MEDI-CAL TELEHEALTH POLICY CHANGES at a GLANCE the Following Are Recent Changes Made to the Medi-Cal Policies Related to Telehealth

FACT SHEETFACT SHEET

AUGUST 2019 [email protected] / 877-707-7172

MEDI-CAL TELEHEALTH POLICY CHANGES AT A GLANCE The following are recent changes made to the Medi-Cal policies related to telehealth. At this time, the manual for teledentistry has not been released.

ISSUE FEE-FOR-SERVICE FQHC/RHC IHS - MOA FAMILY PACT MANAGED CARE VISION CARE LEA

Visit Provider may decide The visit must be The visit must Provider A managed care health plan Teleophthalmology Speech therapy whether to use live video face-to-face, except be face-to-face, may decide MAY cover live video or S&F, if by S&F is covered services must or S&F, if certain conditions in few cases with except in few whether certain conditions are met. for three specific be delivered met. S&F (see below). cases with S&F to use live CPT codes. through (see below). video or S&F, synchronous if certain telemedicine conditions (real time). met.

Eligible The provider rendering All providers eligible All providers Same as fee- Each telehealth provider must Information can Only a licensed Provider covered benefits or to deliver covered eligible to deliver for-service. be licensed in the State of be reviewed by speech- services must meet the FQHC/RHC services. available services California and enrolled as a a physician or language requirements of B&P offered under IHS- Medi-Cal rendering provider optometrist at a pathologist can 2290.5(a)(3) or equivalent MOA services. or non-physician medical distant site. If be reimbursed licensure requirements practitioner (NMP). If the the reviewing for speech under CA law; must be provider is not located in optometrist therapy licensed in CA, enrolled as California, they must be identifies a services Medi-Cal rendering provider affiliated with a Medi-Cal disease or delivered via or non-physician medical enrolled provider condition requiring telehealth. practitioner (NMP) and group in California (or a consultation or affiliated with an enrolled border community) as referral pursuant Medi-Cal provider group; the outlined in the Medi-Cal to Section 3041 enrolled Medi-Cal provider Provider Manual. of the Business group for which the health and Professions care provider renders The same provider licensing Code, a referral services via telehealth must requirements apply as for fee- must be made with meet all Medi-Cal program for-service. an appropriate enrollment requirements physician and and must be located in surgeon or California or a border ophthalmologist, community. as required.

ISSUE FEE-FOR-SERVICE FQHC/RHC IHS - MOA FAMILY PACT MANAGED CARE VISION CARE LEA

Originating Setting not limited. Specific Setting not limited. Setting not limited. Same as fee- Same as fee-for-service. A Not specified. Not specified. Site mention to include the Refers to fee-for- Refers to fee-for- for-service. health care provider is not patient’s home. service policy. service policy. required to be present with the patient at the originating site unless determined medically necessary by the provider at the distant site. Refer to fee-for-service policy.

Distant Site where a health care Same as fee-for- Same as fee-for- Same as fee- Same as fee-for-service. Not specified. Not specified. Site provider is located while service. service. for-service. providing services via a telecommunications system.

Live Video Any covered benefits or Services Services Same as fee- Existing Medi-Cal covered No mention. Speech therapy services identified by provided through provided through for-service. services MAY be covered services are CPT or HCPCS codes are synchronous synchronous as long as they are clinically covered for covered, as long as they are telehealth for an telehealth for an appropriate, meet the certain CPT clinically appropriate, meet established patient established patient definition of the CPT/ codes with the definition of the CPT/ are subject to the are subject to the HCPCS code and meets all modifiers listed HCPCS code and meets same program same program laws of confidentiality and in manual. all laws of confidentiality restrictions, restrictions, patient’s right to their medical and patient’s right to their limitations and limitations and information, and the member medical information. coverage that exist coverage that exist has provided consent. when the service is when the service is provided in-person. provided in-person.

ISSUE FEE-FOR-SERVICE FQHC/RHC IHS - MOA FAMILY PACT MANAGED CARE VISION CARE LEA

Store-and- Any covered benefits or Asynchronous Asynchronous Same as fee- Any covered benefits or Teleophthalmology Forward services identified by CPT or store-and-forward store-and-forward for-service. services identified by CPT by store-and- Not covered. (S&F) HCPCS codes are covered, reimbursement reimbursement or HCPCS codes MAY be forward is covered including (but not limited may not be used to may not be used covered. However, S&F for CPT codes to) teleophthalmology, “establish” a patient, to “establish” a initiated by the patient, 99241-99243. teledermatology, with the exception patient, with the including through mobile teledenistry and of a homeless, exception of a apps are not eligible for teleradiology. homebound homeless patient. reimbursement. or a migratory Reimbursement E-consult is included under or seasonal is permitted E-consult MAY be included S&F. However, S&F initiated worker (HHMS). for established under S&F. by the patient, including Reimbursement patients for through mobile apps are not is permitted teleophthalmology, eligible for reimbursement. for established teledermatology patients for and teledentistry, teleophthalmology, when it is teledermatology and furnished by a teledentistry, when billable provider at it is furnished by a the distant site.COLUMN TITLE billable provider at the distant site.

E-Consult E-Consult is covered E-consult is not E-consult is not Same as fee- Electronic consultations No mention. Not covered. with CPT Code 99451 in a reimbursable a reimbursable for-service. (e-consults) are permissible conjunction with the GQ telehealth service of telehealth service using CPT-4 code 99451, modifier. Certain additional FQHCs/RHCs. of IHS-MOA modifier(s), and medical restrictions apply. clinics. record documentation as defined in the Medi-Cal Provider Manual. E-consults are permissible only between health care providers.

Facility/ The facility fee is FQHCs and RHCs IHS-MOA clinics Same as fee- Not specified. The facility fee Not Trans- reimbursable to are not eligible to bill are not eligible to for-service. is reimbursable reimbursable mission the originating site. an originating site bill an originating to the originating Fee Transmission costs incurred fee or transmission site fee or site. Transmission from providing telehealth fee, as that is transmission fee. costs incurred services via audio/video included within the from providing communication is also PPS rate. telehealth services reimbursable. via audio/video communication is also reimbursable.

ISSUE FEE-FOR-SERVICE FQHC/RHC IHS - MOA FAMILY PACT MANAGED CARE VISION CARE LEA

Modifier GQ is used for Not specified. Refer Not specified. Same as fee- MCP providers must use GQ modifier 95 modifier asynchronous store-and- to fee-for-service. Refer to fee-for- for-service. the modifiers defined in the must be used for must be used. forward. service. Medi-Cal Provider Manual teleophthalmology with the appropriate CPT- by store and 95 modifier is used for 4 or HCPCS codes when forward. synchronous live video. coding for services delivered via telehealth, for both 02 Place of Service code is synchronous interactions used to indicate the services and asynchronous store and were provided through a forward telecommunication system. telecommunications

Consent Verbal or written consent Refer to fee-for- Refer to fee-for- Same as fee- Verbal or written consent A record of the Consent must must be obtained before service policy. service policy. for-service. must be documented, as written or verbal be obtained for utilizing telehealth. A required by BCP Section request for the the student’s general consent agreement All consent for All consent 2290.5. consultation by the parent or that addresses the use of HHMS patients must for homeless referring provider guardian. telehealth that is sufficient be documented. patients must be or other source. The student’s for documentation of documented. Verbal and written written consent patient consent and informed consent to telehealth is must be kept in the from the patient or not required. patient’s medical file. the patient’s legal For teleophthalmology, representative teledermatology or if the consulting teledentistry services provider has or benefits delivered via ultimate authority asynchronous store-and- over the care or forward, the patient must primary diagnosis be notified of their right of the patient. to request and receive interactive communication.