Requirements
Insurers (including employee health plans and Medicaid Managed Care) must reimburse a provider for services delivered through telemedicine or store-and-forward if:
- The plan provides coverage when provided in-person;
- The health care service is medically necessary;
- The health care service is a service recognized as an essential health benefit under section 1302(b) of the federal patient protection and affordable care act (ACA);
- The health care service is determined to be safely and effectively provided through telemedicine or store-and-forward technology according to generally accepted health care practices and standards, and the technology used to provide the health care service meets the standards required by state and federal laws governing the privacy and security of protected health information; and
- Beginning January 1, 2023, for audio-only telemedicine, the covered person has an established relationship with the provider.
SOURCE: RCW 48.43.735 & Sec. 41.05.700, & WAC 284-170-433. (Accessed May 2025).
“Established relationship” means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:
- The covered person has had, within the past three years, at least one in-person appointment or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or a locum tenens or other provider who is the designated back up or substitute provider for the provider providing audio-only telemedicine who is on leave and is not associated with an established medical group, clinic, or integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW; or
- The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine; A referral includes circumstances in which the provider who has had at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person participates in the audio-only telemedicine encounter with the provider to whom the covered person has been referred.
SOURCE: WA Rev. Code Sec. 284-170-130 as amended by Permanent Rule. (Accessed May 2025).
“Established relationship” means the provider providing audio-only telemedicine has access to sufficient health records to ensure safe, effective, and appropriate care services and:
- The covered person has had, within the past three years, at least one in-person appointment or at least one real-time interactive appointment using both audio and video technology, with the provider providing audio-only telemedicine or with a provider employed at the same medical group, at the same clinic, or by the same integrated delivery system operated by a carrier licensed under chapter 48.44 or 48.46 RCW as the provider providing audio-only telemedicine; or
- The covered person was referred to the provider providing audio-only telemedicine by another provider who has had, within the past three years, at least one in-person appointment, or at least one real-time interactive appointment using both audio and video technology, with the covered person and has provided relevant medical information to the provider providing audio-only telemedicine.
SOURCE: RCW Sec. 41.05.700 & RCW 48.43.735, as amended by SB 5821 (2024 Legislative Session). (Accessed May 2025).
Eligible Originating Sites:
- Hospital
- Rural health clinic
- Federally qualified health center
- Physician’s or other health care provider’s office
- Licensed or certified behavioral health agency
- Skilled nursing facility
- Home or any location determined appropriate by the individual receiving the service
- Renal dialysis center, except an independent renal dialysis center
Any originating site (other than #7 above) may charge a facility fee for infrastructure and preparation of the patient. Reimbursement for a facility fee must be subject to a negotiated agreement between the originating site and the health plan. A distant site, a hospital that is an originating site for audio-only telemedicine, or any other site not identified in the list above may not charge a facility fee.
The plan may not distinguish between originating sites that are rural and urban.
SOURCE: RCW 48.43.735 & Sec. 41.05.700 & WAC 284-170-433, (Accessed May 2025).
An originating site that is a home or location determined appropriate by the individual receiving the service includes, but is not limited to: a pharmacy or a school-based health center. If the site chosen by the individual receiving service is in a state other than the state of Washington, a provider’s ability to conduct a telemedicine encounter in that state is determined by the licensure status of the provider and the provider licensure laws of the other state.
SOURCE: WAC 284-170-433. (Accessed May 2025).
Insurers offering a plan shall ensure that their benefits and services provided through electronic and information technology, including telehealth, are accessible to individuals with disabilities, unless doing so would result in undue financial and administrative burdens or a fundamental alteration in the nature of the health programs or activities. When undue financial and administrative burdens or a fundamental alteration exist, the issuer shall provide information in a format other than an electronic format that would not result in such undue financial and administrative burdens or a fundamental alteration but would ensure, to the maximum extent possible, that individuals with disabilities receive the benefits or services of the plan that are provided through electronic and information technology.
SOURCE: WAC 284-43-5965 (Accessed May 2025).
Language assistance services required under subsection (1) of this section must be provided free of charge, be accurate and timely, and protect the privacy and independence of the individual with limited-English proficiency, regardless of whether an associated health service is provided in person or through telehealth.
SOURCE: WAC 284-43-5960 (Accessed May 2025).
Printed and online provider directories must include information about any available telemedicine services, including any audio-only telemedicine services that are available, and specifically describe the services and how to access those services.
SOURCE: WAC 284-170-260. (Accessed May 2025).
Every participating provider contract must, for health plans issued or renewed on or after July 25, 2021, and by July 1, 2022, ensure that access to telemedicine services is inclusive for those patients who may have disabilities or limited-English proficiency and for whom the use of telemedicine technology may be more challenging.
A health carrier is not required to reimburse:
- An originating site for professional fees;
- A provider for a health care service that is not a covered benefit under the plan; or
- An originating site or provider when the site or provider is not a participating provider under the plan.
A health carrier may subject coverage of a telemedicine or store and forward technology health service under subsection (1) of this section to all terms and conditions of the plan in which the covered person is enrolled including, but not limited to, utilization review, prior authorization, deductible, copayment, or coinsurance requirements that are applicable to coverage of a comparable health care service provided in person.
A carrier may not deny, reduce, terminate or fail to make payment for the delivery of health care services using audio and visual technology solely because the communication between the patient and provider during the encounter shifted to audio-only due to unanticipated circumstances. In these instances, a carrier may not require a provider to obtain consent from the patient to continue the communication.
A carrier has no obligation to reimburse a provider for both an audio-visual and an audio-only encounter when both means of communication have been used during the encounter due to unforeseen circumstances.
Every participating provider contract must, effective July 25, 2021, provide that if a provider intends to bill a covered person or the covered person’s health plan for an audio-only telemedicine service, the provider must obtain patient consent from the covered person for the billing in advance of the service being delivered, consistent with the requirements of this subsection and state and federal laws applicable to obtaining patient consent.
A covered person’s consent must be obtained prior to initiation of the first audio-only encounter with a provider and may constitute consent to such encounters for a period of up to 12 months. If audio-only encounters continue beyond an initial 12-month period, consent must be obtained from the covered person for each prospective 12-month period.
Consent to be billed for audio-only telemedicine services must be obtained by the provider or auxiliary personnel under the general supervision of the provider.
A covered person may consent to a provider billing them or their health plan in writing or verbally. Consent to billing for an audio-only telemedicine encounter may be obtained and documented by the provider or auxiliary personnel under the general supervision of the provider as part of the process of making an appointment for an audio-only telemedicine encounter, recorded verbally as part of the audio-only telemedicine encounter record or otherwise documented in the patient record. Consent must be documented and retained by the provider for a minimum of five years. As needed, a carrier also may request documentation of the covered person’s consent as a condition of claim payment.
A patient may revoke consent granted under this subsection. Revocation of the patient’s consent must be communicated by the patient or their authorized representative to the provider or auxiliary personnel under the general supervision of the provider verbally or in writing and must be documented and retained by the provider for a minimum of five years. Once consent is revoked, the revocation must operate prospectively.
SOURCE: WAC 284-170-433. (Accessed May 2025).
Workers’ Compensation
Within the workers’ compensation system, when there is no approved examiner in the worker’s community or in a reasonably convenient location for the worker, the department or self-insurer may make alternate arrangements for the examination including, but not limited to, using telemedicine where appropriate.
The following exams may be conducted via telehealth:
- Mental health;
- Dermatology;
- Speech when there is no documented hearing loss;
- Kidney function;
- Hematopoietic system;
The terms telehealth and telemedicine are used interchangeably and have the same requirements as in-person visits. Telemedicine may be appropriate to effectively conduct an independent medical exam when:
- Face-to-face services by a qualified medical provider can be delivered through a real-time, two-way, audio video connection, and complies with all federal, state, and local rules and laws; and
- A worker is able and willing to participate in an exam via telemedicine; and
- The department or self-insured employer, and worker, have agreed a telemedicine IME is appropriate; these individuals should also agree to the location of the worker during the exam; and
- The agreement is documented in the claim file; and
- A physical or hands-on exam is not required.
Upon request of the department or self-insured employer and with the agreement of the worker, a telemedicine IME may be approved on a case-by-case basis for additional specialties not listed under subsection (1) of this section.
SOURCE: WAC 296-23-358; WAC 296-23-359, as added by Permanent Rule. (Accessed May 2025).