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Maine Finalizes New MaineCare Telehealth and Telemonitoring Rules


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Maine Finalizes New MaineCare Telehealth and Telemonitoring Rules

David Schneider

By Dave Schneider

Effective April 16, 2016, the Department of Health and Human Services adopted new telehealth and telemonitoring rules that make it easier than ever for health care providers to be reimbursed by MaineCare for telehealth services. Health care providers should evaluate whether telehealth services will help them reach new or existing patients and improve outcomes.

According to the most recent census, Maine is the most rural state in the country. In rural areas, residents may be hours away from physicians and specialists. Even in Maine’s most metropolitan areas, residents may lack 24/7 access to certain specialists, such as neurologists specializing in strokes. The implementation of telehealth services in Maine may increase access to health care services and improve the quality of care to all Mainers.

Whether Mainers will be able to take advantage of telehealth services is preconditioned on a number of factors (broadband internet access in rural areas, for example). One major factor is whether, and under what circumstances, health care providers will be reimbursed for telehealth services.

Unfortunately, many providers found MaineCare’s prior rules for the reimbursement of telehealth services too narrow, complex and administratively burdensome to justify the investment costs. For example, patients were required to show a “compelling benefit” to receive telehealth services, which typically meant there was a material geographic distance between the patient and the health care provider. In addition, providers were required to apply for DHHS approval prior to providing and getting reimbursed for telehealth services.

Telehealth Services

Under the new telehealth rules, telehealth services mean the use of information technology by a health care provider to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment. Telehealth Services may be either through (1) real time, interactive visual and audio telecommunications (e.g., Skype-like service) or, if the telecommunications is (1) is not available, (2) telephone communication.

The key for patient eligibility for telehealth services is that the service must be medically appropriate as determined by the health care provider. Diabetes management, stroke evaluation and mental health services may be medically appropriate for telehealth, whereas annual physicals may not.   The provider is eligible to provide telehealth services as long as the provider is acting within the scope of his or her license, enrolled as a MaineCare provider, and otherwise eligible to deliver the underlying service.

Assuming the eligibility requirements above are satisfied, telehealth services will most likely be reimbursed by MaineCare if:

  • The services is medically necessary;
  • The services is not specifically excluded from coverage under the Maine Care rules; and
  • The telehealth service is of comparable quality to what it would be if it were delivered in person.

Prior authorization is required for telehealth services only if prior authorization is required for the underlying service. A face to face encounter prior to telehealth is not required.

Providers who wish to provide telehealth services will most likely have to make investments in telecommunication technology and equipment that protects the privacy and security of protected health information under HIPAA and Maine law. Prior to providing telehealth services, providers must provide certain disclosures to the patient, such as, among others, a description of the telehealth services and what to expect and an explanation that use of telehealth services is voluntary, and obtain the patient’s signed informed consent for the provision of telehealth services.

Assuming the above requirements, providers will typically bill for telehealth services in the same way that they bill for in-person services. For example, if the patient is receiving telehealth services at a health care facility (i.e., the patient site), the health care provider at another site (i.e., the provider site) will receive the MaineCare fee and the patient site may be eligible for a facility fee. The final rules also allow the possibility that a patient may receive telehealth services in his or her residence as long as he or she has the proper equipment.

Telemonitoring Services

Under the new telemonitoring rules, telemonitoring services mean the use of information technology to remotely monitor a patient’s health status through the use of clinical data while the patient remains in the residential setting. Telemonitoring may or may not take place in real time. For example, a provider may prescribe a patient to use or wear a device that tracks a patient’s blood pressure, heart rate, blood glucose level, or oxygen levels. If the data indicates an adverse health event or status, a health care provider may call the patient or otherwise intervene to address the issue.

To be eligible for telemonitoring services, a patient must:

  • Be eligible for Home Health Services under MaineCare rules;
  • Have a current diagnosis of a health condition requiring monitoring of clinical data at a minimum of five times per week, for at least one week;
  • Have had two or more hospitalizations or emergency room visits related to their diagnosis in the past calendar year; OR have continuously received telemonitoring services during the past calendar year and have a continuing need for such services, as documented by an annual note from a health care provider;
  • Have telemonitoring services included in the patient’s Plan of Care.
  • Reside in a setting suitable to support telemonitoring equipment; and
  • Have the physical and cognitive capacity to effectively utilize the telemonitoring equipment or have a caregiver willing and able to assist with the equipment.

It is important to note a notation from a health care provider, dated prior to the beginning of service delivery, must be included in the patient’s Plan of Care. If telemonitoring services begin prior to the date recorded in the provider’s note, services delivered shall not be reimbursed.

To be eligible for reimbursement for telemonitoring services, a health care provider must be a certified Home Health Agency under MaineCare and the Provider ordering the service must be a provider with prescribing privileges (physician, nurse practitioner or physician’s assistant).

Assuming the eligibility requirements above are satisfied, telemonitoring services will most likely be reimbursed by MaineCare if:

  • Telemonitoring services are medically necessary for the patient.
  • The patient is cognitively and physically capable of operating the telemonitoring equipment or assurance that the patient has a caregiver willing and able to assist with the equipment;
  • The patient’s residence to determine suitability for telemonitoring services.
  • The patient is educated and trained on the use, maintenance and safety of the telemonitoring equipment.
  • The patient’s health data is monitored by a registered nurse, nurse practitioner, physician’s assistant or physician, and such person will respond to appropriate clinical interventions.
  • Telephonic services with the patient are provided at least monthly;
  • The equipment is maintained; and
  • The equipment is removed or disconnected from the patient’s home when telemonitoring services are no longer necessary or authorized.