Texas

Last updated 08/21/2023

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.

Documentation of the written or verbal consent must be maintained in the client’s medical record. (In CSHCN Manual).

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 4-5  (Aug. 2023).  TX Medicaid CSHCN Services Program Provider Manual Telecommunication Services (Aug 2023), p. 4.  (Accessed Aug. 2023).

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.

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

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.

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

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

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 11  (Aug. 2023). (Accessed Aug. 2023).

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. 10  (Aug. 2023). (Accessed Aug. 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 Aug. 2023).

Conditions for telemedicine medical services provided in a primary or secondary school-based setting.

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.

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:

• the information in subparagraph (B)(ii) of this paragraph; and
• 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:

• 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 Aug. 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 Aug. 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 (Aug. 2023). (Accessed Aug. 2023).

Managed Care (also applies to START Kids and STAR Health)

When an MCO conducts a change in condition assessment using audio-visual communication, verbal consent must be obtained and documented, and a HIPAA-compliant audio-visual communication product must be used.

If verbal consent for audio-visual communication is not received, the MCO must use in-person communication.

The MCO must inform members who utilize audio-visual communication for change in condition assessments that the member’s services will be subject to the following:

• The MCO must monitor services for fraud, waste, and abuse.
• The MCO must determine whether additional social services or supports are needed.
• The MCO must ensure that verbal consent to use telecommunications is documented in writing.

See rules Sec. 1604-1506 for additional requirements for each program.

SOURCE: Title 1, Part 15, Sec. 353.1503, (Accessed Aug. 2023).

Last updated 08/21/2023

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 Aug. 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 physical 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 Aug. 2023).

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.

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.

Telemedicine medical service–A health-care service delivered to an individual at a different physical location using telecommunications or information technology by:

• a physician licensed in Texas; or
• a health professional who acts under the delegation and supervision of a physician licensed in Texas and within the scope of the health professional’s license in Texas.

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

SOURCE: TX Admin Code Sec. 133.182, (Accessed Aug. 2023).

Children with Special Health Care Needs (CSHCN) Program

Telemedicine is defined as a health-care service that is either initiated by a physician who is licensed to practice medicine in Texas or provided by a health professional who is acting under physician delegation and supervision.

SOURCE:  TX Medicaid CSHCN Services Program Provider Manual: Telecommunication Services (Aug. 2023), p. 4.  (Accessed Aug. 2023).

Last updated 08/21/2023

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

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

• A text-only email message
• A facsimile transmission

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6, 9, 12 &13 (Aug. 2023). (Accessed Aug. 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.

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.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6-7 (Aug. 2023). (Accessed Aug. 2023).

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. 8-9, Aug. 2023 (Accessed Aug. 2023).

Outpatient Mental Health 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.
  • Documented approval of the use of synchronous telephone (audio-only) technology in the plan of care is not required prior to the delivery of crisis intervention services. However, providers must document the justification for using synchronous telephone (audio-only) technology to deliver crisis intervention services in the medical record.

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.

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.

For the aforementioned mental health services, the following is required:

An existing clinical relationship occurs when a person has received at least one in-person or synchronous audiovisual outpatient mental health 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 outpatient mental health 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. See manual for additional information.

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

For the diagnosis, evaluation and treatment of a mental health or substance use condition, the following office and other outpatient 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 client 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 client’s medical record the reason(s) for why services were delivered by synchronous telephone (audio-only) technology. Established patient services provided by synchronous telephone (audio-only) technology must be billed using modifier FQ.

Procedure code 99211 may be delivered by synchronous telephone (audio-only) technology during certain public health emergencies only.

See manual for more details on procedure codes.

SOURCE: TX Medicaid Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook, pg. 175-176. (Aug. 2023). (Accessed Aug. 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 Aug. 2023).

Some service delivery to children or youth and to the parents or caregivers may be delivered remotely. It is the LBA’s responsibility to ensure that remotely delivered telehealth services are within scope of practice, are not contraindicated for the child or youth, family, or particular situation, are clinically appropriate and effective, and are in compliance with Texas licensure and standards for telehealth and the Texas Health Steps-CCP and these Medicaid Autism Services requirements.

ABA evaluation and treatment services may only be delivered via telehealth using synchronous audio-visual technology or a similar technology.

Telehealth services may be provided using synchronous audiovisual technologies if clinically appropriate and safe, as determined by the provider, and agreed to by the client 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 telehealth services.

Providers must defer to the needs of the client receiving services, allowing the mode of service delivery to be accessible, person- and family-centered, and primarily driven by the client in service’s choice and not provider convenience.

Services delivered by synchronous audiovisual technology will require participation of a parent or caregiver to assist with the treatment.

Therapy assistants may deliver services and receive supervision using synchronous audiovisual technology in accordance with each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline.

See manual for applicable codes.

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)

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, pgs. 27, 29, & 30 (Aug. 2023). (Accessed Aug. 2023).

SOURCE: TX Medicaid Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook pg. 10, (Aug. 2023). (Accessed Aug. 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 08/21/2023

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. 5 & 9, 12 (Aug. 2023), (Accessed Aug. 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 Aug. 2023).

The executive commissioner by rule shall require each health and human services agency that administers a part of Medicaid to provide Medicaid reimbursement for a telemedicine medical service initiated or provided by a physician.

The commission shall ensure that reimbursement is provided only for a telemedicine medical service initiated or provided by a physician.

The commission shall ensure that 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.

The commission shall require reimbursement for a telemedicine medical service 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.

TSOURCE: TX Govt. Code Sec. 531.0217(d) (Accessed Aug. 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 Aug. 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, Aug. 2023, p. 5, 7 and 8 (Accessed Aug. 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, & 12-13, (Aug. 2023). (Accessed Aug. 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 Aug. 2023).

CSHCN Program

Authorization is not required for telemedicine or telehealth services, however prior authorization may be required for the individual procedure codes billed. 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. Only those services that involve direct face-to-face interactive video communication between the client and the distant-site provider constitute a telemedicine or telehealth service. No separate reimbursement will be made for the cost of telemedicine and telehealth hardware or equipment, electronic documentation, and transmissions. Telephone conversations, chart reviews, electronic mail messages, and fax transmissions alone do not constitute a telemedicine or telehealth interactive video service and will not be reimbursed as telemedicine or telehealth services.

Telecommunication services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual: Telecommunication Services (Aug 2023), p. 3., 13  (Accessed Aug. 2023).

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).

*See regulations for eligible sites topic for conditions for school-based settings.

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, Aug. 2023, (Accessed Aug. 2023).

Telemedicine medical services, also known as telemedicine, are allowable for Texas Medicaid. Telemedicine 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/telehealth) delivery in the description do not need to be billed with the 95 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 telehealth.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 4, 7-9, 11-12 (Aug. 2023). (Accessed Aug. 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.

Note: 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. (Aug. 2023). (Accessed Aug. 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 Aug. 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. 31-32, 50, 59, 72, 80 & 89 (Aug. 2023). (Accessed Aug. 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. 24, 40, 57, 67, 72 & 182-183, (Aug. 2023), (Accessed Aug. 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, (Aug. 2023). (Accessed Aug. 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. 26-29  (Aug. 2023). (Accessed Aug. 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 Aug. 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 Aug. 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 Aug. 2023).

Physical Therapy, Occupational Therapy, and Speech Therapy

ELIGIBLE PROVIDERS

The information in this handbook is intended for home health agencies, hospitals, nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM), licensed professional counselors (LPC), licensed marriage and family therapists (LMFT), licensed clinical social workers (LCSW), physicians, physician assistants (PA), psychologists, licensed psychological associates, provisionally licensed psychologists, and licensed dieticians.

Telemedicine Services

A distant site is the location of the provider rendering the service. Distant-site telemedicine benefits include services that are performed by the following providers, who must be enrolled as a Texas Medicaid provider:

• 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 must be licensed in Texas.

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.

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, p. 3, 7-8 (Aug. 2023) (Accessed Aug. 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), post-doctoral 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.

Distant site providers who provide mental health services must be appropriately licensed or certified in Texas or be a QMHP-CS as defined in 26 Texas Administrative Code §301.303(48). The distant site provider must obtain informed consent to treatment from the patient, patient’s parent or the patient’s legal guardian prior to rendering a telehealth service. Distant site providers should meet all other telehealth service requirements specified in Texas Occupations Code §111.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 12 (Aug. 2023) (Accessed Aug. 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 Aug. 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 professional counselors, including licensed marriage and family therapists, and licensed clinical social workers (including Comprehensive Care Program social workers)
• Licensed psychologists (including licensed psychological associates) and psychology groups
• Durable medical equipment suppliers

Telemedicine medical services provided in a school-based setting by a physician, even if the physician is not the patient’s primary care physician, will be reimbursed in accordance with the applicable methodologies described in subsection (b)(1) of this section and §355.8443 of this title (relating to Reimbursement Methodology for School Health and Related Services (SHARS)) if the following conditions are met:

•  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 as defined by Government Code §531.0217(a)(1) is present with the patient during the treatment.

Fees for telemedicine, telehealth, and home telemonitoring services are adjusted within available funding as described in §355.201 of this title (relating to Establishment and Adjustment of Reimbursement Rates by the Health and Human Services Commission).

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

School Health and Related Services (SHARS)

See manual for specific requirements.

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.

See manual for procedure codes and requirements that may be provided to children eligible through SHARS as telehealth services via synchronous audiovisual technology if clinically appropriate (as determined by the treating provider), safe and agreed to by the student receiving services.

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, pgs. 26-27 (Aug. 2023). (Accessed Aug. 2023).

FQHCS

FQHCs may be reimbursed the distant-site provider fee for telemedicine services at the Prospective Payment System (PPS) rate or Alternative Prospective Payment System (APPS) rate.

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. 10 & 12 (Aug. 2023). (Accessed Aug. 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 Aug. 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 Aug. 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 Aug. 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.

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 and telehealth.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 4, 10, 12 (Aug. 2023), (Accessed Aug. 2023).

School-Based Setting

See Administrative Code Section for more details.

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

Telemedicine medical services provided in a school-based setting by a physician, even if the physician is not the patient’s primary care physician, will be reimbursed in accordance with the applicable methodologies described in subsection (b)(1) of this section and §355.8443 of this title (relating to Reimbursement Methodology for School Health and Related Services (SHARS)) if the following conditions are met:

• 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 Aug. 2023).

School Health and Related Services (SHARS)

SOURCE: TX Medicaid School Health and Related Services (SHARS) Handbook, pg. 26 & 27 (Aug. 2023). (Accessed Aug. 2023).

Rural Health Clinics

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

CSHCN Program

A patient site is where the client is physically located while the service is rendered. The patient-site must be one of the following:

• Established medical site – A location where clients will present to seek medical care. There must be a patient-site presenter and sufficient technology and medical equipment to allow for an adequate physical evaluation, as appropriate for the client’s presenting complaint. A defined physician-client relationship is required. A client’s private home is not considered an established medical site.
• Established health site – A location where clients will present to seek a health service. There must be a patient-site presenter and sufficient technology and medical equipment to allow for an adequate physical evaluation or assessment, as appropriate for the client’s presenting complaint. A defined health provider-client relationship is required. A client’s private home is not considered an established health site.

SOURCE: TX Medicaid CSHCN Services Program Provider Manual (Aug. 2023), p. 8-9.  (Aug. 2023).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 10-11. (Aug. 2023), (Accessed Aug. 2023).

The facility fee (procedure code Q3014) is not a benefit for telehealth services.

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

Note: Telemedicine and telehealth services must be billed with modifier 95. Procedure codes that indicate remote delivery (telemedicine medical services or telehealth services) in the description do not need to be billed with modifier 95.

Telemedicine and telehealth patient site locations, as defined in §354.1430 and §354.1432 of this title, are reimbursed a facility fee determined by HHSC.

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

Last updated 08/21/2023

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 Aug. 2023).

Children’s Health Insurance Program

The executive commissioner by rule shall establish policies that permit reimbursement under Medicaid and the child health plan program for services provided through telemedicine medical services, teledentistry dental services, and telehealth services to children with special health care needs.

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

Fees for telemedicine, telehealth, and home telemonitoring services are adjusted within available funding as described in §355.201 of this title (relating to Establishment and Adjustment of Reimbursement Rates by the Health and Human Services Commission).

SOURCE: TX Admin Code. 355.7001(g). (Accessed Aug. 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 (Aug. 2023). (Accessed Aug. 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 prescription must be issued for a legitimate medical purpose by the distant site provider as part of a valid practitioner-patient relationship.

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.

A licensed health professional acting under the delegation and supervision of a physician licensed in Texas may also issue a valid prescription. Prescribing must be in accordance with the required prescriptive authority agreement or other forms of delegation.

If the prescription is for a controlled substance, the health professional must have a current valid DEA registration number. If the prescription is for a schedule II controlled substance, the health professional must comply with DEA regulations regarding the use of electronic prescriptions. The health professional may also use the official prescription forms issued with their name, address, phone number, DEA registration number, delegating physician’s name, and delegating physician’s DEA registration number.

As applicable, all drug prescriptions must meet the requirements of the Texas Controlled Substance Act (Texas Health and Safety Code §481), the Texas Dangerous Drug Act (Texas Health and Safety Code §483), and any other federal or state statutes or rules.

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. 9-10 (Aug. 2023). (Accessed Aug. 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 (Aug. 2023). (Accessed Aug. 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. (Aug. 2023). (Accessed Aug. 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 Aug. 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 Aug. 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 Aug. 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 Aug. 2023).

Last updated 08/21/2023

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 (Aug. 2023). (Accessed Aug. 2023).

Last updated 08/21/2023

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.  Texas Medicaid has two telehealth manuals (which they title “telecommunications services”), one for the general Medicaid program and one specifically for Children with Special Health Care Needs (CSHCN) as well as specific telehealth sections in a variety of other program provider manuals.

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

Last updated 08/21/2023

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, a federally qualified health center, a rural health clinic, or a hospital”.

SOURCE: TX Government Code, Sec. 531.001(4-a) as amended by HB 2727 (2023 Session). (Accessed Aug. 2023).

HHSC reimburses eligible providers performing home telemonitoring services in the same manner as their other professional services described in §355.8021 of this title (relating to Reimbursement Methodology for Home Health Services).

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

Note: Some variations in policies in the two cited manuals.  Double-checked the manual for your specific situation.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 14-15 (Aug. 2023).  TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Aug. 2023), p. 9-12. (Accessed Aug. 2023).

CSHCN Program

Telecommunication services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

SOURCE: TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Aug. 2023), p. 13 (Accessed Aug. 2023).

CONDITIONS

Home telemonitoring is a benefit for clients who have been diagnosed with either diabetes or hypertension or both.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 14 (Aug. 2023). (Accessed Aug. 2023).

Home telemonitoring services are available only to Texas Medicaid clients who:

• are diagnosed with diabetes, hypertension, or any other conditions allowed by Texas Government Code §531.02164 and determined by HHSC to be cost effective and feasible; and exhibit two or more of the following risk factors (see below)

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

Home telemonitoring services are available only to Texas Medicaid clients who:

• are diagnosed with diabetes, hypertension, or any other conditions allowed by Texas Government Code §531.02164 and determined by HHSC to be cost effective and feasible; and
• 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
  • A 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 Medicaid Telecommunication Services Handbook, p. 16 (Aug. 2023). (Accessed Aug. 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 Aug. 2023).

Home telemonitoring is a benefit for clients who have been diagnosed with either diabetes or hypertension or both.

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

Prior authorization will be considered for clients who are 20 years of age and younger and have at least one of the following conditions:

• End-stage solid organ disease
• Organ transplant recipient
• Mechanical ventilation

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

The executive commissioner shall adopt rules for the provision and reimbursement of home telemonitoring services under Medicaid as provided under this section.  See sections below for additional details.

For purposes of adopting rules under this section, the commissioner shall:

• Identify and provide home telemonitoring services to persons diagnosed with conditions for which the commission determines the provision of home telemonitoring services would be cost-effective and clinically effective;
• consider providing home telemonitoring services under Subdivision (1) to Medicaid recipients who:
  • Are diagnosed with one or more of the following conditions:
    • pregnancy;
    • diabetes;
    • heart disease;
    • cancer;
    • chronic obstructive pulmonary disease;
    • hypertension;
    • congestive heart failure;
    • mental illness or serious emotional disturbance;
    • asthma;
    • myocardial infarction;
    • stroke;
    • end stage renal disease; or
    • a condition that requires renal dialysis treatment; and
  • Exhibit at least one of the following risk factors
    • two or more hospitalizations in the prior 12-month period;
    • frequent or recurrent emergency room admissions;
    • a documented history of poor adherence to ordered medication regimens;
    • a documented risk of falls; and
    • a documented history of care access challenges
• Ensure that clinical information gathered by the following providers while providing home telemonitoring services is shared with the recipient ’s physician:
  • a home and community support services agency;
  • a federally qualified health center;
  • a rural health clinic; or
  • a hospital
• Ensure that the home telemonitoring provided under this section do not duplicate disease management program services provided under 32.057, Human Resources Code; and require providers to:
  • establish a plan of care that includes outcome measures for each recipient who receives home telemonitoring services under this section; and
  • share the plan and outcome measures with the recipient ’s physician.

Not withstanding any other provision of this section, the commission shall ensure that home telemonitoring services are available to pediatric persons who:

• are diagnosed with end-stage solid organ disease;
• have received an organ transplant; or
• require mechanical ventilation.

In addition to determining whether to provide home telemonitoring services to Medicaid recipients with the conditions described under Subsection (c)(2), the commission shall determine whether high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective. If the commission determines that high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective:

• the commission shall, to the extent permitted by state and federal law, provide recipients experiencing a high-risk pregnancy with clinically appropriate home telemonitoring services equipment for temporary use in the recipient ’s home; and
• the executive commissioner by rule shall:
  • establish criteria to identify recipients experiencing a high-risk pregnancy who would benefit from access to home telemonitoring services equipment;
  • ensure that, if cost-effective, feasible, and clinically appropriate, the home telemonitoring services equipment provided includes uterine remote monitoring services equipment and pregnancy-induced hypertension remote monitoring services equipment;
  • subject to Subsection (c-3), require that a provider obtain:
    • prior authorization from the commission before providing home telemonitoring services equipment to a recipient during the first month the equipment is provided to the recipient; and
    • an extension of the authorization under Subparagraph (i) from the commission before providing the equipment in a subsequent month based on the ongoing medical need of the recipient; and
    • prohibit payment or reimbursement for home telemonitoring services equipment during any period that the equipment was not in use because the recipient was hospitalized or away from the recipient ’s home regardless of whether the equipment remained in the recipient ’s home while the recipient was hospitalized or away.

For purposes of Subsection (c-2), the commission shall require that:

• a request for prior authorization under Subsection (c-2)(2)(C)(i) be based on an in-person assessment of the recipient; and
• documentation of the recipient ’s ongoing medical need for the equipment is provided to the commission before the commission grants an extension under Subsection (c-2)(2)(C)(ii).

If, after implementation, the commission determines that a condition for which the commission has authorized the provision and reimbursement of home telemonitoring services under Medicaid under this section is not cost-effective and clinically effective, the commission may discontinue the availability of home telemonitoring services for that condition and stop providing reimbursement under Medicaid for home telemonitoring services for that condition, notwithstanding Section 531.0216 or any other law.

To comply with state and federal requirements to provide access to medically necessary services under Medicaid, including the Medicaid managed care program, and if the commission determines it is cost-effective and clinically effective, the commission or a Medicaid managed care organization, as applicable, 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.

SOURCE: TX Government Code Sec. 531.02164 as amended by HB 2727 (2023 Session), (Accessed Aug. 2023).

CSHCN Program

Home telemonitoring services are a benefit only for clients who are diagnosed with one or more of the following conditions:

• Diabetes
• Hypertension
• Congestive heart failure
• End-stage solid organ disease
• Organ transplant recipient
• Requiring mechanical ventilation

Clients with diabetes or hypertension must exhibit two or more of the following risk factors for approval of telemonitoring services:

• 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 regimens
• Documented history of falls in the previous six-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 Medicaid CSHCN Services Program Provider Manual Telecommunications Services (Aug. 2023), p. 11.  (Accessed Aug. 2023).

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.

Although Texas Medicaid supports the use of home telemonitoring, clients are not required to use this service.

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

Home telemonitoring service 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 provided under Human Resources Code §32.057 and further described in Division 32 of this subchapter (relating to Texas Medicaid Wellness Program).

See specific documentation requirements for telemonitoring providers in manual.

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

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 (Aug. 2023). (Accessed Aug. 2023).

A cardiac rehabilitation program in which the cardiac monitoring is done using telephonically transmitted electrocardiograms to a remote site is not covered by Texas Medicaid.

Cardiac rehabilitation must be provided in a facility that has the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment (i.e. oxygen, cardiopulmonary resuscitation equipment, or defibrillator) available for immediate use. If no clinically significant arrhythmia is documented during the first three weeks of the program, the provider may have the client complete the remaining portion without telemetry monitoring by the physician’s order.

SOURCE: TX Medicaid Inpatient and Outpatient Hospital Services Handbook, p. 54 (Aug. 2023). (Accessed Aug. 2023)

CSHCN Program

The CSHCN Program has certain requirements around equipment, prior authorization, and billing instructions.  Please refer to manual for specifics.

SOURCE: TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Aug. 2023), p. 9-13 (Accessed Aug. 2023).

Last updated 08/21/2023

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. 5, 6, 9, & 13 (Aug. 2023). (Accessed Aug. 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 Aug. 2023).

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. (Aug. 2023). (Accessed Aug. 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 Aug. 2023).

GEOGRAPHIC LIMITS

No Reference Found

TRANSMISSION FEE

No Reference Found