California

“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. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store-and-forward transfers.”

SOURCE: CA Business & Professions Code Sec. 2290.5. (Accessed Feb. 2023).

Last updated 02/25/2023

Parity

SERVICE PARITY

A health care service plan or insurer shall not require that in-person contact occur between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health care service plan or insurer, and between the health care service plan or insurer and its participating providers or provider groups.

A health care service plan or insurer shall not limit the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health care service plan or insurer, and between the health care service plan or insurer and its participating providers or provider groups.

Applies to Medi-Cal Managed Care.

SOURCE: CA Health & Safety Code Sec. 1374.13 & Insurance Code Sec. 10123.85. (Accessed Feb. 2023).

A health care service plan or health insurer contract shall specify that the health care service plan or insurer shall provide coverage for health care services appropriately delivered through telehealth services on the same basis and to the same extent that the health care service plan or insurer is responsible for coverage for the same service through in-person diagnosis, consultation, or treatment. Coverage shall not be limited only to services delivered by select third-party corporate telehealth providers. Does not apply to Medi-Cal managed care.

SOURCE: CA Health & Safety Code Sec. 1374.14 & Insurance Code 10123.855. (Accessed Feb. 2023).

PAYMENT PARITY

A contract between a health care service plan or insurer and a health care provider for the provision of health care services to an enrollee or subscriber shall specify that the health care service plan or insurer shall reimburse the treating or consulting health care provider for the diagnosis, consultation, or treatment of an enrollee or subscriber appropriately delivered through telehealth services on the same basis and to the same extent that the health care service plan or insurer is responsible for reimbursement for the same service through in-person diagnosis, consultation, or treatment.

Services that are the same, as determined by the provider’s description of the service on the claim, shall be reimbursed at the same rate whether provided in person or through telehealth. When negotiating a rate of reimbursement for telehealth services for which no in-person equivalent exists, a health care service plan or insurer and the provider shall ensure the rate is consistent with subdivision (h) of Section 1367.

Does not apply to Medi-Cal managed care.

SOURCE: CA Health & Safety Code Sec. 1374.14 & Insurance Code 10123.855. (Accessed Feb. 2023).

Last updated 02/25/2023

Requirements

A health care service plan and health insurer shall not require that in-person contact occur between a health care provider and a patient before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health care service plan or insurer, and between the health care service plan or insurer and its participating providers or provider groups.

A health care service plan and health insurer shall not limit the type of setting where services are provided for the patient or by the health care provider before payment is made for the covered services appropriately provided through telehealth, subject to the terms and conditions of the contract entered into between the enrollee or subscriber and the health care service plan or insurer, and between the health care service plan or insurer and its participating providers or provider groups.

Applies to Medi-Cal Managed Care.

SOURCE: CA Health & Safety Code Sec. 1374.13 & Insurance Code Sec. 10123.85. (Accessed Feb. 2023).

Coverage shall not be limited only to services delivered by select third-party corporate telehealth providers. Insurers are not required to cover telehealth services provided by an out-of-network provider, unless coverage is required under other provisions of law. Does not apply to Medi-Cal managed care.

SOURCE: CA Health & Safety Code Sec. 1374.14 & Insurance Code 10123.855. (Accessed Feb. 2023).

If a health care service plan or insurer offers a service via telehealth to an enrollee through a third-party corporate telehealth provider, all of the following conditions shall be met:

The health care service plan or insurer shall disclose to the enrollee in any promotion or coordination of the service both of the following:
- The availability of receiving the service on an in-person basis or via telehealth, if available, from the patients’s primary care provider, treating specialist, or from another contracting individual health professional, contracting clinic, or contracting health facility consistent with the service and existing timeliness and geographic access standards in Sections 1367 and 1367.03 and regulations promulgated thereunder.
- If the patient has coverage for out-of-network benefits, a reminder of the availability of receiving the service either via telehealth or on an in-person basis using the enrollee’s out-of-network benefits, and the cost sharing obligation for out-of-network benefits compared to in-network benefits and balance billing protections for services received from contracted providers.
After being notified pursuant to paragraph (1), the patient chooses to receive the service via telehealth through a third-party corporate telehealth provider.
The patient consents to the service consistent with Section 2290.5 of the Business and Professions Code.
If the patient is currently receiving specialty telehealth services for a mental or behavioral health condition, the enrollee is given the option of continuing to receive that service with the contracting individual health professional, a contracting clinic, or a contracting health facility.

If services are provided to an enrollee through a third-party corporate telehealth provider, a health care service plan or insurer shall comply with all of the following:

Notify the patient of their right to access their medical records.
Notify the patient that the record of any services provided to the enrollee through a third-party corporate telehealth provider shall be shared with their primary care provider, unless the patient objects.
Ensure that the records are entered into a patient record system shared with the patient’s primary care provider or are otherwise provided to the patient’s primary care provider, unless the patent objects, in a manner consistent with state and federal law.
Notify the patient that all services received through the third-party corporate telehealth provider are available at in-network cost-sharing and out-of-pocket costs shall accrue to any applicable deductible or out-of-pocket maximum.

A health care service plan or insurer shall include in its reports submitted to the department all of the following for each product type:

By specialty, the total number of services delivered via telehealth by third-party corporate telehealth providers.
The names of each third-party corporate telehealth provider contracted with the plan or insurer and, for each, the number of services provided by specialty.
For each third-party corporate telehealth provider with which it contracts, the percentage of the third-party corporate telehealth provider’s contracted providers available to the plan’s patients that are also contracting individual health professionals.
For each third-party corporate telehealth provider with which it contracts, the types of telehealth services utilized by patients, including frequency of use, gender, age, and any other information as determined by the department.
For each patient that has accessed services for a third-party corporate telehealth provider, patient demographic data, including gender and age, and any other information as determined by the department.

This section shall not apply when an enrollee seeks services directly from a third-party corporate telehealth provider or to Medicaid.

SOURCE: CA Health & Safety Code Sec. 1374.141 & Insurance Code 10123.856. (Accessed Feb. 2023).

A health care service plan or insurer that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan contract covering dental services that offers a service via telehealth to an enrollee through a third-party corporate telehealth provider shall report to the department, in a manner specified by the department, all of the following for each product type:

The total number of services delivered via telehealth by a third-party corporate telehealth provider.
For each third-party corporate telehealth provider with which it contracts, the percentage of the third-party telehealth provider’s contracted providers available to the plan’s enrollees that are also network providers.
For each third-party corporate telehealth provider with which it contracts, the types of telehealth services utilized by enrollees, including information on the gender and age of the enrollee, and any other information as determined by the department.

A health care service plan or insurer that issues, sells, renews, or offers a plan contract covering dental services, including a specialized health care service plan contract covering dental services that offers a service via telehealth to an enrollee through a third-party corporate telehealth provider, shall disclose to the enrollee the impact of third-party telehealth visits on the enrollee’s benefit limitations, including frequency limitations and the enrollee’s annual maximum.

For the purposes of this section, “third-party corporate telehealth provider” means a corporation that provides dental services exclusively through a telehealth technology platform and has no physical location at which a patient can receive services, and is directly contracted with a health care service plan, including a specialized health care service plan, that issues, sells, renews, or offers a plan contract covering dental services.

SOURCE: CA Health & Safety Code Sec. 1374.142 & Insurance Code 10123.857, as proposed to be added by AB 1982 (2022 Session). (Accessed Feb. 2023).

Medicaid

Last updated 02/25/2023

Consent Requirements

Health care providers must inform the patient prior to the initial delivery of telehealth services about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services.

If a health care provider, whether at the originating site or distant site, maintains a general consent agreement that specifically mentions use of telehealth as an acceptable modality for delivery of services and includes the required information, as explained below, then this is sufficient for documentation of patient consent and should be kept in the patient’s medical file. Providers also need to document when a patient consents to receive services via audio-only prior to initial delivery of services.

The consent shall be documented in the patient’s medical file and be available to DHCS upon request. Providers are required to share additional information with beneficiaries regarding:

Right to in-person services
Voluntary nature of consent
Availability of transportation to access in-person services when other available resources have been reasonably exhausted
Limitations/risks of receiving services via telehealth, if applicable
Availability of translation services

Consent requirements may be found in Business and Professions Code, Section 2290.5 [b] and Welfare and Institutions Code, Section 14132.725 [d]. Model patient consent language may be found on the DHCS website.

FQHCs and RHCs are directed to refer to the above on consent requirements

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 5., CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 13. (Accessed Feb. 2023).

Applies to Healthcare Providers including FQHCs/RHCs

In addition to any existing law requiring beneficiary consent to telehealth, including, but not limited to, subdivision (b) of Section 2290.5 of the Business and Professions Code, all of the following shall be communicated by a health care provider, FQHC, and RHC to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary:

An explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit;
An explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future;
An explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted; and
The potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the provider, FQHC, or RHC.

The provider, FQHC, or RHC shall document in the patient record the provision of this information and the patient’s verbal or written acknowledgment that the information was received.

The department shall develop, in consultation with affected stakeholders, model language for purposes of the communication described in this subdivision.

This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities.

SOURCE: Welfare and Institutions Code 14132.725 & Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refer to fee-for-service policy. All consent for homeless patients must be documented.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8. (Accessed Feb. 2023).

Vision Care

Providers must include a record of the written or verbal request for the consultation by the referring provider or other source in the medical record. Verbal and written informed consent from the patient or the patient’s legal representative is required if the consulting provider has ultimate authority over the care or primary diagnosis of the patient.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual. (Oct. 2022), Pg. 5. (Accessed Feb. 2023).

Local Education Agency Services

The health care provider at the originating site must first obtain oral consent from the student’s parent or legal guardian prior to providing service via telehealth. Written consent to telehealth services is not required.

If oral consent from the student’s parent or legal guardian is received, the health care provider must document oral consent in the student’s medical record, including the following:

A description of the risks, benefits and consequences of telehealth
The student’s parent or legal guardian retains the right to withdraw the student from services via telehealth at any time
All existing confidentiality protections apply, including HIPAA requirements
The student’s parent or legal guardian has access to all transmitted medical information
No dissemination of any student images or information to other entities without further written consent

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Oct. 2022. Pg. 4. (Accessed Feb. 2023).

Audio-Only

Providers must document in the patient’s medical chart that the patient has given a written or verbal consent to the audio-only telemedicine encounter.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan 2023), Pg. 7. (Accessed Feb. 2023).

Remote Physiological Monitoring

Prior to or at the time RPM services are furnished, the patient must give consent to receive the services. Consent may be verbal (written consent is not required) but must be documented in the medical record, along with justification for the use of RPM services.

SOURCE: CA DHCS Evaluation and Management Manual (Dec. 2022), p. 39-41. (Accessed Feb. 2023).

Last updated 02/24/2023

Definitions

“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. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store-and-forward transfers.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 1. (Accessed Feb. 2023).

Last updated 02/25/2023

Email, Phone & Fax

For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

Modifier 93 must be used for Medi-Cal covered benefits or services delivered via synchronous, telephone or other interactive audio-only telecommunications systems. Only the portion(s) of the telehealth service rendered at the distant site are billed with modifier 93. The use of modifier 93 does not alter reimbursement for the CPT or HCPCS code.

Health care providers must use an interactive audio-only telecommunications system that permits real-time communication between the provider at the distant site and the patient at the originating site. The audio telehealth system used must, at a minimum, have the capability of meeting the procedural definition of the code provided through telehealth. The telecommunications equipment must be of a quality or resolution to adequately complete all necessary components to document the level of service for the CPT code or HCPCS code billed.

The totality of the communication of information exchanged between the provider and the patient during the audio-only service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.

Providers must document in the patient’s medical file that the patient has given a written or verbal consent to the audio-only telehealth encounter.

Brief Virtual Communications and Check-ins

Virtual or telephonic communication includes a brief communication with an established patient not physically present (face-to-face). Medi-Cal providers may be reimbursed using HCPCS codes G2010 and G2012 for brief virtual communications.

HCPCS code G2012: Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5 to 10 minutes of medical discussion. G2012 can be billed when the virtual communication via a telephone call.

Establishing a Relationship

Providers may establish a relationship with new patients via audio-only synchronous interaction only if one or more of the following applies:

The visit is related to sensitive services as defined in subsection (n) or Section 56.06 of the Civil Code. Section 56.06 of the Civil Code defines “sensitive services” as all health care services related to mental or behavioral health, sexual and reproductive health, sexually transmitted infections, substance use disorder, gender-affirming care, and intimate partner violence, and includes services described in Sections 6924 through 6930 of the Family Code, and Sections 121020 and 124260 of the Health and Safety Code, obtained by a patient at or above the minimum age specified for consenting to the service specified in the section.
The patient requests an audio-only modality.
The patient attests they do not have access to video.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 3, 6-7, 10. (Accessed Feb. 2023).

FQHCs/RHCs

An audio-only synchronous interaction is eligible for reimbursement if provided by a billable provider and FQHC or RHC patient.

Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter

A patient may not be “established” using an audio-only synchronous interaction unless the visit is related to a “sensitive service”, as defined in the California Civil Code, section 56.05, subdivision (n), or if the patient requests “audio only” or does not have access to video.

SOURCE: CA Dept. Health Care Services, Medi-Cal Part 2 RHCs and FQHCs Manual, (Jan. 2023), p 14. (Accessed Feb. 2023).

Visits shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

An FQHC or RHC may not establish a new patient relationship using an audio-only synchronous interaction. Notwithstanding this prohibition, the department may provide for specific exceptions to this prohibition, which shall be developed in consultation with affected stakeholders and published in departmental guidance. Exceptions shall include but not be limited to:

An FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, or when the patient requests an audio-only modality or attests they do not have access to video – in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, an FQHC or RHC furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice. The department may provide specific exceptions to the requirement based on an FQHC’s or RHC’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance.

Effective on the date designated by the department pursuant to above, an FQHC or RHC furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:

Offer those services via in-person, face-to-face contact.
Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.

SOURCE: Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Feb. 2023).

SOURCE: Welfare and Institutions Code Sec. 14132.723. (Accessed Feb. 2023).

The department shall seek any federal approvals it deems necessary to extend the approved waiver or flexibility implemented pursuant to subdivision (a), as of July 1, 2021, that are related to the delivery and reimbursement of services via telehealth modalities in the Medi-Cal program, including audio-only. The department shall implement those extended waivers or flexibilities for which federal approval is obtained, to commence on the first calendar day immediately following the last calendar day of the federal COVID-19 public health emergency period, and through December 31, 2022.

For purposes of informing the 2022–23 proposed Governor’s Budget, released in January 2022, the department shall convene an advisory group consisting of consultants, subject matter experts, and other affected stakeholders to provide recommendations to inform the department in establishing and adopting billing and utilization management protocols for telehealth modalities to increase access and equity and reduce disparities in the Medi-Cal program. The advisory group shall analyze the impact of telehealth in increased access for patients, changes in health quality outcomes and utilization, best practices for the appropriate mix of in-person visits and telehealth, and the benefits or liabilities of any practice or care model changes that have resulted from telephonic visits.

SOURCE: AB 133, Sec. 380 (2021 Session). (Accessed Feb. 2023).

Vision Services

Asynchronous telecommunications system (store and forward telehealth) in single media format does not include telephone calls, images transmitted via facsimile machine, and text messages without visualization of the patient (electronic mail).

SOURCE: CA Department of Health Care Services. Medi-Cal Professional Services Manual. Page 6. (Dec. 2022). (Accessed Feb. 2023).

LEA Services

Medi-Cal does not reimburse for telephone calls, electronic mail messages or facsimile transmissions.

SOURCE: CA Department of Health Care Services. Medi-Cal Local Educational Agency (LEA) Telehealth Manual. Page 3. (Aug. 2021). (Accessed Feb. 2023).

Drug Medi-Cal Treatment Program

A county that enters into a Drug Medi-Cal Treatment Program contract with the department shall reimburse Drug Medi-Cal certified providers for medically necessary Drug Medi-Cal reimbursable services, as defined in Section 14124.24, provided by a licensed practitioner of the healing arts, or a registered or certified alcohol or other drug counselor or other individual authorized by the department to provide Drug Medi-Cal reimbursable services when those services meet the standard of care, meet the requirements of the service code being billed, and are delivered through video synchronous interaction or audio-only synchronous interaction.

A Drug Medi-Cal certified provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other virtual communication modalities. The department may provide for specific exceptions to this prohibition, which shall be developed in consultation with affected stakeholders and published in departmental guidance.

SOURCE: Welfare and Institutions Code 14132.731, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Last updated 02/24/2023

Live Video

POLICY

Synchronous Interaction

“Synchronous interaction” means a real-time interaction between a patient and a health care provider located at a distant site.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2. (Accessed Feb. 2023).

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality, as outlined in this section, only if all of the following are satisfied:
The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association (AMA), associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual;
The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

For services or benefits provided via synchronous, interactive audio and visual telecommunications systems, the health care provider bills with modifier 95.
For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.
For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 6. (Accessed Feb. 2023).

Recently enacted legislation requires CA Medicaid and Medi-Cal managed care plans to reimburse health care providers of applicable health care services delivered via video synchronous interaction, synchronous audio-only modality, or asynchronous store and forward, as applicable, at payment amounts that are not less than the amounts the provider would receive if the services were delivered via in-person, face-to-face contact, so long as the services or settings meet the applicable standard of care and meet the requirements of the service code being billed.

In-person, face-to-face contact between a health care provider and a patient is not required under the Medi-Cal program for covered health care services and provider types designated by the department, when provided by video synchronous interaction, asynchronous store and forward, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities, when those services and settings meet the applicable standard of care and meet the requirements of the service code being billed.

Applicable health care services appropriately provided through video synchronous interaction, asynchronous store and forward, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities are subject to billing, reimbursement, and utilization management policies imposed by the department. Utilization management protocols adopted by the department pursuant to this section shall be consistent with, and no more restrictive than, those authorized for health care service plans pursuant to Section 1374.13 of the Health and Safety Code.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Brief Virtual Communications and Check-ins

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 10. (Accessed Feb. 2023).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Telehealth services must meet all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter with a billable provider and meet the applicable standard of care.

Services rendered via telehealth must be FQHC or RHC covered services. Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site. Medi-Cal benefits or services being provided are clinically appropriate and meet the procedural and billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter. An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from the FQHC pursuant to the federal Health Resources Services Administration requirements.

See manual for billing examples.

SOURCE: CA Dept. of Health Care Services, Part 2 Manual, Medi-Cal Rural Health Clinics and Federally Qualified Health Centers (Jan. 2023), p. 11, 13-14. (Accessed Feb. 2023).

Visits shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

An FQHC or RHC is not precluded from establishing a new patient relationship through video synchronous interaction.

SOURCE: Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Family PACT

Family PACT telehealth policy mirrors the fee-for-service policy.

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. Aug. 2022, Pg. 6. (Accessed Feb. 2023).

Managed Care

Existing Medi-Cal covered services may be provided via a telehealth modality (includes live video) if certain conditions are met (as outlined in fee-for-service manual).

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 19-009: Telehealth Services Policy. Oct. 16, 2019. (Accessed Feb. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Services rendered via telehealth must be IHS-MOA covered services.

Services provided through synchronous telehealth for an established patient are subject to the same program restrictions, limitations and coverage that exist when the service is provided in-person.

• IHS-MOA clinics must submit claims for telehealth services using the appropriate per visit IHS-MOA billing codes, modifiers and related claims submission requirements. Providers may refer to the Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics: Billing Codes section in the appropriate Part 2 manual.
• IHS-MOA clinics are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the IHS-MOA rate.

See manual for billing examples.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Aug. 2020. Pg. 8. (Accessed Feb. 2023).

Local Education Agency: Speech Therapy

For dates of service on July 1, 2016 up to March 1, 2020, LEAs may only bill for covered speech therapy services provided via telehealth under the LEA Medi-Cal Billing Option Program. Speech therapy services are reimbursable when performed according to telemedicine guidelines and billed with modifier 95 and the appropriate CPT code.

For dates of service on or after March 1, 2020, until the termination of the COVID-19 PHE, all LEA services covered under the LEA Medi-Cal Billing Option Program may be billed by participating LEAs when performed via telehealth, except for services, such as specialized medical transportation services, that preclude a telehealth modality.

For dates of service on or after July 1, 2021, allowable services delivered via telehealth must be billed with modifier 95 (synchronous telehealth service rendered via a real-time interactive audio and video telecommunications system) and the appropriate CPT code.

For all dates, a telemedicine service must use interactive audio, video or data communication to qualify for reimbursement. The qualified service must be in real-time or near real-time (delay in seconds or minutes) to qualify as an interactive two-way transfer of medical data and information between the student and health care provider.

Upon termination of the COVID-19 PHE, DHCS will provide guidance to LEAs on the permanent telehealth policy by which LEAs will be reimbursed for services delivered via telehealth.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Aug. 2021 & Oct. 2022. Pg. 2-3, 5-7. (Accessed Feb. 2023).

Dental Services

The Department of Health Care Services has opted to permit the use of teledentistry (including live video) as an alternative modality for the provision of select dental services.

SOURCE: CA Department of Health Care Services (DHCS). Dental Provider Handbook. (2023) Pg. 4-22 – 4-23 (Accessed Feb. 2023).

Drug Medi-Cal Treatment Program

SOURCE: Welfare and Institutions Code 14132.731, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.

SOURCE: Sec. 14132.72 of the Welfare and Institutions Code. (Accessed Feb. 2023).

ELIGIBLE SERVICES/SPECIALTIES

Medi-Cal covered benefits or services, identified by CPT or HCPCS codes and subject to all existing Medi-Cal coverage and reimbursement policies, including any treatment authorization request requirements, may be provided via a telehealth modality if all of the following are satisfied:

The treating health care provider at the distant site believes that the benefits or services being provided are clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth;
The benefits or services delivered via telehealth meet the procedural definition and components of the CPT or HCPCS code(s), as defined by the American Medical Association, associated with the Medi-Cal covered service or benefit, as well as any extended guidelines as described in this section of the Medi-Cal provider manual; and
The benefits or services provided via telehealth meet all laws regarding confidentiality of health care information and a patient’s right to his or her medical information.

Covered benefits or services provided via a telehealth modality are reimbursable when billed in one of two ways:

For services or benefits provided via synchronous, interactive audio and visual telecommunications systems, the health care provider bills with modifier 95.
For services or benefits provided via asynchronous store and forward telecommunications systems, the health care provider bills with modifier GQ.
For services or benefits provided via synchronous telephone or other real-time interactive audio-only telecommunications systems, the health care provider bills with modifier 93.

Certain types of benefits or services that would not be expected to be appropriately delivered via telehealth include, but are not limited to, benefits or services that are performed in an operating room or while the patient is under anesthesia, require direct visualization or instrumentation of bodily structures, involve sampling of tissue or insertion/removal of medical devices and/or otherwise require the in-person presence of the patient for any reason.

The amount paid by DHCS and Medi-Cal managed care plans for a service rendered via telehealth is the same as the amount paid for the applicable service when rendered in-person.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 4, 6. (Accessed Feb. 2023).

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2. (Accessed Feb. 2023).

Evaluation and management services may be delivered via telehealth when Medi-Cal requirements are met.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 27. Dec 2022. (Accessed Feb. 2023).

Modifier 95 must be used for Medi-Cal covered benefits or services delivered via synchronous, interactive audio/visual, telecommunications systems. Only the portion(s) of the telehealth service rendered at the distant site are billed with modifier 95. The use of modifier 95 does not alter reimbursement for the CPT or HCPCS code. See manual for telecommunications system requirements.

Evaluation and Management (E&M) and all other covered Medi-Cal services provided at the originating site (in-person with the patient) during a telehealth transmission are billed according to standard Medi-Cal policies (without modifier 95). The E&M service must be in real-time or near real-time (delay in seconds or minutes) to qualify as an interactive two-way transfer of medical data and information between the patient and health care provider.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan 2023). Pg. 7-8. (Accessed Feb. 2023).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC) & Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 13-14.; CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7-8. (Accessed Feb. 2023).

Dental Services

Synchronous interaction, or live transmission, is a real-time interaction between a member and a provider located at a distant site. Live transmissions are limited to 90 minutes per member per provider, per day. Please note, live transmissions may be provided at the member’s request or if the health care provider believes the service is clinically appropriate. All dental information transmitted during the delivery of Medi-Cal covered benefits or services via a telehealth modality must become part of the patient’s dental record maintained by the Medi-Cal provider at the distant site.

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. Jan. 2023. Pg. 4-24. (Accessed Feb. 2023).

Home Health & Durable Medical Equipment

Live video telehealth may be used to deliver a face-to-face encounter related to the primary reason a recipient requires home health services or a durable medical equipment item.

SOURCE: Department of Health Care Services. Home Health Agencies (HHA) Provider Handbook. (Feb. 2021), Pg. 3. & Department of Health Care Services. Durable Medical Equipment (DME): An Overview. (July 2021), Pg. 6. (Accessed Feb. 2023).

CA Children’s Services (CCS)

CA Children’s Services Program lists eligible CPT/HCPCS codes in Numbered Letters 16-1217 & 09-0718. Codes specifically include tele-speech, tele-auditory verbal therapy, tele-auditory habilitation and tele-auditory rehabilitation services in the home, with the parent or guardian working with the speech therapist at the distant site.

SOURCE: Department of Health Care Services. Numbered letter 16-1217 to the CA Children’s Services Program and Genetically Handicapped Persons Program (GHPP). Dec. 22, 2017. & Number Letter 09-0718 to CA Children’s Services Program. Jul. 10, 2018. (Accessed Feb. 2023).

Opioid Use Disorder Treatment Services

Outpatient treatment services for opioid use disorder (OUD), which include management, care coordination, psychotherapy and counseling are reimbursable using HCPCS codes G2086, G2087 and G2088. At least one psychotherapy service must be furnished in order to bill for HCPCS codes G2086 thru G2088. Although the descriptions for these codes refer to “office-based treatment,” these services may be delivered via telehealth when they meet Medi-Cal requirements. See Medi-Cal Telehealth Provider Manual.

HCPCS codes G2086 thru G2088 are not reimbursable for treatment in state-licensed Opioid Treatment Programs as defined in Health and Safety Code Section 11875. HCPCS codes G2086 and G2087 each have a frequency limit of once per calendar month, per recipient, any provider and G2088 has a frequency limit of two per calendar month, per recipient, any provider. Only one provider can be reimbursed for HCPCS code G2086, G2087 or G2088 per calendar month.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 47-48. Dec. 2022. (Accessed Feb. 2023).

The Program for All Inclusive Care for the Elderly (PACE)

A PACE organization approved by the department pursuant to Chapter 8.75 (commencing with Section 14591) may use video telehealth to conduct initial assessments and annual re-assessments for eligibility for enrollment in the PACE program.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Doula, Community Health Worker (CHW) and Asthma Preventive Services

Doulas may provide services described in the Doula Services manual via telehealth.

Community Health Workers (CHWs) may provide services described in the Community Health Worker (CHW) Preventive Services manual via telehealth

Asthma preventive education and training services described in the Asthma Preventive Services (APS) manual may be provided via telehealth by unlicensed asthma preventive service providers. In-home environmental trigger assessments for asthma may not be conducted via telehealth and must be conducted in-person.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan 2023). Pg. 4. (Accessed Feb. 2023).

ELIGIBLE PROVIDERS

The health care provider rendering Medi-Cal covered benefits or services provided via a telehealth modality must meet the requirements of Business and Professions Code (B&P Code), Section 2290.5(a)(3), or must be otherwise designated by the Department of Health Care Services (DHCS) pursuant to Welfare and Institutions Code (WIC) 14132.725 (b)(2)(A).

A licensed health care provider rendering Medi-Cal covered benefits or services via a telehealth modality must be licensed in California, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group.

The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

For purposes of telehealth [the distant site] can be different from the administrative location.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2-3. (Accessed Feb. 2023).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

Billable providers are eligible to deliver covered FQHC/RHC services. Providers may refer to “RHC/FQHC Covered Services” in this manual section.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 11. (Accessed Feb. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Billable providers are eligible to deliver available services offered under IHS-MOA services.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7-8. (Accessed Feb. 2023).

Dental Professionals

For Medi-Cal dental benefits or services, Medi-Cal enrolled dentists and allied dental professionals (under the supervision of a dentist) may render limited services via synchronous/live transmission teledentistry, so long as such services are within their scope of practice, when billed using CDT code D9995 for dates of service on or after May 16, 2020.

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. Jan. 2023. Pg. 4-24 (Accessed Feb. 2023).

Psychiatrists

Psychiatrists may bill for services delivered through telehealth in accordance with the Medicaid state plan.

SOURCE: Sec. 14132.73 of the Welfare and Institutions Code. (Accessed Feb. 2023).

Doula, Community Health Worker (CHW) and Asthma Preventive Services

Doulas may provide services described in the Doula Services manual via telehealth.

Community Health Workers (CHWs) may provide services described in the Community Health Worker (CHW) Preventive Services manual via telehealth

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan 2023). Pg. 4. (Accessed Feb. 2023).

ELIGIBLE SITES

For purposes of reimbursement for covered treatment or services provided through telehealth, the type of setting where services are provided for the patient or by the health care provider is not limited (Welfare and Institutions Code [WIC] Section 14132.72(e)). This may include, but is not limited to, a hospital, medical office, community clinic, or the patient’s home.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2. (Accessed Feb. 2023).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC)

The billable provider, employed or under direct contract with an FQHC or RHC can respond from any location, including their home, during a time that they are scheduled to work for the FQHC or RHC.

For the purposes of payment for covered treatment or services provided through telehealth, the department shall not limit the type of setting where services are provided for the patient or by the health care provider.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 15. (Accessed Feb. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

Refers to fee-for-service policy for the definition of an ‘originating site’.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 7. (Accessed Feb. 2023).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

The originating site facility fee is reimbursable only to the originating site when billed with HCPCS code Q3014 (telehealth originating site facility fee). Transmission costs incurred from providing telehealth services via audio/video communication is reimbursable when billed with HCPCS code T1014 (telehealth transmission, per minute, professional services bill separately).

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 11. (Accessed Feb. 2023).

FQHC & RHC/IHS-MOA

FQHCs and RHCs are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the PPS/AIR rate, as applicable.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 12. (Accessed Feb. 2023).

Local Education Agency: Speech Therapy

The facility and transmission fee are not covered.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Aug. 2021. Pg. 5 (Accessed Feb. 2023).

Every Woman Counts Program

Effective retroactively for dates of service on or after November 1, 2013, HCPCS codes Q3014 (telehealth originating site facility fee) and T1014 (telehealth transmission, per minute, professional services bill separately) are benefits of the Every Woman Counts (EWC) program.

SOURCE: Department of Health Care Services. Every Woman Counts Program Manual. Pgs. 39-40. Feb. 2023. (Accessed Feb. 2023).

Last updated 02/25/2023

Miscellaneous

Establishing New Patients via Telehealth

Providers may establish a relationship with new patients via synchronous video telehealth visits. Providers may establish a relationship with new patients via audio-only synchronous interaction only if one or more of the following applies:

The visit is related to sensitive services as defined in subsection (n) or Section 56.06 of the Civil Code. Section 56.06 of the Civil Code defines “sensitive services” as all health care services related to mental or behavioral health, sexual and reproductive health, sexually transmitted infections, substance use disorder, gender-affirming care, and intimate partner violence, and includes services described in Sections 6924 through 6930 of the Family Code, and Sections 121020 and 124260 of the Health and Safety Code, obtained by a patient at or above the minimum age specified for consenting to the service specified in the section.
The patient requests an audio-only modality.
The patient attests they do not have access to video.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 3. (Accessed Feb. 2023).

Documentation

All health care practitioners providing covered benefits or services to Medi-Cal patients must maintain appropriate documentation to substantiate the corresponding technical and professional components of billed CPT® or HCPCS codes. Documentation for benefits or services delivered via telehealth should be the same as for a comparable in-person service. The distant site provider can bill for Medi-Cal covered benefits or services delivered via telehealth using the appropriate CPT or HCPCS codes with the corresponding modifier and is responsible for maintaining appropriate supporting documentation. This documentation should be maintained in the patient’s medical record.

Providers should note the following:

Health care providers at the distant site must determine that the covered Medi-Cal service or benefit being delivered via telehealth meets the procedural definition and components of the CPT or HCPCS code(s) associated with the Medi-Cal covered service or benefit as well as any other requirements described in this section of the Medi-Cal provider manual.
Health care providers are not required to document a barrier to an in-person visit for Medi-Cal coverage of services provided via telehealth (W&I Code, Section 14132.72[d]).
Health care providers at the distant site are not required to document cost effectiveness of telehealth to be reimbursed for telehealth services or store and forward services.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 4. (Accessed Feb. 2023).

Telehealth services and supports are among the services and supports authorized to be included by individual program plans developed for disabled individuals by regional centers that contract with the State Department of Developmental Disabilities.

SOURCE: Welfare and Institutions Code Sec. 4512. (Accessed Feb. 2023).

Medicaid must ensure that all managed care covered services are available and accessible to enrollees of Medicaid managed care plans in a timely manner. Telehealth can be used as a means to meet time and distance standards in some circumstances. See statute for details.

SOURCE: CA Welfare and Institutions Code Sec. 14197. & CA Department of Health Care Services (DHCS). All Plan Letter 20-003: Telehealth Services Policy. Feb. 27, 2020. (Accessed Feb. 2023).

Telehealth services, telephonic services and other specified services must be reimbursed when provided by specific entities during or immediately following an emergency, subject to the Department obtaining federal approval and matching funds. The Department is required to issue guidance for entities to facilitate reimbursement for telehealth or telephonic services in emergency situations by July 1, 2020.

SOURCE: Welfare and Institutions Code Sec. 14132.723 & 724 (AB 1494 – 2019 Legislative Session). (Accessed Feb. 2023).

Issues of privileges and credentialing for distant physicians to care for patients via telehealth are determined by the policies of the originating hospital. Hospitals can accept the privileges and credentials for providers at distant hospitals.

SOURCE: Telehealth FAQs, Providers. March 2021. (Accessed Feb. 2023).

The department shall seek any federal approvals it deems necessary to extend the approved waiver or flexibility implemented pursuant to subdivision (a), as of July 1, 2021, that are related to the delivery and reimbursement of services via telehealth modalities in the Medi-Cal program. Subject to subdivision (e), the department shall implement those extended waivers or flexibilities for which federal approval is obtained, to commence on the first calendar day immediately following the last calendar day of the federal COVID-19 public health emergency period, and through December 31, 2022.

The department may authorize the use of remote patient monitoring as an allowable telehealth modality for covered health care services and provider types it deems appropriate for dates of service on or after July 1, 2021. The department may establish a fee schedule for applicable health care services delivered via remote patient monitoring.

SOURCE: AB 133, Sec. 380 (2021 Session). (Accessed Feb. 2023).

The department shall develop, in consultation with affected stakeholders, an informational notice to be distributed to fee-for-service Medi-Cal beneficiaries and for use by Medi-Cal managed care plans in communicating to their enrollees. Information in the notice shall include, but not be limited to, all of the following:

The availability of Medi-Cal covered telehealth services.
The beneficiary’s right to access all medically necessary covered services through in-person, face-to-face visits, and a provider’s and Medi-Cal managed care plan’s responsibility to offer or arrange for that in-person care, as applicable.
An explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn by the Medi-Cal beneficiary at any time without affecting their ability to access covered Medi-Cal services in the future.
An explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted.
Notification of the beneficiary’s right to make complaints about the offer of telehealth services in lieu of in-person care or about the quality of care delivered through telehealth.

The informational notice shall be translated into threshold languages determined by the department pursuant to subdivision (b) of Section 14029.91 and provided in a format that is culturally and linguistically appropriate.

This subdivision does not apply to Medi-Cal covered services delivered by providers via any telehealth modality to eligible inmates in state prisons, county jails, or youth correctional facilities.

SOURCE: Welfare and Institutions Code 14132.725 (e), as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

On or before January 1, 2023, the department shall develop a research and evaluation plan that does all of the following:

Proposes strategies to analyze the relationship between telehealth and the following: access to care, access to in-person care, quality of care, and Medi-Cal program costs, utilization, and program integrity.
Examines issues using an equity framework that includes stratification by available geographic and demographic factors, including, but not limited to, race, ethnicity, primary language, age, and gender, to understand inequities and disparities in care.
Prioritizes research and evaluation questions that directly inform Medi-Cal policy.

SOURCE: Welfare and Institutions Code 14132.725 (g), as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Applicable health care services provided through asynchronous store and forward, video synchronous interaction, audio-only synchronous interaction, remote patient monitoring, or other permissible virtual communication modalities as described in this section shall comply with the privacy and security requirements contained in the federal Health Insurance Portability and Accountability Act of 1996 found in Parts 160 and 164 of Title 45 of the Code of Federal Regulations, the Medicaid State Plan, and any other applicable state and federal statutes and regulations.

SOURCE: Welfare and Institutions Code 14132.725 (h), as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider furnishing applicable health care services via audio-only synchronous interaction shall also offer those same health care services via video synchronous interaction to preserve beneficiary choice. Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal provider furnishing applicable health care services via synchronous video interaction only shall also offer those same health care services in-person or facilitate access to in-person services for the patient. The department may provide specific exceptions to the requirement based on a Medi-Cal provider’s access to requisite technologies, which shall be developed in consultation with affected stakeholders and published in departmental guidance. In making such exceptions, the department may also take into consideration the availability of broadband access based on speed standards set by the Federal Communications Commission or other applicable federal law or regulation.

Effective on the date designated by the department pursuant to above, a provider furnishing services through video synchronous interaction or audio-only synchronous interaction shall also do one of the following:

Offer those services via in-person, face-to-face contact.
Arrange for a referral to, and a facilitation of, in-person care that does not require a patient to independently contact a different provider to arrange for that care.

In implementing this subdivision, the department shall consider additional recommendations from affected stakeholders regarding the need to maintain access to in-person services without unduly restricting access to telehealth services.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Feb. 2023).

Last updated 02/25/2023

Out of State Providers

Provider must be licensed in CA, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP) and affiliated with an enrolled Medi-Cal provider group. The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 3.; Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Last updated 02/25/2023

Overview

Medi-Cal allows providers to decide what modality, live video, store-and-forward, or audio-only, will be used to deliver eligible services to a Medi-Cal enrollee as long as the service is covered by Medi-Cal and meets all other Medi-Cal guidelines and policies, can be properly provided via telehealth, and meets the procedural and definition components of the appropriate CPT or HCPCS code. Additional requirements apply for specific programs (such as FQHCs/RHCS and Indian Health Services). Medi-Cal also reimburses Medicare CTBS remote patient monitoring codes and one specific e-consult code.

Last updated 02/25/2023

Remote Patient Monitoring

POLICY

Principal care management (PCM) services are provided when medical and/or psychological needs manifested by a single, complex chronic condition are expected to last at least three months. CPT codes 99424 and 99426 each have a frequency limit of once per calendar month, any provider and 99427 has a frequency limit of two per calendar month, any provider.

Remote physiologic monitoring (RPM) services for established patients ages 21 and older are reimbursable when ordered by and billed by physicians or other qualified health professionals (QHP). RPM services may be delivered by auxiliary personnel including contracted employees, when under the supervision of the billing physician or qualified health professional. See manual for codes.

SOURCE: CA DHCS Evaluation and Management Manual (Dec. 2022), p. 39-41. (Accessed Feb. 2023).

SOURCE: Sec. 14124.12 (f)(1)(B) of the Welfare and Institutions Code. As amended by AB 133, Sec. 380 (2021 Session). (Accessed Dec. 2022).

Remote Physiologic Monitoring

Medi-Cal reimburses for 5 remote physiologic monitoring codes (99091, 99453, 99454, 99457, 99458), consistent with Medicare Communication Technology Based Services (CTBS) .

SOURCE: Medi-Cal Rates Information. Nov. 2022. (Accessed Dec. 2022).

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

Remote Physiologic Monitoring

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 41. Dec. 2022. (Accessed Feb. 2023).

OTHER RESTRICTIONS

Principle Care Management Services

CPT codes 99424 and 99426 each have a frequency limit of once per calendar month, any provider and 99427 has a frequency limit of two per calendar month, any provider.

Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) services are reimbursable for established patients ages 21 and older.

CPT code 99453 is reimbursable once per episode of care but cannot be used for monitoring fewer than 16 days during a 30-day billing period. The interactive communication required for 99457 must be real-time synchronous with two-way audio with a minimum of 20 minutes per month and the patient must have a treatment plan for chronic care management. For additional information regarding minimum duration of service and definition of episode care, refer to the CPT book.

The frequency limit for 99453, 99454 and 99091 is one per 30 days, any provider. The frequency limit for 99457 is one per calendar month, any provider. The frequency limit for 99458 is three per interactive communication session.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 39-42. Dec. 2022. (Accessed Feb. 2023).

The department may establish separate fee schedules for applicable health care services delivered via remote patient monitoring or other permissible virtual communication modalities.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

Last updated 02/25/2023

Store and Forward

POLICY

“Asynchronous store-and-forward” means the transmission of a patient’s medical information from an originating site to the health care provider at a distant site. Consultations via asynchronous electronic transmission initiated directly by patients, including through mobile phone applications, are not covered under this policy.

“E-consults” fall under the auspice of store-and-forward. E-consults are asynchronous health record consultation services that provide an assessment and management service in which the patient’s treating health care practitioner (attending or primary) requests the opinion and/or treatment advice of another health care practitioner (consultant) with specific specialty expertise to assist in the diagnosis and/or management of the patient’s health care needs without patient face-to-face contact with the consultant. E-consults between health care providers are designed to offer coordinated multidisciplinary case reviews, advisory opinions and recommendations of care. E-consults are permissible only between health care providers.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 1. (Accessed Feb. 2023).

A health care provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forward, telephonic (audio-only) synchronous interaction, remote patient monitoring, or other virtual communication modalities. The department may provide for specific exceptions to this prohibition, which shall be developed in consultation with affected stakeholders and published in departmental guidance. Additional exceptions apply for audio-only in particular as well. See Email, Phone & Fax Section for audio-only exception information.

SOURCE: Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Feb. 2023).

Brief Virtual Communications and Check-ins

HCPCS code G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 hours, not originating from a related evaluation and management (E/M) service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 10. (Accessed Feb. 2023).

FQHCs/RHCs

Asynchronous store and forward means the transmission of a patient’s medical information from an originating site to the billable provider at a distant site.

A patient may be “established” on an asynchronous store and forward service, if all of the conditions of the “New Patient” requirements in this manual section are met.

Only one visit or store and forward service may be billed at the PPS rate when there is a service payment contract with a non-FQHC/RHC, contractor, or another FQHC or RHC. Conversely, the non-FQHC/RHC or contractor may request fee-for-service reimbursement for a visit or store and forward service directly from the appropriate managed care plan or the Medi-Cal Fiscal Intermediary if no service payment contract exists with the FQHC or RHC.

E-consult is not covered.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 13-15. (Accessed Feb. 2023).

Visits shall also include an encounter between an FQHC or RHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care. A visit described in this clause shall be reimbursed at the applicable FQHC’s or RHC’s per-visit PPS rate to the extent the department determines that the FQHC or RHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter.

An FQHC or RHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:

The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.
The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.

SOURCE: Welfare and Institutions Code 14132.100, as amended by SB 184 (2022 Session) and AB 32 (2022 Session). (Accessed Feb. 2023).

Family PACT

Family PACT telehealth policy mirrors the fee-for-service policy.

SOURCE: CA Department of Health Care Services. Family Planning, Access, Care and Treatment Program. Benefits Manual. Aug. 2022, Pg. 6. (Accessed Feb. 2023).

Managed Care

Existing Medi-Cal covered services may be provided via a telehealth modality (includes store-and-forward) if certain conditions are met (as outlined in fee-for-service manual).

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 19-009: Telehealth Services Policy. Oct. 16, 2019. (Accessed Feb. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

A patient may not be “established” on an asynchronous store and forward service with the exception of a homeless patient. Reimbursement is permitted for an established patient by a billable provider at the distant site.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 9. (Accessed Feb. 2023).

Local Education Agency: Speech Therapy

A telehealth service must use interactive audio, video or data communication to qualify for reimbursement. The qualified service must be in real-time or near real-time (delay in seconds or minutes) to qualify as an interactive two-way transfer of medical data and information between the student and health care provider. Medi-Cal does not reimburse for telephone calls, electronic mail messages or facsimile transmissions.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Aug. 2021. Pg. 3. (Accessed Feb. 2023).

Dental Services

The Department of Health Care Services has opted to permit the use of teledentistry (includes store-and-forward) as an alternative modality for the provision of select dental services. See manual for codes.

SOURCE: CA Department of Health Care Services (DHCS). Medi-Cal Dental Provider Handbook. Jan. 2023 Pg. 4-22 – 4-23. (Accessed Feb. 2023).

ELIGIBLE SERVICES/SPECIALTIES

Modifier GQ must be used for Medi-Cal covered benefits or services, including, but not limited to, teleophthalmology, teledermatology, teledentistry and teleradiology, delivered via asynchronous store and forward telecommunications systems, including e-consults. Only the service(s) rendered from the distant site must be billed with modifier GQ.

The use of modifier GQ does not alter reimbursement for the CPT or HCPCS code billed. For additional information about policy and billing requirements relating to teledentistry, providers may refer to “Teledentistry” in the Medi-Cal Dental Provider Handbook.

For billing purposes, health care providers must ensure that the documentation, typically images, sent via store and forward be specific to the patient’s condition and adequate for meeting the procedural definition and components of the CPT or HCPCS code that is billed. In addition, all services billed via store and forward, including e-consult, are subject to all existing Medi-Cal coverage and reimbursement policies.

E-Consults

A health care provider at the distant site may bill for an e-consult with the CPT code listed below when the benefits or services delivered meet the procedural definition and components of the CPT code as defined by the AMA as well as any requirements described in this section of the Medi-Cal provider manual.

When billing for e-consults, health care providers at the originating and distant sites must clearly document the following information relating to previous and/or pertinent health care services, maintain this information in the patient’s medical record and make it available to DHCS upon request:

A health care provider at the originating site must create and maintain the following: A record that the e-consult is the result of patient care that has occurred or will occur and relates to ongoing patient management; and A record of a request for an e-consult by the health care provider at the originating site.
In order to bill for e-consults, the health care provider at the distant site must create and maintain the following: A record of the review and analysis of the transmitted medical information with written documentation of date of service and time spent; and A written report of case findings and recommendations with conveyance to the originating site.

To bill for e-consults, the health care provider at the distant site (consultant) may use CPT code 99451 in conjunction with the modifier GQ. In accordance with the AMA requirements, CPT code 99451 is not separately reportable or reimbursable if any of the following are true:

The distant site provider (consultant) saw the patient within the last 14 days.
The e-consult results in a transfer of care or other face-to-face service with the distant site provider (consultant) within the next 14 days or next available appointment date of the consultant.
The distant site provider did not spend at least five minutes of medical consultative time, and it did not result in a written report.

If more than one contact or encounter is required to complete the e-consult request, the entirety of the service and cumulative discussion and information review time should be reported only once using CPT code 99451. CPT code 99451 is not reimbursable more than once in a seven-day period for the same patient and health care practitioner. Medi-Cal covered benefits or services provided at the originating site (in-person) with the patient in connection with an e-consult are billed according to standard Medi-Cal policies (without modifier GQ).

E-consults are not applicable for FQHCs, RHCs, or IHS-MOA clinics.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan 2023), Pg. 8-10. (Accessed Feb. 2023).

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Jan. 2023). Pg. 2. (Accessed Feb. 2023).

Managed Care

MCP providers must use the modifiers defined in the Medi-Cal Provider Manual with the appropriate CPT-4 or HCPCS codes when coding for services delivered via telehealth, including asynchronous store and forward telecommunications. Consultations via asynchronous electronic transmission cannot be initiated directly by patients. Electronic consultations (e-consults) are permissible using CPT-4 code 99451, modifier(s), and medical record documentation as defined in the Medi-Cal Provider Manual. E-consults are permissible only between health care providers.

SOURCE: CA Department of Health Care Services (DHCS). All Plan Letter 19-009: Telehealth Services Policy. Oct. 16, 2019. (Accessed Feb. 2023).

Indian Health Services, Memorandum of Understanding Agreement (IHS-MOA)

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 9. (Accessed Feb. 2023).

Vision Care

Teleophthalmology by store-and-forward is covered for three specific CPT codes. Information can be reviewed by a physician or optometrist at a distant site. If the reviewing optometrist identifies a disease or condition requiring consultation or referral pursuant to Section 3041 of the Business and Professions Code, a referral must be made with an appropriate physician and surgeon or ophthalmologist, as required. Teleophthalmology services by store and forward must be billed with modifier GQ (service rendered by store and forward telecommunications system). Only the portion(s) rendered from the distant site (hub) are billed with modifier GQ. The use of modifier GQ does not alter reimbursement for the CPT or HCPCS code billed.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual. (Dec. 2022), Pg. 5-6. (Accessed Feb. 2023).

Dental Services

Reimburses for specific teledentistry codes via store-and-forward (see manual).

SOURCE: CA Department of Health Care Services (DHCS). Medi-Cal Dental Provider Manual. Jan. 2023. Pg. 4-23 – 4-24. (Accessed Feb. 2023).

Opioid Use Disorder Treatment Services

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 47-48 Dec. 2022. (Accessed Feb. 2023).

Drug Medi-Cal Providers

SOURCE: Welfare and Institutions Code 14132.731, as amended by SB 184 (2022 Session). (Accessed Feb. 2023).

GEOGRAPHIC LIMITS

No Reference Found

TRANSMISSION FEE

If billing store and forward, including e-consult, providers at the originating site may bill the originating site fee with HCPCS code Q3014, but may not bill for the transmission fee.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Jan. 2023), Pg. 11. (Accessed Feb. 2023).

FQHC & RHC/IHS-MOA

These sites are not eligible for the facility or transmission fee.

SOURCE: CA Department of Health Care Services (DHCS). Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Jan. 2023. Pg. 8 & Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 12. (Accessed Feb. 2023).

Vision Care

The facility fee is reimbursable to the originating site when billed with HCPCS code Q3014. Transmission costs incurred from providing telehealth services via audio/video communication is also reimbursable for the original site and the consulting provider when billed with HCPCS code T1014. Expenses involving telehealth equipment and telecommunications and transmission costs by Internet service providers will not be reimbursed by Medi-Cal.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual. (Oct. 2022), Pg. 5. (Accessed Feb. 2023).

Dental Care

The originating site and transmission fee and billing rules are not applicable to Safety Net Clinics (Federally Qualified Health Centers, Rural Health Clinics, Indian Health Services Memorandum of Agreement 683 Clinics). For policy and billing information specific to Safety Net Clinics, please refer to those sections of the Medi-Cal Provider Manual (Rural and Ind Health).

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. Jan. 2023. Pg. 4-23. (Accessed Feb. 2023).

Professional Requirements

Last updated 02/25/2023

Cross State Licensing

Physicians need not reside in California, as long as they have a valid, current California license.

Physicians using telehealth technologies to provide care to patients located in California must be licensed in California. Physicians are held to the same standard of care, and retain the same responsibilities of providing informed consent, ensuring the privacy of medical information, and any other duties associated with practicing medicine regardless of whether they are practicing via telehealth or face-to-face, in-person visits.

SOURCE: Medical Board of California. Telehealth Resources. (Accessed Feb. 2023).

All persons engaging in the practice of marriage and family therapy, educational psychology, clinical social work, or professional clinical counseling via telehealth, as defined in Section 2290.5 of the Code, with a client who is physically located in this State must have a valid and current license or registration issued by the Board.

SOURCE: CA Code of Regulations, Title 16, Div. 18, Art. 1, Sec. 1815.5(a). (Accessed Feb. 2023).

In order to provide occupational therapy services via telehealth as defined in Section 2290.5 of the Code, an occupational therapist or occupational therapy assistant providing services to a patient or client in this State must have a valid and current license issued by the Board.

SOURCE: CA Code of Regulations, Title 16, Div. 39, Art. 8, Sec. 4172(a). (Accessed Feb. 2023).

A licensee is permitted to provide psychological health care services via telehealth subject to the laws and regulations of the other jurisdiction where either the licensee and/or the client is located, including, but not limited to, the following circumstances:

To a client at an originating site in this State, as defined in section 2290.5 of the Code, when a licensee is located at a distant site within this State.
To a client who has received services in this State, and who is temporarily located outside of this State.
To a client who is located in this State when a licensee is temporarily located outside of this State.

SOURCE: CA Code of Regulations, Title 16, Div. 13.1, Art. 8, Sec. 1396.8(a). (Accessed Feb. 2023).

Last updated 02/25/2023

Definitions

SOURCE: CA Business & Professions Code Sec. 2290.5. (Accessed Feb. 2023)

Last updated 02/25/2023

Licensure Compacts

No Reference Found

Last updated 02/25/2023

Miscellaneous

Any individual, partnership, corporation or other entity that provides dental services through telehealth shall make available the name, telephone number, practice address and California state license number of any dentist who will be involved in the provision of services to a patient prior to the rendering of services and when requested by a patient.

SOURCE: CA Business and Professions Code, Sec. 1683.1 (Accessed Feb. 2023).

All laws and regulations governing professional responsibility, unprofessional conduct, and standards of practice that apply to a health care provider under the health care provider’s license shall apply to that health care provider while providing telehealth services.

SOURCE: CA Business and Professions Code, Sec. 2290.5. (Accessed Feb. 2023).

An examination, assessment, or evaluation specified, required, or authorized for purposes of involuntary commitments may be conducted using telehealth.

SOURCE: CA Health and Safety Code 1799.111; Welfare and Institutions Code 5150.5 & 5151. (Accessed Feb. 2023).

An associate clinical social worker and a clinical counselor trainee or associate may provide services via telehealth that are in their scope of practice.

SOURCE: CA Business and Professions Code, Secs. 4996.23.2 & 4999.46.3, as amended by AB 1759 (2022 Session). (Accessed Feb. 2023).

On or after July 1, 2023, an applicant for licensure as a marriage and family therapist, educational psychologist, clinical social worker, and professional clinical counselor shall show, as part of the application, that they have completed a minimum of three hours of training or coursework in the provision of mental health services via telehealth, which shall include law and ethics related to telehealth. See statutes for additional details.

SOURCE: CA Business and Professions Code, Secs. 4980.395, 4989.23.1, 4996.27.1, and 4999.67, as proposed to be added by AB 1759 (2022 Session). (Accessed Feb. 2023).

Last updated 02/25/2023

Online Prescribing

Prescribing, dispensing, or furnishing dangerous drugs as defined in Section 4022 without an appropriate prior examination and a medical indication, constitutes unprofessional conduct. An appropriate prior examination does not require a synchronous interaction between the patient and the licensee and can be achieved through the use of telehealth, including, but not limited to, a self-screening tool or a questionnaire, provided that the licensee complies with the appropriate standard of care.

SOURCE: CA Business & Professions Code Sec. 2242 (a). (Accessed Feb. 2023).

Remote Dispensing Site Pharmacies

Remote dispensing site pharmacies are permitted to dispense or provide pharmaceutical care services in medically underserved areas. A supervising pharmacy must provide telepharmacy services to the remote dispensing site pharmacy and shall not be located greater than 150 road miles from the remote dispensing site pharmacy.

SOURCE: CA Business & Professions Code Sec. 4130-4135 (Accessed Feb. 2023).

Occupational Therapy

An occupational therapist shall determine whether an in-person evaluation or in-person interventions are necessary considering: the complexity of the patient’s/client’s condition; his or her own knowledge, skills, and abilities; the nature and complexity of the intervention; the requirements of the practice setting; and the patient’s/client’s context and environment.

SOURCE: CA Code of Regulations, Title 16, Div. 39, Art. 8, Sec. 4172(c). (Accessed Feb. 2023).

Last updated 02/25/2023

Professional Board Standards

CA Board of Occupational Therapy

SOURCE: Title 16, Div. 39, Sec. 4172 (Accessed Feb. 2023).

CA Board of Behavioral Sciences

SOURCE: Title 16, Div. 18, Art. 1, Sec. 1815.5 (Accessed Feb. 2023).

CA Medical Board

Physicians are held to the same standard of care, and retain the same responsibilities of providing informed consent, ensuring the privacy of medical information, and any other duties associated with practicing medicine regardless of whether they are practicing via telehealth or face-to-face, in-person visits.

SOURCE: Medical Board of California. Telehealth Resources. (Accessed Feb. 2023).

CA Board of Psychology

SOURCE: Title 16, Div. 13.1, Art. 8, Sec. 1396.8 (Accessed Feb. 2023)

Federally Qualified Health Center (FQHC)

Last updated 02/26/2023

Definition of Visit

A visit is a face-to-face encounter or an interaction using a telehealth modality (synchronous video, synchronous audio-only or asynchronous store and forward) between an RHC or FQHC recipient and a physician (refer to “Physician Defined” on a previous page in this section), physician assistant, nurse practitioner, certified nurse midwife, clinical psychologist, licensed clinical social worker, marriage and family therapist, licensed acupuncturist, registered dental hygienist or visiting nurse (as defined in Code of Federal Regulations, Title 42, Section 405.2416), hereafter referred to as a “health professional,” to the extent the services are reimbursable under the State Plan and the interactions meet the applicable standards of care.

A face-to-face encounter or an interaction using a telehealth modality with a Comprehensive Perinatal Services Program (CPSP) practitioner also qualifies as a visit. Refer to “CPSP Practitioner Defined” on a previous page in this section.

SOURCE: CA Dept. Health Care Services, Medi-Cal Provider Manual, Part 2: RHCs and FQHCs (Jan. 2023), p. 5. (Accessed Feb. 2023).

An FQHC “visit” means a face-to-face encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, or a visiting nurse. A visit shall also include a face-to-face encounter between an FQHC patient and a comprehensive perinatal practitioner, as defined in Section 51179.7 of Title 22 of the California Code of Regulations, providing comprehensive perinatal services, a four-hour day of attendance at an adult day health care center, and any other provider identified in the state plan’s definition of an FQHC visit. A visit shall also include a face-to-face encounter between an FQHC patient and a dental hygienist, a dental hygienist in alternative practice, or a marriage and family therapist.

A visit shall also include an encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using video synchronous interaction, when services delivered through that interaction meet the applicable standard of care.

A visit shall also include an encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care.

A visit shall also include an encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care.

SOURCE: WIC 14132.100, as amended by SB 184 (2022 Session) – effective January 1, 2023. (Accessed Feb. 2023).

Last updated 02/26/2023

Eligible Distant Site

Yes, see manual for distant site scenarios and billing/reimbursement policies applicable.

The billable provider, employed or under direct contract with an FQHC or RHC can respond from any location, including their home, during a time that they are scheduled to work for the FQHC or RHC.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual (Jan 2023), p. 16-20. (Accessed Feb. 2023).

Last updated 02/26/2023

Eligible Originating Site

Yes, see manual for originating site scenarios and billing/reimbursement policies applicable.

The billable provider, employed or under direct contract with an FQHC or RHC can respond from any location, including their home, during a time that they are scheduled to work for the FQHC or RHC.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.(Jan 2023), p. 15-20. (Accessed Feb. 2023).

Last updated 02/26/2023

Facility Fee

FQHCs are not eligible to bill an originating site fee or transmission charges. The costs of these services should be included in the PPS rate, as applicable.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 12. (Accessed Feb. 2023).

Last updated 02/26/2023

Home Eligible

New Patient – FQHCs and RHCs are not precluded from establishing a new patient relationship through a synchronous video interaction or asynchronous store and forward if all the following conditions are met:

The patient is physically present at an originating site that is a licensed or intermittent site of the FQHC or RHC at the time the service is performed.
The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.
An FQHC or RHC patient who receives telehealth services shall otherwise be eligible to receive in-person services.

Established Patient – A Medi-Cal eligible recipient who meets one or more of the following conditions:

The patient has a health record with the FQHC that was created or updated during a visit that occurred in the clinic or during a synchronous telehealth visit in a patient’s residence or home with a clinic provider and a billable provider at the clinic. The patient’s health record must have been created or updated within the previous three years.
The patient is homeless, homebound or a migratory or seasonal worker (HHMS) and has an established health record that was created from a visit occurring within the last three years that was provided outside the originating site clinic, but within the FQHC’s service area. All consent for telehealth services for these patients must be documented.
The patient is assigned to the FQHC by their Managed Care Plan (MCP) pursuant to a written agreement between the plan and the FQHC.

The billable provider, employed or under direct contract with an FQHC or RHC can respond from any location, including their home, during a time that they are scheduled to work for the FQHC or RHC.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 12, 15 (Accessed Feb. 2023).

FQHC manual refers to fee-for-service policy for the definition of an ‘originating site’:

“Originating site” means a site where a patient is located at the time health care services are provided via a telecommunications system or where the asynchronous store and forward service originates. For purposes of reimbursement for covered treatment or services provided through telehealth, the type of setting where services are provided for the patient or by the health care provider is not limited (Welfare and Institutions Code [W&I Code], Section 14132.72[e]). The type of setting may include, but is not limited to, a hospital, medical office, community clinic or the patient’s home.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2. (Accessed Feb. 2023).

Last updated 02/26/2023

Modalities Allowed

Live Video

Synchronous interaction means a real-time audio-visual, two-way interaction between a new or established patient and an FQHC or RHC billable provider at a distant site.

An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from the FQHC pursuant to the federal Health Resources Services Administration requirements.

A patient may be “established” via synchronous interaction if all of the conditions of the “New Patient” requirements in this manual section are met.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 14. (Accessed Feb. 2023).

SOURCE: WIC 14132.100, as amended by SB 184 (2022 Session) – effective January 1, 2023. (Accessed Feb. 2023).

See: CA Medicaid Live Video

Store and Forward

Asynchronous store and forward means the transmission of a patient’s medical information from an originating site to the billable provider at a distant site.

A patient may be “established” on an asynchronous store and forward service, if all of the conditions of the “New Patient” requirements in this manual section are met.

An e-consult, e-visit, or remote patient monitoring is not a reimbursable telehealth service for FQHCs or RHCs.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 13-15. (Accessed Feb. 2023).

A visit shall also include an encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using an asynchronous store and forward modality, when services delivered through that modality meet the applicable standard of care.

SOURCE: WIC 14132.100, as amended by SB 184 (2022 Session) – effective January 1, 2023. (Accessed Feb. 2023).

See: CA Medicaid Store and Forward

Remote Patient Monitoring

An e-consult, e-visit, or remote patient monitoring is not a reimbursable telehealth service for FQHCs or RHCs.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 13. (Accessed Feb. 2023).

See: CA Medicaid RPM

Audio-Only

An audio-only synchronous interaction is eligible for reimbursement if provided by a billable provider and FQHC or RHC patient.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 14. (Accessed Feb. 2023).

A visit shall also include an encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, clinical psychologist, licensed clinical social worker, visiting nurse, comprehensive perinatal services program practitioner, dental hygienist, dental hygienist in alternative practice, or marriage and family therapist using audio-only synchronous interaction, when services delivered through that modality meet the applicable standard of care.

SOURCE: WIC 14132.100, as amended by SB 184 (2022 Session) – effective January 1, 2023. (Accessed Feb. 2023).

See: CA Medicaid Email, Phone, & Fax

Last updated 02/26/2023

Patient-Provider Relationship

An FQHC is not precluded from establishing a new patient relationship through video synchronous interaction.

An FQHC may not establish a new patient relationship using an audio-only synchronous interaction. Notwithstanding this prohibition, the department may provide for specific exceptions to this prohibition, which shall be developed in consultation with affected stakeholders and published in departmental guidance. Exceptions shall include but not be limited to:

An FQHC or RHC may establish a new patient relationship using an audio-only synchronous interaction when the visit is related to sensitive services, as defined in subdivision (n) of Section 56.05 of the Civil Code, or when the patient requests an audio-only modality or attests they do not have access to video – in accordance with department-specific requirements and consistent with federal and state laws, regulations, and guidance.

An FQHC is not precluded from establishing a new patient relationship through an asynchronous store and forward modality, as defined in subdivision (a) of Section 2290.5 of the Business and Professions Code, if the visit meets all of the following conditions:

The patient is physically present at the FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is performed.
The individual who creates the patient records at the originating site is an employee or contractor of the FQHC, or other person lawfully authorized by the FQHC to create a patient record.
The FQHC determines that the billing provider is able to meet the applicable standard of care.
An FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to HRSA requirements.

SOURCE: WIC 14132.100, as amended by SB 184 (2022 Session) and AB 32 (2022 Session) – effective January 1, 2023. (Accessed Feb. 2023).

The patient is physically present at an originating site that is a licensed or intermittent site of the FQHC or RHC at the time the service is performed.
The individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record.
The FQHC or RHC determines that the billing provider is able to meet the applicable standard of care.
An FQHC or RHC patient who receives telehealth services shall otherwise be eligible to receive in-person services.

Established Patient – A Medi-Cal eligible recipient who meets one or more of the following conditions:

The patient has a health record with the FQHC that was created or updated during a visit that occurred in the clinic or during a synchronous telehealth visit in a patient’s residence or home with a clinic provider and a billable provider at the clinic. The patient’s health record must have been created or updated within the previous three years.
The patient is homeless, homebound or a migratory or seasonal worker (HHMS) and has an established health record that was created from a visit occurring within the last three years that was provided outside the originating site clinic, but within the FQHC’s service area. All consent for telehealth services for these patients must be documented.
The patient is assigned to the FQHC by their Managed Care Plan (MCP) pursuant to a written agreement between the plan and the FQHC.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Jan. 2023. Pg. 12. (Accessed Feb. 2023).

Last updated 02/26/2023

PPS Rate

Telehealth services are billed utilizing existing claiming processes that include billing the appropriate managed care plan first. If applicable, once the managed care plan payment is received, submit the claim to the Med-Cal Fiscal Intermediary for the Prospective Payment System (PPS) rate wrap.

SOURCE: CA Dept. Health Care Services, Medi-Cal Provider Manual, Part 2: RHC and FQHC (Jan. 2023), p. 15. (Accessed Feb. 2023).

Video synchronous and audio-only synchronous visits and visits using an asynchronous store and forward modality shall be reimbursed at the applicable FQHC’s per-visit PPS rate to the extent the department determines that the FQHC has met all billing requirements that would have applied if the applicable services were delivered via a face-to-face encounter and when services delivered through that modality meet the applicable standard of care.

SOURCE: WIC 14132.100, as amended by SB 184 (2022 Session) – effective January 1, 2023. (Accessed Feb. 2023).

Last updated 02/26/2023

Same Day Encounters

Encounters with more than one health care professional and multiple encounters with the same health care professional that take place on the same day and at a single location constitute a single visit. More than one visit may be counted on the same day (which may be at a different location) in either of the following situations:

When a patient, after the first visit, suffers illness or injury that requires another health diagnosis or treatment
When a patient is seen by a health care professional or CPSP practitioner and also receives dental services on the same day

Clinic visits at which the patient receives services “incident to” physician services (for example, a laboratory or X-ray appointment) do not qualify as reimbursable visits.

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Dec. 2020. Pg. 6. (Accessed Feb. 2023).

California

MEDICAID REIMBURSEMENT

PRIVATE PAYER LAW

PROFESSIONAL REQUIREMENTS

FQHCs

STATE RESOURCES

COVID-19

Audio Only Delivery

Cross State Licensing

Easing Consent Requirements

Easing Prescribing Requirements

Miscellaneous

Originating Site

Private Payer

Provider Type

Service Expansion

Private Payer

Definitions

Parity

SERVICE PARITY

PAYMENT PARITY

Requirements

Medicaid

Consent Requirements

Definitions

Email, Phone & Fax

Live Video

POLICY

ELIGIBLE SERVICES/SPECIALTIES

ELIGIBLE PROVIDERS

ELIGIBLE SITES

GEOGRAPHIC LIMITS

FACILITY/TRANSMISSION FEE

Miscellaneous

Out of State Providers

Overview

Remote Patient Monitoring

POLICY

CONDITIONS

PROVIDER LIMITATIONS

OTHER RESTRICTIONS

Store and Forward

POLICY

ELIGIBLE SERVICES/SPECIALTIES

GEOGRAPHIC LIMITS

TRANSMISSION FEE

Professional Requirements

Consent Requirements

Cross State Licensing

Definitions

Licensure Compacts

Miscellaneous

Online Prescribing

Professional Board Standards

Federally Qualified Health Center (FQHC)

Definition of Visit

Eligible Distant Site

Eligible Originating Site

Facility Fee

Home Eligible

Modalities Allowed

Live Video

Store and Forward

Remote Patient Monitoring

Audio-Only

Patient-Provider Relationship

PPS Rate

Same Day Encounters