Maine Regulations
Department of Health and Human Services/Office of MaineCare Services
Department of Health and Human Services/Office of MaineCare Services 2020-03-19
PUBLICATION DATE: 03/19/2020
ACTION DATE: 03/18/2020
EFFECTIVE DATE: 03/17/2020
EXPIRATION DATE: 06/15/2020
PUBLICATION TYPE: Agency
DOCUMENT NUMBER: 2020-055
REGISTER SOURCE: Weekly Newspaper Notices 2020-03-18
PUBLICATION DATE: 03/18/2020
ACTION DATE: 03/18/2020
EFFECTIVE DATE: 03/17/2020
EXPIRATION DATE: 06/15/2020
PUBLICATION TYPE: Centralized Repository
DOCUMENT NUMBER: 2020-055

10-144 Chapter 101

MAINECARE BENEFITS MANUAL

CHAPTER I

SECTION 4 TELEHEALTH Established 4/16/16 EMERGENCY RULE: 3/16/2020

TABLE OF CONTENTS

Page

4.01 DEFINITIONS ..... 1

4.01-1 Department ..... 1

4.01-2 Health Care Provider ..... 1

4.01-3 Home Health Agency ..... 1

4.01-4 MaineCare Covered Services ..... 1

4.01-5 Member ..... 1

4.01-6 Originating Facility Fee ..... 1

4.01-7 Originating (Member) Site ..... 1

4.01-8 Receiving (Provider) Site ..... 1

4.01-9 Interactive Telehealth Services ..... 2

4.01-10 Telehealth Services ..... 2

4.01-11 Telemonitoring Services ..... 2

4.01-12 Telephonic Services ..... 2

4.02 MEMBER ELIGIBILITY

4.02-1 Interactive Telehealth Services ..... 2

4.02-2 Telemonitoring Services ..... 2

4.03 PROVIDER REQUIREMENTS ..... 3

4.03-1 Interactive Telehealth Services ..... 3

4.03-2 Telemonitoring Services ..... 3

4.04 COVERED SERVICES ..... 4

4.04-1 Interactive Telehealth and Services ..... 4

4.04-2 Telephonic Services ..... 4

4.04-3 Telemonitoring Services ..... 4

4.05 NON-COVERED SERVICES AND LIMITATIONS ..... 5

4.06 POLICIES AND PROCEDURES ..... 7

4.06-1 Telehealth Equipment and Technology ..... 7

4.06-2 Member Choice and Education ..... 8

4.06-3 Required Documentation ..... 9

4.07 REIMBURSEMENT ..... 9

4.07-1 General Conditions ..... 9

4.07-2 Interactive Telehealth Services ..... 9

4.07-3 Telemonitoring Services ..... 11

4.07-4 Reimbursement Rates ..... 12

4.01 DEFINITIONS

4.01-1 Department

The Maine Department of Health and Human Services.

4.01-2 Health Care Provider

Individual or entity licensed or certified under the laws of the state of Maine to provide medical, behavioral health, and related services to MaineCare Members. Health Care Providers must be enrolled as MaineCare Providers in order to be reimbursed for services.

4.01-3 Home Health Agency (HHA)

A voluntary, public or private organization or a part of such organization, that is certified under Title XVIII of the Social Security Act for reimbursement for the delivery of home health services, pursuant to Ch. II Section 40 of the MaineCare Benefits Manual ( "Home Health Services" ).

4.01-4 MaineCare Covered Services

Services covered and reimbursed through MaineCare as provided in the MaineCare Benefits Manual.

4.01-5 Member

Any person certified as eligible for services under the MaineCare program.

4.01-6 Originating Facility Fee

Fee paid to the Health Care Provider at the Originating (Member) Site for the service of coordinating Telehealth Services.

4.01-7 Originating (Member) Site

The site at which the Member is located at the time of Telehealth Service delivery. The Originating (Member) Site will usually be a Health Care Provider's office, but it may also be the Member's residence, provided the proper equipment is available for Telehealth Services.

4.01-8 Receiving (Provider) Site

The site at which the Health Care Provider delivering the service is located at the time of service delivery.

4.01 DEFINITIONS (cont.)

4.01-9 Interactive Telehealth Services

Real time, interactive visual and audio telecommunications whereby a Member and a Health Care Provider interact remotely through the use of technology.

4.01-10 Telehealth Services

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 Telephonic or Interactive (combined video/audio).

4.01-11 Telemonitoring Services

The use of information technology to remotely monitor a Member's health status through the use of clinical data while the Member remains in the residential setting. Telemonitoring may or may not take place in real time.

4.01-12 Telephonic Services

The use of telephone communication by a Health Care Provider to deliver clinical services at a distance for the purpose of diagnosis, disease monitoring, or treatment.

4.02 MEMBER ELIGIBILITY

4.02-1 Telehealth Services

If a Member is eligible for the underlying Covered Service to be delivered, and if delivery of the Covered Service via Telehealth is medically appropriate, as determined by the Health Care Provider, the Member is eligible for Telehealth Services.

4.02-2 Telemonitoring Services

In order to be eligible for Telemonitoring Services, a Member must:

A. Be eligible for Home Health Services under Chapter II, Section 40, "Home Health Services" ;

B. 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;

C. Have documentation in the patient's medical record that the patient is at risk of hospitalization or admission to an emergency room;

MEMBER ELIGIBILITY (cont.)

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;

D. Have Telemonitoring Services included in the Member's Plan of Care. A notation from a Health Care Provider, dated prior to the beginning of service delivery, must be included in the Member's Plan of Care. If Telemonitoring Services begin prior to the date recorded in the Provider's note, services delivered shall not be reimbursed.

E. Reside in a setting suitable to support telemonitoring equipment; and

F. Have the physical and cognitive capacity to effectively utilize the telemonitoring equipment or have a caregiver willing and able to assist with the equipment.

4.03 PROVIDER REQUIREMENTS

4.03-1 Telehealth Services

In order to be eligible for reimbursement for Telehealth Services, a Health Care Provider must be:

A. Acting within the scope of his or her license;

B. Enrolled as a MaineCare provider; and

C. Otherwise eligible to deliver the underlying Covered Service according to the requirements of the applicable section of the MaineCare Benefits Manual.

4.03-2 Telemonitoring Services

In order to be eligible for reimbursement for Telemonitoring Services, a Healthcare Provider must be a certified Home Health Agency pursuant to the MaineCare Benefits Manual Ch. II Section 40 ( "Home Health Services" ). Compliance with all applicable requirements listed in Chapter II, Section 40, "Home Health Services" is required.

The Provider ordering the service must be a Provider with prescribing privileges (physician, nurse practitioner or physician's assistant).

4.03 PROVIDER REQUIREMENTS (cont.)

Health Care Providers must document that they have had a face-to-face encounter with the member before a physician may certify eligibility for services under the home health benefit. This may be accomplished through interactive telehealth services, but not by telephone or e-mail.

4.04 COVERED SERVICES

4.04-1 Interactive Telehealth Services

With the exception of those services described in Section 4.05 of this policy (Non- Covered Services and Limitations), any medically necessary MaineCare Covered Service may be delivered via Interactive Telehealth Services, provided the following requirements are met:

1. The Member is otherwise eligible for the Covered Service, as described in the appropriate section of the MaineCare Benefits Manual; and

2. The Covered Service delivered by Interactive Telehealth Services is of comparable quality to what it would be were it delivered in person.

Prior authorization is required for Interactive Telehealth Services only if prior authorization is required for the underlying Covered Service. In these cases, the prior authorization is the usual prior authorization for the underlying Covered Service, rather than prior authorization of the mode of delivery. A face to face encounter prior to telehealth is not required.

4.04-2 Telephonic Services may be reimbursed if the following conditions are met:

1. Interactive Telehealth Services are unavailable; and

2. A Telephonic Service is medically appropriate for the underlying Covered Service .

4.04-3 Telemonitoring Services

A. Telemonitoring Services are intended to collect a Member's health related data, such as pulse and blood pressure readings, that assist Health Care Providers in monitoring and assessing the Member's medical conditions. Telemonitoring Services include:

1. Evaluation of the Member to determine if Telemonitoring Services are medically necessary for the Member. The Home Health Agency must assure that a Health Care Provider's order or note, demonstrating the necessity of telemonitoring services, is included in the Member's Plan of Care.

4.04 COVERED SERVICES (cont.)

2. Evaluation of the Member to assure that the Member is cognitively and physically capable of operating the Telemonitoring equipment or assurance that the Member has a caregiver willing and able to assist with the equipment;

3. Evaluation of the Member's residence to determine suitability for Telemonitoring Services. If the residence appears unable to support Telemonitoring Services, the Home Health Agency may not implement Telemonitoring Services in the Member's residence unless necessary adaptations are made. Adaptations are not reimbursable by MaineCare;

4. Education and training of the Member and/or caregiver on the use, maintenance and safety of the Telemonitoring equipment, the cost of which is included in the monthly flat rate paid by MaineCare to the Home Health Agency;

5. Remote monitoring and tracking of the Member's health data by a registered nurse, nurse practitioner, physician's assistant or physician, and response with appropriate clinical interventions. The Home Health Agency and Health Care Provider utilizing the data shall maintain a written protocol that indicates the manner in which data shall be shared in the event of emergencies or other medical complications;

6. At least monthly Telephonic Services with the Member;

7. Maintenance of equipment, the cost of which is included in the monthly flat rate paid by MaineCare to the Home Health Agency.

8. Removal/disconnection of equipment from the Member's home when Telemonitoring Services are no longer necessary or authorize

4.05 NON-COVERED SERVICES AND LIMITATIONS

A. Services not otherwise covered by MaineCare are not covered when delivered via Telehealth Services.

B. Services covered under other MaineCare Sections but specifically excluded from Telehealth coverage include, but are not limited to the following:

1. Medical Equipment, Supplies, Orthotics and Prosthetics provided by DME (Durable Medical Equipment) suppliers and pharmacies under Chapter II, Section 60 of the MCBM, "Medical Supplies and Durable Medical Equipment" ;

4.05 NON-COVERED SERVICES AND LIMITATIONS (cont.)

2. Personal care aide (PCA) services provided under Chapter II, Section 96 of the MCBM, "Private Duty Nursing and Personal Care Services" ;

3. Assistive Technology services provided under the following Sections of the MaineCare Benefits Manual:

a. Chapter II, Section 18, "Home and Community Based Services for Adults with Brain Injury" ;

b. Chapter II, Section 19, "Home and Community Benefits for the Elderly and for Adults with Disabilities" ;

c. Chapter II, Section 20, "Home and Community-Based Services for Adults with Other Related Conditions" ;

d. Chapter II, Section 21, "Home and Community Benefits for Members with Intellectual Disabilities or Autistic Disorder" ;

d. Chapter II, Section 29, "Support Services for Adults with Intellectual Disabilities or Autistic Disorder" ; and

e. Chapter II, Section 32, "Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders" .

4. Non - Emergency Medical Transportation services provided under Chapter II, Section 113 of the MBM, "Non-Emergency Transportation (NET) Services" ;

5. Ambulance services provided under Chapter II, Section 5 of the MBM, "Ambulance Services" ;

6. Services that require direct physical contact with a Member by a Health Care Provider and that cannot be delegated to another Health Care Provider at the site where the Member is located are not covered;

7. Any service medically inappropriate for delivery through Telehealth Services.

C. Reimbursement will not be provided for communications between Health Care Providers when the Member is not present at the Originating (Member) Site.

D. Reimbursement will not be provided for communications solely between Health Care Providers and Members when such communications would not otherwise be billable.

E. The Originating Facility Fee may only be billed in the event that the Originating (Member) Site is in a Healthcare Provider's facility.

F. The Originating Site Fee may be paid only to a Health Care Provider.

4.06 POLICIES AND PROCEDURES

4.06-1 Telehealth Equipment and Technology

A. Health Care Providers must ensure that the telecommunication technology and equipment used at the Receiving (Provider) Site and the Originating (Member) Site is sufficient to allow the Health Care Provider to appropriately provide the Member with services billed to MaineCare.

B. Security

1. Providers must comply with all federal, state and local regulations that apply to its business including but not limited to the Electronic Communications Privacy Act of 1986. Any services that use networked services must comply with HIPAA requirements.

2. A Telehealth Service shall be performed on a secure telecommunications line or utilize a method of encryption adequate to protect the confidentiality and integrity of the Telehealth Service information in accordance with State and Federal laws, rules and regulations.

3. Both the Originating (Member) Site and the Receiving (Provider) Site shall use authentication and identification to ensure the confidentiality of a Telehealth Service.

4. A Health Care Provider shall implement confidentiality protocols that include but are not limited to:

a. Identifying personnel who have access to a telehealth transmission;

b. Usage of unique passwords or identifiers for each employee or person with access to a telehealth transmission; and

c. Preventing unauthorized access to a telehealth transmission.

5. A Health Care Provider's protocols and guidelines shall be available for inspection by the Department upon request.

C. Services may not be delivered through electronic mail.

4.06 POLICIES AND PROCEDURES (cont.)

D. The Department will not separately reimburse for any charge related to the purchase, installation, or maintenance of telehealth equipment or technology, nor any transmission fees, nor may a Member be billed for such.

4.06-2 Member Choice and Education

A. Before providing a Telehealth Service to a Member, a Health Care Provider shall ensure that the following written information is provided to the Member or authorized representative in a format and manner that the Member is able to understand:

1. A description of the Telehealth Services and what to expect;

2. An explanation that use of Telehealth Services is voluntary. The Member shall have the option to refuse the Telehealth Services at any time without affecting the right to future care or treatment and without risking the loss or withdrawal of a MaineCare benefit to which the Member is entitled;

3. An explanation that MaineCare will pay for the Member's transportation to MaineCare Covered Services pursuant to Section 113 of the MaineCare Benefits Manual ( "Non-Emergency Transportation Services" );

4. An explanation that the Member shall have access to all information resulting from the Telehealth Service as provided by law;

5. The dissemination, storage, or retention of an identifiable Member image or other information from the Telehealth Service shall comply with federal laws and regulations and Maine state laws and regulations requiring individual health care data confidentiality;

6. The Member shall have the right to be informed of the parties who will be present at the Receiving (Provider) Site and the Originating (Member) Site during the Telehealth Service and shall have the right to exclude anyone from either site; and

7. The Member shall have the right to object to the videotaping or other recording of a Telehealth Consultation.

4.06 POLICIES AND PROCEDURES (cont.)

B. Prior to the provision of any Telehealth Service, the Health Care Provider shall document that it has provided the educational information (set forth above) to the Member or authorized representative and obtain the Member's written informed consent to the receipt of Telehealth Services. A copy of the signed informed consent shall be retained in the Member's medical record and provided to the Member or the Member's legally-authorized representative upon request.

4.06-3 Required Documentation

A. Providers must maintain documentation at the Originating (Member) Site and the Receiving (Provider) Site to substantiate the services provided. This requirement does not apply when the Originating Site is the Member's residence.

B. Documentation must indicate the MaineCare Covered Services that were rendered via Telehealth Services, the location of the Originating (Member) Site and the Receiving (Provider) Sites.

4.07 REIMBURSEMENT

4.07-1 General Conditions

A. Services are to be billed in accordance with applicable sections of the MaineCare Benefits Manual. Providers must submit claims in accordance with Department billing instructions. The same procedure codes and rates apply to the underlying Covered Service as if those Services were delivered face to face.

B. Telehealth Services are subject to all conditions and restrictions described in Chapter I Section 1 of the MaineCare Benefits Manual (MBM).

C. Telehealth Services are subject to co-payment requirements for the underlying Covered Service, if applicable, as established in Chapter I, Section 1 of the MCBM. However, there shall be no separate co-payment for telehealth services.

4.07-2 Interactive Telehealth Services

A. Receiving (Provider) Site

1. Except as described below, only the Health Care Provider at the Receiving (Provider) Site may receive payment for Telehealth Services.

4.07 REIMBURSEMENT (cont.)

2. When billing for Interactive Telehealth Services, Health Care Providers at the Receiving (Provider) Site should bill for the underlying Covered Service using the same claims they would if it were delivered face to face, and should add the GT modifier.

3. When billing for Telephonic Services, Health Care Providers at the Receiving (Provider) Site should use E&M codes 99446 through 99449. The GT modifier should not be used.

4. No separate transmission fees will be paid for Interactive Telehealth Services. The only services that may be billed by the Health Care Provider at the Receiving (Provider) Site are the fees for the underlying Covered Service delivered plus the GT modifier or the 99445 - 99449 codes.

B. Originating (Member) Site

1. If the Health Care Provider at the Originating (Member) Site is making a room and telecommunications equipment available but is not providing clinical services, the Health Care Provider at the Originating (Member) Site may bill MaineCare for an Originating Facility Fee using code Q3014 for the service of coordinating the Telehealth Service. An Originating Facility Fee may not be billed for a Telephonic Service.

2. The Health Care Provider at the Originating (Member) Site may not bill for assisting the Health Care Provider at the Receiving (Provider) Site with an examination.

3. No separate transmission fees will be paid for Interactive Telehealth Services.

4. The Health Care Provider at the Originating (Member) Site may bill for any clinical services provided on-site on the same day that a Telehealth Service claim is made, except as specifically excluded elsewhere in this section.

5. Telehealth Services may be included in a Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or Indian Health Center (IHC) scope of practice, as approved by HRSA and the State. If approved, these facilities may serve as the provider site and bill under the encounter rate. When an FQHC or RHC serves as the Originating (Member) Site, the Originating Facility Fee is paid separately from the center or clinic all-inclusive rate.

4.07 REIMBURSEMENT (cont.)

6. In the event an interpreter is required, the Healthcare Provider at either the Originating (Member) Site or the Receiving (Provider) site may bill for interpreter services in accordance with the provisions of Chapter I, Section 1 of the MBM. Members may not bill or be reimbursed by the Department for interpreter services utilized during a telehealth encounter.

7. If the technical component of an X-ray, ultrasound or electrocardiogram is performed at the Originating (Member) Site during a Telehealth

Service, the technical component and the Originating Facility Fee are billed by the Health Care Provider at the Originating (Member) Site. The professional component of the procedure and the appropriate visit code are billed by the Receiving (Provider) Site.

8. The Originating Facility Fee may only be billed in the event that the Originating (Member) Site is in a Health Care Provider's facility.

C. The Health Care Providers at the Receiving and Originating Sites may be part of the same organization. In addition, a Health Care Provider at the Originating (Member) Site may bill MaineCare and receive payment for Telehealth Services if the service is provided by a qualified professional who is under a contractual arrangement with the Originating (Member) Site.

4.07-3 Telemonitoring Services

A. Only the Health Care Provider at the Receiving (Provider) Site will be reimbursed for Telemonitoring Services.

B. No Originating Facility Fee will be paid for Telemonitoring Services.

C. Only a Home Health Agency may receive reimbursement for Telemonitoring Services.

D. Telemonitoring Services shall be billed using code S9110, which provides for a flat monthly fee for services, which is inclusive of all Telemonitoring Services, including but not limited to:

1. equipment installation;

2. training the Member on the equipment's use and care;

3. monitoring of data;

4. consultations with the primary care physician; and

4.07 REIMBURSEMENT (cont.)

5. equipment removal when the Telemonitoring Service is no longer medically necessary.

Except as described in this policy, no additional reimbursement beyond the flat fee is available for Telemonitoring Services.

E. MaineCare will not reimburse separately for Telemonitoring equipment purchase, installation, or maintenance.

F. In the event that in person visits are required, these visits must be billed separately from the Telemonitoring Service in accordance with Chapters II and III, Section 40 ( "Home Health Services" ) of the MBM.

G. In the event an interpreter is required, the Home Health Agency may bill for interpreter services in accordance with another billable service and the requirements of Ch. I, Section 1 of the MBM.

4.07-4 Reimbursement Rates

PROCEDURE CODE DESCRIPTION MAXIMUM ALLOWANCE
Q3014 Telehealth Originating Site Facility Fee, per visit $15.86
S9110 Telemonitoring of Patient in their Home, per month $84.55
99446 Interprofessional Telephone/ internet assessment and management services provided by a consultative physician including a verbal and written report; 5-10 minutes of medical consultative discussion and review $24.14
99447 Interprofessional Telephone/ internet assessment and management services provided by a consultative physician including a verbal and written report; 11-20 minutes of medical consultative discussion and review $40.51
99448 Interprofessional Telephone/ internet assessment and management services provided by a consultative physician including a verbal and written report; 21-30 minutes of medical consultative discussion and review $61.05

4.07 REIMBURSEMENT (cont.)

PROCEDURE CODE DESCRIPTION MAXIMUM ALLOWANCE
99449 Interprofessional Telephone/ internet assessment and management services provided by a consultative physician including a verbal and written report; 31 or more minutes of medical consultative discussion and review $82.60