Robert Dimand, MD Chief Medical Officer

California Children’s Services

Health Plans: Current and Future Policies for Telehealth Reimbursement. AB 415, MediCal and CCS

CCS Program Leadership 2013

• Quality and Access Major Goals

• Medical Policies, Facility & Provider Standards : Vehicles to Increase Focus on Quality, Access

• HCAC Development: Linking Payment and Quality, Synergy with CCS NICU QI and CDPH CLABSI

• Implementation of 1115 Bridge to Reform

• HRIF, Palliative Care, Newborn Hearing Screening, Telemedicine, Pulse Oximetry for CCHD

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Tertiary Pediatric/General 338 CCS Centers

• 124 NICUs • 24 PICUs

• 250 Other SCC

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Total Expenditures Among CCS

Enrolled Children 2009-10

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Improving Access for CSHCN CCS 2013

• Added More than 20 CCS Centers in Last 18 Months

• Significantly Streamlining Process for Applications

• Maintaining High Clinical Standards and Requiring Outcome Measures

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• Updated the Telemedicine Development Act of 1996. • Goal was to “remove barriers in current law to the use

of telehealth in the delivery of health care.” • Based largely on “A Telehealth Model Statute”

developed by a work group for the Center for Connected Health Policy.

• The work group did not consider “constraining fiscal, economic, and political considerations” in developing its proposed statute.

AB 415 Overview

• Replaces the word “telemedicine” with “telehealth” in five sections of state law to reflect a broader range of health services.

• Passed unanimously in both houses. • Applies to Medi-Cal, providers, health plans,

health insurers, and health care service plans.

• Took effect January 1, 2012.

AB 415 Overview (continued)

• Allows for a broader use of technology for health care by more providers without restrictions on settings.

• Does not alter the scope of practice. • Defines telehealth as the “mode of delivering health care

services and public health via information and communication technologies.” – Eliminated definition of telemedicine as interactive,

audio, video, or data communication involving real time or near real time two-way transfer of medical data and information.

• All confidentiality laws apply.

AB 415 general provisions

• Gives Medi-Cal greater flexibility to reimburse providers for a wide range of telehealth services. – Does not require Medi-Cal to add benefits

• Allows Medi-Cal to determine services that are “appropriately provided through telehealth,” subject to reimbursement policies.

• Did not provide funding.

AB 415 & Medi-Cal

• Prohibits Medi-Cal from requiring in-person contact for services appropriately provided through telehealth

• Deleted prohibition against Medi-Cal paying for phone calls, emails, faxes, and phone calls between providers.

• Eliminated 2013 sunset date for store and forward teledermatology and teleophthalmology – Otherwise did not change store and forward law.

AB 415 & Medi-Cal

• Uses the term “telehealth” except when making a distinction for “telemedicine.”

• Removes barrier requirement. • Removes requirement for written consent. • Removes limits on type of setting for

originating and distant sites.

Proposed changes to Medi-Cal Provider Manual

• Clarifies that practitioners of telehealth must be licensed in California.

• Allows interpretation and reports of X-rays and electrocardiograms to be billed as a telehealth transmission.

• Retains policy that Medi-Cal does not reimburse for phone calls, emails, or faxes.

• Retains current E&M and psychiatric CPT-4 codes and transmission reimbursement policies.

Proposed changes to Medi-CalProvider Manual

• Eliminated requirement that providers document a barrier to a face-to-face visit.

• Eliminated restrictions on the types of settings at both the originating and distant sites.

• Eliminated the requirement that providers document written consent for telehealth services. – Providers at the originating site must document verbal

consent.

AB 415 & Medi-Cal

• Telehealth is a tool in medical practice, not a separate form of medicine.

• The standard of care is the same whether the patient is seen in-person, through telehealth, or other methods of electronically enabled health care.

• Physicians have the same responsibilities of providing informed consent, ensuring the privacy of medical information, and any other duties associated with practicing medicine.

• Telehealth is “not a telephone conversation, email/instant messaging conversation, or fax.”

• Physicians using telehealth need a valid, current California license.

Medical Board of California

www.mbc.ca.gov/licensee/telehealth.html

Future Use of Telehealth for CCS Pediatric Subspecialty Care

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Future Use of Telehealth for CCS Pediatric Subspecialty Care (cont)

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Affordable Care Act Physician Reimbursement

Increased Medicaid Payment for Primary Care

• Provides Federal funding to pay the Medicare rates for (E&M) and vaccine adm codes for 2 years (2013 and 2014).

• E&M codes 99201 through 99499 and vaccine adm codes 90460, 90461, 90471, 90472, 90473 and 90474 must be paid at Medicare rates by state Medicaid programs, even in managed care.

• Once attestation procedures are in place and providers are identified as eligible for higher payment, the state will make one or more supplemental payments

• Physicians (MD’s and DO’s) with designation of family medicine, general internal medicine, and pediatric medicine are eligible. Pediatric subspecialists recognized Am. Board of Pediatrics (ABP) are also eligible. physicians must self-attest that they are either Board certified or that at least 60% of all of the Medicaid services they bill are for codes specified

Final Rule released 11/1/12 3

1115 Waiver: Desired Outcomes Vertical Integration

• Improved health outcomes and greater cost-effectiveness

• Improved coordination of care

• More efficient use of public dollars

• Transition planning (Aging out of Program)

• Improved satisfaction with care

• Clearer accountability

• Timely access to care

• Family-centered care

• Maintaining regionalization of provider network

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