Authored by Assemblyman Dan Logue (R-Lake Wildwood), the Telehealth Advancement Act of 2011 (AB 415) became law on January 1, 2012. AB 415 updated legal definitions of telehealth, streamlined medical approval processes for telehealth-delivered services, and broadened the types of allowed telehealth-delivered services.
AB 415 drew from CCHP’s Telehealth Model Statute Report, which recommended modernizing state telemedicine and workforce laws to encourage more robust adoption of telehealth technologies. CCHP provided nonpartisan technical support to Assemblyman Logue and the bill’s sponsor, the California State Rural Health Association.
Assemblyman Logue gained impressive bipartisan support for the bill with four Democratic co-authors: Wesley Chesbro (D-North Coast), Cathleen Galgiani (D-Livingston), Richard Pan (D-Natomas), and V. Manuel Pérez (D-Coachella). The bill passed out of both California legislative houses with no opposition and was signed by Governor Jerry Brown.
Elements of the Telehealth Advancement Act of 2011
AB 415 replaces the outdated legal term of “telemedicine” with “telehealth.”
Telemedicine under the old law’s terminology was defined as the practice of medicine via live video connections between patients and providers in separate locations, or via “data communications.” As technological advances resulted in new telehealth treatment options, this legal definition grew obsolete and became a barrier to implementing these advancements.
For example, while the old law referenced data communications, it did not explicitly include in its definitions the use of store-and-forward technologies, a prominent type of telehealth service delivery. Store-and-forward connects primary care providers (PCPs) and medical specialists via secure high-speed, high-definition communications systems that work like emails with attachments. This type of telehealth speeds patients’ treatment while removing the need for patient travel and provides valuable disease-specific education for PCPs.
While a separate section of the old law allowed store-and-forward, providers seeking reimbursement for these services encountered difficulties from the lack of a clear and explicit presence in its definitions. For example, Medi-Cal would only cover teledermatology, teleophthalmology, and specific diagnostic teleoptometry services, a restriction that some private payers adopted as well. In addition, the old law did not include chronic disease management programs, which use electronic home monitoring systems to monitor patients’ vital signs.
Telehealth, the new legal term, refers to the general technology-enabled delivery of health services rather than a specific medical practice. This shift allows for a far broader range of eligible services than the old law, and includes future telehealth technologies in its encompassing, innovative definition.
“Telehealth means the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.” – California Business and Professions Code Sec. 2290.5
AB 415 removes limits on the locations where telehealth services may take place. Under the old law, telemedicine appointments had to take place only in licensed health care facilities, such as hospitals or physician offices. There were no explicit restrictions on locations beyond the licensed facility requirement, but this limitation would preclude telehealth being used in such places as the home.
Additionally, Medi-Cal policy restricted telemedicine delivery to four types of licensed facilities only: hospitals, clinics, physician offices, and skilled nursing facilities. Some private payers followed suit, cementing the perception that these were the only facilities where telemedicine could occur.
AB 415 explicitly removed limits on the locations for telehealth, allowing for any type of telehealth to be covered regardless of where it takes place. This can include patient care management programs that employ home monitoring devices, in-home patient medical appointments, and physician reviews in any location for store-and-forward cases. However, AB 415 only allows for the expanded types of location and does not mandate that a payer pay for services taking place in these other types of facilities.
AB 415 eliminates the ban on email or telephone-delivered services. Prior to AB 415, California law contained an explicit exclusion of email or telephone-delivered services. AB 415 removed this restriction, but also did not specifically include email or telephone within the definition of telehealth. While reimbursement for services provided via email or telephone is no longer prohibited and allows a payer to reimburse for it, it is not mandated.
AB 415 includes all California-licensed health professionals as telehealth providers. Under the old law, only these medical professionals could provide telehealth services:
- Clinical psychologists
- Marriage, family and child counselors
- Optometrists (in limited scope)
The Act expands this list to include all professionals licensed under Division 2 of the State’s healing arts statute, allowing for expanded provider use of telehealth services and expanded access to needed services.
AB 415 allows California hospitals to streamline medical credentialing for telehealth providers. Federal regulations called “privileging by proxy” allow hospitals and other telehealth-engaged entities to accept the credentialing paperwork of each facility’s practitioners. This process quickens approvals for practitioners, and eliminates expensive and often cumbersome credentialing processes.
The CMS rules also allow non-hospital telehealth sites, such as physician offices and ambulatory centers, to use the same processes for telehealth service delivery at a hospital, as long as those services meet the hospital’s conditions of practice. AB 415 aligns California law with the CMS regulations.
California regulators encountered confusion about whether existing state regulations conflicted with the federal regulation (which is optional), and whether the state’s hospitals would still have to go through full credentialing processes for all telehealth practitioners. An amendment to AB 415 helped clear up the confusion, and streamlined the process for establishing medical credentials of telehealth providers within the state.
AB 415 removes two restrictive Medi-Cal regulations on telehealth services. First, AB 415 eliminated a Medi-Cal rule requiring providers to document that a beneficiary had a “barrier” to an in-person visit before telehealth could be used. Providers widely viewed this rule as a disincentive to using telehealth.
Second, AB 415 removed a sunset date that would have eliminated Medi-Cal coverage of store-and-forward services for teledermatology, teleophthalmology and teleoptometry.
AB 415 changes telehealth’s additional written patient consent requirement to verbal consent. Providers found that the written consent form stigmatized the use of telehealth, and created an unnecessary barrier to care. AB 415 replaces the written consent with a verbal consent. This establishes parity between services provided in person, and those provided via telehealth.
Changes since AB 415
Since the passage of AB 415, there have been three bills that have made amendments to California’s telehealth policy. The first, AB 809, passed in 2014, clarifies patient consent can be obtained orally or in written form and that it doesn’t need to be obtained for every distinct visit with a particular patient. The second, AB 1174 which also passed in the 2014 legislative session, requires Denti-Cal to provide coverage for store-and-forward teledentistry.
Finally, in 2019, with the help of the California Telehealth Policy Coalition, AB 744 was passed to greatly strengthen California’s private payer law. It provided explicit parity in the services that must be covered by insurers when delivered via telehealth, and beginning in 2021 it also provides for payment parity as well. Additionally, it prohibits coverage from being limited to services delivered by a select third-party corporate telehealth provider.
AB 744 also updated various telehealth definitions including removing obsolete references to originating site and distant site, as well as references limiting store-and-forward in Medi-Cal to teleophthalmology, teledermatology, or teledentristry and requiring notification of the right to receive interactive communication with the distant specialist physician, optometrist, or dentist. Lastly, AB 744 clarified that in addition to licensed providers, qualified autism service professionals were eligible to provide services via telehealth, while separate legislation added marriage and family therapists as eligible providers as well.
You can see a complete history of telehealth legislation in California in this timeline.