVER

3.101 Telehealth.

(01/07/2019, GCR 18-037)

3.101.1Definitions For the purposes of this rule, the term:

(a) "Telehealth" means methods for health care service delivery using telecommunications technologies. Telehealth includes telemedicine, store and forward, and telemonitoring.

(b) "Telemedicine" means health care delivery by a provider who is located at a distant site to a beneficiary at an originating site for purposes of evaluation, diagnosis, consultation, or treatment, using telecommunications technology via two-way, real-time, audio and video interactive communication, through a secure connection that complies with HIPAA.

(c) "Store and forward" means an asynchronous transmission of a beneficiary's medical information from a health care professional to a provider at a distant site, through a secure connection that complies with HIPAA, without the beneficiary present in real time.

(d) "Remote Patient Monitoring" means a health service that enables remote monitoring of a beneficiary's physiological health-related data by a home health agency done outside of a conventional clinical setting and in conjunction with a plan of care ordered by a physician, nurse practitioner, clinical nurse specialist, or physician assistant.

(e) "Originating site" means the site where the beneficiary is located, whether or not accompanied by a health care provider, when telemedicine, or audio-only services are provided. The originating site may include the beneficiary's home or another nonmedical setting (e.g., school, workplace), a health care provider's office, a facility, or a hospital.

(f) "Distant site" means the site where the provider is located, and the beneficiary is not located, when telemedicine or store and forward services are provided.

(g) "Clinically appropriate" means clinically accepted standards of medical practice and delivery methods that are considered effective in providing health care services to patients, including for purposes of evaluation, diagnosis, consultation, or treatment.

(h) "Audio-Only" means real-time health care delivery by a provider who is located at a distant site to a beneficiary at an originating site for purposes of evaluation, diagnosis, consultation, or treatment, using audio-only telecommunications technology.

3.101.2Covered Services

(a) Telemedicine:

(1) To be covered, services shall be:

(A) Clinically appropriate for delivery through telemedicine, and

(B) Be medically necessary.

(2) Services delivered shall:

(A) Include any service that a provider would typically provide to a beneficiary in a face-to-face setting, and

(B) Adhere to the same program restrictions, limitations, and coverage that exist for the service when not provided through telemedicine, and

(C) Be reimbursed at the same rate as the service being provided in a face-to-face setting.

(b) Store and Forward

(1) To be covered, services shall:

(A) Clinically appropriate for delivery through store and forward, and

(B) Medically necessary, and

(c) Remote Patient Monitoring

(1) To be covered, services shall be:

(A) Clinically appropriate for delivery through telemonitoring, and

(B) Medically necessary, and

(C) Limited to a Congestive Heart Failure, Hypertension, or Diabetes diagnosis.

(d) Audio-Only

(1) To be covered, services shall be:

(A) Clinically appropriate for delivery through audio-only, and

(B) Medically necessary.

3.101.3Qualified Providers Telehealth services must be provided by a provider who is working within the scope of his or her practice and enrolled in Vermont Medicaid.

3.101.4Beneficiary Eligibility For telemonitoring services, beneficiaries shall:

(a) Have Medicaid as their primary insurance or Medicaid and dually enrolled in Medicare with a non-homebound status,

(b) Have a Congestive Heart Failure diagnosis,

(c) Be clinically eligible for home health services, and

(d) Have a physician's plan of care with an order for home telemonitoring services.

3.101.5Conditions for Coverage

(a) Qualified telemedicine and store and forward providers shall:

(1) Meet or exceed applicable federal and state legal requirements of medical and health information privacy, including compliance with HIPAA.

(2) Provide appropriate informed consent, in a language that the beneficiary understands, consistent with 18 VSA § 936l(c)(l) to include:

(A) Identifying the beneficiary, the provider, and the provider's credentials,

(B) The types of services permitted using telemedicine technologies,

(C) A statement that the provider determines whether the conditions being diagnosed and/or treated are appropriate for a telemedicine encounter,

(D) Details on security measures taken with the use of telemedicine technologies,

(E) Disclosure to the beneficiary that information may be lost due to technical failures,

(F) A statement that the provider will follow all applicable federal and state legal requirements of medical and health information privacy, and

(G) Circumstances under which consent is not required.

(3) Take appropriate steps to establish the provider-patient relationship and conduct all appropriate evaluations and history of the beneficiary consistent with traditional standards of care.

(4) Maintain medical records for all beneficiaries receiving health care services through telemedicine that are consistent with established laws and regulations governing patient health care records.

(5) Establish an emergency protocol when care indicates that acute or emergency treatment is necessary for the safety of the beneficiary.

(6) Address needs for continuity of care for beneficiaries (e.g., informing beneficiary or designee how to contact provider or designee and/or providing beneficiary or identified providers timely access to medical records).

(7) If prescriptions are contemplated, follow traditional standards of care to ensure beneficiary safety in the absence of a traditional physical examination.

(b) Qualified telemonitoring providers shall:

(1) Use the following licensed health care professionals to review data:

(A) Registered nurse (RN)

(B) Nurse Practitioner (NP)

(C) Clinical nurse specialist (CNS)

(D) Licensed practical nurse (LPN) under the supervision of a RN or physician assistant (PA), and

(2) Follow data parameters established by a plan of care, and

(3) Meet or exceed applicable federal and state legal requirements of medical and health information privacy, including compliance with HIPAA.

3.101.6Prior Authorization and Documentation Requirements Services provided through telehealth are subject to the same prior authorization requirements that exist for the service when not provided through telehealth.

3.101.7Non-Covered Services

(a) Services and procedures that are not covered in a face-to-face setting under Vermont Medicaid are not covered under telemedicine or audio-only.

(b) Services delivered via audio-only telephone, facsimile, or electronic mail messages are not considered telemedicine and are not covered.

13-003 Code Vt. R. 13-174-003-X

EFFECTIVE DATE:
January 7, 2019 Secretary of State Rule Log #18-065 [3.101]
AMENDED:
5/1/2023 Secretary of State Rule Log #23-005

STATUTORY AUTHORITY:

3 V.S.A. § 801; 33 V.S.A. § 1901