Sec PARTICIPATION AND REIMBURSEMENT OF TELEMEDICINE MEDICAL SERVICE PROVIDERS UNDER MEDICAID. (a) The commission by rule shall develop and

Transcription

1 Sec PARTICIPATION AND REIMBURSEMENT OF TELEMEDICINE MEDICAL SERVICE PROVIDERS UNDER MEDICAID. (a) The commission by rule shall develop and implement a system to reimburse providers of services under the state Medicaid program for services performed using telemedicine medical services. (b) In developing the system, the executive commissioner by rule shall: (1) review programs and pilot projects in other states to determine the most effective method for reimbursement; (2) establish billing codes and a fee schedule for services; (3) provide for an approval process before a provider can receive reimbursement for services; (4) consult with the Department of State Health Services and the telemedicine advisory committee to establish procedures to: (A) identify clinical evidence supporting delivery of health care services using a telecommunications system; (B) establish pilot studies for telemedicine medical service delivery; and (C) annually review health care services, considering new clinical findings, to determine whether reimbursement for particular services should be denied or authorized; (5) establish pilot programs in designated areas of this state under which the commission, in administering government-funded health programs, may reimburse a health professional participating in the pilot program for telehealth services authorized under the licensing law applicable to the health professional; (6) establish a separate provider identifier for telemedicine medical services providers; and (7) establish a separate modifier for telemedicine medical services eligible for reimbursement.

2 (c) The commission shall encourage health care providers and health care facilities to participate as telemedicine medical service providers in the health care delivery system. The commission may not require that a service be provided to a patient through telemedicine medical services when the service can reasonably be provided by a physician through a face-to-face consultation with the patient in the community in which the patient resides or works. This subsection does not prohibit the authorization of the provision of any service to a patient through telemedicine medical services at the patient's request. (d) Subject to Section , Occupations Code, the commission may adopt rules as necessary to implement this section. In the rules adopted under this section, the commission shall: (1) refer to the site where the patient is physically located as the patient site; and (2) refer to the site where the physician providing the telemedicine medical service is physically located as the distant site. (e) The commission may not reimburse a health care facility for telemedicine medical services provided to a Medicaid recipient unless the facility complies with the minimum standards adopted under Section (f) Not later than December 1 of each even-numbered year, the commission shall report to the speaker of the house of representatives and the lieutenant governor on the effects of telemedicine medical services on the Medicaid program in the state, including the number of physicians and health professionals using telemedicine medical services, the geographic and demographic disposition of the physicians and health professionals, the number of patients receiving telemedicine medical services, the types of services being provided, and the cost of utilization of telemedicine medical services to the program. (g) In this section:

3 (1) "Telehealth service" has the meaning assigned by Section , Utilities Code. (2) "Telemedicine medical service" has the meaning assigned by Section , Utilities Code. Added by Acts 1997, 75th Leg., ch. 1244, Sec. 1, eff. June 20, Amended by Acts 1999, 76th Leg., ch. 62, Sec , eff; Sept. 1, Renumbered from Sec by Acts 1999, 76th Leg., ch. 62, Sec (46), eff. Sept. 1, 1999; Acts 2001, 77th Leg., ch. 1255, Sec. 1, eff. June 15, 2001; Acts 2001, 77th Leg., ch. 1420, Sec , eff. Sept. 1, Amended by: Acts 2005, 79th Leg., Ch. 370, Sec. 1, eff. September 1, Acts 2007, 80th Leg., R.S., Ch. 525, Sec. 1, eff. September 1, Sec TELEMEDICINE TECHNOLOGY STANDARDS. (a) In this section, "telemedicine medical service" has the meaning assigned by Section , Utilities Code. (b) The commission and the Telecommunications Infrastructure Fund Board by joint rule shall establish and adopt minimum standards for an operating system used in the provision of telemedicine medical services by a health care facility participating in the state Medicaid program, including standards for electronic transmission, software, and hardware. (c) In developing standards under this section, the commission and the Telecommunications Infrastructure Fund Board shall address: (1) authentication and authorization of users; (2) authentication of the origin of information; (3) the prevention of unauthorized access to the system or information;

4 (4) system security, including the integrity of information that is collected, program integrity, and system integrity; (5) maintenance of documentation about system and information usage; (6) information storage, maintenance, and transmission; and (7) synchronization and verification of patient profile data. Added by Acts 2001, 77th Leg., ch. 1255, Sec. 2, eff. June 15, Sec MEDICAID SERVICES PROVIDED THROUGH TELEMEDICINE MEDICAL SERVICES AND TELEHEALTH SERVICES TO CHILDREN WITH SPECIAL HEALTH CARE NEEDS. (a) In this section, "child with special health care needs" has the meaning assigned by Section , Health and Safety Code. (b) The commission by rule shall establish policies that permit reimbursement under the state Medicaid and children's health insurance program for services provided through telemedicine medical services and telehealth services to children with special health care needs. (c) The policies required under this section must: (1) be designed to: (A) prevent unnecessary travel and encourage efficient use of telemedicine medical services and telehealth services for children with special health care needs in all suitable circumstances; and (B) ensure in a cost-effective manner the availability to a child with special health care needs of services appropriately performed using telemedicine medical services and telehealth services that are comparable to the same types of services available to that child without the use of telemedicine medical services and telehealth services; and

5 (2) provide for reimbursement of multiple providers of different services who participate in a single telemedicine medical services and telehealth services session for a child with special health care needs, if the commission determines that reimbursing each provider for the session is cost-effective in comparison to the costs that would be involved in obtaining the services from providers without the use of telemedicine medical services and telehealth services, including the costs of transportation and lodging and other direct costs. Added by Acts 2001, 77th Leg., ch. 959, Sec. 2, eff. June 14, Renumbered from Government Code Sec by Acts 2003, 78th Leg., ch. 1275, Sec. 2(63), eff. Sept. 1, Sec TELEPRESENTERS. (a) In this section, "health professional" means an individual who: (1) is licensed or certified in this state to perform health care services; and (2) is not a physician, registered nurse, advanced practice nurse, or physician assistant. (b) The executive commissioner by rule shall establish and adopt minimum standards to permit the use of trained health professionals in presenting patients who are Medicaid recipients for telemedicine medical services consultations to be conducted by physicians at distant sites. (c) Notwithstanding Section , the commission may provide reimbursement under the state Medicaid program for a telemedicine medical service initiated by a trained health professional who complies with the minimum standards adopted under this section. (d) The commission shall provide reimbursement under the state Medicaid program to a physician for overseeing a telemedicine consultation at a telemedicine distant site if the telepresenter at the patient site is another physician or is an advanced practice nurse, registered nurse, or physician

6 assistant acting under physician delegation and supervision throughout the consultation. Added by Acts 2005, 79th Leg., Ch. 370, Sec. 2, eff. September 1, Amended by: Acts 2007, 80th Leg., R.S., Ch. 525, Sec. 2, eff. September 1, Sec REIMBURSEMENT FOR CERTAIN MEDICAL CONSULTATIONS. (a) In this section: (1) "Health professional" means: (A) a physician; (B) an individual who is: (i) licensed or certified in this state to perform health care services; and (ii) authorized to assist a physician in providing telemedicine medical services that are delegated and supervised by the physician; or (C) a licensed or certified health professional acting within the scope of the license or certification who does not perform a telemedicine medical service. (2) "Physician" means a person licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code. (3) "Telehealth service" has the meaning assigned by Section , Utilities Code. (4) "Telemedicine medical service" has the meaning assigned by Section , Utilities Code. (b) The commission by rule shall require each health and human services agency that administers a part of the Medicaid program to provide Medicaid reimbursement for a telemedicine medical service initiated or provided by a physician.

7 (c) The commission shall ensure that reimbursement is provided only for a telemedicine medical service initiated or provided by a physician. (c-1) Notwithstanding Subsection (b) or (c), the commission shall provide for reimbursement under the Medicaid program for an office visit provided through telemedicine by a physician who is assessing and evaluating the patient from a distant site if: (1) a health professional acting under the delegation and supervision of that physician is present with the patient at the time of the visit; and (2) the medical condition, illness, or injury for which the patient is receiving the service is not likely, within a reasonable degree of medical certainty, to undergo material deterioration within the 30-day period following the date of the visit. (c-2) The commission shall develop rules to allocate reimbursement provided under Subsection (c-1) between a physician consulting from a distant site and a health professional present with the patient or shall by rule establish a facility fee that a physician consulting from a distant site and receiving reimbursement under Subsection (c-1) must pay a health professional present with the patient. (c-3) In adopting rules under Subsection (c-2), the commission shall confer with the Centers for Medicare and Medicaid Services on the legality of allocating reimbursement or establishing a facility fee as described in that subsection. Rules adopted by the commission under this subsection or Subsection (c-2) must reflect a policy to build capacity in medically underserved areas of this state. (d) The commission shall require reimbursement for a telemedicine medical service at the same rate as the Medicaid program reimburses for a comparable in-person medical service. A request for reimbursement may not be denied solely because an in-person medical service between a physician and a patient did not occur.

8 (e) A health care facility that receives reimbursement under this section for a telemedicine medical service provided by a physician who practices in that facility or a health professional who participates in a telemedicine medical service under this section shall establish quality of care protocols and patient confidentiality guidelines to ensure that the telemedicine medical service meets legal requirements and acceptable patient care standards. (f) The commission may not require a telemedicine medical service if an in-person consultation with a physician is reasonably available where the patient resides or works. The commission shall require facilities and providers of telemedicine medical services to make a good faith effort to identify and coordinate with existing providers to preserve and protect existing health care systems and medical relationships in an area. (g) If a patient receiving a telemedicine medical service has a primary care physician or provider and consents to the notification, the commission shall require that the primary care physician or provider be notified of the telemedicine medical service for the purpose of sharing medical information. (h) The commission in consultation with the Texas State Board of Medical Examiners shall monitor and regulate the use of telemedicine medical services to ensure compliance with this section. In addition to any other method of enforcement, the commission may use a corrective action plan to ensure compliance with this section. (i) The Texas State Board of Medical Examiners, in consultation with the commission, as appropriate, may adopt rules as necessary to: (1) ensure that appropriate care, including quality of care, is provided to patients who receive telemedicine medical services; (2) prevent abuse and fraud through the use of telemedicine medical services, including rules relating to

9 filing of claims and records required to be maintained in connection with telemedicine; and (3) define those situations when a face-to-face consultation with a physician is required after a telemedicine medical service. (i-1) The Texas State Board of Medical Examiners, in consultation with the commission and the Department of State Health Services, as appropriate, shall adopt rules to establish supervisory requirements for a physician delegating a service to be performed by an individual who is not a physician, registered nurse, advanced practice nurse, or physician assistant, including a health professional who is authorized to be a telepresenter under Section This section may not be construed as authorizing the Texas State Board of Medical Examiners to regulate another licensed or certified health care provider. (j) The commissioner shall establish an advisory committee to coordinate state telemedicine efforts and assist the commission in: (1) evaluating policies for telemedicine medical services under Section and this section; (2) monitoring the types of programs receiving reimbursement under this section; and (3) coordinating the activities of state agencies interested in the use of telemedicine medical services. (k) This section does not affect any requirement relating to: (1) a federally qualified health center; (2) a rural health clinic; or (3) physician delegation of the authority to carry out or sign prescription drug orders to an advanced practice nurse or physician assistant. Added by Acts 1997, 75th Leg., ch. 1251, Sec. 1, eff. Sept. 1, Amended by Acts 1999, 76th Leg., ch. 1377, Sec. 1.25, eff. Sept. 1, Renumbered from Sec by Acts 1999, 76th

10 Leg., ch. 62, Sec (48), eff. Sept. 1, 1999; Acts 2001, 77th Leg., ch. 661, Sec. 3, eff. June 13, 2001; Acts 2001, 77th Leg., ch. 959, Sec. 10, eff. Sept. 1, 2001; Acts 2001, 77th Leg., ch. 1255, Sec. 3, eff. June 15, Amended by: Acts 2005, 79th Leg., Ch. 370, Sec. 3, eff. September 1, Acts 2007, 80th Leg., R.S., Ch. 1293, Sec. 1, eff. September 1, Text of section as added by Acts 2001, 77th Leg., ch. 661, Sec. 1 Sec TELEMEDICINE PILOT PROGRAMS. (a) In this section: (1) "Health professional" means: (A) a physician; (B) an individual who is licensed or certified in this state to perform health care services and who is authorized to assist a physician in providing telemedicine medical services that are delegated and supervised by the physician; or (C) a licensed or certified health professional acting within the scope of the license or certification who does not perform a telemedicine medical service. (2) "Physician" means a person licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code. (3) "Telehealth service" means a health service, other than a telemedicine medical service, delivered by a licensed or certified health professional acting within the scope of the health professional's license or certification who does not perform a telemedicine medical service that requires the use of advanced telecommunications technology, other than by telephone or facsimile, including:

11 (A) compressed digital interactive video, audio, or data transmission; (B) clinical data transmission using computer imaging by way of still-image capture and store and forward; and (C) other technology that facilitates access to health care services or medical specialty expertise. (4) "Telemedicine medical service" means a health care service initiated by a physician or provided by a health professional acting under physician delegation and supervision, for purposes of patient assessment by a health professional, diagnosis or consultation by a physician, treatment, or the transfer of medical data, that requires the use of advanced telecommunications technology, other than by telephone or facsimile, including: (A) compressed digital interactive video, audio, or data transmission; (B) clinical data transmission using computer imaging by way of still-image capture and store and forward; and (C) other technology that facilitates access to health care services or medical specialty expertise. (b) The commission shall establish pilot programs in designated areas of this state under which the commission, in administering government-funded health programs, may reimburse a health professional participating in the pilot program for telemedicine medical services or telehealth services authorized under the licensing law applicable to the health professional. Each pilot program established before January 1, 2003, must provide services in areas of this state that are not more than 150 miles from the border between this state and the United Mexican States. (c) In developing and operating a pilot program under this section, the commission shall: (1) solicit and obtain support for the program from local officials and the medical community;

12 (2) focus on enhancing health outcomes in the area served by the pilot program through increased access to medical services, including: (A) health screenings; (B) prenatal care; (C) medical or surgical follow-up visits; (D) periodic consultation with specialists regarding chronic disorders; (E) triage and pretransfer arrangements; and (F) transmission of diagnostic images or data; (3) establish quantifiable measures and expected health outcomes for each authorized telemedicine medical service or telehealth service; (4) consider condition-specific applications of telemedicine medical services or telehealth services, including applications for: (A) pregnancy; (B) diabetes; (C) heart disease; and (D) cancer; and (5) demonstrate that the provision of services authorized as telemedicine medical services or telehealth services will not adversely affect the provision of traditional medical services within the area served by the pilot program. (d) Notwithstanding an eligibility requirement prescribed by other law or rule, the commission may establish requirements for a person to participate in a pilot project under this section. (e) Participation in the pilot project does not entitle a participant to other services under a government-funded health program. (f) The commission may limit the number of participants of a pilot project under this section. Added by Acts 2001, 77th Leg., ch. 661, Sec. 1, eff. June 13, 2001.

13 Text of section as added by Acts 2001, 77th Leg., ch. 959, Sec. 3 Sec TELEMEDICINE MEDICAL SERVICES AND TELEHEALTH SERVICES PILOT PROGRAMS. (a) In this section: (1) "Health professional" means: (A) a physician; (B) an individual who is licensed or certified in this state to perform health care services and who is authorized to assist a physician in providing telemedicine medical services that are delegated and supervised by the physician; or (C) a licensed or certified health professional acting within the scope of the license or certification who does not perform a telemedicine medical service. (2) "Physician" means a person licensed to practice medicine in this state under Subtitle B, Title 3, Occupations Code. (3) "Telehealth service" has the meaning assigned by Section , Utilities Code. (4) "Telemedicine medical service" has the meaning assigned by Section , Utilities Code. (b) The commission shall establish pilot programs in designated areas of this state under which the commission, in administering government-funded health programs, may reimburse a health professional participating in the pilot program for telemedicine medical services or telehealth services authorized under the licensing law applicable to the health professional. Each pilot program established before January 1, 2003, must provide services in areas of this state that are not more than 150 miles from the border between this state and the United Mexican States. (c) In developing and operating a pilot program under this section, the commission shall:

14 (1) solicit and obtain support for the program from local officials and the medical community; (2) focus on enhancing health outcomes in the area served by the pilot program through increased access to medical or health care services, including: (A) health screenings; (B) prenatal care; (C) medical or surgical follow-up visits; (D) periodic consultation with specialists regarding chronic disorders; (E) triage and pretransfer arrangements; and (F) transmission of diagnostic images or data; (3) establish quantifiable measures and expected health outcomes for each authorized telemedicine medical service or telehealth service; (4) consider condition-specific applications of telemedicine medical services or telehealth services, including applications for: (A) pregnancy; (B) diabetes; (C) heart disease; and (D) cancer; and (5) demonstrate that the provision of services authorized as telemedicine medical services or telehealth services will not adversely affect the delivery of traditional medical services or other health care services within the area served by the pilot program. Added by Acts 2001, 77th Leg., ch. 959, Sec. 3, eff. June 14, Sec TELEMEDICINE ADVISORY COMMITTEE. (a) The commissioner shall establish an advisory committee to assist the commission in:

15 (1) evaluating policies for telemedical consultations under Sections and ; (2) evaluating policies for telemedicine medical services or telehealth services pilot programs established under Section ; (3) ensuring the efficient and consistent development and use of telecommunication technology for telemedical consultations and telemedicine medical services or telehealth services reimbursed under government-funded health programs; (4) monitoring the type of programs receiving reimbursement under Sections and ; and (5) coordinating the activities of state agencies concerned with the use of telemedical consultations and telemedicine medical services or telehealth services. (b) The advisory committee must include: (1) representatives of health and human services agencies and other state agencies concerned with the use of telemedical consultations in the Medicaid program and the state child health plan program, including representatives of: (A) the commission; (B) the Department of State Health Services; (C) the Texas Department of Rural Affairs; (D) the Texas Department of Insurance; (E) the Texas Medical Board; (F) the Texas Board of Nursing; and (G) the Texas State Board of Pharmacy; (2) representatives of health science centers in this state; (3) experts on telemedicine, telemedical consultation, and telemedicine medical services or telehealth services; and (4) representatives of consumers of health services provided through telemedical consultations and telemedicine medical services or telehealth services. (c) A member of the advisory committee serves at the will of the commissioner.

16 Added by Acts 2001, 77th Leg., ch. 959, Sec. 3, eff. June 14, 2001; Acts 2001, 77th Leg., ch. 661, Sec. 1, eff. June 13, Reenacted and amended by Acts 2003, 78th Leg., ch. 609, Sec. 18, eff. Sept. 1, Amended by: Acts 2005, 79th Leg., Ch. 370, Sec. 4, eff. September 1, Acts 2007, 80th Leg., R.S., Ch. 831, Sec. 8, eff. September 1, Acts 2007, 80th Leg., R.S., Ch. 889, Sec. 58, eff. September 1, Acts 2009, 81st Leg., R.S., Ch. 112, Sec. 93, eff. September 1, Sec ALIGNMENT OF MEDICAID TELEMEDICINE REIMBURSEMENT POLICIES WITH MEDICARE REIMBURSEMENT POLICIES. (a) The commission shall periodically review policies regarding reimbursement under the Medicaid program for telemedicine medical services to identify variations between permissible reimbursement under that program and reimbursement available to providers under the Medicare program. (b) To the extent practicable, and notwithstanding any other state law, after conducting a review under Subsection (a) the commission may modify rules and procedures applicable to reimbursement under the Medicaid program for telemedicine medical services as necessary to provide for a reimbursement system that is comparable to the reimbursement system for those services under the Medicare program. (c) The commission shall perform its duties under this section with assistance from the telemedicine advisory committee established under Section Added by Acts 2003, 78th Leg., ch. 870, Sec. 1, eff. Sept. 1, 2003.

17 Sec ADDITIONAL AUTHORITY REGARDING TELEMEDICINE MEDICAL SERVICES. (a) In addition to the authority granted by other law regarding telemedicine medical services, the commission may review rules and procedures applicable to reimbursement of telemedicine medical services provided through any government-funded health program subject to the commission's oversight. (b) The commission may modify rules and procedures described by Subsection (a) as necessary to ensure that reimbursement for telemedicine medical services is provided in a cost-effective manner and only in circumstances in which the provision of those services is clinically effective. (c) This section does not affect the commission's authority or duties under other law regarding reimbursement of telemedicine medical services under the Medicaid program. Added by Acts 2003, 78th Leg., ch. 870, Sec. 1, eff. Sept. 1, 2003.