Or. Admin. R. 410-141-3566 - Telehealth Service and Reimbursement Requirements

Current through Register Vol. 60, No. 12, December 1, 2021

(1) For the purpose of this rule, the Authority defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration.

(a) Information related to telehealth services may be transmitted via landlines, and wireless communications, including the Internet and telephone networks;

(b) Services can be synchronous (using audio and video, video only or audio only) or asynchronous (using audio and video, audio, or text-based media) and may include transmission of data from remote monitoring devices. Communications may be between providers, or be between one or more providers and one or more patients, family members /caregivers /guardians).

(2) Telehealth encompasses different types of programs, services and delivery mechanisms for medically appropriate services for covered physical, behavioral and oral health conditions within the patient's defined benefit package.

(3) CCOs shall provide reimbursement for telehealth services and reimburse Certified and Qualified Health Care Interpreters (HCIs) for interpretation services provided via telemedicine at the same reimbursement rate as if it were provided in person. This requirement does not supersede the CCOs direct agreement(s) with providers, including but not limited to, alternative payment methodologies, quality and performance measures or Value Based Payment methods described in the CCO contract. However, nothing either in this requirement or within CCO direct agreement(s) with providers referenced herein supersedes any federal or state requirements with regard to the provision and coverage of health care interpreter services.

(4) Providers are prohibited from excluding or otherwise limiting OHP members to using exclusively telehealth services, except where Authority has implemented section (9) of this rule.

(5) CCOs shall ensure patient choice and accommodation encompass the following standards and services:

(a) Consistent with Care Coordination requirements in OAR 410-141- 3865, CCOs shall work with their contracted providers to ensure meaningful access to services by assessing members' capacities to use specific approved methods of telehealth delivery that comply with accessibility standards including alternate formats, and provides the optimal quality of care for the patient given their capacity;

(b) Pursuant to Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act and the corresponding Code of Federal Regulation (CFR) at 45 CFR Part 92 (Section 1557) and The Americans with Disabilities Act and Amendments Act of 2008 (ADA), CCOs shall provide access to auxiliary aids and services to ensure that telehealth services accommodate the needs of individuals who have difficulty communicating due to a medical condition, who need accommodation due to a disability, advanced age or who have limited English proficiency (LEP);

(c) CCOs shall ensure access to health care services for LEP and Deaf and hard of hearing patients and their families through the use of qualified and certified health care interpreters, embedded or third-party interpretive services to provide meaningful language access services as described in OAR 333-002-0040;

(d) CCOs shall ensure that telehealth services provided are culturally and linguistically appropriate as described in the relevant standards:

(A) National Culturally and Linguistically Appropriate Services (CLAS) Standards, https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53;

(B) Tribal based practice standards, https://www.oregon.gov/OHA/HSD/AMH/Pages/EBP.aspx;

(C) Trauma-informed approach to care as defined in 410-141-3500.

(6) Consistent with OAR 410-120-1990 privacy and security standards must be met by satisfying the following:

(a) Prior to the delivery of services via a telehealth modality, a patient oral, recorded, or written consent to receive services using a telehealth delivery method shall be obtained and documented annually. Consent must be updated at least annually thereafter. For LEP and Deaf and hard of hearing patients and their families, providers must use qualified and certified health care interpreters, when obtaining patient consent.

(b) Consistent with ORS 109.640, provision of birth control information and services shall be provided to any person regardless of age without consent of parent or legal guardian.

(c) Consistent with ORS 109.640, provision of any other medical or dental diagnosis and treatment shall be provided to any person 15 years of age or older without consent of parent or legal guardian.

(d) Services provided using a telehealth platform shall comply with Health Insurance Portability and Accountability Act (HIPAA, https://aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996) and with the Authority's Privacy and Confidentiality Rules (Chapter 943 Division 14) except as noted in section (9) below.

(e) The patient may be located in the community or in a health care setting.

(f) Providers may be located in any location where privacy can be ensured.

(g) Persons providing interpretive services and supports shall be in any location where patient privacy and confidentiality can be ensured.

(7) CCOs shall ensure their network providers offer telehealth services that meet the following requirements:

(a) Provide services via telehealth that are within their respective certification or licensing board's scope of practice and comply with telehealth requirements including but not limited to:

(A) Documenting patient and provider agreement of consent to receive services;

(B) Allowed physical location of provider and patient;

(C) Establishing or maintaining an appropriate provider-patient relationship.

(b) Complying with HIPAA and the Authority's Privacy and Confidentiality Rules and security protections for the patient in connection with the telehealth communication and related records requirements (OAR chapter 943 division 14 and 120, OAR 410-120-1360 and 1380, 42 CFR Part 2, if applicable, and ORS 646A.600 to 646A.628 (Oregon Consumer Identity Theft Protection Act)) except as noted in section (9) below;

(c) Obtaining and maintaining technology used in telehealth communication that is compliant with privacy and security standards in HIPAA and the Authority's Privacy and Confidentiality Rules described in subsection (A) except as noted in section (9) below;

(d) Ensuring policies and procedures are in place to prevent a breach in privacy or exposure of patient health information or records (whether oral or recorded in any form or medium) to unauthorized persons;

(e) Maintaining clinical and financial documentation related to telehealth services as required in OAR 410-120-1360;

(f) Complying with all federal and state statutes as required in OAR 410-120-1380.

(8) CCO reimbursement to network providers offering telehealth services shall meet the following requirements:

(a) Services provided shall be medically and clinically appropriate for covered conditions within the Health Evidence Review Commission's (HERC) prioritized list and in compliance with relevant guideline notes;

(b) Dependent on individual certification or licensing board's scope of practice standards, telehealth delivered services for covered conditions are covered when an established relationship exists between a provider and patient as defined by a patient who has received in person professional services from the physician or other qualified health care professional within the same practice within the past three years, and for establishing a patient-provider relationship;

(c) For all claim types except dental, CCOs shall ensure that encounter submissions for services covered using synchronous audio and video include modifiers GT or 95, and can be billed with either telephone codes (e.g. 99441) or regular in-person codes. For all telehealth services including dental, CCOs shall ensure that encounter submissions include Place of Service code 02;

(d) All physical, behavioral and oral telehealth services except School Based Health Services (SBHS) shall include Place of Service code 02;

(e) When provision of the same service via synchronous audio and video is not available or feasible, e.g. the patient declines to enable video, or necessary consents cannot reasonably be obtained with appropriate documentation in patient's medical record, then encounter submissions should not include any modifiers but should continue billing Place of Service as 02.

(9) In the event of a declared emergency or changes in federal requirements, the Authority may adopt flexibilities to remove administrative barriers and support telehealth delivered services:

(a) The Authority will follow guidance from the US Department of Health and Human Services (HHS) Office for Civil Rights (OCR) which may allow enforcement discretion related to privacy or security requirements;

(b) The Authority may expand network capacity through remote care and telehealth services provided across state lines;

(c) The Authority may expand access to telehealth services for new patients;

(d) Should the Authority exercise options in this section (9), all CCO obligations for Network Adequacy requirements as described in OAR 410-141-3515 remain in full effect.

Notes

Or. Admin. R. 410-141-3566

DMAP 16-2020, temporary adopt filed 03/26/2020, effective 03/26/2020 through 09/21/2020; DMAP 43-2020, adopt filed 09/01/2020, effective 9/10/2020; DMAP 62-2020, amend filed 12/16/2020, effective 1/1/2021

Statutory/Other Authority: ORS 413.042, 414.572, 414.591, 414.605 & 414.615

Statutes/Other Implemented: ORS 414.572