MISSISSIPPI LEGISLATURE REGULAR SESSION 2016 By: Representative Mims To: Public Health and Human Services HOUSE BILL NO. 1187 1 AN ACT TO AMEND SECTION 73-25-34, MISSISSIPPI CODE OF 1972, 2 TO REVISE THE PROVISIONS THAT DEFINE AND REGULATE THE PRACTICE OF 3 TELEMEDICINE; TO BRING FORWARD SECTION 83-9-351, MISSISSIPPI CODE 4 OF 1972, WHICH RELATES TO TELEMEDICINE, FOR THE PURPOSES OF 5 POSSIBLE AMENDMENT; TO AMEND SECTIONS 41-29-137 AND 83-9-353, 6 MISSISSIPPI CODE OF 1972, WHICH RELATE TO TELEMEDICINE, TO MAKE 7 SOME MINOR NONSUBSTANTIVE CHANGES; AND FOR RELATED PURPOSES. 8 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI: 9 10 11 12 13 14 15 16 17 18 19 SECTION 1. Section 73-25-34, Mississippi Code of 1972, is amended as follows: 73-25-34. * * * (1) Telemedicine is the practice of medicine using electronic communications, information technology or other means, including, but not limited to, secure videoconferencing or interactive audio using asynchronous store and forward transfer technology, between a provider in one (1) location and a patient in another location, with or without an intervening health care provider. Telemedicine is a method of practicing medicine as defined by Section 73-25-33, and is not a separate form of medicine. G3/5 PAGE 1 (RF\KW)
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 (2) The practice of medicine is deemed to occur at the location of the patient. A provider may use telemedicine to offer medical services as part of his or her practice, provided that the provider at all times acts within the applicable standard of care. (3) If a provider offering telemedicine services in his or her practice does not have an established provider-patient relationship with a person seeking those services, the provider may use his or her professional judgment within the standard of care to take appropriate steps to establish a provider-patient relationship by use of appropriate telemedicine technologies, including, but not limited to, the use of interactive audio using asynchronous store and forward technology or videoconferencing. The technological method by which the provider-patient relationship is established shall be within the discretion and medical judgment of the provider, but shall comply with the applicable medical standard of care. (4) Before providing treatment via telemedicine, a provider shall obtain and document a patient's relevant clinical history and current symptoms to establish the diagnosis and identify underlying conditions and contraindications to the treatment recommended. After establishment of the provider-patient relationship, the provider may prescribe medications using telemedicine services within the scope of the applicable standard of care; however, the prescription drug shall not be a controlled PAGE 2 (RF\KW)
44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 substance unless prescribed in compliance with 21 USC Section 802(54)(A). (5) A patient's informed consent for the use of telemedicine services shall be obtained as required by any applicable law. (6) Any provider offering telemedicine services shall refer a patient to an appropriate medical facility or provider for in-person treatment if medically indicated. (7) Any provider offering telemedicine services as part of his or her practice shall comply with any applicable state and federal laws, rules and regulations, including the Health Insurance Portability and Accountability Act (HIPAA), P.L. 104-191 (1996), and the Health Information Technology for Economic and Clinical Health Act (HITECH), P.L. 111-115 (2009). Such records shall be accessible to other providers and to the patient in accordance with applicable laws, rules and regulations. SECTION 2. Section 41-29-137, Mississippi Code of 1972, is amended as follows: 41-29-137. (a) (1) Except when dispensed directly by a practitioner, other than a pharmacy, to an ultimate user, no controlled substance in Schedule II, as set out in Section 41-29-115, may be dispensed without the written valid prescription of a practitioner. A practitioner shall keep a record of all controlled substances in Schedule I, II and III administered, dispensed or professionally used by him otherwise than by prescription. PAGE 3 (RF\KW)
69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 (2) In emergency situations, as defined by rule of the State Board of Pharmacy, Schedule II drugs may be dispensed upon the oral valid prescription of a practitioner, reduced promptly to writing and filed by the pharmacy. Prescriptions shall be retained in conformity with the requirements of Section 41-29-133. No prescription for a Schedule II substance may be refilled unless renewed by prescription issued by a licensed medical doctor. (b) Except when dispensed directly by a practitioner, other than a pharmacy, to an ultimate user, a controlled substance included in Schedule III or IV, as set out in Sections 41-29-117 and 41-29-119, shall not be dispensed without a written or oral valid prescription of a practitioner. The prescription shall not be filled or refilled more than six (6) months after the date thereof or be refilled more than five (5) times, unless renewed by the practitioner. (c) A controlled substance included in Schedule V, as set out in Section 41-29-121, shall not be distributed or dispensed other than for a medical purpose. (d) An optometrist certified to prescribe and use therapeutic pharmaceutical agents under Sections 73-19-153 through 73-19-165 shall be authorized to prescribe oral analgesic controlled substances in Schedule IV or V, as pertains to treatment and management of eye disease by written prescription only. PAGE 4 (RF\KW)
93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 (e) Administration by injection of any pharmaceutical product authorized in this section is expressly prohibited except when dispensed directly by a practitioner other than a pharmacy. (f) (1) For the purposes of this article, Title 73, Chapter 21, and Title 73, Chapter 25, Mississippi Code of 1972, as it pertains to prescriptions for controlled substances, a "valid prescription" means a prescription that is issued for a legitimate medical purpose in the usual course of professional practice by: (A) A practitioner who has conducted at least one (1) in-person medical evaluation of the patient; or (B) A covering practitioner. (2) (A) "In-person medical evaluation" means a medical evaluation that is conducted with the patient in the physical presence of the practitioner, without regard to whether portions of the evaluation are conducted by other health professionals. (B) "Covering practitioner" means a practitioner who conducts a medical evaluation other than an in-person medical evaluation at the request of a practitioner who has conducted at least one (1) in-person medical evaluation of the patient or an evaluation of the patient through the practice of telemedicine within the previous twenty-four (24) months and who is temporarily unavailable to conduct the evaluation of the patient. (3) A prescription for a controlled substance based solely on a consumer's completion of an online medical questionnaire is not a valid prescription. PAGE 5 (RF\KW)
118 (4) Nothing in this subsection ( * * *f) shall apply 119 to: 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 (A) A prescription issued by a practitioner engaged in the practice of telemedicine as authorized under state or federal law; or (B) The dispensing or selling of a controlled substance pursuant to practices as determined by the United States Attorney General by regulation. SECTION 3. Section 83-9-351, Mississippi Code of 1972, is brought forward as follows: 83-9-351. (1) As used in this section: (a) "Employee benefit plan" means any plan, fund or program established or maintained by an employer or by an employee organization, or both, to the extent that such plan, fund or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, medical, surgical, hospital care or other benefits. (b) "Health insurance plan" means any health insurance policy or health benefit plan offered by a health insurer, and includes the State and School Employees Health Insurance Plan and any other public health care assistance program offered or administered by the state or any political subdivision or instrumentality of the state. The term does not include policies PAGE 6 (RF\KW)
142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 or plans providing coverage for specified disease or other limited benefit coverage. (c) "Health insurer" means any health insurance company, nonprofit hospital and medical service corporation, health maintenance organization, preferred provider organization, managed care organization, pharmacy benefit manager, and, to the extent permitted under federal law, any administrator of an insured, self-insured or publicly funded health care benefit plan offered by public and private entities, and other parties that are by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service. (d) "Telemedicine" means the delivery of health care services such as diagnosis, consultation, or treatment through the use of interactive audio, video, or other electronic media. Telemedicine must be "real-time" consultation, and it does not include the use of audio-only telephone, e-mail, or facsimile. (2) All health insurance and employee benefit plans in this state must provide coverage for telemedicine services to the same extent that the services would be covered if they were provided through in-person consultation. (3) A health insurance or employee benefit plan may charge a deductible, co-payment, or coinsurance for a health care service provided through telemedicine so long as it does not exceed the deductible, co-payment, or coinsurance applicable to an in-person consultation. PAGE 7 (RF\KW)
167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 (4) A health insurance or employee benefit plan may limit coverage to health care providers in a telemedicine network approved by the plan. (5) Nothing in this section shall be construed to prohibit a health insurance or employee benefit plan from providing coverage for only those services that are medically necessary, subject to the terms and conditions of the covered person's policy. (6) In a claim for the services provided, the appropriate procedure code for the covered services shall be included with the appropriate modifier indicating interactive communication was used. (7) The originating site is eligible to receive a facility fee, but facility fees are not payable to the distant site. SECTION 4. Section 83-9-353, Mississippi Code of 1972, is brought forward as follows: 83-9-353. (1) As used in this section: (a) "Employee benefit plan" means any plan, fund or program established or maintained by an employer or by an employee organization, or both, to the extent that such plan, fund or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, medical, surgical, hospital care or other benefits. (b) "Health insurance plan" means any health insurance policy or health benefit plan offered by a health insurer, and PAGE 8 (RF\KW)
192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 includes the State and School Employees Health Insurance Plan and any other public health care assistance program offered or administered by the state or any political subdivision or instrumentality of the state. The term does not include policies or plans providing coverage for specified disease or other limited benefit coverage. (c) "Health insurer" means any health insurance company, nonprofit hospital and medical service corporation, health maintenance organization, preferred provider organization, managed care organization, pharmacy benefit manager, and, to the extent permitted under federal law, any administrator of an insured, self-insured or publicly funded health care benefit plan offered by public and private entities, and other parties that are by statute, contract, or agreement, legally responsible for payment of a claim for a health care item or service. (d) "Store-and-forward telemedicine services" means the use of asynchronous computer based communication between a patient and a consulting provider or a referring health care provider and a medical specialist at a distant site for the purpose of diagnostic and therapeutic assistance in the care of patients who otherwise have no access to specialty care. Store-and-forward telemedicine services involve the transferring of medical data from one (1) site to another through the use of a camera or similar device that records (stores) an image that is sent PAGE 9 (RF\KW)
216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 (forwarded) via telecommunication to another site for consultation. (e) "Remote patient monitoring services" means the delivery of home health services using telecommunications technology to enhance the delivery of home health care, including: (i) Monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry and other condition-specific data, such as blood glucose; (ii) Medication adherence monitoring; and (iii) Interactive video conferencing with or without digital image upload as needed. (f) "Mediation adherence management services" means the monitoring of a patient's conformance with the clinician's medication plan with respect to timing, dosing and frequency of medication-taking through electronic transmission of data in a home telemonitoring program. (2) Store-and-forward telemedicine services allow a health care provider trained and licensed in his or her given specialty to review forwarded images and patient history in order to provide diagnostic and therapeutic assistance in the care of the patient without the patient being present in real time. Treatment recommendations made via electronic means shall be held to the same standards of appropriate practice as those in traditional provider-patient setting. PAGE 10 (RF\KW)
240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 (3) Any patient receiving medical care by store-and-forward telemedicine services shall be notified of the right to receive interactive communication with the distant specialist health care provider and shall receive an interactive communication with the distant specialist upon request. If requested, communication with the distant specialist may occur at the time of the consultation or within thirty (30) days of the patient's notification of the request of the consultation. Telemedicine networks unable to offer the interactive consultation shall not be reimbursed for store-and-forward telemedicine services. (4) Remote patient monitoring services aim to allow more people to remain at home or in other residential settings and to improve the quality and cost of their care, including prevention of more costly care. Remote patient monitoring services via telehealth aim to coordinate primary, acute, behavioral and long-term social service needs for high-need, high-cost patients. Specific patient criteria must be met in order for reimbursement to occur. (5) Qualifying patients for remote patient monitoring services must meet all the following criteria: (a) Be diagnosed, in the last eighteen (18) months, with one or more chronic conditions, as defined by the Centers for Medicare and Medicaid Services (CMS), which include, but are not limited to, sickle cell, mental health, asthma, diabetes, and heart disease; PAGE 11 (RF\KW)
265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 (b) Have a recent history of costly service use due to one or more chronic conditions as evidenced by two (2) or more hospitalizations, including emergency room visits, in the last twelve (12) months; and (c) The patient's health care provider recommends disease management services via remote patient monitoring. (6) A remote patient monitoring prior authorization request form must be submitted to request telemonitoring services. The request must include the following: (a) An order for home telemonitoring services, signed and dated by the prescribing physician; (b) A plan of care, signed and dated by the prescribing physician, that includes telemonitoring transmission frequency and duration of monitoring requested; (c) The client's diagnosis and risk factors that qualify the client for home telemonitoring services; (d) Attestation that the client is sufficiently cognitively intact and able to operate the equipment or has a willing and able person to assist in completing electronic transmission of data; and (e) Attestation that the client is not receiving duplicative services via disease management services. (7) The entity that will provide the remote monitoring must be a Mississippi-based entity and have protocols in place to address all of the following: PAGE 12 (RF\KW)
290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 (a) Authentication and authorization of users; (b) A mechanism for monitoring, tracking and responding to changes in a client's clinical condition; (c) A standard of acceptable and unacceptable parameters for client's clinical parameters, which can be adjusted based on the client's condition; (d) How monitoring staff will respond to abnormal parameters for client's vital signs, symptoms and/or lab results; (e) The monitoring, tracking and responding to changes in client's clinical condition; (f) The process for notifying the prescribing physician for significant changes in the client's clinical signs and symptoms; (g) The prevention of unauthorized access to the system or information; (h) System security, including the integrity of information that is collected, program integrity and system integrity; (i) Information storage, maintenance and transmission; (j) Synchronization and verification of patient profile data; and (k) Notification of the client's discharge from remote patient monitoring services or the de-installation of the remote patient monitoring unit. (8) The telemonitoring equipment must: PAGE 13 (RF\KW)
315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 (a) Be capable of monitoring any data parameters in the plan of care; and (b) Be a FDA Class II hospital-grade medical device. (9) Monitoring of the client's data shall not be duplicated by another provider. (10) To receive payment for the delivery of remote patient monitoring services via telehealth, the service must involve: (a) An assessment, problem identification, and evaluation that includes: (i) Assessment and monitoring of clinical data including, but not limited to, appropriate vital signs, pain levels and other biometric measures specified in the plan of care, and also includes assessment of response to previous changes in the plan of care; and (ii) Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care. (b) Implementation of a management plan through one or more of the following: (i) Teaching regarding medication management as appropriate based on the telemedicine findings for that encounter; (ii) Teaching regarding other interventions as appropriate to both the patient and the caregiver; PAGE 14 (RF\KW)
338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 (iii) Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services; (iv) Coordination of care with the ordering health care provider regarding telemedicine findings; (v) Coordination and referral to other medical providers as needed; and (vi) Referral for an in-person visit or the emergency room as needed. (11) The telemedicine equipment and network used for remote patient monitoring services should meet the following requirements: (a) Comply with applicable standards of the United States Food and Drug Administration; (b) Telehealth equipment be maintained in good repair and free from safety hazards; (c) Telehealth equipment be new or sanitized before installation in the patient's home setting; (d) Accommodate non-english language options; and (e) Have 24/7 technical and clinical support services available for the patient user. (12) All health insurance and employee benefit plans in this state must provide coverage and reimbursement for the asynchronous telemedicine services of store-and-forward telemedicine services and remote patient monitoring services based on the criteria set PAGE 15 (RF\KW)
363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 out in this section. Store-and-forward telemedicine services shall be reimbursed to the same extent that the services would be covered if they were provided through in-person consultation. (13) Remote patient monitoring services shall include reimbursement for a daily monitoring rate at a minimum of Ten Dollars ($10.00) per day each month and Sixteen Dollars ($16.00) per day when medication adherence management services are included, not to exceed thirty-one (31) days per month. These reimbursement rates are only eligible to Mississippi-based telehealth programs affiliated with a Mississippi health care facility. (14) A one-time telehealth installation/training fee for remote patient monitoring services will also be reimbursed at a minimum rate of Fifty Dollars ($50.00) per patient, with a maximum of two (2) installation/training fees/calendar year. These reimbursement rates are only eligible to Mississippi-based telehealth programs affiliated with a Mississippi health care facility. (15) No geographic restrictions shall be placed on the delivery of telemedicine services in the home setting other than requiring the patient reside within the State of Mississippi. (16) Health care providers seeking reimbursement for store-and-forward telemedicine services must be licensed Mississippi providers that are affiliated with an established Mississippi health care facility in order to qualify for PAGE 16 (RF\KW)
388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 reimbursement of telemedicine services in the state. If a service is not available in Mississippi, then a health insurance or employee benefit plan may decide to allow a non-mississippi-based provider who is licensed to practice in Mississippi reimbursement for those services. (17) A health insurance or employee benefit plan may charge a deductible, co-payment, or coinsurance for a health care service provided through store-and-forward telemedicine services or remote patient monitoring services so long as it does not exceed the deductible, co-payment, or coinsurance applicable to an in-person consultation. (18) A health insurance or employee benefit plan may limit coverage to health care providers in a telemedicine network approved by the plan. (19) Nothing in this section shall be construed to prohibit a health insurance or employee benefit plan from providing coverage for only those services that are medically necessary, subject to the terms and conditions of the covered person's policy. (20) In a claim for the services provided, the appropriate procedure code for the covered service shall be included with the appropriate modifier indicating telemedicine services were used. A "GQ" modifier is required for asynchronous telemedicine services such as store-and-forward and remote patient monitoring. PAGE 17 (RF\KW)
412 413 414 415 (21) The originating site is eligible to receive a facility fee, but facility fees are not payable to the distant site. SECTION 5. This act shall take effect and be in force from and after July 1, 2016. ST: Telemedicine; revise provisions defining PAGE 18 (RF\KW) and regulating the practice of.