California

Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

At A Glance
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MEDICAID REIMBURSEMENT

  • Live Video: Yes
  • Store-and-Forward: Yes
  • Remote Patient Monitoring: Yes* (CMS RPM codes)
  • Audio Only: Yes

PRIVATE PAYER LAW

  • Law Exists: Yes
  • Payment Parity: Yes

PROFESSIONAL REQUIREMENTS

  • Licensure Compacts: None
  • Consent Requirements: Yes

FQHCs

  • Originating sites explicitly allowed for Live Video: Yes
  • Distant sites explicitly allowed for Live Video: Yes
  • Store and forward explicitly reimbursed: Yes
  • Audio-only explicitly reimbursed: Yes
  • Allowed to collect PPS rate for telehealth: Yes

STATE RESOURCES

  1. Medicaid Program: Medi-Cal
  2. Program Administrator: California Dept. of Health Care Services (DHCS)
  3. Regional Telehealth Resource Center: California Telehealth Resource Center
Disclaimer

PLEASE NOTE: CCHP is providing the following for informational purposes only. We are not providing legal advice or interpretation of the laws and regulations and policies. CCHP encourages you to check with the appropriate state agency for further information and direction. This information should not be construed as legal counsel. Consult with an attorney if you are seeking a legal opinion.

Last updated 09/06/2022

Audio Only Delivery

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

STATUS: Active, expiration varies depending on policy

STATUS: Active

Medicaid: 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: Active

STATUS: Active, until further notice

STATUS: Active

Medicaid: Narcotic Treatment Program

STATUS: Active, expiration varies depending on policy

Medicaid: Updates to Behavioral Health Information Notice No: 21-046E – Supercedes BHIN No.: 20-009

STATUS: Active

Medicaid: Behavioral Health Information Notice 20-031

STATUS: Active

Medicaid: State Plan Amendment

STATUS: Active

Medicaid 1135 Waiver: Medi-Cal 2020

STATUS: Active, through end of the PHE

Medicaid 1915(c) Waiver: Appendix K HCBS Waiver

STATUS: Active

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

STATUS: Active

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

STATUS: Active

Medicaid 1915(c) Waiver: Multipurpose Senior Services Program

STATUS: Active

STATUS: Active, until 6 months after end of federal PHE

Department of Managed Health Care: Reimbursement for Telehealth Services (APL 20-009)

STATUS: Active

Department of Managed Health Care: Telehealth Services (APL 20-13)

STATUS: Active

Department of Managed Health Care: All Plan Letter (20-032) Continuation of APL 20-013 & 20-009; FAQs

STATUS: Active

STATUS: Enacted

Status: Pending

STATUS: Enacted

Last updated 09/06/2022

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/Policy Update Memo

STATUS: Active, until end of state PHE

Office of the Governor: Executive Order Continues EMS Authority to Approve Out-of-State Personnel

STATUS: Active, until end of state PHE

Last updated 09/06/2022

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

Medical Board of California: FAQ on Internet Prescribing

STATUS: Active

Last updated 09/06/2022

Miscellaneous

STATUS: Active during state emergency

STATUS: Active

STATUS: Active

Medicaid: Behavioral Health Information Notice 20-068

STATUS: Active

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

STATUS: Active, until 6 months after end of federal PHE

Division of Workers’ Compensation: Emergency Rule Allowing Medical-Legal Evaluations via Telehealth/Emergency MLE Regulations Newsline

STATUS: Active until October 18, 2022

Division of Workers’ Compensation: List of Telehealth Services for Calendar Year 2021 (ZIP) – Updated 06/17/2022

STATUS: Active consistent with Medicare updated list

Division of Workers’ Compensation: Order of the Administrative Director – Effective August 1, 2021

STATUS: Active

Division of Workers’ Compensation: Order of the Administrative Director – Effective April 1, 2021

STATUS: Active

Division of Workers’ Compensation: Order of the Administrative Director –Effective October 14, 2020

STATUS: Active

Division of Workers’ Compensation: Order of the Administrative Director – Effective April 15, 2020

STATUS: Active

Emergency Medical Services Authority: Out-of-State Personnel

STATUS: Active, until end of State PHE

Office of the Governor: Executive Order Updating/Extending/Rolling Back COVID-19 Executive Orders

STATUS: Active, policy expirations vary

Last updated 09/06/2022

Originating Site

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

STATUS: Active, expiration varies depending on policy

Last updated 09/06/2022

Private Payer

Department of Managed Health Care: Reimbursement for Telehealth Services (APL 20-009)

STATUS: Active

Department of Managed Health Care: Telehealth Services (APL 20-13)

STATUS: Active

STATUS: Active during state emergency

STATUS: Active

Department of Insurance: Increased Telehealth Access

STATUS: Active

Department of Insurance: Notice regarding Telehealth

STATUS: Active

Department of Insurance:  Maximizing Telehealth

STATUS: Active

Last updated 09/06/2022

Provider Type

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

STATUS: Active, expiration varies depending on policy

Medicaid: Telehealth for Family PACT

STATUS: Active

Medicaid: Teledentistry Guidance

STATUS: Active

Medicaid: Teledentistry FAQs for Medi-Cal Dental Providers During Novel Coronavirus (COVID-19) Restrictions

STATUS: Active

Medicaid:  Telehealth and Virtual Communication

STATUS: Active

Medicaid: Narcotic Treatment Program

STATUS: Active, expiration varies depending on policy

STATUS: Active

Medicaid: Behavioral Health Information Notice 20-055

STATUS: Active

STATUS: Active

STATUS: Active

Medicaid 1115 Waiver: Medi-Cal 2020

STATUS: Active, through end of the PHE

Department of Managed Health Care: Telehealth Services (APL 20-13)

STATUS: Active

Department of Managed Health Care: All Plan Letter (20-032) Continuation of APL 20-013 & 20-009; FAQs

STATUS: Active

SB 184: Permanent Medi-Cal Telehealth Policy Changes/Continues Certain COVID-19 Telehealth Expansions

STATUS: Enacted

AB 32: Exceptions to Certain Permanent Medi-Cal Telehealth Policies

Status: Pending

STATUS: Enacted

Last updated 09/06/2022

Service Expansion

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

STATUS: Active, expiration varies depending on policy

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

STATUS: Active

Medicaid: 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: Narcotic Treatment Program

STATUS: Active, expiration varies depending on policy

STATUS: Active

STATUS: Active

Medicaid: Behavioral Health Information Notice 20-055

STATUS: Active

STATUS: Active

Medicaid 1135 Waiver: Medi-Cal 2020

STATUS: Active, through end of the PHE

Medicaid 1915(c) Waiver: Multiple Section Flexibilities

STATUS: Active

Medicaid 1915(c) Waiver: Appendix K HCBS Waiver

STATUS: Active

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

STATUS: Active

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

STATUS: Active

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

STATUS: Active, until 6 months after end of federal PHE

Department of Managed Health Care: Reimbursement for Telehealth Services (APL 20-009)

STATUS: Active

Department of Managed Health Care: Telehealth Services (APL 20-13)

STATUS: Active

Department of Managed Health Care: All Plan Letter (20-032) Continuation of APL 20-013 & 20-009; FAQs

STATUS: Active

Department of Aging: Guidance for Community-Based Adult Services (CBAS) In Response to COVID-19 Public Health Emergency

STATUS: Active

SB 184: Permanent Medi-Cal Telehealth Policy Changes/Continues Certain COVID-19 Telehealth Expansions

STATUS: Enacted

AB 32: Exceptions to Certain Permanent Medi-Cal Telehealth Policies

Status: Pending

AB 133: Extends COVID-19 Medicaid Waivers and Flexibilities Related to Delivery and Reimbursement of Services via Telehealth until December 31, 2022

STATUS: Enacted

Last updated 09/06/2022

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 Sept. 2022).

 

Last updated 09/06/2022

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(AB 744 – 2019 Legislative Session). (Accessed Sept. 2022).

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 (AB 744, 2019 – Legislative Session). (AB 457, 2021 – Legislative Session). (Accessed Sept. 2022).

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 (AB 744, 2019 – Legislative Session). (AB 457, 2021 – Legislative Session). (Accessed Sept. 2022).

Last updated 09/06/2022

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. (AB 744 – 2019 Legislative Session). (Accessed Sept. 2022).

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 Sept. 2022).

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 (AB 457, 2021 – Legislative Session). (Accessed Sept. 2022).

Last updated 09/06/2022

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 Sept. 2022).

Last updated 09/06/2022

Email, Phone & Fax

Synchronous, Telephone or Other Interactive Audio-only Telecommunications Systems: 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. See manual for audio-only telecommunications system requirements, totality of communication information components, and consent specific to audio-only policy.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (July 2022), Pg. 7. (Accessed Sept. 2022).

Effective January 1, 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 telehealth, including via synchronous audio-only modalities, 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.

A health care provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forwardtelephonic (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.

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. 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.

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). (Accessed Sept. 2022).

FQHCs/RHCs – Effective January 1, 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.

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). (Accessed Sept. 2022).

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 Sept. 2022).

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 and Department guidance.

SOURCE: Welfare and Institutions Code Sec. 14132.723 & 724 (AB 1494 – 2019 Legislative Session). (Accessed Sept. 2022).

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 Sept. 2022).

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. (Aug. 2020). (Accessed Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

Last updated 09/06/2022

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 Sept. 2022). 

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 Sept. 2022).

Effective January 1, 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.

A health care provider may establish a new patient relationship with a Medi-Cal beneficiary via video synchronous interaction consistent with any requirements imposed by the department.

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.

Pursuant to an effective date designated by the department that is no sooner than January 1, 2024, a Medi-Cal 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). (Accessed Sept. 2022).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC) – Effective January 1, 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.

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 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). (Accessed Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).  

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 Sept. 2022). 

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. Pg. 2-3, 5-7.  (Accessed Sept. 2022). 

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.

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.

SOURCE:  CA Department of Health Care Services (DHCS). Dental Provider Handbook. Aug. 2022. Pg. 4-21 – 4-24 (Accessed Sept. 2022). 

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.

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

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 Sept. 2022).


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 Sept. 2022).  

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 (Aug. 2020). Pg. 2. (Accessed Sept. 2022).

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 29. June 2022. (Accessed Sept. 2022).

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 (July 2022). Pg. 7-8. (Accessed Sept. 2022).

Federally Qualified Health Center (FQHC) & Rural Health Clinic (RHC) & 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).  Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. Aug. 2020. Pg. 12.; CA Department of Health Care Services (DHCS).  Indian Health Services, Memorandum of Agreement (MOA) 638, Clinics Manual. Aug. 2020. Pg. 8. (Accessed Sept. 2022). 

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. Aug. 2022. Pg. 4-21 – 4-24. (Accessed Sept. 2022).

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 Sept. 2022).

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 Sept. 2022). 

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. Aug. 2022. Accessed Sept. 2022.

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 Sept. 2022).


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. 2-3. (Accessed Sept. 2022). 

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. 11-12. (Accessed Sept. 2022).

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. Aug. 2020. Pg. 7-8. (Accessed Sept. 2022). 

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. Aug. 2022. Pg. 4-23. (Accessed Sept. 2022). 

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 Sept. 2022).


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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).


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 Sept. 2022). 

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 Sept. 2022).

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. 5,7  (Accessed Sept. 2022).

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. 34-35. April 2022. (Accessed Sept. 2022).

Last updated 09/06/2022

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 Sept. 2022).

Health care providers must inform the patient 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, then this is sufficient for documentation of patient consent and should be kept in the patient’s medical file. The consent shall be documented in the patient’s medical file (B&P Code, Section 2290.5(b)) and be available to the Department of Health Care Services (DHCS) upon request.

SOURCE: CA Department of Health Care Services. Medi-Cal Part 2 General Medicine Manual. Telehealth. (May 2022), Pg. 5. (Accessed Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

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.

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

Last updated 09/06/2022

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.; Welfare and Institutions Code 14132.725, as amended by SB 184 (2022 Session). (Accessed Sept. 2022).

Last updated 09/06/2022

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 09/06/2022

Remote Patient Monitoring

POLICY

Effective July 1, 2021, remote physiologic monitoring​ (RPM) was implemented for fee-for-service and managed care beneficiaries with full scope Medi-Cal or pregnancy-only coverage.

SOURCE: DHCS Telehealth FAQs, Coverage Questions. March 2022. (Accessed Sept. 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: Sec. 14124.12 (f)(1)(B) of the Welfare and Institutions Code. As amended by AB 133, Sec. 380 (2021 Session). (Accessed Sept. 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. Aug. 2022. (Accessed Sept. 2022).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) services 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.

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 41. Aug. 2022. (Accessed Sept. 2022).


OTHER RESTRICTIONS

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.

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: Department of Health Care Services. Evaluation & Management Manual. Page 41-42. Aug. 2022. (Accessed Sept. 2022).

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 Sept. 2022).

Last updated 09/06/2022

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 Sept. 2022).

Effective January 1, 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.

A health care provider shall not establish a new patient relationship with a Medi-Cal beneficiary via asynchronous store and forwardtelephonic (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.

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 Sept. 2022).

FQHCs/RHCs – Effective January 1, 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 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.

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

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).  

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 Sept. 2022). 

Local Education Agency: Speech Therapy

A telehealth service must use interactive audio, video or data communication to qualify for reimbursement, billed with modifier 95 and the appropriate CPT code.

SOURCE: CA Department of Health Care Services (DHCS). Local Education Agency (LEA) Telehealth. Aug. 2021. Pg. 3.  (Accessed Sept. 2022). 

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). Medi-Cal Dental Provider Handbook. Aug. 2022. Pg. 4-21 – 4-23.  (Accessed Sept. 2022). 


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. The use of modifier GQ does not alter reimbursement for the CPT or HCPCS code billed.

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 (July 2022), Pg. 6, 8, 9-10. (Accessed Sept. 2022).

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. (Accessed Sept. 2022).

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 Sept. 2022). 

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 Sept. 2022). 

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. 8-9. (Accessed Sept. 2022).  

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. (Aug. 2020), Pg. 5-6.  (Accessed Sept. 2022).

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. Aug. 2022. Pg. 4-22 – 4-23.  (Accessed Sept. 2022).

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. Aug. 2022. (Accessed Sept. 2022).

Drug Medi-Cal Providers

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 Sept. 2022).


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. (Aug. 2020), Pg. 11. (Accessed Sept. 2022).  

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 Sept. 2022).  

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 Sept. 2022).

Dental Care

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

SOURCE: CA Department of Health Care Services (DHCS). Denti-Cal Manual. Aug. 2022. Pg. 4-23. (Accessed Sept. 2022).

Last updated 09/06/2022

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

Last updated 09/06/2022

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 Sept. 2022)

Last updated 09/06/2022

Licensure Compacts

No Reference Found

Last updated 09/06/2022

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 (AB 1519 – 2019 Legislative Session). (Accessed Sept. 2022).

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 Sept. 2022).

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, as amended by AB 3242 (2020 Session). (Accessed Sept. 2022).

Last updated 09/06/2022

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 Sept. 2022).

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 Sept. 2022).

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 Sept. 2022).

Last updated 09/06/2022

Professional Board Standards

CA Board of Occupational Therapy

SOURCE: Title 16, Div. 39, Sec. 4172 (Accessed Sept. 2022).

CA Board of Behavioral Sciences

SOURCE: Title 16, Div. 18, Art. 1, Sec. 1815.5 (Accessed Sept. 2022).

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 Sept. 2022).

CA Board of Psychology

SOURCE: Title 16, Div. 13.1, Art. 8, Sec. 1396.8 (Accessed Sept. 2022)

Last updated 09/06/2022

Definition of Visit

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 Sept. 2022).

Last updated 09/06/2022

Eligible Distant Site

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

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. (Accessed Sept. 2022).

Last updated 09/06/2022

Eligible Originating Site

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

SOURCE: CA Department of Health Care Services (DHCS). Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHC) Outpatient Services Manual. (Accessed Sept. 2022).

Last updated 09/06/2022

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.

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 Sept. 2022).

Last updated 09/06/2022

Home Eligible

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. Aug. 2020. Pg. 11. (Accessed Sept. 2022).

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 Sept. 2022).

Last updated 09/06/2022

Modalities Allowed

Live Video

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.

  • FQHCs may bill for a telehealth visit if it is medically necessary for a billable provider to be present with a patient during the telehealth visit.
  • FQHCs must submit claims for telehealth services using the appropriate all-inclusive billing code sets and related claims submission requirements. For more information, providers may refer to the Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): Billing Codes section in the appropriate Part 2 manual.

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 Sept. 2022).

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.

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

See: CA Medicaid Live Video


Store and Forward

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

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 Sept. 2022).

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 Sept. 2022).

See: CA Medicaid Store and Forward


Remote Patient Monitoring

No explicit coverage for RPM for FQHCs.

See: CA Medicaid RPM


Audio-Only

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 Sept. 2022).

See: CA Medicaid Email, Phone, & Fax

Last updated 09/06/2022

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.

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 an originating site that is a licensed or intermittent site of the FQHC 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) – effective January 1, 2023. (Accessed Sept. 2022).

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. Aug. 2020. Pg. 11. (Accessed Sept. 2022).

A patient may not be “established” on an asynchronous store and forward service, with the exception of HHMS.

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 Sept. 2022).

Last updated 09/06/2022

PPS Rate

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 Sept. 2022).

Last updated 09/06/2022

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 Sept. 2022).