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Using the site "The Center for Connected Health Policy" (http://cchpca.org/state-laws-and-reimbursement-policies), locate your state of residence. Next, review the attached American Telemedicine Association (ATA) 2016 "State Telemedicine Gap Analysis: Coverage and Reimbursement Report. Locate the findings of your current state within the Gap Analysis. Analyze, assess, compare and discuss your interpretation of the findings (that may include implemented laws or regulations).

Note: If there are no immediate actions in your home state, simply select a state of choice to complete the assignment.

Share your response in a 500-word briefing. Your submission must include an APA-formatted cover sheet. Submit one (1) single Microsoft Word document

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                                    50  State  Telemedicine  Gaps  Analysis   Coverage  &  Reimbursement     Latoya  Thomas  and     Gary  Capistrant     January  2016                 None  of  the  information  contained  in  the  Gaps  Analysis  Series  or  in  this  document  constitutes   legal  advice.    The  information  presented  is  informational  and  intended  to  serve  as  a  reference   for  interested  parties,  and  not  to  be  relied  upon  as  authoritative.    Your  own  legal  counsel  should   be  consulted  as  appropriate. 50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     TABLE  OF  CONTENTS   Executive  Summary ................................................................................................................ 1   Purpose .................................................................................................................................. 5   Overview................................................................................................................................ 5   Assessment  Methods.............................................................................................................. 6   Scoring ........................................................................................................................................6   Limitations ..................................................................................................................................7   Indicators ............................................................................................................................... 8   Parity...........................................................................................................................................8   Private  Insurance ....................................................................................................................8   Medicaid .................................................................................................................................9   State  Employee  Health  Plans ................................................................................................10   Medicaid  Service  Coverage  &  Conditions  of  Payment..............................................................11   Patient  Setting.......................................................................................................................11   Eligible  Technologies .............................................................................................................14   Distance  or  Geography  Restrictions......................................................................................15   Eligible  Providers...................................................................................................................17   Physician-­‐provided  Telemedicine  Services ...........................................................................19   Mental  and  Behavioral  Health  Services ................................................................................20   Rehabilitation  Services ..........................................................................................................22   Home  Health  Services ...........................................................................................................23   Informed  Consent .................................................................................................................24   Telepresenter ........................................................................................................................25   Innovative  Payment  or  Service  Delivery  Models ......................................................................26   State  Report  Cards................................................................................................................ 28   Alabama....................................................................................................................................29   Alaska........................................................................................................................................30   Arizona......................................................................................................................................31     American  Telemedicine  Association  2016   50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Arkansas....................................................................................................................................32   California...................................................................................................................................33   Colorado ...................................................................................................................................34   Connecticut...............................................................................................................................35   Delaware...................................................................................................................................36   District  of  Columbia ..................................................................................................................37   Florida .......................................................................................................................................38   Georgia .....................................................................................................................................39   Hawaii .......................................................................................................................................40   Idaho.........................................................................................................................................41   Illinois........................................................................................................................................42   Indiana ......................................................................................................................................43   Iowa ..........................................................................................................................................44   Kansas .......................................................................................................................................45   Kentucky ...................................................................................................................................46   Louisiana ...................................................................................................................................47   Maine........................................................................................................................................48   Maryland...................................................................................................................................49   Massachusetts ..........................................................................................................................50   Michigan ...................................................................................................................................51   Minnesota.................................................................................................................................52   Mississippi.................................................................................................................................53   Missouri ....................................................................................................................................54   Montana ...................................................................................................................................55   Nebraska ...................................................................................................................................56   Nevada......................................................................................................................................57   New  Hampshire ........................................................................................................................58   New  Jersey................................................................................................................................59   New  Mexico ..............................................................................................................................60     American  Telemedicine  Association  2016   50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   New  York...................................................................................................................................61   North  Carolina ..........................................................................................................................62   North  Dakota ............................................................................................................................63   Ohio ..........................................................................................................................................64   Oklahoma..................................................................................................................................65   Oregon ......................................................................................................................................66   Pennsylvania .............................................................................................................................67   Rhode  Island .............................................................................................................................68   South  Carolina ..........................................................................................................................69   South  Dakota ............................................................................................................................70   Tennessee .................................................................................................................................71   Texas .........................................................................................................................................72   Utah ..........................................................................................................................................73   Vermont....................................................................................................................................74   Virginia......................................................................................................................................75   Washington...............................................................................................................................76   West  Virginia.............................................................................................................................77   Wisconsin..................................................................................................................................78   Wyoming...................................................................................................................................79   Appendix .............................................................................................................................. 80   State  Ratings  –  Map:    Parity  Laws  for  Private  Insurance  Coverage  of  Telemedicine................81   State  Ratings  –  Map:    Medicaid  Policies  for  Telemedicine  CoverageState  Ratings ..................82   State  Ratings  –  Map:    State  Employee  Health  Plan  Laws  for  Telemedicine  Coverage..............83   State  Ratings  –  Map:    Medicaid  Patient  Setting .......................................................................84   State  Ratings  –  Map:    Medicaid  Eligible  Technologies..............................................................85   State  Ratings  –  Map:    Medicaid  Distance  or  Geography  Restrictions.......................................86   State  Ratings  –  Map:    Medicaid  Eligible  Providers....................................................................87   State  Ratings  –  Map:    Medicaid  Physician-­‐provided  Telemedicine  Services ............................88   State  Ratings  –  Map:    Medicaid  Mental  and  Behavioral  Health  Services .................................89     American  Telemedicine  Association  2016   50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   State  Ratings  –  Map:    Medicaid  Rehabilitation  Services...........................................................90   State  Ratings  –  Map:    Medicaid  Home  Health  Services ............................................................91   State  Ratings  –  Map:    Medicaid  Informed  Consent ..................................................................92   State  Ratings  –  Map:    Medicaid  Telepresenter.........................................................................93   References ........................................................................................................................... 94       American  Telemedicine  Association  2016   50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     EXECUTIVE  SUMMARY   Payment  and  coverage  for  services  delivered  via  telemedicine  are  some  of  the  biggest   challenges  for  telemedicine  adoption.    Patients  and  health  care  providers  may  encounter  a   patchwork  of  arbitrary  insurance  requirements  and  disparate  payment  streams  that  do  not   allow  them  to  fully  take  advantage  of  telemedicine.         The  American  Telemedicine  Association  (ATA)  has  captured  the  complex  policy  landscape  of  50   states  with  50  different  telemedicine  policies,  and  translated  this  information  into  an  easy  to   use  format.    This  report  complements  our  50  State  Gaps  Analysis:    Physician  Practice  Standards   &  Licensure,  and  extracts  and  compares  telemedicine  coverage  and  reimbursement  standards   for  every  state  in  the  U.S.  ultimately  leaving  each  state  with  two  questions:     • “How  does  my  state  compare  regarding  policies  that  promote  telemedicine  adoption?”   • “What  should  my  state  do  to  improve  policies  that  promote  telemedicine  adoption?”     Using  data  categorized  into  13  indicators  related  to  coverage  and  reimbursement,  our  analysis   continues  to  reveal  a  mix  of  strides  and  stagnation  in  state-­‐based  policy  despite  decades  of   evidence-­‐based  research  highlighting  positive  clinical  outcomes  and  increasing  telemedicine   utilization.         Since  our  initial  report  in  September  2014  11  states  and  D.C.  have  adopted  policies  that   improved  coverage  and  reimbursement  of  telemedicine-­‐provided  services,  while  two  states   have  adopted  policies  further  restricting  coverage  (Figure  1).1         FIGURE  1  –  Sept.  2014  -­‐  December  2015  Comparison     American  Telemedicine  Association  2016    |      Page.  1       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     States  have  made  efforts  to  improve  their  grades  through  the  removal  of  arbitrary  restrictions   and  adoption  of  laws  ensuring  coverage  parity  under  private  insurance,  state  employee  health   plans,  and/or  Medicaid  plans,  as  indicated  in  Figure  2.    Overall,  there  are  more  states  now  with   above  average  grades,  “A”  or  “B”,  including  Iowa  which  improved  from  an  ‘F’  to  ‘B’,  than   reported  in  September  2014.           FIGURE  2  –  Sept.  2014  -­‐  December  2015  Comparison   Sept.  2014   Dec.  2015   COMPOSITE  GRADES   A   B   C   F   0   5   10   15   20   25   30   35   NUMBER  OF  STATES       In  recent  months,  five  states  (Delaware,  Iowa,  Mississippi,  Nevada,  and  Oklahoma)  have  higher   scores  suggesting  a  supportive  policy  landscape  that  accommodates  telemedicine  adoption   while  one  state  saw  a  drop  in  their  composite  grade.    New  Hampshire  dropped  from  an  ‘A’  to   ‘B’  as  a  result  of  adopted  legislation  that  includes  Medicaid  telehealth  coverage  language   similar  to  Medicare.    Despite  the  adoption  of  a  private  insurance  parity  law  earlier  this  year,   Connecticut,  like  Rhode  Island,  continues  to  average  the  lowest  composite  score  suggesting   many  barriers  and  little  opportunity  for  telemedicine  advancement  (Table  1).                         American  Telemedicine  Association  2016    |      Page.  2       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     Table  1  –  Composite  Scores  by  State   State   AK   AL   AR   AZ   CA   CO   CT   DC   DE   FL   GA   HI   IA   Composite   Grade   B   B   C   B   B   B   F   A   A   C   B   C   B   State   ID   IL   IN   KS   KY   LA   MA   MD   ME   MI   MN   MO   MS   Composite   Grade   C   C   C   B   B   B   B   B   A   B   B   B   A   State   MT   NC   ND   NE   NH   NJ   NM   NV   NY   OH   OK   OR   PA   Composite   Grade   B   C   B   B   B   C   A   A   B   B   A   B   B   State   RI   SC   SD   TN   TX   UT   VA   VT   WA   WI   WV   WY     Composite   Grade   F   B   B   A   B   B   A   B   B   C   C   B       When  broken  down  by  the  13  indicators,  the  state-­‐by-­‐state  comparisons  reveal  even  greater   disparities.     • Eight  states  have  enacted  telemedicine  parity  laws  since  the  initial  report  in  2014.    Of   the  29  states  that  have  telemedicine  parity  laws  for  private  insurance,  22  of  them  and   D.C.  scored  the  highest  grades  indicating  policies  that  authorize  state-­‐wide  coverage,   without  any  provider  or  technology  restrictions  (Figure  3).    Less  than  half  of  the  country,   22  states,  ranked  the  lowest  with  failing  scores  for  having  either  no  parity  law  in  place  or   numerous  artificial  barriers  to  parity.    This  is  a  significant  improvement  as  more  states   adopt  parity  laws.    Arkansas  maintains  a  failing  grade  because  it  places  arbitrary  limits  in   its  parity  law.     • Forty-­‐eight  state  Medicaid  programs  have  some  type  of  coverage  for  telemedicine.    Only   eight  states  and  D.C.  scored  the  highest  grades  by  offering  more  comprehensive   coverage,  with  few  barriers  for  telemedicine-­‐provided  services  (Figure  4).    Delaware,   Iowa,  Nevada,  and  Oklahoma  passed  reforms  that  ensure  parity  coverage  with  little  or   no  restrictions.    Connecticut,  Hawaii,  Idaho,  New  Hampshire,  Rhode  Island,  and  West   Virginia  ranked  the  lowest  with  failing  scores  in  this  area.      New  Hampshire  dropped   from  an  ‘A’  to  ‘B’  as  a  result  of  adopted  legislation  that  includes  Medicaid  telehealth   coverage  language  similar  to  Medicare.         • Another  area  of  improvement  includes  coverage  and  reimbursement  for  telemedicine   under  state  employee  health  plans.    Twenty-­‐six  states  have  some  type  of  coverage  for   telehealth  under  one  or  more  state  employee  health  plan.    Most  states  self-­‐insure  their   plans  thus  traditional  private  insurer  parity  language  does  not  automatically  affect   them.    Oregon  is  an  exception  which  amended  its  parity  law  this  year  to  include  self-­‐ American  Telemedicine  Association  2016    |      Page.  3       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   insured  state  employee  health  plans.    50  percent  of  the  country  is  ranked  the  lowest   with  failing  scores  due  to  partial  or  no  coverage  of  telehealth  (Figure  5).     Regarding  Medicaid,  states  continue  to  move  away  from  the  traditional  hub-­‐and-­‐spoke  model   and  allow  a  variety  of  technology  applications.    Twenty-­‐six  states  and  D.C.  do  not  specify  a   patient  setting  as  a  condition  for  payment  of  telemedicine  (Figure  6).    Aside  from  this,  36  states   recognize  the  home  as  an  originating  site,  while  18  states  recognize  schools  and/or  school-­‐ based  health  centers  as  an  originating  site  (Figures  7-­‐8).             Vermont  improved  a  letter  grade  because  it  now  covers  home  remote  patient  monitoring.    Half   of  the  country  ranks  the  lowest  with  failing  scores  either  because  they  only  cover  synchronous   only  or  provide  no  coverage  for  telemedicine  at  all.    Idaho,  Missouri,  North  Carolina  and  South   Carolina  prohibit  the  use  of  “cell  phone  video”  to  facilitate  a  telemedicine  encounter  (Figure  9).     There  is  still  a  national  trend  to  allow  state-­‐wide  Medicaid  coverage  of  telemedicine  instead  of   focusing  solely  on  rural  areas  or  designated  mileage  requirements  (Figure  10).     States  are  also  increasingly  using  telemedicine  to  fill  provider  shortage  gaps  and  ensure  access   to  specialty  care.    Seventeen  states  and  D.C.  do  not  specify  the  type  of  healthcare  provider   allowed  to  provide  telemedicine  as  a  condition  of  payment  (Figure  11).  While  20  states  ranked   the  lowest  with  failing  scores  for  authorizing  less  than  nine  health  provider  types.    Florida,   Idaho,  and  Montana  ranked  the  lowest  with  coverage  for  physicians  only.     Overall,  coverage  of  specialty  services  for  telemedicine  under  Medicaid  is  a  checkered  board   and  no  two  states  are  alike.     • Ten  states  and  D.C.  rank  the  highest  for  coverage  of  telemedicine-­‐provided  physician   services  and  most  states  cover  an  office  visit  or  consultations,  with  ultrasounds  and   echocardiograms  being  the  least  covered  telemedicine-­‐provided  services  (Figure  12).     • For  mental  and  behavioral  health  services,  generally  mental  health  assessments,   individual  therapy,  psychiatric  diagnostic  interview  exam,  and  medication  management   are  the  most  covered  via  telemedicine.    Twelve  states  and  D.C.  rank  the  highest  for   coverage  of  mental  and  behavioral  health  services  (Figure  13).    The  lowest  ranking   states  for  all  Medicaid  services,  scoring  an  ‘F’,  are  Connecticut  and  Rhode  Island  which   have  no  coverage  for  telemedicine  under  their  Medicaid  plans.     • Although  state  policies  vary  in  scope  and  application,  five  more  states  have  expanded   coverage  to  include  telerehabilitation.    Seventeen  states  are  known  to  reimburse  for   telerehabilitative  services  in  their  Medicaid  plans.    Of  those,  11  states  rank  the  highest   with  telemedicine  coverage  for  therapy  services  (Figure  14).     • Alaska  is  the  only  state  with  the  highest  ranking  for  telemedicine  provided  services   under  the  home  health  benefit  (Figure  15).    Seventy  percent  of  the  country  ranked  the   American  Telemedicine  Association  2016    |      Page.  4       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   lowest  with  failing  scores  due  to  a  lack  of  telemedicine  services  covered  under  the  home   health  benefit.     Finally,  twenty-­‐seven  states  have  unique  patient  informed  consent  requirements  for   telemedicine  encounters  (Figure  16).    Twenty-­‐two  states  do  not  require  a  telepresenter  during   the  encounter  or  on  the  premises  (Figure  17).       PURPOSE     Patients  and  health  care  enthusiasts  across  the  country  want  to  know  how  their  state  compares   to  other  states  regarding  telemedicine.    While  there  are  numerous  resources  that  detail  state   telemedicine  policies,  they  lack  a  state-­‐by-­‐state  comparison.    ATA  has  created  a  tool  that   identifies  state  policy  gaps  with  the  hope  that  states  will  respond  with  more  streamlined   policies  that  improve  health  care  quality  and  reduce  costs  through  accelerated  telemedicine   adoption.         This  report  fills  that  gap  by  answering  the  following  questions:         • “How  does  my  state’s  telemedicine  policies  compare  to  others?”     • “Which  states  offer  the  best  coverage  for  telemedicine  provided  services?”   • “Which  states  impose  barriers  to  telemedicine  access  for  patients  and  providers?”     It  is  important  to  note  that  this  report  is  not  a  “how-­‐to  guide”  for  telemedicine  reimbursement.     This  is  a  tool  aimed  to  serve  as  a  reference  for  interested  parties  and  to  inform  future  policy   decision  making.    The  results  presented  in  this  document  are  based  on  information  collected   from  state  statutes,  regulations,  Medicaid  program  manuals/bulletins/fee  schedules,  state   employee  handbooks,  and  other  federal  and  state  policy  resources.    It  is  ATA’s  best  effort  to   interpret  and  understand  each  state’s  policies.    Your  own  legal  counsel  should  be  consulted  as   appropriate.     OVERVIEW     State  lawmakers  around  the  country  are  giving  increased  attention  to  how  telehealth  can  serve   their  constituents.    Policymakers  seek  to  reduce  health  care  delivery  problems,  contain  costs,   improve  care  coordination,  and  alleviate  provider  shortages.    Many  are  using  telemedicine  to   achieve  these  goals.     Over  the  past  four  years  the  number  of  states  with  telemedicine  parity  laws  –  that  require   private  insurers  to  cover  telemedicine-­‐provided  services  comparable  to  that  of  in-­‐person  –  has   doubled.2    Moreover,  Medicaid  agencies  are  developing  innovative  ways  to  use  telemedicine  in   their  payment  and  delivery  reforms  resulting  in  48  state  Medicaid  agencies  with  some  type  of   coverage  for  telemedicine  provided-­‐services.     American  Telemedicine  Association  2016    |      Page.  5       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Driving  the  momentum  for  telemedicine  adoption  is  the  creation  of  new  laws  that  enhance   access  to  care  via  telemedicine,  and  the  amendment  of  existing  policies  with  greater   implications.    Patients  and  health  care  providers  are  benefitting  from  policy  improvements  to   existing  parity  laws,  expanded  service  coverage,  and  removed  statutory  and  regulatory  barriers.     While  there  are  some  states  with  exemplary  telemedicine  policies,  lack  of  enforcement  and   general  awareness  have  led  to  a  lag  in  provider  participation.    Ultimately  these  pioneering   telemedicine  reforms  have  trouble  reaching  their  true  potential.         Other  areas  of  concern  include  states  that  have  adopted  policies  which  are  limiting  in  scope  or   prevent  providers  and  patients  from  realizing  the  full  benefits  of  telemedicine.    Specifically,   artificial  barriers  such  as  geographic  discrimination  and  restrictions  on  provider  and  patient   settings  and  technology  type  are  harmful  and  counterproductive.     ASSESSMENT  METHODS     Scoring     This  report  considers  telemedicine  coverage  and  reimbursement  policies  in  each  state  based  on   two  categories:         • Health  plan  parity   • Medicaid  conditions  of  payment.         These  categories  were  measured  using  13  indicators.    The  indicators  were  chosen  based  on  the   most  recent  and  generally  accessible  information  assembled  and  published  by  state  public   entities.    Using  this  information,  we  took  qualitative  characteristics  based  on  scope  of  service,   provider  and  patient  eligibility,  technology  type,  and  arbitrary  conditions  of  payment  and   assigned  them  quantitative  values.    States  were  given  a  certain  number  of  points  for  each   indicator  depending  on  its  effectiveness.    The  points  were  then  used  to  rank  and  compare  each   state  by  indicator.    We  used  a  four-­‐graded  system  to  rank  and  compare  each  state.    This  is   based  off  of  the  scores  given  to  each  state  by  indicator.    Each  of  the  two  categories  was  broken   down  into  indicators  –  three  indicators  for  health  plan  parity  and  10  indicators  for  Medicaid   conditions  of  payment.         Each  indicator  was  given  a  maximum  number  of  points  ranging  from  1  to  35.    The  aggregate   score  for  each  indicator  was  ranked  on  a  scale  of  A  through  F  based  on  the  maximum  number   of  points.     The  report  also  includes  a  category  to  capture  innovative  payment  and  service  delivery  models   implemented  in  each  state.    In  addition  to  state  supported  networks  in  specialty  care  and   correctional  health,  the  report  identifies  a  few  federally  subsidized  programs  and  waivers  that   states  can  leverage  to  enhance  access  to  health  care  services  using  telemedicine.     American  Telemedicine  Association  2016    |      Page.  6       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Limitations     Telemedicine  policies  in  state  health  plans  vary  according  to  a  number  of  factors  –  service   coverage,  payment  methodology,  distance  requirements,  eligible  patient  populations  and   health  care  providers,  authorized  technologies,  and  patient  consent.    These  policy  decisions  can   be  driven  by  many  considerations,  such  as  budget,  public  health  and  safety  needs,  available   infrastructure  or  provider  readiness.     As  such,  the  material  in  this  report  is  a  snapshot  of  information  gathered  through  December   2015.    The  report  relies  on  dynamic  policies  from  payment  streams  that  are  often  dissimilar  and   unaligned.         Illinois  and  Massachusetts  have  enacted  “If,  then”  telemedicine  coverage  laws  which  prevent   the  enforcement  of  discriminatory  practices  such  as  an  in-­‐person  encounter.34    “If”  the  state   regulated  plan  chooses  to  cover  telemedicine-­‐provided  services,  “then”  the  plan  is  prohibited   from  requiring  an  in-­‐person  visit.    ATA  does  not  interpret  these  statutes  as  parity  laws.     We  analyzed  both  Medicaid  fee-­‐for-­‐service  (FFS)  and  managed  care  plans.    Benefit  coverage   under  these  plans  vary  by  size  and  scope.    We  used  physician,  mental  and  behavioral  health,   home  health,  and  rehabilitation  services  as  a  benchmark  for  our  analysis.    Massachusetts  and   New  Hampshire  do  not  cover  telemedicine-­‐provided  services  under  their  FFS  plans  but  do  have   some  coverage  under  at  least  one  of  their  managed  care  plans.    As  such,  the  analysis  and  scores   are  reflective  of  the  telemedicine  offerings  in  each  program,  and  not  the  Medicaid  program   itself,  regardless  of  size  and  scope.     We  did  not  analyze  state  Children’s  Health  Insurance  Plans  (CHIP)  plans.    We  are  aware  that   states  provide  some  coverage  of  telemedicine-­‐provided  services  for  CHIP  beneficiaries.     Additionally,  some  states  recognize  schools  and/or  school-­‐based  health  centers  as  originating   sites,  however  we  did  not  separately  score  or  rank  school-­‐based  programs.       Although  two  states  include  coverage  of  telemedicine-­‐provided  services  under  worker’s   compensation  plans,  we  did  not  analyze  this  coverage  benefit.    ATA  may  include  these  plans  in   future  versions  of  this  report  as  states  extend  coverage  to  include  telemedicine  under  worker’s   compensation  and  disability  insurance.     Other  notable  observations  in  our  analysis  include  state  Medicaid  plans  that  do  not  cover   therapy  services  (i.e.  physical  therapy,  occupational  therapy,  and  speech  language  pathology).5     States  with  no  coverage  for  these  benefits  were  not  applicable  for  scoring  or  ranking.         Additionally,  some  states  policies  can  be  conflicting.    States  like  Arkansas  and  New  York  have   enacted  laws  requiring  telemedicine  parity  in  their  Medicaid  plans.    However,  regulations  and   Medicaid  provider  manuals  do  not  reflect  all  of  these  policy  changes.    In  those  cases,  the   analysis  and  scores  are  reflective  of  the  authorized  regulations  and  statutes  enacted  by  law   unless  otherwise  noted.    Future  reports  will  reflect  changes  in  the  law  if  applicable.   American  Telemedicine  Association  2016    |      Page.  7       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     Also,  this  report  is  about  what  each  state  has  “on  paper”,  not  necessarily  in  service.    Important   factors,  such  as  the  actual  provision  and  utilization  of  telemedicine  services  and  provider   collaboration  to  create  service  networks  are  beyond  the  scope  of  this  report.     Indicators     Parity     A. Private  Insurance   Full  parity  is  classified  as  comparable  coverage  for  telemedicine-­‐provided  services  to  that  of  in-­‐ person  services.    Twenty-­‐eight  states  and  the  District  of  Columbia  have  enacted  full  parity  laws.     Only  Arizona  has  enacted  a  partial  parity  law  that  requires  coverage  and  reimbursement,  but   limits  coverage  to  a  certain  geographic  area  (e.g.,  rural)  or  a  predefined  list  of  health  care   services.    Since  our  initial  report,  some  parity  laws  have  included  restrictions  on  patient   settings.    For  this  report’s  purpose,  we  added  this  component  to  our  methodology,  and   continue  to  measure  other  components  of  state  policies  that  enable  or  impede  parity  for   telemedicine-­‐provided  services  under  private  insurance  health  plans.     Scale  –  Private  Insurance  Parity   A     7  points   B     6  points   C     5  points   F     ≤  4  points                                     American  Telemedicine  Association  2016    |      Page.  8       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   FIGURE  3  –  Private  Insurance  Parity       States  with  the  highest  grades  for  private  insurance  telemedicine  parity  provide  state-­‐wide   coverage,  and  have  no  provider,  technology,  or  patient  setting  restrictions  (Figure  3).    Among   states  with  parity  laws,  Arizona,  New  York,  and  Vermont  scored  about  average  (C).    New  York   and  Vermont  lawmakers  have  placed  patient  setting  restrictions  on  those  services  eligible  for   coverage  parity.    While  Arizona  continues  to  limit  coverage  to  interactive  audio-­‐video  only   modalities  and  the  types  of  services  and  conditions  that  are  covered  via  telemedicine.    Despite   enacting  a  parity  law  in  March  2015,  Arkansas  maintains  a  failing  grade  because  it  places   arbitrary  limits  on  patient  location,  eligible  provider  type,  and  requires  an  in-­‐person  visit  to   establish  a  provider-­‐patient  relationship.    Forty-­‐four  percent  of  the  country  ranks  the  lowest   with  failing  (F)  scores,  a  drop  from  the  initial  report.         B. Medicaid   Each  state’s  Medicaid  plan  was  assessed  based  on  service  limits  and  patient  setting  restrictions.     Other  components  assessed  for  all  three  plans  include  provider  eligibility  and  the  type  of   technology  allowed  were  also  examined  to  determine  the  state’s  capacity  to  fully  utilize   telemedicine  to  overcome  barriers  to  care.    For  this  report’s  purpose,  we  measured   components  of  state  policies  that  enable  or  impede  parity  for  telemedicine-­‐provided  services   under  Medicaid  plans.             American  Telemedicine  Association  2016    |      Page.  9       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     A     B     C     F   Scale  –  Medicaid  Coverage   14+  points   10-­‐13  points   6-­‐9  points   ≤  5  points     Forty-­‐eight  state  Medicaid  programs  have  some  type  of  coverage  for  telemedicine.         FIGURE  4  –  Medicaid  Coverage       Eight  states  and  D.C.  have  the  highest  grades  for  Medicaid  coverage  of  telemedicine-­‐provided   services  (Figure  4).    Connecticut,  Hawaii,  Idaho,  New  Hampshire,  Rhode  Island,  and  West   Virginia  ranked  the  lowest  with  failing  (F)  scores.    Iowa,  Nevada,  Oklahoma,  and  Washington   have  all  made  improvements  to  expand  coverage  of  telemedicine  for  their  Medicaid   populations.    Connecticut  and  Rhode  Island  are  the  only  states  without  coverage  for   telemedicine  under  their  Medicaid  plans.    Of  the  48  states  with  coverage,  Idaho  offers  the  least   amount  of  coverage  for  telemedicine-­‐provided  services.    While  Hawaii,  Idaho,  New  Hampshire,   and  West  Virginia  still  apply  geography  limits  in  addition  to  restrictions  on  service  coverage,   provider  eligibility,  and  patient  setting.     C. State  Employee  Health  Plans     We  measured  components  of  state  policies  that  enable  or  impede  parity  for  telemedicine-­‐ provided  services  under  state-­‐employee  health  plans.    Most  states  self-­‐insure  their  plans   therefore  traditional  private  insurer  parity  language  does  not  automatically  affect  them.     American  Telemedicine  Association  2016    |      Page.  10       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Oregon  is  an  exception  which  amended  its  parity  law  this  year  to  include  self-­‐insured  state   employee  health  plans.     Scale  –  State-­‐employee  Health   Plan  Parity   A     7  points   B     6  points   C     5  points     F     ≤  4  points     Twenty-­‐six  states  provide  some  coverage  for  telemedicine  under  their  state  employee  health   plans  with  26  states  extending  coverage  under  their  parity  laws  (Figure  5).    Most  states  self-­‐ insure  their  plans  and  50  percent  of  the  country  is  ranked  the  lowest  with  failing  scores  due  to   partial  or  no  coverage  of  telehealth.     FIGURE  5  –  State  Employee  Health  Plan  Coverage       Medicaid  Service  Coverage  &  Conditions  of  Payment     D. Patient  Setting   In  telemedicine  policy,  the  place  where  the  patient  is  located  at  the  time  of  service  is  often   referred  to  as  the  originating  site  (in  contrast,  to  the  site  where  the  provider  is  located  and   often  referred  to  as  the  distant  site).    The  location  of  the  patient  is  a  contentious  component  of   telemedicine  coverage.    A  traditional  approach  to  telemedicine  coverage  is  to  require  that  the   patient  be  served  from  a  specific  type  of  health  facility,  such  as  a  hospital  or  physician's  office.     American  Telemedicine  Association  2016    |      Page.  11       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Left  out  by  these  approaches  are  the  sites  where  people  predominantly  spend  their  time,  such   as  homes,  office/place  of  work,  schools,  or  traveling  around.    With  advances  in  decentralized   computing  power,  such  as  cloud  processing,  and  mobile  telecommunications,  such  as  4G   wireless,  the  current  approach  is  to  cover  health  services  to  patients  wherever  they  are.       For  this  report,  we  measured  components  of  state  Medicaid  policies  that,  for  conditions  of   coverage  and  payment,  broaden  or  restrict  the  location  of  the  patient  when  telemedicine  is   used.      The  following  sites  are  observed  as  qualified  patient  locations:         • Hospitals   • doctor’s  office   • other  provider’s  office   • dentist  office   • home   • federally  qualified  health  center  (FQHC)   • critical  access  hospital  (CAH)   • rural  health  center  (RHC)   • community  mental  health  center  (CMHC)   • sole  community  hospital   • school/school-­‐based  health  center  (SBHC)   • assistive  living  facility  (ALF)   • skilled  nursing  facility  (SNF)   • stroke  center   • rehabilitation/therapeutic  health  setting   • ambulatory  surgical  center   • residential  treatment  center   • health  departments   • renal  dialysis  centers   • habilitation  centers.         States  received  one  (1)  point  for  each  patient  setting  authorized  as  an  eligible  originating  site.     Those  states  that  did  not  specify  an  originating  site  were  given  the  maximum  score  possible   (20).     Scale  –  Medicaid:       Patient  Settings   A     16+  points   B     11-­‐15  points   C     6-­‐10  points   F     ≤  5  points     Twenty-­‐six  states  and  D.C.  do  not  specify  a  patient  setting  or  patient  location  as  a  condition  of   payment  for  telemedicine  (Figure  6).     American  Telemedicine  Association  2016    |      Page.  12       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement       FIGURE  6  –  Medicaid:    Patient  Setting       Aside  from  this,  36  states  allow  the  home  as  an  originating/patient  site,  while  18  states   recognize  schools  and/or  SBHCs  as  an  originating  site  (Figures  7-­‐8).     FIGURE  7  –  Medicaid:    Home  Setting         American  Telemedicine  Association  2016    |      Page.  13       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     FIGURE  8  -­‐  Medicaid:    School  Setting       Six  states  ranked  the  lowest  with  failing  (F)  scores  for  designating  less  than  six  patient  settings   as  originating  sites  with  Florida  and  New  Jersey  ranking  the  lowest  with  only  two  eligible   originating  sites.     E. Eligible  Technologies   Telemedicine  includes  the  use  of  numerous  technologies  to  exchange  medical  information  from   one  site  to  another  via  electronic  communications.    The  technologies  closely  associated  with   services  enabled  by  telemedicine  include  videoconferencing,  the  transmission  of  still  images   (also  known  as  store-­‐and-­‐forward),  remote  patient  monitoring  (RPM)  of  vital  signs,  and   telephone  calls.    For  this  report,  we  measured  components  of  state  Medicaid  policies  that  allow   or  prohibit  the  coverage  and/or  reimbursement  of  telemedicine  when  using  these  technologies.     Scale  –  Medicaid:       Eligible  Technologies   A     5  points   B     4  points   C     3  points   F     ≤  2  points           American  Telemedicine  Association  2016    |      Page.  14       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     FIGURE  9  –  Medicaid:    Eligible  Technologies       Seven  states  score  above  average  on  our  scale  with  Alaska  taking  the  highest  ranking  (Figure  9).     The  state  covers  telemedicine  when  providers  use  interactive  audio-­‐video,  store-­‐and-­‐forward,   remote  patient  monitoring,  and  audio  conferencing  for  some  telemedicine  encounters.    Alaska,   Minnesota,  Mississippi,  Nebraska,  and  Texas  all  cover  telemedicine  when  using  synchronous   technology  as  well  as  store-­‐and-­‐forward  and  remote  patient  monitoring  in  some  capacity.    Fifty   percent  of  the  states  rank  the  lowest  with  failing  (F)  scores  either  because  they  only  cover   synchronous  only  or  provide  no  coverage  for  telemedicine  at  all.     Further,  Idaho,  Missouri,  North  Carolina  and  South  Carolina  prohibit  the  use  of  “cell  phone   video”  or  “video  phone”  to  facilitate  a  telemedicine  encounter.     F. Distance  or  Geography  Restrictions     Distance  restrictions  are  measured  in  miles  and  designate  the  amount  of  distance  necessary   between  a  distance  site  provider  and  patient  as  a  condition  of  payment  for  telemedicine.     Geography  is  classified  as  rural,  urban,  metropolitan  statistical  area  (MSA),  defined  population   size,  or  health  professional  shortage  area  (HPSA).         We  measured  components  of  state  Medicaid  policies  that  apply  distance  or  geography   restrictions  for  conditions  of  coverage  and  payment  when  telemedicine  is  performed.         American  Telemedicine  Association  2016    |      Page.  15       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement         Scale  –  Medicaid:    Distance  &   Geography  Restrictions   A     3  points   B     2  points   C     1  point   F     0  points     Over  the  past  year,  states  have  made  considerable  efforts  to  rescind  mileage  requirements  for   covered  telemedicine  services.    Nevada  and  Oklahoma  now  offer  telemedicine  state-­‐wide,   while  Iowa  successfully  removed  its  distance  requirements.      New  Hampshire  adopted   legislation  that  includes  geographically  restricted  language  similar  to  Medicare.    Indiana  has   statutory  authority  to  remove  their  mileage  requirements  for  all  distance  site  providers  but   chooses  to  enforce  the  mileage  requirement  for  some  eligible  providers.    Earlier  this  year,  Ohio   Medicaid  approved  a  regulation  that  would  expand  coverage  of  telemedicine  services,  and   includes  a  five  mile  distance  restriction  as  a  condition  of  payment.           FIGURE  10  -­‐  Medicaid:    Distance/Geography  Restrictions         Eighty-­‐six  percent  of  the  states  cover  telemedicine  services  state-­‐wide  without  distance   restrictions  or  geographic  designations  (Figure  10).    This  evidence  dispels  the  misconception   that  telemedicine  is  only  appropriate  for  rural  settings  only.       American  Telemedicine  Association  2016    |      Page.  16       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     G. Eligible  Providers   Most  states  allow  physicians  to  perform  telemedicine  encounters  within  their  scope  of  practice.         We  measured  components  of  state  Medicaid  policies  that,  for  conditions  of  coverage  and   payment,  broaden  or  restrict  the  types  of  distant  site  providers  allowed  to  perform  the   telemedicine  encounter.    The  following  providers  are  observed  as  qualified  health  care   professionals  for  covered  telemedicine-­‐provided  services:         • physician  (MD  and  DO)   • podiatrist   • chiropractor   • optometrist   • genetic  counselor   • dentist   • physician  assistant  (PA)   • nurse  practitioner  (NP)   • registered  nurse   • licensed  practical  nurse   • certified  nurse  midwife   • clinical  nurse  specialist   • psychologist   • marriage  and  family  therapist   • clinical  social  worker  (CSW)   • clinical  counselor   • behavioral  analyst   • substance  abuse/addictions  specialist   • clinical  therapist   • pharmacist   • physical  therapist   • occupational  therapist   • speech-­‐language  pathologist  and  audiologist   • registered  dietitian/nutritional  professional   • diabetes/asthma/nutrition  educator   • home  health  aide   • home  health  agency  (HHA)   • FQHC   • CAH   • RHC   • CMHC   • SNF.     American  Telemedicine  Association  2016    |      Page.  17       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Each  state  received  two  (2)  points  for  designating  a  physician,  and  one  (1)  point  for  each   additional  eligible  provider  authorized  to  provide  covered  telemedicine  services.    Those  states   that  did  not  specify  an  eligible  provider  were  given  the  maximum  score  possible  (35).     Scale  –  Medicaid:       Eligible  Providers   A     25+  points   B     17-­‐24  points   C     9-­‐16  points   F   ≤  8  points     Sixteen  states  and  D.C.  do  not  specify  the  type  of  health  care  provider  allowed  to  provide   telemedicine  as  a  condition  of  payment  (Figure  11).       FIGURE  11  -­‐  Medicaid:    Eligible  Providers       Other  interesting  trends  include  Alaska,  California,  and  Illinois  which  cover  services  when   provided  by  a  podiatrist.    Alaska,  California,  and  Kentucky  cover  services  when  provided  by  a   chiropractor.    California,  Kentucky,  and  Washington  are  the  only  states  to  specify  coverage  for   services  when  provided  by  an  optometrist,  while  Arizona,  California,  and  New  York  will  cover   services  provided  by  a  dentist.    Although  CMS  has  issued  guidance  clarifying  their  position  on   coverage  for  services  related  to  autism  spectrum  disorder,  only  New  Mexico,  Oklahoma,  and   Washington  specify  coverage  for  telemedicine  when  provided  by  behavioral  analysts.    This   trend  is  unique  because  these  specialists  are  critical  for  the  treatment  of  autism  spectrum   disorders.    New  Mexico,  Oklahoma,  Virginia,  West  Virginia,  and  Wyoming  specify  coverage  for   telemedicine  when  provided  by  a  substance  abuse  or  addiction  specialist.   American  Telemedicine  Association  2016    |      Page.  18       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     Eighteen  states  ranked  the  lowest  with  failing  (F)  scores  for  authorizing  less  than  nine  health   provider  types.    Florida,  Idaho,  and  Montana  ranked  the  lowest  with  coverage  for  physicians   only.     H. Physician-­‐provided  Telemedicine  Services   Physician-­‐provided  telemedicine  services  are  commonly  covered  and  reimbursed  by  Medicaid   health  plans.    However,  some  plans  base  coverage  on  a  prescribed  set  of  health  conditions  or   services,  place  restrictions  on  patient  or  provider  settings,  the  frequency  of  covered   telemedicine  encounters,  or  exclude  services  performed  by  other  medical  professionals.     For  this  report,  we  measured  components  of  state  Medicaid  policies  that  broaden  or  restrict  a   physician’s  ability  to  use  telemedicine  for  conditions  of  coverage  and  payment.     Scale  –  Medicaid:       Physician-­‐provided  Services   A     13  points   B     10-­‐12  points   C     7-­‐9  points   F   ≤  6  points     Eleven  states  and  D.C.  rank  the  highest  for  coverage  of  telemedicine-­‐provided  physician   services  (Figure  12).    These  states  have  no  restrictions  on  service  coverage  or  additional   conditions  of  payment  for  services  provided  via  telemedicine.    Additionally,  these  states  also   allow  a  physician  assistant  and/or  advanced  practice  nurse  as  eligible  distant  site  providers.     Moreover,  most  states  cover  an  office  visit  or  consultations,  with  ultrasounds  and   echocardiograms  being  the  least  covered  telemedicine-­‐provided  services.                               American  Telemedicine  Association  2016    |      Page.  19       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     FIGURE  12  –  Medicaid:    Physician  Services       The  lowest  ranking  states,  which  scored  an  F,  are  Connecticut  and  Rhode  Island  which  have  no   coverage  for  telemedicine  under  their  Medicaid  plans  and  Iowa  and  Ohio  with  limited  service   coverage  and  other  arbitrary  restrictions.     I. Mental  and  Behavioral  Health  Services     According  to  ATA’s  telemental  health  practice  guidelines,  telemental  health  consists  of  the   practice  of  mental  health  specialties  at  a  distance  using  video-­‐conferencing.      The  scope  of   services  that  can  be  delivered  using  telemental  health  includes:  mental  health  assessments,   substance  abuse  treatment,  counseling,  medication  management,  education,  monitoring,  and   collaboration.    Forty-­‐eight  states  have  some  form  of  coverage  and  reimbursement  for  mental   health  provided  via  telemedicine  video-­‐conferencing.    While  the  number  of  states  with   coverage  in  this  area  suggests  enhanced  access  to  mental  health  services,  it  is  important  to   note  that  state  policies  for  telemental  health  vary  in  specificity  and  scope.     We  measured  components  of  state  Medicaid  policies  that  broaden  or  restrict  the  types  of   providers  allowed  to  perform  the  telemedicine  encounter,  telemedicine  coverage  for  mental   and  behavioral  health  services.               American  Telemedicine  Association  2016    |      Page.  20       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     Scale  –  Medicaid:    Mental  and   Behavioral  Health  Services   A     14  points   B     10-­‐13  points   C     6-­‐9  points   F     ≤  5  points     Generally  the  telemedicine-­‐provided  services  that  are  most  often  covered  under  state  Medicaid   plans  include  mental  health  assessments,  individual  therapy,  psychiatric  diagnostic  interview   exam,  and  medication  management.    Twelve  states  and  D.C.  rank  the  highest  for  coverage  of   mental  and  behavioral  health  services  (Figure  13).    These  states  have  no  restrictions  on  service   coverage  or  additional  conditions  of  payment  for  services  provided  via  telemedicine.     Additionally,  these  states  also  classify  at  least  one  other  medical  professional  (i.e.  physician   assistant  and  advanced  practice  nurse)  as  an  eligible  distant  site  provider.     FIGURE  13  –  Medidcaid:    Mental/Behavioral  Health  Services       It  is  also  more  common  for  states  with  telemental  health  coverage  to  allow  physicians  that  are   psychiatrists,  advanced  practice  nurses  with  clinical  specialties,  and  psychologists  to  perform   the  telemedicine  encounter.    However,  many  states  allow  non-­‐medical  providers  to  perform   and  reimburse  for  the  telemedicine  encounter.    States  including  Alaska,  Arizona,  Arkansas,   California,  Hawaii,  Indiana,  Kentucky,  Michigan,  Minnesota,  Nevada,  New  Hampshire,  New   Mexico,  New  York,  North  Carolina,  Ohio,  Oklahoma,  Texas,  Virginia,  Washington,  West  Virginia   and  Wyoming  cover  telemedicine  when  performed  by  a  licensed  social  worker.    Alaska,  Arizona,   Arkansas,  California,  Indiana,  Kentucky,  Minnesota,  Nevada,  New  Mexico,  Ohio,  Oklahoma,   American  Telemedicine  Association  2016    |      Page.  21       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Texas,  Virginia,  Washington,  West  Virginia,  and  Wyoming  cover  telemedicine  when  provided  by   a  licensed  professional  counselor.           Further,  New  Mexico,  Oklahoma,  and  Washington  are  the  only  states  to  specify  coverage  for   telemedicine  when  provided  by  behavioral  analysts.    This  trend  is  unique  because  these   specialists  are  critical  for  the  treatment  of  autism  spectrum  disorders.     The  lowest  ranking  states,  which  scored  an  F,  are  Connecticut  and  Rhode  Island  which  have  no   coverage  for  telemedicine  under  their  Medicaid  plans.    Iowa  improved  their  grade  from  an  ‘F’   to  ‘B’  due  to  expanded  service  coverage  offered  through  a  contracted  plan.     J. Rehabilitation  Services     The  ATA  telerehabilitation  guidelines  define  telerehabilitation  as  the  “delivery  of  rehabilitation   services  via  information  and  communication  technologies.    Clinically,  this  term  encompasses  a   range  of  rehabilitation  and  habilitation  services  that  include  assessment,  monitoring,   prevention,  intervention,  supervision,  education,  consultation,  and  counseling”.    Rehabilitation   professionals  utilizing  telerehabilitation  include:  neuropsychologists,  speech-­‐language   pathologists,  audiologists,  occupational  therapists,  and  physical  therapists.   We  measured  components  of  state  Medicaid  policies  that  broaden  or  restrict  the  types  of   providers  allowed  to  perform  the  telemedicine  encounter,  restrictions  on  patient  or  provider   settings,  and  coverage  for  telerehabilitation  services.     Scale  –  Medicaid:       Rehabilitation  Services   A     6+  points   B     4-­‐5  points   C     2-­‐3  points   F   ≤  1  points     Only  37  states  were  analyzed,  scored  and  ranked  for  this  indicator.    Thirteen  states  and  D.C.  do   not  cover  rehabilitation  services  for  their  Medicaid  recipients.  Although  state  policies  vary  in   scope  and  application,  17  states  are  known  to  reimburse  for  telerehabilitative  services  in  their   Medicaid  plans.    Of  those,  11  states  rank  the  highest  with  telemedicine  coverage  for  therapy   services  (Figure  14).                     American  Telemedicine  Association  2016    |      Page.  22       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement     FIGURE  14  –  Medicaid:    Rehabilitation  Services       Further,  of  the  25  states  that  cover  home  telemedicine,  only  Alaska,  Colorado,  Delaware,  Iowa,   Kentucky,  Maine,  Nebraska,  Nevada,  New  Mexico,  and  Tennessee  reimburse  for   telerehabilitative  services  within  the  home  health  benefit.         K. Home  Health  Services     One  well-­‐proven  form  of  telemedicine  is  remote  patient  monitoring.    Remote  patient   monitoring  may  include  two-­‐way  video  consultations  with  a  health  provider,  ongoing  remote   measurement  of  vital  signs  or  automated  or  phone-­‐based  check-­‐ups  of  physical  and  mental   well-­‐being.    The  approach  used  for  each  patient  should  be  tailored  to  the  patient’s  needs  and   coordinated  with  the  patient’s  care  plan.     For  this  report,  we  measured  components  of  state  Medicaid  policies  that  broaden  or  restrict   the  types  of  providers  allowed  to  perform  the  telemedicine  encounter  and  services  covered  for   home  health  services.     Scale  –  Medicaid:    Home  Health   A     6+  points   B     4-­‐5  points   C     2-­‐3  points   F   ≤  1  point     American  Telemedicine  Association  2016    |      Page.  23       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Alaska  is  the  only  state  with  the  highest  ranking  for  telemedicine  provided  services  under  the   home  health  benefit  (Figure  15).         FIGURE  15  –  Medicaid:    Home  Health  Services       Of  the  25  states  that  cover  home  telemedicine,  only  Alaska,  Colorado,  Delaware,  Iowa,   Kentucky,  Maine,  Nebraska,  Nevada,  New  Mexico,  and  Tennessee  reimburse  for   telerehabilitative  services  within  the  home  health  benefit.    Additionally,  Pennsylvania  is  the   only  state  that  will  cover  telemedicine  in  the  home  when  provided  by  a  caregiver.         Arizona  no  longer  covers  telemedicine  under  their  home  health  benefit.    Seventy  percent  of  the   country  ranked  the  lowest  with  failing  (F)  scores  due  to  a  lack  of  telemedicine  services  covered   under  the  home  health  benefit.     L. Informed  Consent   We  measured  components  of  state  Medicaid  and  medical  licensing  board  policies  that  apply   more  stringent  requirements  for  telemedicine  as  opposed  to  in-­‐person  services.    States  were   evaluated  based  on  requirements  for  written  or  verbal  informed  consent,  or  unspecified   methods  of  informed  consent  before  a  telemedicine  encounter  can  be  performed.               American  Telemedicine  Association  2016    |      Page.  24       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Scale  –  Medicaid:      Informed  Consent   A     4  points   B     3  points   C     2  points   F   ≤  1  point     FIGURE  16  –  Medicaid:    Informed  Consent       Of  the  27  states  with  informed  consent  requirements,  19  states  have  such  requirements   imposed  by  their  state  Medical  Board  (Figure  16).    Although  their  Medicaid  programs  do  not   cover  telehealth,  Rhode  Island  and  Connecticut’s  Medical  Boards  require  informed  consent.     M. Telepresenter   We  measured  components  of  state  Medicaid  and  medical  licensing  board  policies  that  apply   more  stringent  requirements  for  telemedicine  as  opposed  to  in-­‐person  services.    States  were   evaluated  based  on  requirements  for  a  telepresenter  or  health  care  provider  on  the  premises   during  a  telemedicine  encounter.     Scale  –  Medicaid:    Telepresenter   A     3  points   B     2  points   C     1  point   F   0  points     American  Telemedicine  Association  2016    |      Page.  25       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement       FIGURE  17  –  Medicaid:    Telepresenter       Alabama,  Georgia,  Iowa,  Maryland,  Minnesota,  Missouri,  New  Jersey,  North  Carolina,  and  West   Virginia  only  require  a  health  care  provider  to  be  on  the  premises  and  not  physically  with  the   patient  during  a  telemedicine  encounter  (Figure  17).    Although  Connecticut  and  Rhode  Island   have  no  telemedicine  coverage  under  Medicaid,  their  Medical  Boards  do  not  require  a   telepresenter  for  telemedicine  related  services.     Innovative  Payment  or  Service  Delivery  Models     This  report  also  includes  a  category  to  capture  innovative  payment  and  service  delivery  models   implemented  in  each  state.    In  addition  to  state  supported  networks  in  specialty  care  and   correctional  health,  the  report  identifies  a  few  federally  subsidized  programs  and  waivers  that   states  have  leveraged  to  enhance  access  to  health  care  services  using  telemedicine.       Over  the  years,  states  have  increasingly  used  managed  care  organizations  (MCOs)  to  create   payment  and  delivery  models  involving  capitated  payments  to  provide  better  access  to  care   and  follow-­‐up  for  patients,  and  also  to  control  costs.    The  variety  of  payment  methods  and   other  operational  details  among  Medicaid  managed  care  arrangements  is  a  useful  laboratory   for  devising,  adapting  and  advancing  long-­‐term  optimal  health  delivery.    MCOs  experimenting   with  innovative  delivery  models  including  medical  homes  and  dual-­‐eligible  coordination  have   incorporated  telemedicine  as  a  feature  of  these  models  especially  because  it  helps  to  reduce   costs  related  to  emergency  room  use  and  hospital  admissions.         American  Telemedicine  Association  2016    |      Page.  26       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement       Twenty-­‐four  states  authorize  telemedicine-­‐provided  services  under  their  Medicaid  managed   care  plans.    Most  notably,  Massachusetts  and  New  Hampshire  offer  coverage  under  select   managed  care  plans  but  not  under  FFS.     The  federal  Affordable  Care  Act  (ACA)  offers  states  new  financing  and  flexibility  to  expand  their   Medicaid  programs,  as  well  as  to  integrate  Medicare  and  Medicaid  coverage  for  dually  eligible   beneficiaries  (“duals”).    Michigan,  New  York  and  Virginia  are  the  only  states  that  extend   coverage  of  telemedicine-­‐provided  services  to  their  dual  eligible  population  through  the   Centers  for  Medicare  and  Medicaid  Services  (CMS)  Capitated  Financial  Alignment  Model  for   Medicare-­‐Medicaid  Enrollees.6     The  ACA  also  includes  a  health  home  option  to  better  coordinate  primary,  acute,  behavioral,   and  long-­‐term  and  social  service  needs  for  high-­‐need,  high-­‐cost  beneficiaries.    The  chronic   conditions  include  mental  health,  substance  use  disorder,  asthma,  diabetes,  heart  disease,   overweight  (body  mass  index  over  25),  and  other  conditions  that  CMS  may  specify.     Nineteen  states  have  approved  health  home  state  plan  amendments  (SPAs)  from  CMS.7     Alabama,  Iowa,  Maine,  New  York,  Ohio,  and  West  Virginia  are  the  only  states  that  have   incorporated  some  form  of  telemedicine  into  their  approved  health  home  proposals.       Medicaid  plans  have  several  options  to  cover  remote  patient  monitoring,  usually  under  a   federal  waiver  such  as  the  Home  and  Community-­‐based  Services  (HCBS)  under  Social  Security   Act  section  1915(c).8    States  may  apply  for  this  waiver  to  provide  long-­‐term  care  services  in   home  and  community  settings  rather  than  institutional  settings.    Kansas,  Pennsylvania,  and   South  Carolina  are  the  only  states  that  have  used  their  waivers  to  provide  telemedicine  to   beneficiaries  in  the  home,  specifically  for  the  use  of  home  remote  patient  monitoring.       American  Telemedicine  Association  2016    |      Page.  27       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement                 State  Report  Cards         American  Telemedicine  Association  2016    |      Page.  28       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Telemedicine  in   Alabama     PARITY:   Private  Insurance     Medicaid9   State  Employee  Health  Plan       GAPS:   F   C   F   AL  has  no  parity  law  and  is  bordered  by  GA,  MS,   and  TN  which  enacted  private  insurance  parity   laws.       •   Medicaid   MEDICAID  SERVICE  COVERAGE  &   • Limited  patient  settings  include  hospital,   CONDITIONS  OF  PAYMENT:   physician’s  office,  FQHC,  CAH,  RHC,  CMHC.    The   Patient  Setting   C   home  is  recognized  as  an  originating  site  under   the  Health  Home  model  for  RPM  use  only.   Eligible  Technologies   C   Distance  or  Geography   A   • Eligible  providers  are  restricted  to  MDs/DOs,   PAs,  and  NPs  for  physician  and  mental  health   Restrictions   services.       Eligible  Providers   F   • Requires  written  informed  consent  and  a   Physician-­‐provided  Services   B   telepresenter  on  the  premises.           Mental/behavioral  Health   B     Services10   Innovation   Rehabilitation   N/A   • CMS  approved  Health  Home  program  based  off   Home  Health11   F   of  the  successful  Patient  1st  medical  home   model  uses  home  health  nurses  employed  by   Informed  Consent   F   the  Department  of  Health  to  remotely  monitor   Telepresenter   B   vital  signs  for  patients  with  diabetes,   hypertension,  and  congestive  heart  disease.     INNOVATIVE  PAYMENT  OR   Although  the  use  of  RPM  was  approved  for  this   SERVICE  DELIVERY  MODELS:   program,  there  is  no  mention  of  using  other   State-­‐wide  Network     telemedicine  modalities.     Medicaid  Managed  Care       Medicare-­‐Medicaid  Dual  Eligibles     12 ✔     Health  Home     HCBS  Waiver     ✔   Corrections   13 ✔   Other         American  Telemedicine  Association  2016    |      Page.  29       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Telemedicine  in   Alaska     PARITY:     GAPS:   F   B   F   Private  Insurance     Medicaid15-­‐21   State  Employee  Health  Plan     • AK  has  no  parity  law.   • Telemedicine  coverage  under  the  Medicaid  plan   is  broad  and  the  least  restrictive  compared  to   other  states.    However  not  all  benefits  are   covered  when  using  telemedicine,  thus  leaving   out  services  including  dental  and  ocular  care.   Will  cover  services  when  delivered  using   dedicated  audio  conferencing  system.     Alaska  Medicaid  covers  school-­‐based  services   when  provided  via  telemedicine:    audiology,   behavioral  health,  nursing,  occupational   therapy,  physical  therapy,  and  speech-­‐language   therapy.14   Although  Medicaid  does  not  require  a   telepresenter  as  a  condition  of  payment,  the   state’s  Medical  Board  has  such  practice   standard  requirements.     Medicaid   MEDICAID  SERVICE  COVERAGE  &   CONDITIONS  OF  PAYMENT:   A   A   A   Patient  Setting   Eligible  Technologies   Distance  or  Geography   Restrictions   Eligible  Providers   • • B   A   A   Physician-­‐provided  Services   Mental/behavioral  Health   Services22-­‐23   Rehabilitation24   Home  Health25   • A   A   A   C   Informed  Consent   Telepresenter     INNOVATIVE  PAYMENT  OR   SERVICE  DELIVERY  MODELS:   State-­‐wide  Network   Medicaid  Managed  Care   Medicare-­‐Medicaid  Dual   Eligibles   Health  Home   HCBS  Waiver     N/A     Corrections   Other     American  Telemedicine  Association  2016    |      Page.  30       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Telemedicine  in   Arizona     PARITY:   Private  Insurance     Medicaid27-­‐28   State  Employee  Health  Plan     GAPS:   C   B   C   MEDICAID  SERVICE  COVERAGE  &   CONDITIONS  OF  PAYMENT:   Patient  Setting   Eligible  Technologies29   Distance  or  Geography   Restrictions   Eligible  Providers   Physician-­‐provided  Services30   Mental/behavioral  Health   Services   Rehabilitation   Home  Health   Informed  Consent   Telepresenter   A   B   A   C   B   B   F   F   B   C   INNOVATIVE  PAYMENT  OR   SERVICE  DELIVERY  MODELS:   State-­‐wide  Network31   Medicaid  Managed  Care32   Medicare-­‐Medicaid  Dual   Eligibles   Health  Home   HCBS  Waiver   Corrections   Other       ✔   ✔         ✔     Arizona’s  partial  parity  law  was  enacted  in  2013.     Coverage  under  private  and  state  employee   health  plans  applies  to  rural  areas  and  only   seven  health  services.26         •   Medicaid   • AZ  has  varying  service  coverage  under  its   Medicaid  FFS,  managed  care  plans,  and  Indian   Health  Service.    This  includes  echocardiography,   retinal  screening,  medical  nutrition  therapy  and   patient  education  for  diabetes  and  chronic   kidney  disease  care.   • The  agency  now  covers  teledentistry.   • The  eligible  distant  site  provider  and  patient  site   varies  according  to  the  participating  AHCCCS   program.     • Does  not  cover  for  the  use  of  RPM.     Innovation   • AZ  Telemedicine  Program  offers  clinical,   educational,  and  administrative  services  via   telemedicine  across  the  state.                   American  Telemedicine  Association  2016    |      Page.  31       50  State  Telemedicine  Gaps  Analysis:     Coverage  &  Reimbursement   Telemedicine  in   Arkansas     PARITY:   Private  Insurance     Medicaid   State  Employee  Health  Plan       GAPS:   F   C   F   MEDICAID  SERVICE  COVERAGE  &   CONDITIONS  OF  PAYMENT:   Patient  Setting   Eligible  Technologies   Distance  or  Geography   Restrictions   Eligible  Providers   Physician-­‐provided  Services33   Mental/behavioral  Health   Services34   Rehabilitation   Home  Health   Informed  Consent   Telepresenter   C   F   A   Health  Home   HCBS  Waiver   Corrections   Other35-­‐36         ✔   Progress   • Arkansas’s  parity  law  was  enacted  in  2015  and   includes  telemedicine  coverage  for  physician-­‐ provided  services  under  private  insurance,   Medicaid,  and  state  employee  health  plans.     Effective  January  2016,  the  new  parity  law  will   affect  payment  for  physician  services.    This  is   the  only  telemedicine  parity  law  that  requires  an   in-­‐person  encounter  as  a  condition  of  coverage   and  payment.         Medicaid   • Effective  January  2016,  the  new  parity  law  will   affect  payment  for  physician  services.       • Telemedicine  coverage  under  Medicaid  includes   limits  on  service  coverage,  frequency,  patient   N/A   settings  and  eligible  distant  site  providers.   F   • One  of  few  states  with  coverage  for  fetal   echography  and  echocardiography.   A   • Medicaid  also  places  frequency  limits  on   C   covered  telemedicine  services.   • Requires  a  telepresenter  at  the  originating  site.   INNOVATIVE  PAYMENT  OR   • Coverage  for  interactive  audio-­‐video  only...
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Running head: TELEMEDICINE

1

Telemedicine

(Author’s name)

(Institutional Affiliation)

TELEMEDICINE

2

Telemedicine
Arkansas State
The use of electronic facts and communication technology to deliver healthcare
services such as diagnosis, consultations, education, care management, treatment, and selfmanagement of the patients refers to as telemedicine. Telemedicine comprises the advanced
technology and remote patient monitoring. Telemedicine does not entail the use of audio
communication only but also involves a facsimile machine, text messaging, or electronic mailing
("State Laws and Reimbursement Policies | Center for Connected Health Policy", 2018).
According to Arkansas Medicaid telemedicine is a medical service done as electronic
transactions in real time. For telemedicine encounter to be covered by Medicaid, the patient and
the physician are supposed to see and get each other in real time. Physician understanding of
...


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