Texas

Last updated 03/16/2023

Consent Requirements

A parent or legal guardian must provide written or verbal consent to the distant site provider to allow any other individual, other than the health professional as required by Texas Government Code §531.0217(c-4)(4) for school-based telemedicine, to be physically present in the distant or patient site environment during a telehealth or telemedicine service with a child.

An adult client must also provide written or verbal consent to the distant site provider to allow any other individual to be physically present in the distant or patient site environment during a telehealth or telemedicine service.

Provider must obtain informed consent from the client, client’s parent, or the client’s legally authorized representative prior to rendering a behavioral health service through a synchronous audio-only technology platform; except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.

The distant site provider must obtain informed consent to treatment from the patient, patient’s parent, or the patient’s guardian prior to rendering a telemedicine medical service.

If a patient has a primary care provider who is not the distant site provider and the patient or their parent or legal guardian provides consent to a release of information, a distant site provider must provide the patient’s primary care provider with the following information:

• A medical record or report with an explanation of the treatment provided by the distant site provider
• The distant site provider’s evaluation, analysis, or diagnosis of the patient

School-Based Setting

The parent or legal guardian of the client provides consent before the service is provided.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 5, 6, 8, 10,& 11  (Mar. 2023). (Accessed Mar. 2023).

If a patient receiving a telemedicine medical service has a primary care physician or provider and consents or, if appropriate, the patient’s parent or legal guardian consents to the notification, the commission shall require that the primary care physician or provider be notified of the telemedicine medical service for the purpose of sharing medical information.  In the case of a service provided to a child in a school-based setting as described by Subsection (c-4), the notification, if any, must include a summary of the service, including exam findings, prescribed or administered medications, and patient instructions.

If a patient receiving a telemedicine medical service in a school-based setting as described by Subsection (c-4) does not have a primary care physician or provider, the commission shall require that the patient’s parent or legal guardian receive:

• The notification required under Subsection (g); and
• A list of primary care physicians or providers from which the patient may select the patient’s primary care physician or provider.

SOURCE: TX Govt. Code Sec. 531.0217. (Accessed Mar. 2023).

For a child receiving telemedicine medical services in a primary or secondary school-based setting, advance parent or legal guardian consent for a telemedicine medical service must be obtained.

The patient’s primary care physician or provider must be notified of a telemedicine medical service, unless the patient does not have a primary care physician or provider.

• The patient receiving the telemedicine medical service, or the patient’s parent or legal guardian, must consent to the notification.
• For a telemedicine medical service provided to a child in a primary or secondary school-based setting, the notification must include a summary of the service, including:
  • exam findings;
  • prescribed or administered medications; and
  • patient instructions.

Telemedicine medical services provided in a school-based setting by a physician, even if the physician is not the patient’s primary care physician or provider, are reimbursed if:

• the physician is enrolled as a Medicaid provider;
• the patient is a child who receives the service in a primary or secondary school-based setting; and
• the parent or legal guardian of the patient provides consent before the service is provided.

SOURCE: TX Admin Code, Title 1, Part 15, Sec. 354.1432, (Accessed Mar. 2023).

Behavioral Analysts Program

A telehealth provider shall obtain client consent before services may be provided through telehealth.  If a client previously consented to in-person services, a telehealth provider shall obtain updated consent to include telehealth services.

SOURCE: TX Admin Code, Title 16, Sec. 121.71, (Accessed Mar. 2023).

Physical Therapy, Occupational Therapy, and Speech Therapy

• The provider should obtain informed consent for treatment from the patient, patient’s parent, or the patient’s legal guardian prior to rendering a telehealth service. Verbal consent is permissible and should be documented in the client’s medical record.

SOURCE: TX Medicaid Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook pg. 9 (Mar. 2023). (Accessed Mar. 2023).

Last updated 03/16/2023

Definitions

Teledentistry

“Teledentistry dental service” means a health care service delivered by a dentist, or a health professional acting under the delegation and supervision of a dentist, acting within the scope of the dentist’s or health professional’s license or certification to a patient at a different physical location than the dentist or health professional using telecommunications or information technology.

SOURCE: Insurance Code Title 8, Subtitle F, Ch. 1455.001 refers to Occupations Code, Sec. 111.001. (Accessed Mar. 2023).

 “Telehealth service” means a health service, other than a telemedicine medical service or a teledentistry dental service, delivered by a health professional licensed, certified, or otherwise entitled to practice in this state and acting within the scope of the health professional’s license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.

“Telemedicine medical service” means a health care service delivered by a physician licensed in this state, or a health professional acting under the delegation and supervision of a physician licensed in this state, and acting within the scope of the physician’s or health professional’s license to a patient at a different location than the physician or health professional using telecommunications or information technology.

SOURCE: TX Admin. Code, Title 1 Sec. 354.1430, & TX Government Code, Sec. 531.001  refers to Occupations Code, Sec. 111.001. (Accessed Mar. 2023).

 Texas Medicaid managed care organiziations (MCOs) are prohibited from denying reimbursement for covered services solely because they are delivered remotely. MCOs must consider reimbursement for all medically necessary Medicaid-covered services that are provided using telemedicine or telehealth.

SOURCE: TX Medicaid Telecommunication Services Handbook, Mar. 2023, p. 5 (Accessed Mar. 2023).

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 7 & 12 (Mar. 2023). (Accessed Mar. 2023).

Standards of Care in Crisis Stabilization Units

Telehealth service–A health-care service, other than telemedicine medical services, delivered by a health professional licensed, certified or otherwise entitled to practice in Texas and acting within the scope of the health professional’s license, certification or entitlement to an individual at a different physical location other than the health professional using telecommunications or information technology.

SOURCE: TX Admin Code, Title 26, Part 1, Ch. 306, Subchapter B, Sec. 306.45, (Accessed Dec. 2022).

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 5 (Mar. 2023), (Accessed Mar. 2023).

Last updated 12/13/2022

Email, Phone & Fax

Telemedicine medical services and telehealth services are authorized service delivery methods for Texas Medicaid covered services as provided in this section. All telemedicine medical services and telehealth services are subject to the specifications, conditions, limitations, and requirements established by the Texas Health and Human Services Commission (HHSC) or its designee.

• A client must not be required to receive a covered service as a telemedicine medical service or telehealth service except in the event of an active declaration of state of disaster and at the direction of HHSC.
• In the event of a declaration of state of disaster, HHSC may issue direction to providers regarding the use of telemedicine medical services and telehealth services, including the use of an audio-only platform, to provide covered services to clients who reside in the area subject to the declaration of state of disaster.
• HHSC considers the following criteria when determining whether a covered service may be delivered as telemedicine medical service or telehealth service, including via an audio-only platform:
  • Clinical effectiveness;
  • Cost effectiveness;
  • Health and safety;
  • Patient choice and access to care; and
  • Other criteria specific to the service.

Conditions for reimbursement applicable to behavioral health services provided through an audio-only platform are described in this section.

• The provider must be enrolled in Texas Medicaid.
• The provider must obtain informed consent from the client, client’s parent, or the client’s legally authorized representative prior to rendering a behavioral health service via an audio-only platform; except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.
• The covered services must be provided in compliance with the standards established by the respective licensing or certifying board of the professional providing the audio-only telemedicine medical service or audio-only telehealth service.
• Behavioral health services provided via audio-only platform must be designated for reimbursement by HHSC. Behavioral health services provided via an audio-only platform designated for reimbursement are those that are clinically effective and cost-effective, as determined by HHSC and in accordance with §354.1432(3) of this subchapter (relating to Telemedicine and Telehealth Benefits and Limitations). Behavioral health services that HHSC has determined are clinically effective and cost-effective when provided via an audio-only platform can be found in the Texas Medicaid Provider Procedures Manual (TMPPM).

• Synchronous audio-only technology between the distant site provider and the client in another location

Synchronous audio-only, also called synchronous telephone (audio-only), technology – An interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of the Health Insurance Portability and Accountability Act.

Conditions for reimbursement applicable to behavioral health services provided using a synchronous audio-only technology platform are those that meet the following conditions:

• Must be designated for reimbursement by HHSC.
• Provider must obtain informed consent from the client, client’s parent, or the client’s legally authorized representative prior to rendering a behavioral
• health service through a synchronous audio-only technology platform; except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.
• Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
  May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audio-only technology platform to receive reimbursement for the service.
• Other conditions for reimbursement applicable to behavioral health services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on audio-only coverage conditions.

Conditions for reimbursement applicable to non-behavioral health services provided using a synchronous audio-only technology platform:

• Must be designated for reimbursement by HHSC.
• Clinically effective and cost-effective, as determined and published by HHSC.
• May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audio-only technology platform to receive reimbursement for the service.

Note: Behavioral or non-behavioral health services that HHSC has determined are clinically effective and cost-effective when provided via a synchronous audio-only technology platform can be found in the appropriate TMPPM handbooks.

Procedure codes that are reimbursed to distant site providers when billed with the 93 modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the 93 modifier.

Behavioral health procedure codes that are reimbursed to distant site providers when billed with the FQ modifier (audio-only services) are included in the individual TMPPM handbooks. Procedure codes that indicate telephone or audio-only delivery in their description do not need to be billed with the FQ modifier.

See manual for codes MCOs must reimburse when delivered via telemedicine services.

Texas Medicaid MCOs may optionally provide reimbursement for telemedicine services that are provided through asynchronous audio-only technology, such as voice mail technology. Distant site providers should contact each MCO to determine whether an MCO provides reimbursement for a specified modality.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6-7, 8, & 12 (Mar. 2023). (Accessed Mar. 2023).

The following delivery methods may be used to provide telemedicine within fee-for-service (FFS) Medicaid:

• Synchronous audiovisual technology between the distant site provider and the client in another location
• Synchronous audio-only technology between the distant site provider and the client in another location
• Store and forward technology in conjunction with synchronous audio-only technology between the distant site provider and the client in another location. The distant site provider must use one of the following:
  • Clinically relevant photographic or video images, including diagnostic images
  • The client’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories

A Texas Medicaid Managed Care organization (MCO) is not required to provide reimbursement for telemedicine services that are provided through the following methods:

• A text-only email message
• A facsimile transmission

Texas Medicaid MCOs may optionally provide reimbursement for telemedicine services that are provided through asynchronous audio-only technology, such as voice mail technology. Distant site providers should contact each MCO to determine whether an MCO provides reimbursement for a specified modality.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 9 & 12-13 (Mar. 2023). (Accessed Mar. 2023).

Mental Health Rehabilitative Services

The following MHR services may be provided by by synchronous telephone (audio-only) technology to persons with whom the treating provider has an existing clinical relationship and if clini- cally appropriate and safe, as determined by the provider, and agreed to by the person receiving services or LAR. In addition, except for crisis intervention services, approval to deliver the services by synchronous telephone (audio-only) technology must be documented in the plan of care of the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. MHR services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. See manual for procedure codes and additional requirements.

• Medication training and support
• Skills training and development
• Psychosocial rehabilitation services
• Crisis intervention services

Synchronous telephone (audio-only) technology may only be used for crisis intervention services as a back-up mode of delivery only, meaning if the person who is in crisis, not the treating provider, is unwilling or has limited technological capabilities that prevent them from using a synchronous audiovisual platform at the time the crisis intervention services are delivered. Also, the existing clinical relationship requirement is waived.

Peer Specialist Services

Peer specialist services may be provided by synchronous telephone (audio-only) technology to persons with whom the peer specialist has an existing clinical relationship and if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. In addition, approval to deliver the services by synchronous telephone (audio-only) technology must be documented in the person-centered recovery plan of the person receiving services.

Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. Peer specialist services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.

An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual peer specialist service from the same provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology. The six-month requirement for at least one in-person or synchronous audiovisual service prior to the initial synchronous telephone (audio-only) service may not be waived.

The provider is required to conduct at least one in-person or synchronous audiovisual peer specialist service every rolling 12 months from the date of the initial service delivered by synchronous telephone (audio-only) technology unless the person receiving services and the provider agree that an in-person or synchronous audiovisual service is clinically contraindicated, or the risks or burdens of an in-person or synchronous audiovisual service outweigh the benefits. The decision to waive the 12- month requirement applies to that particular rolling 12-month period and the basis for the decision must be documented in the person’s medical record. Examples of when a synchronous telephone (audio-only) service may be more clinically appropriate or beneficial than an in-person or synchronous audiovisual service include, but are not limited to, the following:

• The person receiving services is located at a qualifying originating site in an eligible geographic area, e.g., a practitioner office in a rural Health Professional Shortage Area.
• An in-person or synchronous audiovisual service is likely to cause disruption in service delivery or has the potential to worsen the person’s condition.

See manual for additional information.

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

SBIRT services may be provided by synchronous telephone (audio-only) technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. SBIRT services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.  See manual for additional information.

Medication Assisted Treatment Services

The following SUD services may be provided by synchronous telephone (audio-only) technology to persons with whom the treating provider has an existing clinical relationship and if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. SUD services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.

• Comprehensive assessment (procedure code H0001) – Only during certain public health emergencies or natural disasters; to the extent allowed by federal law (assessments for withdrawal management services are excluded); and the existing clinical relationship requirement is waived.
• Individual and group counseling (procedure codes H0004 and H0005)

See manual for additional requirements.

SOURCE: TX Medicaid Behavioral Health and Case Management Services Handbook, pgs. 32, 50, 59, 73, 80-81, & 89,  (Mar. 2023). (Accessed Mar. 2023).

A cardiac rehabilitation program in which the cardiac monitoring is done using telephonically transmitted electrocardiograms (ECGs) to a remote site is not a benefit of Texas Medicaid.

SOURCE: TX Medicaid Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, pg. 65. (Mar. 2023). (Accessed Mar. 2023).

To the extent permitted by state and federal law and to the extent it is cost-effective and clinically effective, as determined by the commission, the executive commissioner by rule shall develop and implement a system that ensures behavioral health services may be provided using an audio-only platform consistent with Section 111.008, Occupations Code, to a Medicaid recipient, a child health plan program enrollee, or another individual receiving those services under another public benefits program administered by the commission or a health and human services agency.

If the executive commissioner determines that providing services other than behavioral health services is appropriate using an audio-only platform under a public benefits program administered by the commission or a health and human services agency, in accordance with applicable federal and state law, the executive commissioner may by rule authorize the provision of those services under the applicable program using the audio-only platform. In determining whether the use of an audio-only platform in a program is appropriate under this subsection, the executive commissioner shall consider whether using the platform would be cost-effective and clinically effective.

SOURCE: TX Government Code Title 4, Subtitle I, Chapter 531, Subchapter A, Sec. 531.02161. (Accessed Mar. 2023).

Telehealth Exclusions

Any PT, OT, ST, and SST services delivered through synchronous telephone (audio-only) technology is not a benefit.

During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of a telehealth service to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.

See Children’s Services Handbook for a list of procedure codes that are in-person only and will not be reimbursed if provided through telehealth delivery.

Health and Behavior Assessment and Intervention

HBAI services may be provided by synchronous telephone (audio-only) technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit, as well as the use of synchronous audiovisual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. HBAI services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ. See manual for eligible services and additional requirements.

Medical Nutrition Counseling Services (CCP)

Counseling and psychological telehealth services provided by LEAs during school hours through SHARS may also be delivered via synchronous telephone (audio-only) technologies.

Synchronous telephone (audio-only) technology is defined as an interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of HIPAA.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, pgs. 28, 30, 32 & 33 (Mar. 2023). (Accessed Mar. 2023).

SOURCE: TX Medicaid Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook pg. 10, (Mar. 2023). (Accessed Mar. 2023).

Healthy Texas Women Program

Certain telemedicine and telehealth services may be provided for HTW clients if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interactions, such as an in-person visit, as well as the use of synchronous audio-visual technology over synchronous telephone (audio-only) technology of telemedicine and telehealth services. Therefore, providers must document in the person’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology.

Last updated 03/16/2023

Live Video

POLICY

Synchronous audiovisual technology – An interactive, two-way audio and video telecommunications platform that meets the privacy requirements of the Health Insurance Portability and Accountability Act.

Synchronous audiovisual technology between the distant site provider and the client in another location is reimbursable under Texas Medicaid fee-for-service.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 1 & 12 (Mar. 2023), (Accessed Mar. 2023).

The executive commissioner by rule shall develop and implement a system to reimburse providers of services under Medicaid for services performed using telemedicine medical services, teledentistry dental services, or telehealth services.

SOURCE: TX Govt. Code Sec. 531.0216. (Accessed Mar. 2023).

Provider reimbursement for telemedicine services must be at the same rate as Medicaid reimburses for the same in-person medical service.  A request for reimbursement may not be denied solely because an in-person medical service between a physician and a patient did not occur.  The commission may not limit a physician’s choice of platform for providing a telemedicine medical service or telehealth service by requiring that the physician use a particular platform to receive reimbursement for the service.

SOURCE: TX Govt. Code Sec. 531.0217(d). (Accessed Mar. 2023).

Telemedicine and telehealth services are reimbursed in accordance with 1 TAC §355.

In the event of a Declaration of State of Disaster, HHSC will issue direction to providers regarding the use of telemedicine or telehealth services to include the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described herein to the extent permitted by Texas law.

Declaration of State of Disaster is when to an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Texas Government Code §418.014.

A valid practitioner-patient relationship must exist between the distant site provider and the patient receiving telemedicine services. A valid practitioner-patient relationship exists between the distant site provider and the patient if:

• The distant site provider meets the same standard of care required for and in-person service.
• The relationship can be established through:
  • A prior in-person service.

SOURCE: TX Medicaid Telecommunication Services Handbook, Mar. 2023, p. 5, 7 & 8 (Accessed Mar. 2023).

The following delivery methods may be used to provide telemedicine within fee-for-service (FFS) Medicaid:

• Synchronous audiovisual technology between the distant site provider and the client in another location
• Synchronous audio-only technology between the distant site provider and the client in another location
• Store and forward technology in conjunction with synchronous audio-only technology between the distant site provider and the client in another location. The distant site provider must use one of the following:
  • Clinically relevant photographic or video images, including diagnostic images
  • The client’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 9, & 13, (Mar. 2023). (Accessed Mar. 2023).

Eligible distant site providers are reimbursed in the same manner as their other professional services.  See administrative code for each provider type and the reference for the code under which TX Medicaid pays in the same manner of.

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001, (Accessed Mar. 2023).

Telemedicine:  Texas health and human services agencies that administer a part of Medicaid are required to provide Medicaid reimbursement for a telemedicine service initiated or provided by a physician. Reimbursement is provided only for a telemedicine medical service initiated or provided by a physician.

A request for reimbursement may not be denied solely because an in-person medical service between a physician and a patient did not occur. Medicaid cannot limit a physician’s choice of platform for providing a telemedicine or telehealth service by requiring the use of a particular platform to receive reimbursement.

Medicaid reimbursement is provided to a physician for a telemedicine medical service provided by the physician, even if the physician is not the patient’s primary care physician or provider, if:

• The physician is an authorized health care provider under Medicaid;
• The patient is a child who receives the services in a primary or secondary school-based setting; and
• The parent or legal guardian of the patient provides consent before the services is provided.

SOURCE: TX Govt. Code Sec. 531.0217, (Accessed Mar. 2023).

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ELIGIBLE SERVICES/SPECIALTIES

Telemedicine medical services and telehealth services are authorized service delivery methods for Texas Medicaid covered services as provided in this section. All telemedicine medical services and telehealth services are subject to the specifications, conditions, limitations, and requirements established by the Texas Health and Human Services Commission (HHSC) or its designee.

• A client must not be required to receive a covered service as a telemedicine medical service or telehealth service except in the event of an active declaration of state of disaster and at the direction of HHSC.
• In the event of a declaration of state of disaster, HHSC may issue direction to providers regarding the use of telemedicine medical services and telehealth services, including the use of an audio-only platform, to provide covered services to clients who reside in the area subject to the declaration of state of disaster.
• HHSC considers the following criteria when determining whether a covered service may be delivered as telemedicine medical service or telehealth service, including via an audio-only platform:
  • Clinical effectiveness;
  • Cost effectiveness;
  • Health and safety;
  • Patient choice and access to care; and
  • Other criteria specific to the service.

Conditions for reimbursement applicable to telemedicine medical services.

• The provider must be enrolled in Texas Medicaid.
• The covered services must be provided in compliance with Texas Occupations Code Chapter 111 and Title 22 Texas Administrative Code Chapter 174 (relating to Telemedicine).
• A telemedicine medical service must be designated for reimbursement by HHSC. Telemedicine medical services designated for reimbursement are those that are clinically effective and cost-effective, as determined by HHSC and in accordance with paragraph (3) of this section. Covered services that HHSC has determined are clinically effective and cost-effective when provided as a telemedicine medical service can be found in the Texas Medicaid Provider Procedures Manual (TMPPM).

Conditions for reimbursement applicable to telehealth services.

• The provider must be enrolled in Texas Medicaid.
• The covered services must be provided in compliance with Texas Occupations Code Chapter 111 and standards established by the respective licensing or certifying board of the professional providing the telehealth service.
• Telehealth services must be designated for reimbursement by HHSC. Telehealth services designated for reimbursement are those that are clinically effective and cost-effective, as determined by HHSC and in accordance with paragraph (3) of this section. Covered services that HHSC has determined are clinically effective and cost-effective when provided as a telehealth service can be found in the TMPPM.

Telemedicine & Telehealth

Not all Medicaid-covered services are authorized by HHSC for telemedicine or telehealth delivery in fee-for-service. Providers must always ensure the covered service is allowable by HHSC for telemedicine or telehealth services delivery.

Note: For example, if a service is authorized for telemedicine or telehealth delivery only when using synchronous audiovisual technology, that service may not be delivered using store and forward technology, store and forward technology in conjunction with synchronous audio-only technology, synchronous audio-only technology, or asynchronous audio-only technology.

Telemedicine or telehealth may be provided if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6, (Accessed Mar. 2023).

Texas Medicaid reimburses for telemedicine and telehealth codes specified in the TX Medicaid Provider Procedures Manual. See individual manuals for reimbursable services provided through telehealth.

Telemedicine medical services, also known as telemedicine, are allowable for Texas Medicaid. Telemed- icine has the meaning assigned by Texas Occupations Code §111.001. Telemedicine services are defined as health-care services delivered by a physician licensed in Texas or a health professional who acts under the delegation and supervision of a health professional licensed in Texas and within the scope of the health professional’s license to a client at a different physical location using telecommunications or information technology. Telemedicine excludes teledentistry services.

Telehealth services, also known as telehealth, are allowable for Texas Medicaid. Telehealth has the meaning assigned by Texas Occupations Code §111.001. Telehealth services are defined as health-care services, other than telemedicine medical services or a teledentistry service, delivered by a health profes- sional licensed, certified or otherwise entitled to practice in Texas and acting within the scope of the health professional’s license, certification or entitlement to a patient at a different physical location other than the health professional using telecommunications or information technology.

Telehealth services are reimbursed in accordance with 1 TAC §355.

Telemedicine and telehealth services must be provided in compliance with standards established by the respective licensing or certifying board of the professional providing the services.

The use of telemedicine and telehealth services within intermediate care facilities for individuals with intellectual disabilities (ICD-IID) and State Supported Living Centers is subject to the policies established by the Health and Human Services Commission (HHSC).

More than one medically necessary telemedicine service or telehealth service may be reimbursed for the same date and same place of service if the services are billed by providers of different specialties.

Procedure codes that are reimbursed to distant site providers when billed with the 95 modifier (synchronous audiovisual technology) are included in the individual TMPPM handbooks. Procedure codes that indicate remote (telemedicine) delivery in the description do not need to be billed with the 95 modifier.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 4, 6-7, 8, 11 & 12 (Mar. 2023). (Accessed Mar. 2023).

Conditions for reimbursement applicable to telemedicine and telehealth provided using a synchronous audiovisual technology platform, or using store and forward technology in conjunction with synchronous audio-only are those that meet the following conditions:

• Must be designated for reimbursement by HHSC.
• Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
• May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audiovisual technology platform to receive reimbursement for the service.

Other conditions for reimbursement applicable to services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on synchronous audiovisual technology platform coverage conditions.

Telemedicine and telehealth services that HHSC has determined are clinically effective and cost-effective when provided via a synchronous audiovisual technology platform or using store and forward technology in conjunction with synchronous audio-only technology can be found in the appropriate TMPPM handbooks.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 6. (Mar. 2023). (Accessed Mar. 2023).

To the extent permitted by federal law and to the extent it is cost-effective and clinically effective, as determined by the commission, the commission shall ensure that Medicaid recipients, child health plan program enrollees, and other individuals receiving benefits under a public benefits program administered by the commission or a health and human services agency, regardless of whether receiving benefits through a managed care delivery model or another delivery model, have the option to receive services as telemedicine medical services, telehealth services, or otherwise using telecommunications or information technology, including the following services:

• preventive health and wellness services;
• case management services, including targeted case management services;
• subject to Subsection (c), behavioral health services;
•  occupational, physical, and speech therapy services;
• nutritional counseling services; and
• assessment services, including nursing assessments under the following Section 1915(c) waiver programs:
  • the community living assistance and support services (CLASS) waiver program;
  • the deaf-blind with multiple disabilities (DBMD) waiver program;
  • the home and community-based services (HCS) waiver program; and
  • the Texas home living (TxHmL) waiver program.

SOURCE:  TX Statute Sec. 531.02161, (Accessed Mar. 2023).

The commission by rule shall require each health and human services agency that administers a part of the Medicaid program to provide Medicaid reimbursement for teledentistry dental services provided by a dentist licensed to practice dentistry in this state.

The commission shall require reimbursement for a teledentistry dental service at the same rate as the Medicaid program reimburses for the same in-person dental service. A request for reimbursement may not be denied solely because an in-person dental service between a dentist and a patient did not occur. The commission may not limit a dentist’s choice of platform for providing a teledentistry dental service by requiring that the dentist use a particular platform to receive reimbursement for the service.

SOURCE: TX Govt. Code Sec. 531.02172, (Accessed Mar. 2023)

Outpatient Mental Health Services

The following outpatient mental health services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Outpatient mental health services provided by synchronous audiovisual technology must be billed using modifier 95.

The following SUD services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. SUD services provided by synchronous audiovisual technology must be billed using modifier 95. See manual for procedure codes.

• Comprehensive assessment
• Individual and group counseling
• MAT services – Prescribing of certain MAT medications may be done via telemedicine presuming all other applicable state and federal laws and regulations are followed.

SOURCE:  TX Medicaid Behavioral Health and Case Management Svcs. Handbook, pgs. 31, 50, 59 & 73, 80 & 89 (Mar. 2023). (Accessed Mar. 2023).

The following procedure codes may be provided through telehealth delivery using synchronous audiovisual technology:

• Specialized skills training (SST)
• Targeted case management (TCM)
• Physical therapy (PT) evaluations and reevaluations
• Occupational therapy (OT) evaluations and reevaluations
• PT and OT treatments

Health and Behavior Assessment and Intervention

HBAI services may be provided by synchronous audiovisual technology if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. HBAI services provided by synchronous audiovisual technology must be billed using modifier 95. See manual for eligible services.

Medical Nutrition Counseling Services (CCP)

Synchronous audio-visual technology may be provided using procedure code S9470 if clinically appropriate and safe, as determined by the provider, and agreed to by the client receiving services. Services provided by synchronous audio-visual technology must be billed using modifier 95.

Medical Checkups During a Declaration of State Disaster

The following limitations apply to all THSteps preventive medical checkups and exception-to-periodicity checkups during a Declaration of State Disaster when HHSC issues direction regarding the use of synchronous audiovisual and synchronous telephone (audio-only) technologies:

• Clients who are 2 years through 20 years of age may receive a THSteps medical checkup or exception-to-periodicity checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies.
• Clients from birth through 2 years of age may not receive a THSteps checkup or exception-to-periodicity checkup using synchronous audiovisual or synchronous telephone (audio-only) technologies.
• Clients from birth through 24 months of age must receive in-person checkups.

A medical checkup provided using synchronous audiovisual or synchronous telephone (audio-only) technologies must be completed according to the age-specific checkup requirements listed on the THSteps Periodicity Schedule.

Synchronous audiovisual delivery for medical checkups is preferred over synchronous telephone (audio-only) delivery.

An in-person THSteps follow-up visit must be completed within six months of the synchronous audiovisual or synchronous telephone (audio-only) checkup in order for the checkup to be considered a complete THSteps checkup.

THSteps providers should use their clinical judgement regarding which checkup components may be appropriate for completion using synchronous audiovisual or synchronous telephone (audio-only) technologies.

See Children’s Services Handbook for additional information and a list of procedure codes.

SOURCE:  TX Medicaid Children’s Services Handbook, pgs. 57, 66 & 72, (Mar. 2023), (Accessed Mar. 2023).

Treatment of a client for chronic pain with scheduled drugs using telemedicine is prohibited, as provided by 22 TAC §174.5(e). Chronic pain is defined in 22 TAC §170.2(2).

Treatment of a client for acute pain with scheduled drugs using telemedicine is permitted, as provided by 22 TAC §174.5(e). Acute pain is defined by 22 TAC §170.2(2).

All physicians must comply by 22 TAC §174.5 when issuing prescriptions through a telemedicine service.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 10, (Mar. 2023). (Accessed Mar. 2023).

LEAs that participate in the SHARS program may be reimbursed for telehealth occupational therapy (OT), physical therapy (PT), speech therapy (ST), counseling, and psychological services. All other reimbursement and billing guidelines that are applicable to in-person services will also apply when OT, PT, ST, counseling, and psychological services are delivered as telehealth services. OT, PT, ST, counseling, and psychological telehealth services provided by LEAs during school hours through SHARS may be delivered via synchronous audiovisual technologies.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, pg. 27, 28, 31 & 32  (Mar. 2023). (Accessed Mar. 2023).

Pre-admission assessments for admission into a crisis stabilization unit can be conducted either in person or through telemedicine. The additional assessments needed for children and adolescents can also be done through telehealth or telemedicine medical services.

SOURCE: TX Admin Code, Title 26, Part 1 Ch. 306, Sec. 306.67, (Accessed Mar. 2023).

In providing covered benefits to a child with special health care needs, a health plan provider must permit benefits to be provided through telemedicine medical services, teledentistry dental services, and telehealth services in accordance with policies developed by the commission.  See statute for additional requirements.

SOURCE: TX Statute 62.157 (Accessed Mar. 2023).

Federally Qualified Health Center Services Reimbursement

A visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, visiting nurse, a qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exist:

After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or

The FQHC patient has a medical visit and an “other” health visit, as defined in paragraph (13) of this subsection.

A medical visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, or visiting nurse. An “other” health visit includes, but is not limited to, a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a Texas Health Steps Medical Screen.

SOURCE: TX Admin Code, Title 1, Part 15, Ch. 355 Subchapter J, 355. 8261. (Accessed Mar. 2023).

Physical Therapy, Occupational Therapy, and Speech Therapy

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ELIGIBLE PROVIDERS

Telemedicine Services

Telemedicine eligible distant site providers are enrolled as a Texas Medicaid provider and are a:

• Physician
• Clinical Nurse Specialist (CNS)
• Nurse Practitioner (NP)
• Physician Assistant (PA)
• Certified Nurse Midwife (CNM)
• Federally Qualified Health Center (FQHC) (in manual only)

A distant site provider is the physician, or PA, NP, or CNS who is supervised by and has delegated authority from a licensed Texas physician, who uses telemedicine to provide health-care services to a client in Texas.

Distant site providers that provide mental health services must be appropriately licensed or certified in Texas, or be a qualified mental health professional-community services (QMHP-CS), as defined in 26 TAC §301.303(48).

A distant site provider should provide patients who receive a telemedicine service with guidance on the appropriate follow-up care.

Distant site providers must be licensed in Texas.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 7-8 (Mar. 2023) (Accessed Mar. 2023).

Providers may provide telecommunication services for Texas Medicaid clients under the provider’s National Provider Identifier (NPI). No additional enrollment is required to provide telemedicine medical service or telehealth services.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 3 (Mar. 2023) (Accessed Mar. 2023).

Telehealth Services

A distant site is the location of the provider rendering the service. A distant site provider is the health professional licensed, certified, or otherwise entitled to practice in Texas who uses telehealth services to provide health care services to a patient in Texas.

Licensed psychological associates (LPAs), provisionally licensed psychologists (PLPs), postdoctoral psychology fellows, and pre-doctoral psychology interns under psychologist supervision may also deliver telehealth services. All requirements outlined in the Outpatient Mental Health Services benefit language must be met.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 12 (Mar. 2023) (Accessed Mar. 2023).

The executive commissioner by rule shall ensure that a rural health clinic as defined by 42 U.S.C. Section 1396d(l)(1) and a federally-qualified health center as defined by 42 U.S.C. Section 1396d(l)(2)(B) may be reimbursed for the originating site facility fee or the distant site practitioner fee or both, as appropriate, for a covered telemedicine medical service, teledentistry dental service, or telehealth service delivered by a health care provider to a Medicaid recipient. The commission is required to implement this subsection only if the legislature appropriates money specifically for that purpose. If the legislature does not appropriate money specifically for that purpose, the commission may, but is not required to, implement this subsection using other money available to the commission for that purpose.

SOURCE: TX Statute Sec. 531.0216, (Accessed Mar. 2023).

The Health and Human Services Commission (HHSC) reimburses eligible distant site professionals providing telemedicine medical services as follows:

• Physicians
• Physician assistants
• Advanced Practice Registered Nurses (APRNs)
• Certified nurse midwives
• HHSC reimburses eligible distant site professionals providing telehealth services as follows:
• Licensed marriage and family therapist (LMFT)
• Licensed clinical social worker (LCSW) (including Comprehensive Care Program social workers)
• Licensed psychologist
• Licensed psychological associate
• School Health and Related Services (SHARS)
• Durable medical equipment suppliers

SOURCE:  TX Admin Code. Title 1, Sec. 355.7001 (Accessed Mar. 2023).

School Health and Related Services (SHARS)

Schools that participate in the SHARS program may be reimbursed for telehealth OT, ST, and Counseling services delivered to children in school-based settings.

A school-based setting is defined in Texas Government Code §531.02171(b) as a school district or an open enrollment charter school.

• Reimbursement for providers is only available when the patient site is a school-based setting.

• All medical necessity criteria and prior authorization requirements for in-person services apply when services are delivered to children in school-based settings.

See manual for procedure codes are reimbursed when rendered as telehealth services to children eligible through SHARS. The patient site must be a school, home, or community-based setting in order for the distant site provider to be eligible for reimbursement of these services. All telehealth services provided by synchronous audiovisual technology must be billed using modifier 95.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, pgs. 27-28 (Mar. 2023). (Accessed Mar. 2023).

FQHCS

FQHCs providing distant-site telehealth services may be reimbursed as the following:

• FQHCs may be reimbursed the distant-site provider fee for telehealth services at the Prospective Payment System (PPS) rate or Alternative Prospective Payment System (APPS) rate.
• FQHC practitioners may be employees of the FQHC or contracted with the FQHC.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 12 (Mar. 2023). (Accessed Mar. 2023).

The executive commissioner by rule shall ensure that a rural health clinic as defined by 42 U.S.C. Section 1396d(l)(1) and a federally-qualified health center as defined by 42 U.S.C. Section 1396d(l)(2)(B) may be reimbursed for the originating site facility fee or the distant site practitioner fee or both, as appropriate, for a covered telemedicine medical service, teledentistry dental service, or telehealth service delivered by a health care provider to a Medicaid recipient. The commission is required to implement this subsection only if the legislature appropriates money specifically for that purpose. If the legislature does not appropriate money specifically for that purpose, the commission may, but is not required to, implement this subsection using other money available to the commission for that purpose.

SOURCE: TX Statute Sec. 531.0216, (Accessed Mar. 2023).

A visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, visiting nurse, a qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exist:

After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or

The FQHC patient has a medical visit and an “other” health visit, as defined in paragraph (13) of this subsection.

A medical visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, or visiting nurse. An “other” health visit includes, but is not limited to, a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a Texas Health Steps Medical Screen.

SOURCE:  Texas Admin Code Title 1, Sec. 355.8261, (Accessed Mar. 2023).

The commission by rule shall require each health and human services agency that administers a part of the Medicaid program to provide Medicaid reimbursement for teledentistry dental services provided by a dentist licensed to practice dentistry in this state.

The commission shall require reimbursement for a teledentistry dental service at the same rate as the Medicaid program reimburses for the same in-person dental service. A request for reimbursement may not be denied solely because an in-person dental service between a dentist and a patient did not occur. The commission may not limit a dentist’s choice of platform for providing a teledentistry dental service by requiring that the dentist use a particular platform to receive reimbursement for the service.

SOURCE: TX Govt. Code Sec. 531.02172, (Accessed Mar. 2023)

Federally Qualified Health Center Services Reimbursement

A visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse-midwife, visiting nurse, a qualified clinical psychologist, clinical social worker, other health professional for mental health services, dentist, dental hygienist, or an optometrist. Encounters with more than one health professional and multiple encounters with the same health professional that take place on the same day and at a single location constitute a single visit, except where one of the following conditions exist:

• After the first encounter, the patient suffers illness or injury requiring additional diagnosis or treatment; or
• The FQHC patient has a medical visit and an “other” health visit, as defined in paragraph (13) of this subsection.

A medical visit is a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, or visiting nurse. An “other” health visit includes, but is not limited to, a face-to-face, telemedicine, or telehealth encounter between an FQHC patient and a qualified clinical psychologist, clinical social worker, other health professional for mental health services, a dentist, a dental hygienist, an optometrist, or a Texas Health Steps Medical Screen.

SOURCE: TX Admin Code, Title 1, Part 15, Ch. 355 Subchapter J, 355. 8261. (Accessed Mar. 2023).

Rural Health Clinics

RHCs rendering patient-site telemedicine services may be reimbursed the facility fee (procedure code Q3014) as an add-on procedure code that should not be included in any cost reporting that is used to calculate the RHC AIR (All Inclusive Rate) PPS per visit encounter rate.

To receive reimbursement for more than one facility fee for the same client on the same date of service, an RHC must submit documentation of medical necessity. The documentation must include a signed letter from the client’s treating health-care provider at the RHC. The signed letter must describe the client’s medical need for receiving multiple distant-site provider consultations on the same date of service. The letter must state that the client suffered an illness or injury that required additional diagnosis or treatment by a distant-site provider.

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ELIGIBLE SITES

The physical environments of the client and the distant site provider must ensure that the client’s protected health information remains confidential. A parent or legal guardian may be physically located in the patient site or distant site environment during a telehealth or telemedicine service with a child.

A patient site is the place where the client is physically located. A client’s home may be the patient site for telemedicine.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 4, 10 (Mar. 2023), (Accessed Mar. 2023).

School-Based Setting

If a child receiving a telemedicine medical service in a primary or secondary school-based setting does not have a primary care physician or provider, the child’s parent or legal guardian must be offered: (i) the information in subparagraph (B)(ii) of this paragraph; and (ii) a list of primary care physicians or providers from which to select the child’s primary care physician or provider.

Telemedicine medical services provided in a school-based setting by a physician, even if the physician is not the patient’s primary care physician or provider, are reimbursed if: (i) the physician is enrolled as a Medicaid provider; (ii) the patient is a child who receives the service in a primary or secondary school-based setting; and (iii) the parent or legal guardian of the patient provides consent before the service is provided.

SOURCE: TX Admin Code Title 1, Sec. 354.1432, (Accessed Mar. 2023).

Telemedicine provided in a school-based setting by a physician, even if the physician is not the client’s primary care physician or provider, are benefits if all of the following criteria are met:

• The physician is an authorized health-care provider enrolled in Texas Medicaid.
• The client is a child who is receiving the service in a primary or secondary school-based setting.
• The parent or legal guardian of the client provides consent before the service is provided.

Telemedicine services provided in a school-based setting are also a benefit if the physician delegates provision of services to a nurse practitioner, clinical nurse specialist, or physician assistant, as long as the nurse practitioner, clinical nurse specialist, or physician assistant is working within the scope of their professional license and within the scope of their delegation agreement with the physician.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 10 (Mar. 2023), (Accessed Mar. 2023).

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 12. (Mar. 2023), (Accessed Mar. 2023).

TX Medicaid is required to reimburse school districts or open enrollment charter schools for telehealth services delivered by a health professional even if the specialist is not the patient’s primary care provider if the school district or charter school is an authorized health care provider under Medicaid and the parent or guardian of the patient consents.

A health professional is defined as:

• Licensed, registered certified, or otherwise authorized by Texas to practice as a social worker, occupational therapist or speech language pathologist
• Licensed professional counselor
• Licensed marriage and family therapist
• Licensed specialist in school psychology.

SOURCE: TX Government Code Sec. 531.02171. (Accessed Mar. 2023).

Services may take place in a school-based setting if:

• The physician is an authorized health care provider under Medicaid;
• The patient is a child who receives the service in a primary or secondary school-based setting;
• The parent or legal guardian of the patient provides consent before the service is provided; and
• A health professional is present with the patient during treatment.

SOURCE: TX Admin. Code, Title 1, Sec. 355.7001(f). (Accessed Mar. 2023).

School Health and Related Services (SHARS)

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, pg. 27-28 (Mar. 2023). (Accessed Mar. 2023).

Rural Health Clinics

SOURCE: TX Medicaid Clinics and other Outpatient Facility Services Handbook, pg. 32, (Mar. 2023). (Accessed Mar. 2023).

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GEOGRAPHIC LIMITS

No Reference Found

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FACILITY/TRANSMISSION FEE

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001(d) & TX Medicaid Telecommunication Services Handbook, p. 10. (Mar. 2023). (Accessed Mar. 2023).

Patient Site

FQHCs may be reimbursed the facility fee (procedure code Q3014) as an add-on procedure code that should not be included in any cost reporting that is used to calculate a PPS or APPS per visit encounter rate.

To receive reimbursement for more than one facility fee for the same client on the same date of service, an FQHC must submit documentation of medical necessity that indicates that the client needed multiple distant-site provider consultations. An FQHC can use a signed letter from the client’s treating health- care provider at the FQHC to document the client’s medical need for receiving multiple distant-site provider consultations on the same date of service. The letter must state that the client suffered an illness or injury that required additional diagnosis or treatment by a distant-site provider.

If an FQHC is eligible for payment of both an encounter fee and a facility fee for the same client on the same date of service, the FQHC must submit a claim for the facility fee separate from the claim that was submitted for the encounter.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 10 (Mar. 2023), (Accessed Mar. 2023).

Last updated 03/16/2023

Miscellaneous

The commission in coordination with the department and single source continuum contractors shall establish guidelines in the STAR Health program to improve the use of telehealth services to provide and enhance mental health and behavioral health care for children placed in the managing conservatorship of the state.

SOURCE: Human Resources Code Title 2, Section D, Chapter 42, 42.260. (Accessed Mar. 2023).

Children’s Health Insurance Program

Allows reimbursement for live video telemedicine and telehealth services to children with special health care needs.

SOURCE: TX Govt. Code Sec. 531.02162, (Accessed Mar. 2023).

Procedure codes that are benefits for distant site providers when billed with the 95 modifier (synchronous audiovisual technology) are included in the individual TMPPM handbooks. Procedure codes that indicate remote (telehealth service) delivery in the description do not need to be billed with the 95 modifier.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 8 and 12 (Mar. 2023). (Accessed Mar. 2023).

Providers of telehealth or telemedicine must maintain the confidentiality of protected health information (PHI) as required by Federal Register 42, Code of Federal Regulations (CFR) Part 2, 45 CFR Parts 160 and 164, Chapters 111 and 159 of the Texas Occupations Code, and other applicable federal and state law.

See provider manual for other information security and documentation requirements.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 4. (Mar. 2023). (Accessed Mar. 2023).

Fees for telemedicine, telehealth and home telemonitoring services are adjusted within available funding.

SOURCE: TX Admin Code. 355.7001(g). (Accessed Mar. 2023).

A valid practitioner-patient relationship must exist between the distant site provider and the patient receiving telemedicine services. A valid practitioner-patient relationship exists between the distant site provider and the patient if:

The distant site provider meets the same standard of care required for and in-person service.

The relationship can be established through:

• A prior in-person service.
  
• A prior telemedicine service that meets the delivery method requirements specified in Texas Occupations Code §111.005(a)(3).
  
• The current telemedicine service that meets the delivery method requirements specified in Texas Occupations Code §111.005(a)(3).

The valid practitioner-patient relationship can be established through a call coverage agreement established in accordance with Texas Medical Board (TMB) administrative rules in 22 TAC §177.20.

A distant site provider should provide patients who receive a telemedicine service with guidance on the appropriate follow-up care.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 8 (Mar. 2023). (Accessed Mar. 2023).

Prescriptions Generated from a Telemedicine Medical Service

A distant site provider may issue a valid prescription as part of a telemedicine service. An electronic prescription (e-script) may be used as permitted by applicable federal and state statues and rules.

The same standards that apply for the issuance of a prescription during an in-person setting apply to prescriptions issued by a distant site provider.. The prescribing physician must be licensed in Texas. If the prescription is for a controlled substance, the prescribing physician must have a current valid U.S. Drug Enforcement Administration (DEA) registration number.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 9 (Mar. 2023). (Accessed Mar. 2023).

Radiation Therapy Services

Teletherapy is covered by Texas Medicaid once per day in an outpatient hospital setting.

SOURCE: TX Medicaid Inpatient and Outpatient Hospital Services Handbook, p. 61 (Mar. 2023). (Accessed Mar. 2023).

All client health information generated or utilized during a telehealth or telemedicine service must be stored by the distant site provider in a client health record. If the distant site provider stores the patient health information in an electronic health record, the provider should use software that complies with Health Insurance Portability and Accountability Act (HIPAA) confidentiality and data encryption requirements, as well as with the United States Department of Health and Human Services (HHS) rules implementing HIPAA.

Medical records must be maintained for all telemedicine services.

Documentation for a service provided via telemedicine must be the same as for a comparable in-person service.

If a patient has a primary care provider who is not the distant site provider and the patient or their parent or legal guardian provides consent to a release of information, a distant site provider must provide the patient’s primary care provider with the following information:

• A medical record or report with an explanation of the treatment provided by the distant site provider
• The distant site provider’s evaluation, analysis, or diagnosis of the patient

Unless the telemedicine services are rendered to a child in a school-based setting, distant site providers of mental health services are not required to provide the patient’s primary care provider with a treatment summary. For telemedicine provided to a child in a school-based setting, a notification provided by the telemedicine physician to the child’s primary care provider must include a summary of the service, exam findings, prescribed or administered medications, and patient instructions.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 5 & 11. (Mar. 2023). (Accessed Mar. 2023).

Screening activities for crisis stabilization units, including triage and determining if the individual’s need is urgent can be conducted in person or through telehealth.

SOURCE: TX Admin Code, Title 26, Part 1, Ch. 306, Subchapter B, Sec. 306.45, (Accessed Mar. 2023).

A patient can be admitted on a voluntary admission only if a physician has conducted or consulted with a physician who has conducted, either in person or through telemedicine medical services, an admission examination within 72 hours before or 24 hours after admission.

SOURCE: TX Admin Code, Title 26, Part 1, Ch. 568, Subchapter B, Sec. 568.22, (Accessed Mar. 2023).

The commission shall establish policies and procedures to improve access to care under the Medicaid managed care program by encouraging the use of telehealth services, telemedicine medical services, home telemonitoring services, and other telecommunications or information technology under the program.

To the extent permitted by federal law, the executive commissioner by rule shall establish policies and procedures that allow a Medicaid managed care organization to conduct assessments and provide care coordination services using telecommunications or information technology.  See rule for details.

SOURCE: TX Statute Sec. 533.039, (Accessed Mar. 2023).

In the event of a state of disaster declared pursuant to Texas Government Code §418.014 for statewide disasters or limited areas subject to the declaration, the flexibilities listed under subsection (c) of this section will be available until the state of disaster is terminated. Telehealth and telemedicine have the same meaning as the terms telehealth services and telemedicine medical services defined in §111.001 of the Texas Occupations Code (relating to Definitions).

See rule for additional details.

SOURCE: TX Admin Code Title 26, Part 1, Ch. 306, Subchapter X, 306.1251. (Accessed Mar. 2023).

 

Last updated 03/16/2023

Out of State Providers

Distant site providers must be licensed in Texas.

An out-of-state physician who is a distant site provider may provide episodic telemedicine without a Texas medical license as outlined in Texas Occupations Code §151.056 and Title 22 Texas Administrative Code (TAC) §172.2(g)(4) and 172.12(f).

Distant site providers that provide mental health services must be appropriately licensed or certified in Texas, or be a qualified mental health professional-community services (QMHP-CS), as defined in 26 TAC §301.303(48).

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 8 (Mar. 2023). (Accessed Mar. 2023).

Last updated 03/16/2023

Overview

Texas Medicaid reimburses for live video, and store-and-forward in some circumstances. Home telemonitoring is reimbursable for some conditions when a provider is approved to deliver those services.

Audio-only service deliver is also allowed for behavioral health services under certain circumstances.

Last updated 03/16/2023

Remote Patient Monitoring

POLICY

Home telemonitoring service means “a health service that requires scheduled remote monitoring of data related to a patient’s health and transmission of the data to a licensed home and community support services agency or a hospital”.

SOURCE: TX Government Code, Sec. 531.001(4-a). (Accessed Mar. 2023).

Texas Medicaid will reimburse for home telemonitoring in the same manner as their other professional services provided by a home health agency.

SOURCE: TX Admin Code, Title 1, Sec. 355.7001(e). (Accessed Mar. 2023).

Home telemonitoring is a health service that requires scheduled remote monitoring of data related to a client’s health, and transmission of the data from the client’s home to a licensed home health agency or a hospital. The data transmission must comply with standards set by HIPAA.

Data parameters are established as ordered by a physician’s plan of care.

Data must be reviewed by a registered nurse (RN), NP, CNS, or PA, who is responsible for reporting data to the prescribing physician in the event of a measurement outside the established parameters.

The provision and maintenance of home telemonitoring equipment is the responsibility of the home health agency or the hospital. The one-time initial setup and installation of the equipment in the client’s home is a benefit when services are provided by a home health agency or an outpatient hospital. Monthly home monitoring services are a benefit when services are provided by a home health agency or an outpatient hospital.

Documentation supporting medical necessity for telemonitoring services must be maintained in the client’s medical record by the entity providing the service (home health agency or hospital) and is subject to retrospective review. All paid telemonitoring services not supported by documentation of medical necessity are subject to recoupment.

Home telemonitoring services may be approved for up to 180 days per prior authorization request. Requests for additional home telemonitoring services received after the current prior authorization period ends will be denied for dates of service provided before the date the request was received. See manual for prior authorization requirements.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 14-15 (Mar. 2023). (Accessed Mar. 2023).

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CONDITIONS

Home Telemonitoring is available only to patients who:

• Are diagnosed with diabetes, hypertension; or
• When it is determined by Texas Health and Human Services Commission to be cost effective and feasible (in Administrative Code only).

To be eligible for home telemonitoring services, clients who are diagnosed with diabetes or hypertension must exhibit two or more of the following risk factors:

• Two or more hospitalizations in the previous 12-month period
• Frequent or recurrent emergency department visits
• A documented history of poor adherence to ordered medication regime
• Documented history of falls in the previous 6-month period
• Limited or absent informal support systems
• Living alone or being home alone for extended periods of time
• A documented history of care access challenges

SOURCE: TX Admin Code. Title 1, Sec. 354.1434, TX Admin Code. Title 4 Sec. 531.02164 & TX Medicaid Telecommunication Services Handbook, p. 14; 16 (Mar. 2023). (Accessed Mar. 2023).

Home telemonitoring services are reimbursed in accordance with Chapter 355 of this title (relating to Reimbursement Rates).

Home telemonitoring services are available to Texas Medicaid clients who are 20 years of age and younger, with one or more of the following conditions:

• end-stage solid organ disease;
• organ transplant recipient; or
• requiring mechanical ventilation.

SOURCE: TX Admin Code. Title 1, Sec. 354.1434, (Accessed Mar. 2023).

Home telemonitoring is a benefit for clients who have been diagnosed with either diabetes or hypertension or both. Telemonitoring services will not be approved for clients of any age who have diabetes or hypertension unless they have two or more of the risk factors mentioned above.

Home telemonitoring services is also a benefit for clients who are 20 years of age and younger, with one or more of the following conditions:

• End-stage solid organ disease
• Organ transplant recipient
• Requiring mechanical ventilation

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 14; 16 (Mar. 2023). (Accessed Mar. 2023).

The following conditions are also included in telemonitoring if the commission determines that it is cost-effective and feasible:  pregnancy, diabetes, heart disease, cancer, chronic obstructive pulmonary disease, hypertension, congestive heart failure, mental illness, asthma, myocardial infarction or stroke.

Home telemonitoring services are also available to pediatric persons who:

• Are diagnosed with end-stage solid organ disease;
• Have received an organ transplant; or
• Require mechanical ventilation.

If, after implementation, the commission determines that the program established under this section is not cost-effective, the commission may discontinue the program and stop providing reimbursement under Medicaid for home telemonitoring services.

The commission shall determine whether the provision of home telemonitoring services to persons who are eligible to receive benefits under both Medicaid and the Medicare program achieves cost savings for the Medicare program.

To comply with state and federal requirements to provide access to medically necessary services under the Medicaid managed care program, a Medicaid managed care organization may reimburse providers for home telemonitoring services provided to persons who have conditions and exhibit risk factors other than those expressly authorized by this section. In determining whether the managed care organization should provide reimbursement for services under this subsection, the organization shall consider whether reimbursement for the service is cost-effective and providing the service is clinically effective.

SOURCE: TX Government Code Sec. 531.02164, (Accessed Mar. 2023).

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PROVIDER LIMITATIONS

Data must be reviewed by a registered nurse (RN), NP, CNS, or PA, who is responsible for reporting data to the prescribing physician in the event of a measurement outside the established parameters.

Scheduled periodic reporting of the client data to the physician is required at least once every 30 days, even when there have been no readings outside the parameters established in the physician’s orders. The RN, NP, CNS, or PA in a licensed home health agency or a hospital is responsible for reporting data to the prescribing physician. Telemonitoring providers must be available 24 hours a day, 7 days a week. Although transmissions are generally at scheduled times, they can occur any time of the day or any day of the week, according to the client’s plan of care.

Collection and interpretation of a client’s data for home telemonitoring services (procedure code 99091) is a benefit in the office or outpatient hospital setting when services are provided by a physician or other qualified health care professional. Procedure code 99091 is limited to once in a 30-day period.

The physician who orders home telemonitoring services has a responsibility to ensure the following:

• The client has a choice of home telemonitoring providers.
• The client has the right to discontinue home telemonitoring services at any time.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 13-14 (Mar. 2023). (Accessed Mar. 2023).

Providers must:

• Comply with all applicable federal, state and local laws and regulations;
• Be enrolled and approved as home telemonitoring services providers;
• Bill for the services covered under the Texas Medicaid Program in the manner and format prescribed by HHSC;
• Share clinical information gathered while providing home telemonitoring services with the patient’s physician; and
• Not duplicate disease management program services.

See specific documentation requirements for telemonitoring providers in manual.

SOURCE: TX Admin Code. Title 1, Sec. 354.1434(c). (Accessed Mar. 2023).

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OTHER RESTRICTIONS

Home health agency and hospital providers who wish to provide telemonitoring services must notify the Texas Medicaid & Healthcare Partnership (TMHP) as follows:

• Current providers must use the Provider Enrollment and Management System (PEMS) to indicate that they provide telemonitoring services.
• Newly enrolling or re-enrolling home health agency or outpatient hospital providers must indicate whether they provide telemonitoring services during the enrollment process.

The provision and maintenance of home telemonitoring equipment is the responsibility of the home health agency or the hospital. The one-time initial setup and installation (procedure code S9110 with modifier U1) of the equipment in the client’s home is a benefit when services are provided by a home health agency or an outpatient hospital. Monthly home monitoring services (procedure code S9110 with the appropriate modifier) are a benefit when services are provided by a home health agency or an outpatient hospital. Hospital providers must submit revenue code 780 with procedure code S9110 and one of the appropriate modifiers listed in the table within this section.

Documentation supporting medical necessity for telemonitoring services must be maintained in the client’s medical record by the entity providing the service (home health agency or hospital) and is subject to retrospective review. All paid telemonitoring services not supported by documentation of medical necessity are subject to recoupment.

Requests for additional home telemonitoring services that are received after the current prior authorization expires will be denied for dates of service that occurred before the date the submitted request was received.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 3 & 14-15 (Mar. 2023). (Accessed Mar. 2023).

Last updated 03/16/2023

Store and Forward

POLICY

The following delivery methods may be used to provide telehealth/telemedicine within fee-for-service (FFS) Medicaid:

• Synchronous audiovisual technology between the distant site provider and the client in another location
• Synchronous audio-only technology between the distant site provider and the client in another location
• Store and forward technology in conjunction with synchronous audio-only technology between the distant site provider and the client in another location. The distant site provider must use one of the following:
  • Clinically relevant photographic or video images, including diagnostic images
  • The client’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6, 9, & 13 (Mar. 2023). (Accessed Mar. 2023).

Reimbursement to eligible providers must be made in the same manner as in-person services.

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001. (Accessed Mar. 2023).

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ELIGIBLE SERVICES

Not all Medicaid-covered services are authorized by HHSC for telemedicine or telehealth delivery in fee-for-service. Providers must always ensure the covered service is allowable by HHSC for telemedicine or telehealth services delivery.

Note: For example, if a service is authorized for telemedicine or telehealth delivery only when using synchronous audiovisual technology, that service may not be delivered using store and forward technology, store and forward technology in conjunction with synchronous audio-only technology, synchronous audio-only technology, or asynchronous audio-only technology.

Telemedicine or telehealth may be provided if clinically appropriate and safe, as determined by the provider, and agreed to by the person receiving services. Whenever possible, HHSC encourages face-to-face interaction, such as an in-person visit.

Conditions for reimbursement applicable to telemedicine and telehealth provided using a synchronous audiovisual technology platform, or using store and forward technology in conjunction with synchronous audio-only are those that meet the following conditions:

• Must be designated for reimbursement by HHSC.
• Must be clinically effective and cost-effective, as determined and published in the benefit language by HHSC.
• May not be denied solely because an in-person medical service between a provider and client did not occur.
• May not be limited by requiring the provider to use a particular synchronous audiovisual technology platform to receive reimbursement for the service.

Other conditions for reimbursement applicable to services may vary by service type. Providers may refer to the appropriate TMPPM handbook for additional information on synchronous audiovisual technology platform coverage conditions.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 6. (Mar. 2023). (Accessed Mar. 2023).

To the extent permitted by federal law and to the extent it is cost-effective and clinically effective, as determined by the commission, the commission shall ensure that Medicaid recipients, child health plan program enrollees, and other individuals receiving benefits under a public benefits program administered by the commission or a health and human services agency, regardless of whether receiving benefits through a managed care delivery model or another delivery model, have the option to receive services as telemedicine medical services, telehealth services [includes store and forward], or otherwise using telecommunications or information technology, including the following services:

• preventive health and wellness services;
• case management services, including targeted case management services;
• subject to Subsection (c), behavioral health services;
•  occupational, physical, and speech therapy services;
• nutritional counseling services; and
• assessment services, including nursing assessments under the following Section 1915(c) waiver programs:
  • the community living assistance and support services (CLASS) waiver program;
  • the deaf-blind with multiple disabilities (DBMD) waiver program;
  • the home and community-based services (HCS) waiver program; and
  • the Texas home living (TxHmL) waiver program.

SOURCE:  TX Statute Sec. 531.02161, (Accessed Mar. 2023).

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GEOGRAPHIC LIMITS

No Reference Found

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TRANSMISSION FEE

No Reference Found