Establishing New Patients via Telehealth
Providers may establish a relationship with new patients via synchronous video telehealth visits. Providers may establish a relationship with new patients via audio-only synchronous interaction only if one or more of the following applies:
- The visit is related to sensitive services as defined in subsection (n) or Section 56.06 of the Civil Code. Section 56.06 of the Civil Code defines “sensitive services” as all health care services related to mental or behavioral health, sexual and reproductive health, sexually transmitted infections, substance use disorder, gender-affirming care, and intimate partner violence, and includes services described in Sections 6924 through 6930 of the Family Code, and Sections 121020 and 124260 of the Health and Safety Code, obtained by a patient at or above the minimum age specified for consenting to the service specified in the section.
- The patient requests an audio-only modality.
- The patient attests they do not have access to video.
SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Mar. 2024), Pg. 3. (Accessed Jun. 2024).
Documentation
All health care practitioners providing covered benefits or services to Medi-Cal patients must maintain appropriate documentation to substantiate the corresponding technical and professional components of billed CPT® or HCPCS codes. Documentation for benefits or services delivered via telehealth should be the same as for a comparable in-person service. The distant site provider can bill for Medi-Cal covered benefits or services delivered via telehealth using the appropriate CPT or HCPCS codes with the corresponding modifier and is responsible for maintaining appropriate supporting documentation. This documentation should be maintained in the patient’s medical record.
Providers should note the following:
- Health care providers at the distant site must determine that the covered Medi-Cal service or benefit being delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code(s) associated with the Medi-Cal covered service or benefit as well as any other requirements described in this section of the Medi-Cal provider manual.
- Health care providers are not required to document a barrier to an in-person visit for Medi-Cal coverage of services provided via telehealth (W&I Code, Section 14132.72[d]).
- Health care providers at the distant site are not required to document cost effectiveness of telehealth to be reimbursed for telehealth services or store and forward services.
SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 4. (Accessed Jul. 2024).
Family PACT
Documentation for benefits or services delivered via telehealth should be the same as for a comparable in-person service. The distant site provider can bill for Family PACT covered benefits or services delivered via telehealth using the appropriate CPT® or HCPCS codes with the corresponding modifier and is responsible for maintaining appropriate supporting documentation. This documentation must be maintained in the client’s medical record.
SOURCE: CA DHCS Medi-Cal Provider Enrollment and Responsibilities Manual. (June 2023). Pg. 18. (Accessed Jul. 2024).
Disabled Individuals
Telehealth services and supports are among the services and supports authorized to be included by individual program plans developed for disabled individuals by regional centers that contract with the State Department of Developmental Disabilities.
SOURCE: Welfare and Institutions Code Sec. 4512. (Accessed Jul. 2024).
Network Adequacy
Medicaid must ensure that all managed care covered services are available and accessible to enrollees of Medicaid managed care plans in a timely manner. Telehealth can be used as a means to meet time and distance standards in some circumstances. See APL for details.
SOURCE: CA Welfare and Institutions Code Sec. 14197. & CA Department of Health Care Services (DHCS). All Plan Letter 23-001: Network Certification Requirements. Jan. 6, 2023. (Accessed Jul. 2024).
Behavioral Health Plans (BHPs) are permitted to use the synchronous mode of telehealth services to meet network adequacy standards. See APL for details.
SOURCE: CA Department of Health Care Services. Behavioral Health Information Notice 24-020: 2024 Network Certification Requirements for County MHPs and DMC-ODS Plans. May 28, 2024. (Accessed Jul. 2024).
Emergency Clinic Telephonic Services
Telehealth services, telephonic services and other specified services must be reimbursed when provided by specific entities during or immediately following an emergency, subject to the Department obtaining federal approval and matching funds. The Department is required to issue guidance for entities to facilitate reimbursement for telehealth or telephonic services in emergency situations by July 1, 2020.
SOURCE: Welfare and Institutions Code Sec. 14132.723 & 724. (Accessed Jul. 2024).
Privileges/Credentialing
Issues of privileges and credentialing for distant physicians to care for patients via telehealth are determined by the policies of the originating hospital. Hospitals can accept the privileges and credentials for providers at distant hospitals.
SOURCE: Telehealth FAQs, Providers. (Accessed Jul. 2024).
COVID Telehealth Flexibilities
The department shall seek any federal approvals it deems necessary to extend the approved waiver or flexibility implemented pursuant to subdivision (a), as of July 1, 2021, that are related to the delivery and reimbursement of services via telehealth modalities in the Medi-Cal program. Subject to subdivision (e), the department shall implement those extended waivers or flexibilities for which federal approval is obtained, to commence on the first calendar day immediately following the last calendar day of the federal COVID-19 public health emergency period, and through December 31, 2022.
The department may authorize the use of remote patient monitoring as an allowable telehealth modality for covered health care services and provider types it deems appropriate for dates of service on or after July 1, 2021. The department may establish a fee schedule for applicable health care services delivered via remote patient monitoring.
For purposes of informing the 2022–23 proposed Governor’s Budget, released in January 2022, the department shall convene an advisory group consisting of consultants, subject matter experts, and other affected stakeholders to provide recommendations to inform the department in establishing and adopting billing and utilization management protocols for telehealth modalities to increase access and equity and reduce disparities in the Medi-Cal program. The advisory group shall analyze the impact of telehealth in increased access for patients, changes in health quality outcomes and utilization, best practices for the appropriate mix of in-person visits and telehealth, and the benefits or liabilities of any practice or care model changes that have resulted from telephonic visits.
SOURCE: AB 133, Sec. 380 (2021 Session). (Accessed Jul. 2024).
Consent
The department shall develop, in consultation with affected stakeholders, an informational notice to be distributed to fee-for-service Medi-Cal beneficiaries and for use by Medi-Cal managed care plans in communicating to their enrollees. Information in the notice shall include, but not be limited to, all of the following:
- The availability of Medi-Cal covered telehealth services.
- The beneficiary’s right to access all medically necessary covered services through in-person, face-to-face visits, and a provider’s and Medi-Cal managed care plan’s responsibility to offer or arrange for that in-person care, as applicable.
- An explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn by the Medi-Cal beneficiary at any time without affecting their ability to access covered Medi-Cal services in the future.
- An explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted.
- Notification of the beneficiary’s right to make complaints about the offer of telehealth services in lieu of in-person care or about the quality of care delivered through telehealth.
The informational notice shall be translated into threshold languages determined by the department pursuant to subdivision (b) of Section 14029.91 and provided in a format that is culturally and linguistically appropriate.
This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities.
SOURCE: Welfare and Institutions Code 14132.725 (e). (Accessed Jul. 2024).
DHCS Telehealth Research and Evaluation Plan
On or before January 1, 2023, the department shall develop a research and evaluation plan that does all of the following:
- Proposes strategies to analyze the relationship between telehealth and the following: access to care, access to in-person care, quality of care, and Medi-Cal program costs, utilization, and program integrity.
- Examines issues using an equity framework that includes stratification by available geographic and demographic factors, including, but not limited to, race, ethnicity, primary language, age, and gender, to understand inequities and disparities in care.
- Prioritizes research and evaluation questions that directly inform Medi-Cal policy.
SOURCE: Welfare and Institutions Code 14132.725 (g). (Accessed Jul. 2024).
Medi-Cal Telehealth Utilization Dashboard
As part of an overall initiative aimed at monitoring telehealth utilization within Medi-Cal, the Department of Health Care Services (DHCS) is building a foundation to further evaluate telehealth data in the form of data analytics which includes the below Interactive Telehealth Dashboard. See Telehealth Dashboard and Medi-Cal Telehealth website for more information.
SOURCE: CA Department of Health Care Services. Medi-Cal & Telehealth & CA Department of Health Care Services. Medi-Cal Telehealth Utilization Dashboard. (Accessed Jul. 2024).
HIPAA/Privacy Compliance
Applicable health care services provided through asynchronous store and forward, video synchronous interaction, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities as described in this section shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid State Plan, and any other applicable state and federal statutes and regulations.
SOURCE: Welfare and Institutions Code 14132.725 (h). (Accessed Jul. 2024).
Telehealth Requirements
Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider – including FQHCs/RHCs – furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice. The department may provide specific exceptions to the requirement based on a Medi-Cal provider’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance. In making such exceptions, the department may also take into consideration the availability of broadband access based on speed standards set by the Federal Communications Commission or other applicable federal law or regulation.
Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider – including FQHCs/RHCs – furnishing applicable health care services via synchronous video interaction or audio-only synchronous interaction shall also offer those same health care services in-person or facilitate access to in-person services for the patient. The department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services.
SOURCE: Welfare and Institutions Code 14132.725 & Welfare and Institutions Code 14132.100. (Accessed Jul. 2024).
Patient Choice of Telehealth Modality
Medi-Cal providers can offer a variety of telehealth modalities for covered Medi-Cal services to the extent that the service can be appropriately rendered via the allowable telehealth modalities. For Medi-Cal providers who do offer telehealth modalities, they are required to offer Medi-Cal recipients the ability to choose whether they want to receive covered Medi-Cal services via:
- Synchronous, interactive audio/visual telecommunication systems (for example, video) or
- Synchronous, telephone or other interactive audio-only telecommunications systems.
While Medi-Cal providers are required to offer both video and telephone telehealth modalities, Medi-Cal recipients may freely choose, and change at any time, their desired telehealth modalities, which includes the ability to decline video modalities and select audio-only (telephone) modalities if preferred and/or necessary given the recipient’s needs. For example, if the visit is related to sensitive services as defined in subsection (s) of Section 56.05 of the Civil Code, then the Medi-Cal recipient may prefer to utilize an audio-only (telephone) modality. Medi-Cal recipients shall be given the choice of how they receive their covered Medi-Cal services.
Exception to Telehealth Modalities Provider Requirement
Since broadband is necessary to ensure quality and effective communication between Medi-Cal providers and recipients, Medi-Cal providers are exempt from the requirement to offer both telehealth modalities if the Medi-Cal provider does not have access to broadband. Note: Broadband refers to high-speed internet access that is always on and faster than traditional dial-up access. Broadband includes several high-speed transmission technologies, such as fiber, wireless, satellite, digital subscriber line, and cable. For the purposes of delivering telehealth services to patients, DHCS uses the Federal Communications Commission’s (FCC) definition of broadband and the FCC minimum mbps upload/download speeds. Medi-Cal providers claiming this exception must maintain appropriate supporting documentation, which should be made available to DHCS upon request. For example, supporting documentation might include confirmation from an internet services provider regarding the lack of broadband service in a particular coverage area.
Right to In-person Services
Medi-Cal providers furnishing services to Medi-Cal recipients through telehealth modalities must also either offer services in-person or have a documented process in place to link Medi-Cal recipients to in-person care within a reasonable time if in-person services are unavailable from the provider.
If the Medi-Cal provider chooses to link the Medi-Cal recipient to in-person care to satisfy this requirement, then they must provide a referral to and facilitation of in-person care that does not require a recipient to independently contact a different Medi-Cal provider to arrange for such care. The Medi-Cal provider may initiate a process by which a different Medi-Cal provider in their office or an affiliated in-person care site contacts the Medi-Cal recipient directly to schedule an in-person visit.
The referring Medi-Cal provider or a member of their staff must confirm the referred Medi-Cal provider has at least attempted to contact the recipient to schedule an in-person appointment. However, the Medi-Cal referring provider is not required to schedule an appointment with a different provider on behalf of the Medi-Cal recipient. The Medi-Cal provider must offer referral and facilitation support that is minimally burdensome to the Medi-Cal recipient. Medi-Cal providers must maintain documentation of their process to link Medi-Cal recipients to in-person care, which should be made available to DHCS upon request.
SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Mar. 2024). Pg. 6-7. (Accessed Jul. 2024).
Medi-Cal Enrollment Procedure and Exemptions for Remote Mental Health Services
Effective March 29, 2023, the Department of Health Care Services (DHCS) is establishing Medi-Cal provider enrollment requirements and procedures that will be exempt from certain established place of business requirements for the following modes of service:
- Remote service providers who offer mental health services exclusively through telehealth modalities, and
- Transportation providers located in California.
In accordance with Welfare & Institutions (W&I) Code Section 14043.75(b), enrollment requirements and procedures are established for providers offering Medi-Cal covered mental health services exclusively through telehealth modalities, including non-specialty mental health services (NSMHS) covered under Medi-Cal Fee-For-Service and Medi-Cal Managed Care Plans and Specialty Mental Health Services (SMHS) covered by county mental health plans, and for Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT) providers.
The following provider types are able to apply for enrollment as remote service-only providers:
- Licensed Clinical Social Workers;
- Licensed Marriage and Family Therapists;
- Licensed Professional Clinical Counselors;
- Nurse Practitioners specializing in Psychiatry;
- Physicians specializing in Psychiatry; and
- Psychologists
Remote service providers requesting consideration for enrollment in the Medi-Cal program must complete and submit an application for their appropriate provider type through the Provider Application and Validation for Enrollment (PAVE) portal with the required supporting documents and a completed and signed Remote Services-Only Provider Attestation. For more detailed information, providers may refer to the Requirements and Procedures for the Medi-Cal Enrollment of Providers Offering Services Remotely or Indirectly from their Business Address located on the Provider Enrollment page of the Medi-Cal Provider website.
SOURCE: CA Dept. of Health Care Services. Medi-Cal Update – Psychological Services. Feb. 2023. (Accessed Jul. 2024).
Community-Based Adult Services (CBAS)
CBAS Emergency Remote Services (ERS) are authorized under the California Advancing and Innovating Medi-Cal (CalAIM) 1115 Demonstration Waiver (Waiver) that was implemented October 1, 2022. CBAS supports and services delivered in the community, at the doorstep or in the home, and via telehealth allow for immediate response during participant emergencies. DHCS and MCPs are required to cover ERS as part of the CBAS benefit when participants meet the criteria established in ERS policy, including that ERS is determined to be the appropriate service for the participant and their emergency situation, and the CBAS provider meets the criteria specified in this ACL. See ACL for additional information.
SOURCE: CA Dept. of Health Care Services. All Center Letter 22-04. Launch of New CBAS ERS. Oct. 2023. (Accessed Jul. 2024).
Signature Requirement for Medication Delivery
In accordance with W&I Code, Section 14043.341, providers must obtain either a handwritten or electronic signature for prescription medications sent to a client. Providers may obtain the signature of a client or the recipient either before the medication is sent, or upon receipt when delivered to the client.
Signature Prior to Delivery – Providers have two options to obtain a client’s signature when the client is not in person, such as during a telehealth visit:
- Recorded oral signature: Providers must ensure that they are able to collect an audio or video recording that can be stored in the provider’s case record and retrieved upon request. Providers may use either of the following two options for audio or videorecorded signatures
- Recording only the signature portion of the telehealth visit. When recording only the signature portion of the visit, providers must record the portion of the visit where the client acknowledges and confirms the medications they will be receiving and provides their understanding that the oral signature holds the same weight as a written signature; or –
- Recording the entire visit with the oral signature included
- Electronic signature: Providers may obtain an electronic signature. Consistent with the Uniform Electronic Transactions Act, California Civil Code Section 1633.2, an “electronic signature” is an electronic sound, symbol, or process attached to or logically associated with an electronic record and executed or adopted by a person with the intent to sign the electronic record. An electronic signature includes a “digital signature” defined in subdivision (d) of Section 16.5 of the Government Code to mean an electronic identifier, created by a computer, intended by the party using it to have the same force and effect as a manual signature. Regardless of the type of electronic signature collected, providers must ensure that they are able to store and/or easily access documentation of the electronic signature in the client’s medical record
Signature upon Receipt of Delivery – Providers may obtain a client’s handwritten or electric signature upon receipt of delivery if the delivery service offers physical or electronic return receipts, such as those offered through the United States Postal Service. Providers must retain documentation of the signature in the client’s medical record.
SOURCE: CA DHCS Medi-Cal Provider Enrollment and Responsibilities Manual. (Aug. 2022). Pg. 20-21. (Accessed Jul. 2024).
Workers’ Compensation
Telehealth is included in the Official Medical Fee Schedule (OMFS) for California’s Workers’ Compensation system and consistent with Medicare’s List of Telehealth Services.
Regulations authorize a remote health evaluation or medical-legal evaluations through the use of electronic means of creating a virtual meeting between the physician and injured worker when both parties can visually see and hear each other and may not be in the same physical space or site. Evaluations can be completed through remote health when a hands on physical examination is not necessary and certain conditions are met.
Remote health is defined as remote visits via video-conferencing, video-calling, or such similar technology that allows each party to see and converse with the other via a video and audio connection. The evaluation must be conducted with the same standard of care as in person visit and must comply with all relevant state and federal privacy laws.
SOURCE: CA Division of Workers’ Compensation Order of the Administrative Director – Effective July 1, 2023; CA Code of Regulations, Title 8, Section 9789.12.2, 9789.19 & CA Code of Regulations, Title 8, Section 46.3. (Accessed Jul. 2024).
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