State State- Specific Information ARIZONA

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1 ARIZONA State Recent news, pending action: Insurance law and regulations: Medicaid law and regulations: State- Specific Information SB 1414 and HB 2666 would mandate private health insurance coverage for benefits provided by telehealth. Arizona health care service organizations (HCSO) have the option to allow services to be delivered via telemedicine as an alternative access (Arizona Administrative Code: R ), but coverage for telemedicine services is not mandated. Arizona statutes recognize the use of telemedicine services Title 36, Article 1. The Arizona Health Care Cost Containment System (AHCCCS) covers telemedicine services delivered either in real time or store and forward. The AHCCCS provider billing manuals can be found here. Among others, some of the services covered and reimbursed for include: o Home health o Radiology o Cardiology o Behavioral health services o Dermatology Certain conditions and limitations must be met, including that the recipient s physician/pcp/agent must be present at the time of the delivery of the services. Details can be found in Chapter 10 of the Fee- for- Service manual. Type of Service(s) Which Can Be Reimbursed o Medically necessary consultative and/or treatment for all eligible members within certain limitations. Conditions or Limitations o Covered behavioral health services for Title XIX and Title XXI members include: 1) diagnostic consultation and evaluation 2) psychotropic medication adjustment and monitoring 3) Individual and family counseling and 4) case management- real time only. Payments to Non- physician health care providers o Yes, referring provider can be physician, PA, RN practitioner, RN midwife, or clinical psychologist. o Medical professional personnel as consultants also can include behavioral health professional, or an occupation, physical, speech, or respiratory therapist. o At the time of service delivery, the health care provider can designate a trained telepresenter if the PCP is not present. Licensure Requirements o Only services provided by AHCCS registered provider can be reimbursed. o A consulting service delivered via telemedicine by other than an Arizona licensed provider must be a single, or infrequent, service provided and the consultant must be licensed to practice in the state from which the consultation is provided.

2 CALIFORNIA Telehealth licensure: Telehealth networks: Organization and people resources: Recent news, pending action: Payment Method o FFS o Same as reimbursement for covered services furnished in the conventional, face- to- face manner Reimbursement Type o Reimbursement is at both ends (hub and spoke). o State would review "add- on" costs but none have been presented How Identified in Claims/Use of Modifiers o CPT codes using the "GT" modifier and are billed by the consulting provider. Store and Forward vs. Live o Reimburses for both real- time and "store and forward". Arizona participates in the inter- state Nurse Licensure Compact. The University of Arizona, Arizona Telemedicine Program maintains and enhances the state s telehealth network with funding from both State and Federal sources. It offers information on both educational and clinical services in the state and is a great resource for the telehealth community. Northern Arizona Regional Behavioral Health Authority (NARBHA) has provided over 60,000 telepsychiatry sessions since 1996 via its award- winning telemedicine network, NARBHAnet. A private, nonprofit MCO, NARBHA contracts with the State of Arizona to administer publicly funded behavioral health services in northern Arizona. Policy Contacts in Arizona Kristine Erps The University of Arizona Health Sciences Center P.O. Box Tucson, AZ kerps@telemedicine.arizona.edu Phone: February AB 1733 introduced to specify that the Knox- Keene Health Care Service Plan Act prohibition on requiring in- person contact also applies to other health care service plan contracts with the State Department of Health Care Services for services under the Medi- Cal program publicly supported programs other than Medi- Cal, and for services pursuant to the Program of All- Inclusive Care for the Elderly. By expanding the scope of a crime, the bill would impose a state- mandated local program. October 7, 2011 California enacted a comprehensive law to advance telehealth. Before signing by the Governor, AB 415 was unanimously approved by the Legislature (Legislature background

3 Pending legislation: information). Independent fiscal estimate. The new law: o Replaces the outdated legal terminology of telemedicine with telehealth o Updates the definition of telehealth to reflect the broader range of services in use today, and apply the definition to all licensed health professionals o Changes the need for an additional written patient consent specifically for telehealth services to a verbal consent o Removes the Medi- Cal (California s Medicaid program) rule requiring documentation of a barrier to an in- person visit before a beneficiary can receive telehealth services o Removes a twice- extended sunset date in Medi- Cal on store and forward services reimbursement for teledermatology and teleopthalmalogy o Eliminates restrictions on reimbursement of services provided via or telephone o Eliminates restrictions on the physical location, such as doctors offices or hospitals, where telehealth services may be provided o Allows California hospitals to use new federal rules to more easily establish medical credentials of telehealth providers. March 1, The Center for Connected Health Policy released a telehealth model statute for California that recommends modernizing state telemedicine and workforce laws, to encourage more robust adoption of telehealth technologies. The model statute report makes 13 recommendations in 4 categories: o Revisions to the state s Telemedicine Development Act of 1996, focusing primarily on financial incentives and informed consent; o Recommendations to incorporate telehealth into state workforce law; o Statutory recommendations to promote interoperability of technology and consumer o education; Recommendations on increasing research and education efforts in telehealth technologies. November Implementation of Telehealth in Community Clinics, California HealthCare Foundation, November 2010 June 7, Telemedicine Struggles in Central Valley Amid Hope, Hardship SB 136: Extends the implementation of provisions that provide fast- to- face contact between a health care provider and a patient shall not be required under the Medi- Cal program to for teleopthalmology and teledermatology by store and forward. Revises the reposting requirement of the department of Health Care Services regarding the type of services provided for store and forward telemedicine as a Medi- Cal benefit. SB 393: Establishes the Patient- Centered Medical Home Act and defines medical home and other terms. SB 764: as amended April 14, 2011 to require the Department of Developmental Services to establish an Autism TeleHealth Program to promote the use of telehealth systems to provide

4 Private insurance coverage, reimbursement, law and regulations: Medicaid law and regulations: Telehealth networks: services for individuals with autism spectrum disorders. SB 946: Amends provisions of existing law relating to public health to include the replacement of terminology telemedicine with telehealth, the reposting of moneys and expenditures of a county emergency medical service fund, the hand- washing and protective gloves and lesion or wounds reporting requirements for food employees, a food substance definition, the HIV reporting form, implementation and reporting requirements of HIPAA, county mental health services under Medi- Cal, and Medi- Cal rate- setting methodology. AB 389: Requires the Department of Corrections and Rehabilitation to require and operational telehealth services program at all adult institutions. Requires the Department to schedule a patient for an evaluation with a distant physician when it is determined to be medically necessary. Allows the Department to use telehealth only when it is in the best interest of the health and safety of the inmate patient. Requires the department to ensure telehealth not be used to supplant civil service physicians and dentists. California law mandates that all health care service plans cover services that can be adequately provided through telemedicine. California Health and Safety Code, Section , lists the standards which health care service plans must meet and requires that the Medi- Cal managed care program plans also cover telemedicine services. Anthem Blue Cross Telemedicine Program The California Welfare and Institutions Code, Section , requires that appropriate telemedicine services be covered and reimbursed under the Medi- Cal program. The Medi- Cal program sets the rates for reimbursement. The Provider Manuals section on the Medi- Cal website has more information regarding the services covered. Medi- Cal recognizes physician consultations (medical & mental health) by an interactive video conference. Payment is on a fee- for- service basis, which is the same as the reimbursement for covered services furnished in the conventional, face- to- face manner. Reimbursement is made at both ends (hub and spoke sites) for telemedicine services. The state uses consultative CPT codes with the modifier "TM" to identify telemedicine services. Medi- Cal also covers teleophthalmology and teledermatology by store and forward, under AB 175 enacted in October The California Telehealth Network program is funded primarily by the Federal Communications Commission s Rural Health Care Pilot Program, and its goal is to increase access to acute, primary and preventative health care by connecting over 300 California health care providers in underserved areas. Reports, studies: The State of Health Information Technology in California, California HealthCare Foundation, May 2011 The State of Health Information Technology in California: Use Among Physicians and Community Clinics, California HealthCare Foundation, May 2011

5 HAWAII Organization and people resources: Recent news, pending action: Pending legislation: Achieving the Promise of Telehealth in California (December 2009) from California HealthCare Foundation School- Based Telehealth: An Innovative Approach to Meet the Health Care Needs of California Children from The Children's Partnership, September 2009 Connecting California: The Impact of the Stimulus Package on Telehealth and Broadband Expansion, Center for Connected Health Policy, April 2009 Telemedicine in California: Progress, Challenges, and Opportunities, from California HealthCare Foundation, July 2008 The State of Technology in Aging Services in California, published March 2008 Meeting the Health Care Needs of California's Children: The Role of Telemedicine, from The Children's Partnership, March 2008 California Telemedicine & ehealth Center is a leading source of expertise and comprehensive knowledge on the development and operation of telemedicine and telehealth programs. CTEC is nationally recognized as one of six federally designated Telehealth Resource Centers around the country. Southern California Telemedicine Learning Center UC Davis Telehealth Program, established 1996, brings together programs in distance education, telehealth training, community outreach and telemedicine specialty care. Center for Connected Health Policy Southern Sierra Telehealth Network Policy Contacts in California Steve Ward CHA Vice President of Rural Health and Hospitals Steve.ward@cha.com Report on a Hawai i Strategic Plan for Telehealth to the 2010 Legislature by the University of Hawai i at Mānoa, John A. Burns School of Medicine SB 285 and HB 326: Provides for telehealth services coverage for Medicaid and QUEST patients using Kona Hospital s medical van program. SB 886 and HB 51: Exempt from licensing requirement to practice medicine in the State and commissioned medical officer of commissioned or civilian behaviors health professional employed by the U.S. Department of Defense, who are credentialed by Tripler Army Medical Center, while providing direct telemedicine support or services to neighbor island beneficiaries. SB 1468: Establishes the patient centered health home pilot program; establishes the Medicaid modernization and innovation council to design and implement the program. Enables sharing of patient and treatment data and collection and reporting at the patient and provider level. Provides that health home should have electronic health record systems that met the federal Meaningful

6 Insurance law and regulations: Medicaid law and regulations: From Telemedicine Reimbursement Report (2003) prepared by the Center for Telemedicine Law: Telehealth networks: use guidelines. HB 1708: Authorizes the emergency examination of a patient by telemedicine for the purposes of emergency hospitalization in a psychiatric facility. Senate Bill 1676 Became Law 4/29/09. Attempts to foster the use of telemedicine by better defining the practice, setting forth the circumstances under which treatment recommendations can be made, clarifies licensure requirements, and reaffirms that insurance covers telemedicine services. Hawaii requires all health, accident, and sickness insurance plans to cover telemedicine services that can appropriately replace a face- to- face contact between the health care provider and patient. However, a health care provider- patient relationship is required before reimbursement for the services. Mutual benefit society plans are located in a different section. Finally, health maintenance organization plans can be found. Despite the requirement for a provider- patient relationship, the laws allow for a relationship to be established by a telehealth mechanism. Hawaii Medicaid (Med- Quest) covers and reimburses for telehealth services that meet the required criteria listed on the Department of Human Services Administrative Rules. Telehalth services are allowed only if the patients are located in either a: o Rural Health Professional Shortage Area (HPSA) as defined by section 332(a)(1)(A) of the Public Health Service Act; o In a county outside of a Metropolitan Statistical Area, as defined by Section 1886(d)(2)(D) o of the Social Security Act; or From an entity that participates in a Federal telemedicine demonstration project that has been approved by the Secretary of Health and Human Services as of December 31, In addition, Med- Quest requires interactive video and audio telecommunications systems and requires the patient to be present and participating in the telehealth consultation, which excludes store- and- forward telemedicine services. The full text of the telehealth section can be found under Title of the Department s Rules, which needs to be updated on the website. "Hawaii is in the process of developing rules for reimbursement of telemedicine. It has received inquiries from telemedicine programs, especially those which provide health services among the various islands. Transportation costs are reimbursed and can be substantial, but the more important factor is ensuring appropriate access to needed services and the ability to ensure follow- up and monitoring. The Hawaii Medicaid program is supportive of reimbursement for telemedicine services, yet must follow an established process for making changes in reimbursement policies. They are considering using Medicare reimbursement policies as a guideline." The ATA Pacific Islands Chapter (PICATA) is an alliance of professionals with an interest in increasing the effectiveness of telemedicine in the Pacific Islands. The ATA Pacific Islands Chapter allows members to collaborate with each other, share ideas and experiences, and interface with

7 NEVADA AMERICAN SAMOA COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS FEDERATED STATES OF MICRONESIA GUAM Organization and people resources: Pending legislation: From Telemedicine Reimbursement Report (2003) prepared by the Center for Telemedicine Law: one another utilizing the existing networks to enhance healthcare. The Chapter is a point of contact, resource, and advocate for the State of Hawaii in telemedicine and telehealth issues. ATA Pacific Islands Chapter (PICATA) SB 273: Revises various provisions governing the practice of osteopathic medicine. Authorizes an osteopathic physician to engage in telemedicine if the osteopathic physician is properly licensed and meets certain other criteria. Authorizes the Board to seek injunctive relief against an osteopathic physician for engaging in telemedicine without a required license. Status: Enacted "Consideration for reimbursement of telemedicine services is not on the policy agenda at this point, in part, because there have not been specific requests for payment. Transportation costs are substantial due to geography of the state, but the agency has not discussed any cost- offsets based on telemedicine." Licensure For physicians, the seo services Telemedicine Act of 2008 (Public Law 29-92, signed July 22, 2008) provides a less onerous process for physicians outside of Guam providing consultation to a Guam licensed physician through the use of telemedicine technology. The core of the Act is the following: A new subitem (8) is hereby added to $ 12202(b) of Chapter 12, Part 1 of Title 10 of the Guam Code Annotated to read as follows: o "(8) A licensed physician who resides outside of Guam within a State, Federal jurisdiction or country is not subject to Guam medical licensure requirements where said licensed physician is providing consultation to a Guam licensed physician through the use of telemedicine technology if:

8 MARSHALL ISLANDS REPUBLIC OF PALAU (i) the non- resident licensed consulting physician operates no clinical practice or office on Guam; (ii) the non- resident licensed consulting physician does not render any final written or otherwise documented final medical opinion concerning the diagnosis or treatment of a patient on Guam directly to the patient; and (iii) the non- resident licensed consulting physician does not render any treatment to any patient on Guam. (iv) The non- resident licensed consulting physician may render care and provide final diagnostic and treatment decisions without an active Guam license if the consultant is to act as a receiving physician for the patient in the consultant's jurisdiction. (v) The non- resident licensed consulting physician may render care and provide diagnostic and treatment recommendations without an active Guam license if the consulting physician acts jointly and directly with the local attending physician of the patient who is the subject of the consultation. (vi) The non- resident licensed consulting physician rendering consultation shall abide by all local and federal laws with regard to patient confidentiality." Source: American Telemedicine Association (2013). State Telemedicine Policy Center. Retrieved from