State Medicaid Best Practice

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2 State Medicaid Best Practice Telerehabilitation January 2014 This document was made possible by Grant #G22RH from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS. None of the information contained in the State Best Practice 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.

3 State Medicaid Best Practice Telerehabilitation The ATA s 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. 1 Rehabilitation professionals utilizing telerehabilitation include: audiologists, neuropsychologists, occupational therapists, physical therapists, and speech-language pathologists. 2 Telerehabilitation is a cost-effective post-acute care service that allows patients to stay at home thereby decreasing the need for costlier care in hospitals or nursing home facilities. 3 Further, the use of telerehabilitation has extended beyond traditional healthcare facility and into communitybased settings (i.e. homes, community health clinics, educational settings/schools). State Medicaid plans including Ohio and Virginia allow children to receive speech therapy services from a remote specialist using video-conferencing. When used in this capacity, telerehabilitation enables school-based health professionals to meet the therapeutic needs of children, particularly those in underserved communities. This service delivery model improves access to skilled professionals with minimum disruption to the child's classroom environment or the parent's work day. 4-6 For a therapist, telerehabilitation facilitates efficient delivery of services by distributing scarce expertise in a cost-effective means as a result of decreased travel time. 7 Medicaid Overview Medicaid coverage for telerehabilitation is rare. Today, 44 states reimburse for some form of telehealth through their Medicaid plans. Yet only 9 states are known to reimburse for telerehabilitation services in their Medicaid plans: Alabama, Kentucky, Minnesota, New Mexico, Nevada, Ohio, South Carolina, Virginia, and Wyoming. Moreover, these state policies vary in scope and application. Some states follow Medicare s restrictions, which do not recognize audiologists, occupational therapists, physical therapists, speech-language pathologists as eligible telehealth providers. 8 Coverage for telerehabilitation in the home is even rarer. Of the 18 states that cover home telehealth, only one, Kentucky, reimburses for telerehabilitation services within a home health benefit. In July 2013, the state issued final rules expanding coverage of telehealth-provided services to include rehabilitation services administered remotely in the home, nursing facility, physician s office, or hospital. Unlike Kentucky, other states, such as Washington, which reimburse home health agencies for services performed via home video visits and remote patient monitoring, do not reimburse for remote specialized therapy services (e.g., physical, occupational, or speech-language therapy). Page 1

4 State Policy Best Practices To improve patient access to healthcare through telehealth expansion, ATA analyzed enacted state telehealth policies and highlighted those respective states with the best policy models for telehealth services. These best practice models can be used as benchmarks for other states considering new or revising existing telehealth policies. In the area of telerehabilitation, ATA examined enacted laws, published fiscal notes and bill reports, published regulations, and Medicaid provider manual guides for the states with Medicaid coverage in those areas. ATA also reviewed state issued reports and clinical programs demonstrating quality and cost-effective telehealth deployment and utilization. The following information identifies notable policies from three states: Kentucky, New Mexico, and Virginia. Kentucky Kentucky statute requires their Medicaid program to reimburse for telehealth provided services, including telerehabilitation, covered under their fee-for-service and managed care plans. However, managed care organizations are not required to reimburse the same amount for telehealth-provided services as compared to fee-for-service telehealth encounters. The Cabinet for Health and Family Services and any regional managed care partnership or other entity under contract with the cabinet for the administration or provision of the Medicaid program shall provide Medicaid reimbursement for a telehealth consultation that is provided by a Medicaid-participating practitioner who is licensed in Kentucky and that is provided in the telehealth network established in KRS 194A.125(3)(b). A request for reimbursement shall not be denied solely because an in-person consultation between a Medicaid-participating practitioner and a patient did not occur. 9 The department shall reimburse a telehealth provider who is eligible for reimbursement from the department for a telehealth consultation an amount equal to the amount paid for a comparable in-person service. 10 In July 2013, Kentucky issued final rules expanding the coverage of telehealth-provided services for Medicaid beneficiaries. Although the changes do not authorize the use of alternate technologies (e.g., remote patient monitoring and store-and-forward), Medicaid beneficiaries will have access to a broader list of providers and telehealth-provided services including telerehabilitation services: Occupational therapy evaluation or treatment provided by an occupational therapist who is employed by a physician, home health agency, or nursing facility; Physical therapy evaluation or treatment provided by a physical therapist who is employed by a physician, home health agency, hospital outpatient department or nursing facility; Page 2

5 Speech therapy evaluation or treatment provided by a speech-language pathologist who is employed by a physician, home health agency, hospital outpatient department or nursing facility; Neurobehavioral status exam provided by a psychiatrist, physician, or psychologist; Mental health evaluation or management service, individual or group psychotherapy, and medication management provided by a psychiatrist, a physician, APRN, psychologist, licensed professional clinical counselor, licensed clinical social worker, licensed marriage and family therapist; and Individual medical nutrition therapy consultation services provided by a licensed dietitian or certified nutritionist. 11 Unlike other states that reimburse for telehealth-provided services, providers eligible for reimbursement under Kentucky s Medicaid plan must enroll with the Medicaid plan and become an approved member of the Kentucky Telehealth Network. New Mexico New Mexico Medicaid has been reimbursing for telerehabilitation services delivered via videoconferencing since According to the regulations, telehealth-provided services are covered at the same rate of in-person services. All services are covered to the same extent the service and the provider are covered when not provided through telehealth. 12 The following medically-necessary health services are covered when using real-time interactive audio-video technology to facilitate a telerehabilitation service encounter: consultations, evaluation and management services, individual psychotherapy, pharmacologic management, psychiatric diagnostic interview examinations, and individual medical nutrition services. The program also covers an extensive list of providers who are eligible for reimbursement of telehealth-provided services if they are licensed in the state and enrolled as a Medicaid provider including physical therapists, occupational therapists, and speech-language pathologists: (1) physicians licensed to practice medicine or osteopathy; (2) podiatrists; (3) facilities licensed as diagnostic and treatment centers by the New Mexico department of health (DOH), community mental health centers, core service agencies, hospitals, rural health clinics, school-based health centers, and federally qualified health centers; services performed in these facilities must be furnished by individual practitioners who are enrolled as providers; (4) certified nurse practitioners and registered nurses may provide services in collaboration with a physician or as independent providers within the scope of their practice; (5) certified physician assistants; (6) nurse midwives licensed by the board of nursing as registered nurses and licensed by the department health as certified nurse midwives; Page 3

6 (7) pharmacist clinicians; (8) individuals licensed as clinical nurse specialists may provide services in collaboration with a physician or as independent providers within the scope of their practice; (9) psychologists (Ph.D., Psy.D. or Ed.D.) licensed or board eligible as clinical psychologists; (10) licensed independent social workers (LISW) licensed by the New Mexico board of social work examiners, licensed professional clinical counselors licensed by, and marriage and family therapists licensed by New Mexico counseling and therapy practice board; (11) registered dietitians or nutrition professionals when furnishing services within the scope of their practice as defined by state law under the direction of a licensed physician; (12) Indian health service and tribal 638 facilities; (13) physical therapists; (14) occupational therapist; or (15) speech pathologists. 13 Although New Mexico does not include geographic or distance limitations as a condition for reimbursement for telehealth-provided health services, the state only allows certain originating sites to be eligible for a facility fee reimbursement. A telehealth originating-site communication system fee is covered if the eligible recipient was present at and participated in the telehealth visit at the an originating-site located in a health professional shortage area (HPSA); a county not classified as a metropolitan statistical area (MSA); a primary medical care health professional shortage area for physicians, nurse practitioners, and physician assistants; primary behavioral health care professional shortage area for psychiatrists and clinical psychologists; a medical specialist shortage area for non-primary care medical specialties; an IHS or tribal 638 facility, a federally qualified health center or rural health clinic or a federal or state telemedicine demonstration project area. Allowed originating sites include a physician/practitioner office, hospital, critical access hospital, rural health clinic, FQHC, rural health clinic, community mental health center, school-based health center, ambulatory surgical or treatment center, skilled nursing facility, residential treatment center, home health agency, diagnostic lab/imaging center, rehab or therapeutic health setting, or patient s home. Virginia Speech-language therapy is an allied health service that can be successfully administered in schools to treat children with speech and language delay. The Virginia Medicaid program has covered school-based speech-language therapy delivered via telehealth since VA will reimburse the distant provider for the telehealth-provided service under the fee-for-service model but they must use a GT modifier when claiming reimbursement for telerehabilitation services. Virginia Medicaid will reimburse a qualified school aide who is present with the child during the Page 4

7 telerehabilitation encounter, and the aide may be billed as a personal care assistant using the following code, Q3014. Virginia Medicaid will reimburse for interactive live video-conferencing for speech therapy services covered under their Medicaid school program when provided by speech-language pathologists. Virginia Medicaid classifies telehealth-provided speech-language therapy as telepractice. Telepractice, as it is used here, is the delivery of speech therapy services by a DMAS approved provider through the use of videoconferencing to a child at a remote location. Telepractice delivered services are subject to the same DMAS requirements as when speech therapy services are delivered without telemedicine services such as provider qualifications, service requirements, confidentiality of information and documentation of services. 14 Evidence-Based Outcomes for Telerehabilitation Services Numerous studies have demonstrated the value of telerehabilitation among different patient populations and health conditions During the school year, the INTEGRIS Speech TelePractice Program in Oklahoma provided speech-language pathology treatments via telepractice to 324 students in 18 schools within 8 school districts. The treatment outcomes for these students were recorded as comparable to or better than similar treatments provided inperson. 23 Further, similar findings have also shown significant provider and patient satisfaction using telerehabilitation in home and community-based settings A study published in 2011 highlighted the value of using telehealth to provide assessments to patients with hearing impairments. Telehealth was shown to have comparable effects to that of in-person services. 27 Other research studies have used telerehabilitation to assess and treat disorders including dysarthria, apraxia of speech, aphasia, and mild Alzheimer s disease, and have shown the benefits of using telerehabilitation to deliver speech and language services. 28 Model Medicaid Policy Considerations Based on state best practices, ATA suggests the following basic provision for policymakers and health care stakeholders to start from in developing telerehabilitation service policies to fit their needs. Medicaid will provide coverage for telerehabilitation services, which includes the use of real-time audio and video, store-and-forward technology, and remote patient monitoring, to the same extent that the services would be covered if they were provided through inperson consultation. Page 5

8 Reimbursement for telerehabilitation services will be made when the service is rendered by a licensed individual, or practice or group that directly employs or contracts with these individuals. More specifically, model policies for Medicaid coverage of telerehabilitation should include: Definitions of technology with little to no restrictions on the types of technology approved for use in a clinical service; Unrestricted geographic coverage areas or patient settings; Applicable health services and conditions such as audiology, neuropsychology, occupational therapy, physical therapy, and speech-language pathology; Eligible telehealth providers such as audiologists, clinical nurse specialists, neuropsychologists, occupational therapists, physical therapists, and speech-language pathologists; Allowances for innovative payment models other than fee-for-service. Reimbursement considerations should be made for managed care, medical homes, accountable care organizations, and other service and payment innovations; and Parity coverage for services that are also provided in-person, coverage under plans that provide long-term services and supports (LTSS), as well as Medicaid expansion plans created under the Affordable Care Act (ACA). In the case of telerehabilitation in schools, states have several additional options to improve children s access to educational and therapeutic services using telehealth. These include enacting legislation, proposing administrative regulations, or applying for a federal block grant under Title V of the Social Security Act to improve maternal and child health or a formula grant under the Individuals with Disabilities Education Act (IDEA) to enhance services for children with special needs. Many school-age Medicaid recipients are also eligible for services under these federal programs. 1 A Blueprint for Telerehabilitation Guidelines. American Telemedicine Association. October Ibid. 3 Bendixen RM, Levy CE, Olive ES, Kobb RF, Mann WC. Cost effectiveness of a telerehabilitation program to support chronically ill and disabled elders in their homes. Telemed J E Health Jan;15(1):31-8. doi: /tmj Rose DAD, Furner S, Hall A, Montgomery K, Katsavras E, Clarke P. Videoconferencing for speech and language therapy in schools. BT Technology Journal, Banotai, A. Teletherapy in the Schools. Advance for Speech-Language Pathologists & Audiologists, McCullough A. Viability and effectiveness of teletherapy for pre-school children with special needs. International Journal of Language and Communication Disorders, Polovoy, C. Telepractice in Schools Helps Address Personnel Shortages. ASHA Leader, Brannon, JA and Cason, J. (2011) Telehealth Regulatory and Legal Considerations: Frequently Asked Questions, International Journal of Telerehabilitation, 3(2), KY Revised Statutes (2012). 10 KY 907 KAR 3: Ibid. Section New Mexico Administrative Code Section Ibid. Section Page 6

9 14 Virginia Department of Medical Assistant Services, Medicaid Provider Manual, Local Education Agency Provider Manual, Covered Svcs. and Limitations, p. 13 (Oct. 24, 2012). 15 Winters JM, Winters JM. A telehomecare model for optimizing rehabilitation outcomes. Telemed J E Health 2004;10: Savard L, Borstad A, Tkachuck J, Lauderdale D, Conroy B. Telerehabilitation consultations for clients with neurologic diagnoses: Cases from rural Minnesota and American Samoa. NeuroRehabilitation 2003;18: Sanford JA, Jones M, Daviou P, Grogg K, Butterfield T. Using telerehabilitation to identify home modification needs. Assist Technol 2004;16: Galea M, Tumminia J, Garback LM. Telerehabilitation in spinal cord injury persons: A novel approach. Telemed J E Health 2006;12: Lai JC, Woo J, Hui E, Chan WM. Telerehabilitation a new model for community-based stroke rehabilitation. J Telemed Telecare 2004;10: Lum PS, Uswatte G, Taub E, Hardin E, Mark VW. A telerehabilitation approach to delivery of constraint-induced movement therapy. J Rehabil Res Dev 2006;43: Sanford JA, Griffiths PC, Richardson P, Hargraves K, Butterfield T, Hoenig H. The effects of in-home rehabilitation on task self-efficacy in mobility impaired adults: A randomized clinical trial. J Am Geriatr Soc 2006;54: Bendixen R, Horn K, Levy C. Using telerehabilitation to support chronically ill elders in their homes. Topics Geriat Rehab 2006;23: INTEGRIS Telehealth, Speech TelePractice Program Memorandum to Oklahoma Health Care Authority Telemedicine Policy Group. June 13, Tousignant M, Boissy P, Moffet H, Corriveau H, Cabana F, Marquis F, Simard J. Patients' satisfaction of healthcare services and perception with in-home telerehabilitation and physiotherapists' satisfaction toward technology for post-knee arthroplasty: an embedded study in a randomized trial. Telemed J E Health Jun;17(5): doi: /tmj Epub 2011 Apr Tousignant M, Boissy P, Corriveau H, Moffet H. In home telerehabilitation for older adults after discharge from an acute hospital or rehabilitation unit: A proof-of-concept study and costs estimation. Disabil Rehabil Assist Technol Sep;1(4): McCue M, Fairman A, Pramuka M. Enhancing quality of life through telerehabilitation. Phys Med Rehabil Clin N Am Feb;21(1): Crowell, E., Givens, G., Jones, G., Brechtelsbauer, P., and Yao, J. (2011) Audiology Telepractice in a Clinical Environment: A Communication Perspective, Journal of Otology, Rhinology and Laryngology, 120 (7), Cherney, LR and van Vuuren, S. Telerehabilitation, Virtual Therapists, and Acquired Neurologic Speech and Language Disorders. Semin Speech Lang August; 33(3): Page 7