Texas

Last updated 09/22/2021

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 medical services, to be physically present in the distant or patient site environment during a telehealth or telemedicine medical 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 medical service.

Distant site providers that communicate with clients using electronic communication methods other than phone or facsimile must provide clients with written notification of the physician’s privacy practices prior to evaluation and treatment. Providers must make a “good faith effort” to obtain the client’s written acknowledgment of the notice, including by email response. A distant site provider should provide patients who receive a telemedicine medical service with guidance on the appropriate follow-up care.

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. 5-7  (Sept. 2021). (Accessed Sept. 2021).

Additional parental or guardian consent may be required if online or web-based screening tools are used that could result in client data being stored electronically in an outside database other than the provider’s electronic medical record system, or if the data is used for purposes other than THSteps screening. The provider should seek legal advice regarding the need for this consent.

SOURCE:  TX Medicaid Children’s Services Handbook, p. 175, (Sept. 2021), (Accessed Sept. 2021).

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. 531.001. (Accessed Sept. 2021).

Behavioral Analysts Program & Dyslexia Therapy 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. 121.70 & Sec. 121.71, (Accessed Sept. 2021).

Last updated 09/21/2021

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 & TX HB 2056 (2021 Session) (Accessed Sept. 2021).

“Telehealth service” means a health service, other than a telemedicine medical service, delivered by a licensed or certified health professional acting within the scope of the health professional’s license or certification who does not perform a telemedicine medical service and that requires the use of advanced telecommunications technology, other than telephone or facsimile technology, including:

• Compressed digital interactive video, audio, or data transmission;
• Clinical data transmission using computer imaging by way of still-image capture and store-and-forward; and
• Other technology that facilitates access to health care services or medical specialty expertise.

“Telemedicine medical service” means a health care service, initiated by a physician or provided by a health professional acting under physician delegation and supervision, that is provided for purposes of patient assessment by a health professional, diagnosis or consultation by a physician, or treatment, or for the transfer of medical data, and that requires the use of advanced telecommunications technology, other than telephone or facsimile technology, including:

• Compressed digital interactive video, audio, or data transmission;
• Clinical data transmission using computer imaging by way of still-image capture and store-and-forward; and
• Other technology that facilitates access to health care services or medical specialty expertise.

SOURCE: TX Admin. Code, Title 1 Sec. 354.1430 (Accessed Sept. 2021).

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

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

SOURCE: TX Government Code, Sec. 531.001 refers to Occupations Code, Sec. 111.001. (Accessed Sept. 2021)

Texas Medicaid managed care organizations (MCOs) are prohibited from denying reimbursement for covered services solely because they are delivered remotely. MCOs must consider reimbursement for all medically necessary Medicaid-covered services that are provided using telemedicine or telehealth and must consider clinical effectiveness and cost-effectiveness to determine whether a telemedicine or telehealth visit is appropriate.  See manual for list of considerations.

SOURCE: TX Medicaid Telecommunication Services Handbook, Sept. 2021, p. 5 (Accessed Sept. 2021).

Telemedicine medical services are defined as healthcare 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 patient at a different location using telecommunications or information technology.

Telehealth services are defined as health-care services 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 a patient at a different physical location other than the health professional using telecommunications or information technology.

SOURCE: TX Medicaid Telecommunication Services Handbook, Feb. 2021, p. 6 & 10 (Sept. 2021) (Accessed Sept. 2021).

Standards of Care in Crisis Stabilization Units

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

SOURCE: TX Admin Code, Title 26, Part 1, Ch. 306, Subchapter B, Sec. 306.45, (Accessed Sept. 2021).

Last updated 09/22/2021

Email, Phone & Fax

A health benefit plan, including a Texas Medicaid managed care organization (MCO), is not required to provide reimbursement for telemedicine medical services that are provided through only synchronous or asynchronous audio interactions including:

• An audio-only telephone consultation
• A text-only email message
• A facsimile transmission

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 8 & 14 (Sept. 2021). (Accessed Sept. 2021).

For behavioral health and case management services, service coordination funded as TCM can be reimbursed as a Supportive Encounter, which can be face-to-face, telephone, or telemedicine contact with an individual or with a collateral on the individual’s behalf to provide service coordination.

SOURCE: TX Medicaid Behavioral Health and Case Management Services Handbook, pg. 38 (Sept. 2021). (Accessed Sept. 2021).

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. (Sept. 2021). (Accessed Sept. 2021).

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 as amended by TX HB 4 (2021 Session) (Accessed Sept. 2021)

Last updated 09/21/2021

Live Video

POLICY

Synchronous audiovisual interaction is reimbursable under Texas Medicaid fee-for-service.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 14 (Sept. 2021) (Accessed Sept. 2021).

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 Sept. 2021).

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

SOURCE: TX Govt. Code Sec. 531.0217(d). (Accessed Sept. 2021).

Texas Medicaid managed care organizations (MCOs) are prohibited from denying reimbursement for covered services solely because they are delivered remotely. MCOs must consider reimbursement for all medically necessary Medicaid-covered services that are provided using telemedicine or telehealth and must consider clinical effectiveness and cost-effectiveness to determine whether a telemedicine or telehealth visit is appropriate.

Texas Medicaid MCOs must consider reimbursement for all services that are currently a Medicaid benefit when they are provided using telemedicine or telehealth, including the procedure codes that are identified in certain tables in the handbook (see handbook).

All other medically necessary Medicaid-covered services that are provided using telemedicine or telehealth must also be considered for reimbursement. Texas Medicaid MCOs cannot deny, limit, or reduce reimbursement for a covered health-care service or procedure based on the provider’s choice of telecommunications platform to provide the service or procedure using telemedicine or telehealth.  Providers should refer to individual MCO policies for additional coverage information.

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 medical service that meets the delivery modality requirements specified in Texas Occupations Code §111.005(a)(3).
  • The current telemedicine medical service.

SOURCE: TX Medicaid Telecommunication Services Handbook, Sept. 2021, p. 5-6 (Accessed Sept. 2021).

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 Sept. 2021).

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

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

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

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

SOURCE: TX Govt. Code Sec. 531.0217, (Accessed Sept. 2021)

Telehealth:  Before receiving a telehealth service, the patient must receive an initial evaluation for the same diagnosis or condition by a physician or other qualified healthcare professional licensed in Texas which can be performed in-person or as a telemedicine visit that conforms to 22 TAC Ch. 174.  A patient receiving telehealth services must be evaluated annually by a physician or other healthcare professional (in-person or via a telemedicine visit) to determine if the patient has a continued need for the service.  If the patient is receiving the telehealth services to treat a mental health diagnosis or condition, the patient is not required to receive an initial evaluation.

SOURCE: TX Admin. Code, Title 1, Sec. 354.1432(2) (Accessed Sept. 2021).

Preventive health visits under Texas Health Steps (THSteps) are not benefits if performed using telemedicine medical services. See provider manual for special rules for Texas Health Steps program.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 7 (Sept. 2021), (Accessed Sept. 2021).

ELIGIBLE SERVICES/SPECIALTIES

Telemedicine & Telehealth

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

More than one medically necessary telemedicine 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.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 4, 7, & 11, (Sept. 2021). (Accessed Sept. 2021).

Texas Medicaid MCOs must consider reimbursement for all services that are currently a Medicaid benefit when they are provided using telemedicine or telehealth, including the procedure codes that are identified in the tables of subsection 3.3.4 *, “Telemedicine Benefits for FQHCs” and subsection 3.4.8 *, “Distant-Site Telehealth Benefits for FQHCs” in this handbook.  All other medically necessary Medicaid-covered services that are provided using telemedicine or telehealth must also be considered for reimbursement.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 5. (Sept. 2021). (Accessed Sept. 2021).

Telemedicine

Texas Medicaid reimburses for live video for the following services provided through telemedicine:

• Consultations;
• Office or other outpatient visits;
• Psychiatric diagnostic interviews;
• Pharmacologic management;
• Psychotherapy;
• Data transmission

SOURCE: TX Admin. Code, Title 1, Sec. 354.1432(1). (Accessed Sept. 2021).

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 Sept. 2021).

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. 531.0272, (Accessed Sept. 2021)

Certain outpatient mental health services may be provided by distant site providers through telemedicine or telehealth when billed with modifier 95.

Mental health services delivered through telemedicine or telehealth do not require a patient site presenter unless the patient is experiencing a mental health emergency.

Prescribing of certain MAT medications may be done via telemedicine presuming all other applicable state and federal laws are followed.  With the exception of prescribing MAT medications via telemedicine, SUD treatment services may not be delivered via telemedicine or telehealth.

SOURCE:  TX Medicaid Behavioral Health and Case Management Svcs. Handbook, p. 25 & 74, (Sept. 2021). (Accessed Sept. 2021).

THSteps preventive medical checkups are not a benefit under telemedicine or telehealth.

SOURCE:  TX Medicaid Children’s Services Handbook, p. 176, (Sept. 2021), (Accessed Sept. 2021).

Treatment of a client for chronic pain with scheduled drugs using telemedicine medical services is prohibited.  Treatment of a client for acute pain with scheduled drugs using telemedicine medical services is permitted.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 8, (Sept. 2021). (Accessed Sept. 2021).

School based telehealth services, SHARS telehealth services and early childhood intervention telehealth services are allowed for certain codes and certain circumstances.  See ‘Eligible Provider’ section below or provider manual for more details.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 12, (Sept. 2021). (Accessed Sept. 2021).

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, Sec. 306.51 & Sec. 306.67, (Accessed Jun. 2021).

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 62.1571 (Accessed Sept. 2021).

ELIGIBLE PROVIDERS

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

• Physician
• Clinical Nurse Specialist (CNS)
• Nurse Practitioner (NP)
• Advanced Practice Registered Nurse (APRNs) (in administrative code only)
• 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 in Texas. Hospitals may also serve as the distant site provider.

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).

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 6 (Sept. 2021)  & TX Admin Code. Title 1, Sec. 355.7001, (Accessed Sept. 2021).

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. 531.0215, (Accessed Sept. 2021).

Telehealth eligible distant site providers listed in both Administrative Code & Telecommunications Medicaid Manual

• Licensed professional counselors
• Licensed marriage and family therapist (LMFT)
• Licensed clinical social worker (LCSW) (including Comprehensive Care Program social workers)
• Licensed psychologist
• Licensed psychological associate
• School Health and Related Services (SHARS)

Telehealth eligible distant sites listed in Administrative Code only:

• Durable medical equipment suppliers

Telehealth eligible distant sites listed in Telecommunications Medicaid Manual only:

• Early Childhood Intervention (ECI)
• Licensed professional counselor
• LMFT
• LCSW
• Psychologist
• Licensed psychological associate
• Provisionally licensed psychologist
• Licensed dietician
• CCP providers (occupational therapist, speech-language pathologist)
• Home health agency
• School Health Related Services (SHARS)
• FQHC

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 10 (Sept. 2021) & TX Admin Code. Title 1, Sec. 355.7001 (Accessed Sept. 2021).

School-Based Telehealth Services

Occupational Therapist (OT) and Speech Therapist (ST) providers may be reimbursed for telehealth services delivered to children in school-based settings with the following criteria:

• Reimbursement for OT and ST providers is only available when the patient site is a school-based setting.
• Children receiving telehealth services rendered by OT and ST providers must be eligible for these services through Texas Health Steps comprehensive Care Program (CCP).
• All medical necessity criteria and prior authorization requirements for in-person OT and ST services apply when services are delivered to children in school-based settings.
• Services provided to a patient on public school or open-enrollment charter school premises are only permitted when delivered before or after school hours.

All other prior authorization, reimbursement, and billing guidelines that are applicable to in-person services will also apply when OT and ST services are delivered as telehealth services.

Licensed clinical social workers (LCSW), licensed professional counselors (LPC), licensed marriage and family therapists (LMFT), and psychologist providers may be reimbursed for telehealth services in school-based settings.

Children receiving telehealth services rendered by LCSW, LPC, LMFT, and psychologist providers must be eligible for these services through Texas Health Steps CCP or through SHARS.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 11-12 (Sept. 2021), (Accessed Sept. 2021).

Early Childhood Intervention

Telehealth services delivered to children who are eligible for the Early Childhood Intervention (ECI) Program are a benefit of Texas Medicaid.

The following procedure codes may be reimbursed for services rendered as telehealth services through the ECI program.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 12 (Sept. 2020),  (Accessed Sept. 2021).

FQHCS

See p. 9 of Telecommunication Services Handbook for allowed procedure codes for telemedicine services furnished by FQHCs.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 9 (Sept. 2021). (Accessed Sept. 2021).

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. 531.0215, (Accessed Sept. 2021).

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 Sept. 2021).

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. 531.0272, (Accessed Sept. 2021)

ELIGIBLE SITES

Telemedicine/Telehealth eligible originating (patient) sites:

• An established medical site
• A state mental health facility
• State supported living centers.

SOURCE: TX Admin. Code, Title 1, Sec. 354.1432(1)(C) (Accessed Sept. 2021).

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

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 8 & 13 (Sept. 2021), (Accessed Sept. 2021).

School-Based Telemedicine Services

Telemedicine medical services 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 medical 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, pg. 9 (Sept. 2021), (Accessed Sept. 2021).

FQHCs may be reimbursed the distant-site provider fee for telemedicine and 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, pg. 9 & 13. (Sept. 2021), (Accessed Sept. 2021).

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

A health professional is defined as:

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

SOURCE: TX Government Code Sec. 531.02171. (Accessed Sept. 2021).

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

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

SOURCE: TX Admin. Code, Title 1, Sec. 355.7001(f); & TX Admin. Code, Title 1, Sec. 354.1432(1)(G). (Accessed Sept. 2021).

School-Based Telehealth Services

Occupational therapists and speech-language therapists may be reimbursed for telehealth services delivered to children in school-based settings if the patient is eligible for those services through Texas Health Steps-Comprehensive Care Program (CCP). Services delivered to a patient on public or open-enrollment charter school premises may only be delivered before or after school hours.  Other criteria apply.  See manual.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 11 (Sept. 2021). (Accessed Sept. 2021).

School Health and Related Services (SHARS)

Schools that participate in the SHARS program may be reimbursed for telehealth OT and ST services delivered to children in school-based settings with the following criteria:

• Children who are eligible for OT and ST services through SHARS may receive additional therapy through Texas Health Steps-CCP if medical necessity criteria is met.
• OT and ST services provided by school districts through SHARS can be delivered during school hours.

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 12 (Sept. 2021), (Accessed Sept. 2021).

GEOGRAPHIC LIMITS

No Reference Found

FACILITY/TRANSMISSION FEE

Patient-site providers that are enrolled in Texas Medicaid may only be reimbursed for the facility fee using procedure code Q3014. Procedure code Q3014 is payable to NP, CNS, PA, physicians, and outpatient hospital providers. Charges for other services that are performed at the patient site may be submitted separately. Procedure code Q3014 is not a benefit if the patient site is the client’s home.

SOURCE: TX Admin. Code, Title 1 Sec. 355.7001(d) & TX Medicaid Telecommunication Services Handbook, p. 8. (Sept. 2021). (Accessed Sept. 2021). 

Patient Site

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

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

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

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 9 (Sept. 2021), (Accessed Sept. 2021).

Last updated 09/22/2021

Miscellaneous

Recently Passed Legislation (Now Effective) 

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 & TX SB 1896 (2021 Session). (Accessed Sept. 2021).

Children’s Health Insurance Program

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

SOURCE: TX Govt. Code Sec. 531.02162, (Accessed Sept. 2021).

Must use the “95” modifier for telemedicine/telehealth services (except for services that already indicate remote delivery in the description).  See manual for codes that can be billed with the “95” modifier.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 7 and 11 (Sept. 2021). (Accessed Sept. 2021).

The software system used by the distant site and originating site (when patient presenter is used) must allow secure authentication of the distant site provider and the client.

See provider manual for other information security and documentation requirements.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 4-5. (Sept. 2021). (Accessed Sept. 2021).

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

SOURCE: TX Admin Code. 355.7001(g). (Accessed Jun. 2021).

A valid practitioner-patient relationship must exist between the distant site provider and patient.  The relationship exists if the distant site provider meets the same standard of care required for an in-person service.  A relationship is established through: a prior in-person services; a prior telemedicine medical services that meets the delivery modality requirements in TX Occupations Code Sec. 111.005(a)(3); or through the current telemedicine medical service.  The relationship can be established through a call coverage agreement established in accordance with the Texas Medical Board rules.

Distant site providers should provide patients with written notification of the physician’s privacy practices as well as guidance on appropriate follow-up care.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 6-7 (Sept. 2021). (Accessed Sept. 2021).

A distant site provider may issue a valid prescription as part of a telemedicine medical service. The prescribing physician must be licensed in Texas. If the prescription is for a controlled substance, the prescribing physician must have a current valid U.S. Drug Enforcement Administration (DEA) registration number.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 8 (Sept. 2021). (Accessed Sept. 2021).

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. 62 (Jun. 2021). (Accessed Jun. 2021).

All patient health information generated or utilized during a telehealth or telemedicine medical service must be stored by the distant site provider in a patient 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 HHS rules implementing HIPAA.

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 medical 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 medical services provided to a child in a school-based setting, a notification provided by the telemedicine medical services 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 & 8-10. (Sept. 2021). (Accessed Sept. 2021).

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 Sept. 2021).

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 Sept. 2021).

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 Sept. 2021).

Last updated 09/22/2021

Out of State Providers

An out-of-state physician who is a distant site provider may provide episodic telemedicine medical services without a Texas medical license as outlined in Texas Statute and Regulation.

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).

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 6 (Sept. 2021). (Accessed Sept. 2021).

Last updated 09/21/2021

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.

The Commission is required to develop and implement a system that ensures behavioral health services may be provided using an audio-only platforms.

Last updated 09/22/2021

Remote Patient Monitoring

POLICY

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

SOURCE: TX Government Code, Sec. 531.001(4-a). (Accessed Sept. 2021).

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

SOURCE: TX Admin Code, Title 1, Sec. 355.7001(e). (Accessed Sept. 2021).

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 HIPPA.  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. See manual for documentation requirements.

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

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 14-16 (Sept. 2021). (Accessed Sept. 2021).

CONDITIONS

Home Telemonitoring is available only to patients who:

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

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

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

SOURCE: TX Admin Code. Title 1, Sec. 354.1434, TX Admin Code. Title 4 Sec. 531.02164 & TX Medicaid Telecommunication Services Handbook, p. 15; 17 (Sept. 2021). (Accessed Sept. 2021).

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

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

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

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 15; 17 (Sept. 2021). (Accessed Sept. 2021).

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

Home telemonitoring services are also available to pediatric persons who:

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

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

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

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

SOURCE: TX Government Code Sec. 531.02164, (Accessed Sept. 2021).

PROVIDER LIMITATIONS

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

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

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

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

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

SOURCE:  TX Medicaid Telecommunication Services Handbook, p. 14-17 (Sept. 2021). (Accessed Sept. 2021).

Providers must:

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

See specific documentation requirements for telemonitoring providers in manual.

SOURCE: TX Admin Code. Title 1, Sec. 354.1434(c). (Accessed Sept. 2021).

OTHER RESTRICTIONS

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. 15-16 (Sept. 2021). (Accessed Sept. 2021).

Last updated 09/21/2021

Store and Forward

POLICY

Asynchronous store-and-forward technology, including asynchronous store-and-forward technology in conjunction with synchronous audio interaction between the distant site provider and the patient in another location is reimbursable under Texas Medicaid. The distant site provider would need to use one of the following:

• Clinically relevant photographic or video images, including diagnostic images
• The patient’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories

Other forms of audiovisual telecommunication technologies that allow the distant site provider to meet the in-person visit standard of care may also be used.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 7 & 14, (Accessed Sept. 2021).

TX Administrative Code includes definitions of “Telemedicine Medical Service,” “Telehealth Services” and “Telemedicine” which encompasses store-and-forward, stating that it includes “clinical data transmission using computer imaging by way of still-image capture and store-and-forward.”

SOURCE: TX Admin. Code, Title 1 Sec. 354.1430 (Accessed Sept. 2021).

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 Sept. 2021).

ELIGIBLE SERVICES

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 Sept. 2021).

GEOGRAPHIC LIMITS

No Reference Found

TRANSMISSION FEE

No Reference Found