California

CURRENT STATE LAWS & POLICY

AT A GLANCE

Medicaid Program

Medi-Cal

Program Administrator

California Dept. of Health Care Services (DHCS)

Regional Telehealth Resource Center

California Telehealth Resource Center

Medicaid Reimbursement

Live Video: Yes
Store-and-Forward: Yes
Remote Patient Monitoring: No

Private Payer Law

Law Exists: Yes
Payment Parity: Yes

Professional Requirements

Licensure Compacts:
Consent Requirements: Yes

Last updated 02/28/2021

Audio Only Delivery

Medicaid:  Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus

STATUS: Varies, some expire at end of federal PHE

Medicaid:  DMHC Telehealth Services (APL 20-13)

STATUS: Effective for duration of state of emergency

Medicaid: DMHC Telehealth FAQs

STATUS: Effective for duration of state of emergency

Medicaid: DMHC Reimbursement for Telehealth Services (APL 20-009)

STATUS: Active

Medicaid: DMHC Supplement Letter for APL 19-009

STATUS: Active, until further notice

Medicaid: Teledentistry Guidance

STATUS: Active

Medicaid: Family PACT Guidance for Virtual/Telephonic Communication

STATUS: Permanent

Medicaid: State Plan Amendment

STATUS: Active, ends with termination of PHE

Medicaid: Narcotic Treatment Program

STATUS: Active, expiration varies depending on policy

Medicaid 1135 Waiver: Medi-Cal 2020

STATUS: Active, through date that is 60 days after the end of the PHE

Medicaid 1915(c) Waiver: Appendix K HCBS Waiver

STATUS: Active, until February 28, 2021

Medicaid 1915(c) Waiver: Appendix K Assisted Living Waiver

STATUS: Expired

Medicaid 1915(c) Waiver:  Appendix K HIV/AIDS

STATUS: Expired

Medicaid 1915(c) Waiver: Multipurpose Senior Services Program

STATUS: Expired

Medicaid: Money follows the person

STATUS: Expired

AB 32: Telehealth Access

Status: Pending

Last updated 02/28/2021

Cross State Licensing

Medicaid: Emergency Requirements for Medi-Cal Enrollment

STATUS: Active, until end of national PHE

Emergency Medical Services Authority:  Out-of-State Personnel

STATUS: Active, for duration of emergency

Last updated 02/28/2021

Easing Prescribing Requirements

Medicaid: DHCS COVID-19 Medication-Assisted Treatment and Telehealth

STATUS: Active. Expirations vary.  Federal policies are active during federal state of emergency/PHE

Medicaid: Narcotic Treatment Program

STATUS: Active, expiration varies depending on policy

Last updated 02/28/2021

Miscellaneous

Medicaid: DMHC All Plan Letter (20-007) on Social Distancing Measures

STATUS: Effective for duration of state of emergency

Medicaid: DMHC All Plan Letter (20-032) Continuation of APL 20-013 & 20-009

STATUS: Active, until further notice

Medicaid: Behavioral Health Information Notice 20-068

STATUS: Active

Emergency Medical Services Authority:  Out-of-State Personnel

STATUS: Active, for duration of emergency

Division of Workers’ Compensation: Order of the Administrative Director – Dated October 20, 2020 (effective date October 14, 2020 for 11 newly eligible telehealth codes)

STATUS: Permanent?

Medicaid 1915(c) Waiver: Appendix K Amendment to 1915(c) Home and Community-Based Services waivers and Assisted Living Waivers

STATUS: Expired February 28, 2021

Last updated 02/28/2021

Originating Site

Medicaid:  Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus

STATUS: Varies, some expire at end of federal PHE.

Last updated 02/28/2021

Private Payer

Medicaid:  DMHC Telehealth Services (APL 20-13)

STATUS: Effective for duration of state of emergency

Medicaid: DMHC Reimbursement for Telehealth Services (APL 20-009)

STATUS: Active

Department of Insurance:  Increased Telehealth Access

STATUS: Active, until end of CA State of Emergency

Department of Insurance: Notice regarding Telehealth

STATUS: Active, until end of CA State of Emergency

Department of Insurance:  Maximizing Telehealth

STATUS: Active, until end of CA State of Emergency

Last updated 02/28/2021

Provider Type

Medicaid:  Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus

STATUS: Varies, some expire at end of federal PHE

Medicaid:  DMHC Telehealth Services (APL 20-13)

STATUS: Effective for duration of state of emergency

Medicaid: Telehealth for Family PACT

STATUS: Active

Medicaid:  Telehealth and Virtual Communication

STATUS: Active

Medicaid: State Plan Amendment

STATUS: Active, ends with termination of PHE

Medicaid: Narcotic Treatment Program

STATUS: Active, expiration varies depending on policy

Medicaid: Behavioral Health Information Notice 20-055

STATUS: Active

1115 Waiver: Medi-Cal 2020

STATUS: Active, through date that is 60 days after the end of the PHE

AB 32: Telehealth Access

Status: Pending

Last updated 02/28/2021

Service Expansion

Medicaid:  Medi-Cal Payment for Telehealth and Virtual/Telephonic Communications Relative to the 2019-Novel Coronavirus

STATUS: Varies, some expire at end of federal PHE

Medicaid:  DMHC Telehealth Services (APL 20-13)

STATUS: Effective for duration of state of emergency

Medicaid: DMHC Telehealth FAQs

STATUS: Effective for duration of state of emergency

Medicaid: All Plan Letter 20-004 – Emergency Guidance for Managed Care Plans (revised)

STATUS: Active

Medicaid: DMHC Reimbursement for Telehealth Services (APL 20-009)

STATUS: Active

Medicaid: DMHC Supplement Letter for APL 19-009

STATUS: Active, until further notice

Medicaid: Teledentistry Guidance

STATUS: Active

Medicaid: Family PACT Guidance for Virtual/Telephonic Communication

STATUS: Permanent

Medicaid:  COVID-19 Screening and Testing

STATUS: Active, until further notice

Medicaid:  Telehealth and Virtual Communication

STATUS: Active

Medicaid: State Plan Amendment

STATUS: Active, ends with termination of PHE

Medicaid: Narcotic Treatment Program

STATUS: Active, expiration varies depending on policy

Medicaid: Behavioral Health Information Notice 20-055

STATUS: Active

Office of the Governor: Executive Order on Telehealth

STATUS: Active

Medicaid 1135 Waiver: Medi-Cal 2020

STATUS: Active, through date that is 60 days after the end of the PHE

Medicaid 1915(c) Waiver: Multiple Section Flexibilities

STATUS: Active, until the termination of the PHE

Medicaid 1915(c) Waiver: Appendix K HCBS Waiver

STATUS: Active, until February 28, 2021

Medicaid 1915(c) Waiver: Appendix K Assisted Living Waiver

STATUS: Expired

Medicaid 1915(c) Waiver:  Appendix K HIV/AIDS

STATUS: Expired

AB 32: Telehealth Access

Status: Pending

Last updated 02/28/2021

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 (Aug. 2020). Pg. 1. (Accessed Feb. 2021).

Last updated 02/28/2021

Email, Phone & Fax

E-Consult includes interprofessional telephone/internet/electronic health record assessment and management services.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual.  Telehealth.  (Aug. 2020), Pg. 9. (Accessed Feb. 2021).

Last updated 02/28/2021

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 (Aug. 2020). Pg. 2. (Accessed Feb. 2021). 

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.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 6. (Accessed Feb. 2021).

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. 2020, Pg. 6. (Accessed. Feb. 2021).

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. 2021).  

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

Services rendered via telehealth must be FQHC or RHC 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.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Feb. 2021).

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.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Aug. 2020. Pg. 8.  (Accessed Feb. 2021). 

Local Education Agency:  Speech Therapy

Speech therapy services are reimbursable when performed according to telemedicine guidelines and billed with modifier 95 and the appropriate CPT code.

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.

SOURCE:  CA Department of Health Care Services (DHCS).  Local Education Agency (LEA)Telehealth.  Aug. 2020. Pg. 2-3.  (Accessed Feb. 2021). 

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 when the beneficiary requests it or if the health care provider believes the service is clinically appropriate.

SOURCE:  CA Department of Health Care Services (DHCS).  Denti-Cal Manual.  Nov. 2020. Pg. 4-14.  (Accessed Feb. 2021). 

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. 2021).


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.

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.

SOURCE: CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 6. (Accessed Feb. 2021).  

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal. A Treatment Authorization Request is required.  See manual for applicable codes.

SOURCE:  CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2 & 10. (Accessed Feb. 2021).

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

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.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Feb. 2021). 

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

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.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 8.  (Accessed Feb. 2021). 

Dental Services

Synchronous live transmissions are covered.  Live transmissions are limited to 90 minutes per beneficiary per provider, per day.  They may be provided at the beneficiary’s request or if the health care provider believes the service is clinically appropriate.  All dental information transmitted during the delivery of services 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.  Nov. 2020. Pg. 4-16 & 4-17.  (Accessed Feb. 2021).  

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. (Aug. 2020), Pg. 3. & Department of Health Care Services. Durable Medical Equipment (DME): An Overview. (Sept. 2020), Pg. 6. (Accessed Feb. 2021).

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. 2021). 

Drug Medi-Cal certified providers may receive reimbursement for individual counseling provided through telehealth. However, implementation is dependent on the extent of federal participation and federal approval. The Department of Health Care Services must adopt regulations by July 1, 2022 to implement this section in accordance with the Administrative Procedure Act.

SOURCE: Sec. 14132.731 of the Welfare and Institutions Code. (Accessed Feb. 2021).


ELIGIBLE PROVIDERS

Providers must meet all of the following criteria:

  • The provider rendering covered benefits or services must meet the requirements of B&P 2290.5(a)(3) or equivalent requirements under California law in which the provider is considered licensed (ex: Behavior Analyst Certification Board).
  • Provider 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 (Aug. 2020). Pg. 3. (Accessed Feb. 2021). 

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

Billable providers are eligible to deliver covered FQHC/RHC services.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 11.  (Accessed Feb. 2021).

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

Billable providers 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.  Aug. 2019. Pg. 8.  (Accessed Feb. 2021). 

Dental Services

Enrolled Denti-Cal billing providers may submit documents for services rendered utilizing teledentistry. Allied dental professionals may render limited services via teledentistry so long as such services are within their scope of practice, and are rendered under the general supervision of a licensed dentist.

SOURCE:  CA Department of Health Care Services (DHCS).  Denti-Cal Manual. Nov. 2020. Pg. 4-15.  (Accessed Feb. 2021). 

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. 2021)


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 (Aug. 2020). Pg. 2. (Accessed Feb. 2021).

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

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

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 13.  (Accessed Feb. 2021).

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.  Aug. 2020. Pg. 10.  (Accessed Feb. 2021).


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 (Aug. 2020). Pg. 11. (Accessed Feb. 2021). 

FQHC & RHC/IHS-MOA

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

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Feb. 2021).

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. 2020. Pg. 3.  (Accessed Feb. 2021).

Last updated 02/28/2021

Miscellaneous

Specific documentation requirements apply to substantiate the corresponding technical and professional components of billed CPT or HCPCS codes.  Providers are not required to document a barrier to in-person visit for Med-Cal coverage or to document the cost effectiveness of telehealth or store-and-forward. Providers at the distant site are not required to document cost effectiveness of telehealth to be reimbursed for telehealth or store-and-forward services.  The distant site provider is, however, responsible for billing Medi-Cal for the covered services and supplying the appropriate supporting documentation.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (Aug. 2020), Pg. 4. (Accessed Feb. 2021).

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. 2021).

Medicaid must ensure that all managed care covered services are available and accessible to enrollees of Medicaid managed care plans in a timely manner. Telecommunications technologies 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. (Accessed Feb. 2021). & CA Department of Health Care Services (DHCS).  All Plan Letter 20-003:  Telehealth Services Policy.  Feb. 27, 2020. (Accessed Feb. 2021).

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. 2021).

Last updated 02/28/2021

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. (Aug. 2020), Pg. 3. (Accessed Feb. 2021).

Last updated 02/28/2021

Overview

Medi-Cal allows providers to decide what modality, live video or store-and-forward, 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, 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 for one specific e-consult code.

Last updated 02/28/2021

Remote Patient Monitoring

POLICY

No Reference Found


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

Last updated 02/28/2021

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 (Aug. 2020). Pg. 1. (Accessed Feb. 2021).

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. 2020, Pg. 6. (Accessed. Feb. 2021).  

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. 2021).  

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

Store-and-forward covered for specific specialties for established patients, with the exception of a homeless, homebound or a migratory or seasonal worker (HHMS).  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.  Aug. 2020. Pg. 11-12.  (Accessed Feb. 2021).  

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

Store-and-forward covered for specific specialties for established patients, with the exception of a homeless patient.  E-consult is not covered.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 9.  (Accessed Feb. 2021). 

Local Education Agency:  Speech Therapy

Only interactive telehealth can be billed with modifier 95.

SOURCE:  CA Department of Health Care Services (DHCS).  Local Education Agency (LEA) Telehealth.  Aug. 2020. Pg. 3.  (Accessed Feb. 2021). 

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.

SOURCE:  CA Department of Health Care Services (DHCS).  Denti-Cal Manual.  Nov. 2020. Pg. 4-14.  (Accessed Feb. 2021). 


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 through e-consult. Only the service(s) rendered from the distant site must be billed with modifier GQ.

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.

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.

E-consult code 99451 in conjunction with the GQ modifier (indicating store-and-forward) is reimbursed. For e-consult the following requirements must be met for distant and originating site providers:

  • Originating Site Providers 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
  • Distant Site providers must create and maintain the following:
    • A record of the review and analysis of the transmitted medical information with written documentation of the date of service and time spent; and
    • A written report of case findings and recommendations with conveyance to the originating site.

See manual for instances when e-consult is not reimbursable.

If more than one contact or encounter is required to complete the e-consult request, the entirety of the service and cumulative discussion and review time should be reported only once using CPT code 99451.  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 (Aug. 2020), Pg. 6, 8, 9-10. (Accessed Feb. 2021).

Medi-Cal covers an ‘e-visit’ which are communications between a patient and their provider through an online patient portal. A Treatment Authorization Request is required.  See manual for applicable codes.

SOURCE:  CA Department of Health Care Services.  Medi-Cal Part 2 General Medicine Manual. Telehealth (Aug. 2020). Pg. 2 & 10. (Accessed Feb. 2021).

Managed Care

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. 2021). 

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

Reimbursement is permitted for established patients for teleophthalmology, teledermatology and teledentistry, when it is furnished by a billable provider at the distant site.

Asynchronous store-and-forward reimbursement may not be used to “establish” a patient, with the exception of a homeless, homebound or a migratory or seasonal worker (HHMS).  E-consult is not a reimbursable telehealth service of FQHCs/RHCs.

SOURCE: CA Department of Health Care Services (DHCS).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Feb. 2021). 

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

Reimbursement is permitted for established patients for teleophthalmology, teledermatology and teledentistry, when it is furnished by a billable provider at the distant site.

Asynchronous store-and-forward reimbursement may not be used to “establish” a patient, with the exception of a homeless patient.  E-consult is not a reimbursable telehealth service of IHS-MOA clinics.

SOURCE: CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual.  Aug. 2020. Pg. 9.  (Accessed Feb. 2021).  

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.

SOURCE: CA Department of Health Care Services, Vision Care: Professional Services Manual.  (Aug. 2020), Pg. 5.  (Accessed Feb. 2021).

Dental Services

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

SOURCE:  CA Department of Health Care Services (DHCS).  Denti-Cal Manual.  Nov. 2020. Pg. 4-15.  (Accessed Feb. 2021).


GEOGRAPHIC LIMITS

No Reference Found


TRANSMISSION FEE

The originating site is eligible for a facility fee with HCPCS code Q3014.  A transmission fee is only reimbursed for live video; therefore, store-and-forward is not eligible.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual.  Telehealth.  (Aug. 2020), Pg. 11. (Accessed Feb. 2021).  https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/mednetele.pdf

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.  Aug. 2020. Pg. 8 & Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual.  Aug. 2020. Pg. 12.  (Accessed Feb. 2021).  

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.  (Aug. 2020), Pg. 5.  (Accessed Feb. 2021).

Dental Care

Transmission costs associated with store-and-forward are not reimbursable.

SOURCE:  CA Department of Health Care Services (DHCS).  Denti-Cal Manual. Nov. 2020. Pg.4-15.  (Accessed Feb. 2021).

Last updated 02/28/2021

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 Business & Professions Code Sec. 2290.5. (Accessed Feb. 2021).

 

Last updated 02/28/2021

Parity

SERVICE PARITY

A health care service plan 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, and between the health care service plan and its participating providers or provider groups.

A health care service plan 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, and between the health care service plan and its participating providers or provider groups.

Applies to Medi-Cal Managed Care.

Private payers cannot require that in-person contact occur before covering a telehealth delivered service, but it is subject to the terms and conditions of the contract.

SOURCE: CA Health & Safety Code Sec. 1374.13. (Accessed Feb. 2021).

Recently Passed Legislation

A contract issued, amended, or renewed on or after January 1, 2021, between a health care service plan 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 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 is responsible for reimbursement for the same service through in-person diagnosis, consultation, or treatment. Does not apply to Medi-Cal managed care.

SOURCE: CA Health & Safety Code Sec. 1374.14 & Insurance Code 10123.855 (AB 744 – 2019 Legislative Session). (Accessed Feb. 2021).


PAYMENT PARITY

Recently Passed Legislation

A contract issued, amended, or renewed on or after January 1, 2021, between a health care service plan 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 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 is responsible for reimbursement for the same service through in-person diagnosis, consultation, or treatment. Does not apply to Medi-Cal managed care.

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 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 (AB 744 – 2019 Legislative Session). (Accessed Feb. 2021).

Last updated 02/28/2021

Requirements

A health care service plan 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, and between the health care service plan and its participating providers or provider groups.

A health care service plan 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, and between the health care service plan and its participating providers or provider groups.

Applies to Medi-Cal Managed Care.

SOURCE: CA Health & Safety Code Sec. 1374.13 (AB 744 – 2019 Legislative Session). (Accessed Feb. 2021).

Recently Passed Legislation

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 (AB 744, 2019 – Legislative Session). (Accessed Feb. 2021).

Last updated 02/28/2021

Cross State Licensing

No Reference Found

Last updated 02/28/2021

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 Business & Professions Code Sec. 2290.5. (Accessed Feb. 2021)

Last updated 02/28/2021

Licensure Compacts

No Reference Found

Last updated 02/28/2021

Miscellaneous

Recently Passed Legislation

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 (AB 1519 – 2019 Legislative Session). (Accessed Feb. 2021).

Recently Passed Legislation

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 (AB 1519 – 2019 Legislative Session). (Accessed Feb. 2021).

Recently Passed Legislation

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

SOURCE: AB 3242 (2019-2020 Legislative Session). (Accessed Feb. 2021).

Last updated 02/28/2021

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. 2242.1(a). (AB 1264 – 2019 Legislative Session). (Accessed Feb. 2021).

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 & Professionals Code Sec. 4130-4135 (Accessed Feb. 2021).

Last updated 02/28/2021

Professional Board Standards

CA Board of Occupational Therapy

SOURCE: Title 16, Div. 39, Sec. 4172 (Accessed Feb. 2021).

CA Board of Behavioral Sciences

SOURCE: Title 16, Div. 18, Art. 1, Sec. 1815.5 (Accessed Feb. 2021).