Medicaid & Medicare

Remote Patient Monitoring

Remote patient monitoring (RPM) is the collection of a wide range of health data from the point of care, such as vital signs, weight, and blood pressure. The data is transmitted to health professionals in facilities such as monitoring centers in primary care settings, hospitals and intensive care units, and skilled nursing facilities.  A little over half of state Medicaid programs reimburse for RPM, however there are a multitude of restrictions associated with its use. The most common include only offering reimbursement to home health agencies, restricting the clinical conditions for which symptoms can be monitored, and limiting the type of monitoring device and information that can be collected.

See overview of states with RPM reimbursement >
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Federal

Last updated 10/10/2021

POLICY

Although not considered to fall under the definition of …

POLICY

Although not considered to fall under the definition of telehealth, in 2018 CMS began making separate payment for the collection and interpretation of physiologic data.  In 2019, they expanded their reimbursement to three remote physiologic monitoring codes, and an add-on code was added in 2020.  Currently eligible codes include 99091, 99453, 99454, 99457, 99458.  Each code has its own requirements in the code description.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125 & CY 2020 Final Physician Fee Schedule, CMS, p. 429, (Accessed Oct. 2021).

Note that chronic care management, principle care management, and transitional care management may also have remote monitoring applications.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 126-128; CY 2020 Final Physician Fee Schedule. CMS, p. 390-421 & Medicare Learning Network Booklet, Chronic Care Management Services, July 2019 (Accessed Oct. 2021). 


CONDITIONS

Note that specific condition requirements apply for chronic care management, principle care management, and transitional care management which may also have remote monitoring applications.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125; CY 2020 Final Physician Fee Schedule, CMS, p. 429 & Medicare Learning Network Booklet, Chronic Care Management Services, July 2019, (Accessed Oct. 2021).


PROVIDER LIMITATIONS

For remote physiologic monitoring, we note that the term, ‘‘other qualified healthcare professionals,’’ used in the code descriptor is defined by CPT, and that definition can be found in the CPT Codebook.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125, (Accessed Oct. 2021).

CMS has designated RPM codes 99457 and 99458 as defined in Sec. 410.26(b)(5).  See below for referenced definition:

In general, services and supplies must be furnished under the direct supervision of the physician (or other practitioner). Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner). The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly. However, only the supervising physician (or other practitioner) may bill Medicare for incident to services.

SOURCE: CY 2020 Final Physician Fee Schedule. CMS, p. 431 & 42 CFR 410.26, (Accessed Oct. 2021).

FQHCs/RHCs

Services such as RPM are not separately billable because they are already included in the RHC AIR or FQHC PPS payment.

SOURCE: CY 2020 Final Physician Fee Schedule. CMS, p. 432, (Accessed Oct. 2021).

Home Health Agencies

An individualized plan of care must be established and periodically reviewed by the certifying physician or allowed practitioner.  The plan of care must include all of the following: … Any provision of remote patient monitoring or other services furnished via telecommunications technology (as defined in § 409.46(e)) or audio-only technology. Such services must be tied to the patient-specific needs as identified in the comprehensive assessment, cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment.

Telecommunications technology, as indicated on the plan of care, can include: remote patient monitoring, defined as the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency; teletypewriter (TTY); and 2-way audio-video telecommunications technology that allows for real-time interaction between the patient and clinician. The costs of any equipment, set-up, and service related to the technology are allowable only as administrative costs. Visits to a beneficiary’s home for the sole purpose of supplying, connecting, or training the patient on the technology, without the provision of a skilled service, are not separately billable.

SOURCE:  42 CFR Sec. 409.43 & 409.46 as updated by CMS Final Rule for CY 2021 Home Health Prospective Payment System (Accessed Oct. 2021).


OTHER RESTRICTIONS

No reference found.

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Alabama

Last updated 09/24/2021

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Alabama Medicaid will reimburse remote patient monitoring for specified …

POLICY

Alabama Medicaid will reimburse remote patient monitoring for specified conditions through the In-Home Remote Patient Monitoring Program.  The program is administered by the Alabama Coordinated Health Network (ACHN). Patients may be referred to the program by any SOURCE including a physician, ACHN Care Coordinators, patient or caregiver, the Health Department, hospitals, home health agencies or community-based organizations. Orders for In-Home Monitoring along with the specific parameters for daily monitoring must be obtained from the patient’s primary medical provider prior to evaluation and admission.

SOURCE: AL Medicaid Management Information System Provider Manual, Primary Care Physician (ch. 40.28, Pg. 32). Oct. 2021. (Accessed Oct. 2021).


CONDITIONS

Patients with the following medical conditions may register for the program:

  • Diabetes
  • Congestive Heart Failure
  • Hypertension

SOURCE: AL Medicaid Management Information System Provider Manual, Primary Care Physician (ch. 40.28, Pg. 32). Oct. 2021. (Accessed Oct. 2021).


PROVIDER LIMITATIONS

ADPH must be enrolled with provider type 05 (home health) and provider specialty 970 (disease management).

SOURCE: AL Medicaid Management Information System Provider Manual, Primary Care Physician (ch. 40.28, Pg. 32). Oct. 2021. (Accessed Oct. 2021).


OTHER RESTRICTIONS

No Reference Found

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Alaska

Last updated 10/15/2021

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Alaska Medicaid will reimburse for services delivered through self-monitoring, …

POLICY

Alaska Medicaid will reimburse for services delivered through self-monitoring, where the patient is monitored in their home via a telemedicine application, with the provider indirectly involved from another location.

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Community Behavioral Health Services; Mental Health Physician Clinic (1/2/2019); Physician, ARNP and PA Services (5/13) & Alaska Medicaid Policy Clarification: Medicaid Telehealth Coverage. May 8, 2020. (Accessed Oct. 2021).

To be eligible for payment under self-monitoring or testing, “the services must be provided by a telemedicine application based in the recipient’s home, with the provider only indirectly involved in the provision of the service.”

SOURCE: AK Admin. Code, Title 7, 110.625(a). (Accessed Oct. 2021).


CONDITIONS

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OTHER RESTRICTIONS

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Arizona

Last updated 09/20/2021

POLICY

Service delivery via telehealth can be done via teledentistry, …

POLICY

Service delivery via telehealth can be done via teledentistry, remote patient monitoring, telemedicine, or asynchronous (store and forward).

Remote Patient Monitoring is “personal health and medical data collection from a member in one location via electronic communication technologies, which is transmitted to a provider in a different location for use in providing improved chronic disease management, care, and related support. Such monitoring may be either synchronous (real-time) or asynchronous (store-and-forward).

AHCCCS will reimburse for remote patient monitoring in their fee-for-service program. Managed care organizations must abide by AHCCCS fee-for-service coverage policy.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Medical Policy for AHCCCS Covered Services, Ch. 300, (320-I pg. 1-2). Oct. 2019; AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (10/47-48), (07/12/2021) & IHS/Tribal Provider Billing Manual, (8/49), (07/12/2021). (Accessed Sept. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

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OTHER RESTRICTIONS

Remote patient monitoring:

  1. Shall not replace provider choice for healthcare delivery modality.
  2. Shall not replace member choice for healthcare delivery modality.
  3. Shall be AHCCCS-covered services that are medically necessary and cost effective.

SOURCE: AZ Medical Policy for AHCCCS Covered Services. Telehealth and Telemedicine Ch 300, (320-I pg. 3), Oct. 2019. (Accessed Sept. 2021).

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Arkansas

Last updated 10/07/2021

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Remote patient monitoring means the use of electronic information …

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Remote patient monitoring means the use of electronic information and communication technology to collect personal health information and medical data from a patient at an originating site that is transmitted to a healthcare provider at a distant site for use in the treatment and management of medical conditions that require frequent monitoring.

SOURCE: AR Medicaid Provider Manual. Section I General Policy. Rule 105.190. Updated Aug. 1, 2018. & AR Admin. Rule 016.06.18. p. 6 (Accessed Oct. 2021).

Although remote patient monitoring is included in Medicaid’s definition of telemedicine, no information was found regarding reimbursement of store-and-forward.

Patient-Led Arkansas Shared Savings Entity (PASSE) Program
Virtual providers can use mobile telemonitoring technologies to remotely monitor and evaluate the patient’s functional and health status.

SOURCE: PASSE Program, p. II-9 (3/1/19). (Accessed Oct. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

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OTHER RESTRICTIONS

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California

Last updated 08/28/2021

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Medi-Cal has not adopted reimbursement policies for remote patient …

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Medi-Cal has not adopted reimbursement policies for remote patient monitoring.

SOURCE: DHCS Telehealth FAQs, Coverage Questions. March 2021. Accessed Aug. 2021.

The department may authorize the use of remote patient monitoring as an allowable telehealth modality for covered health care services and provider types it deems appropriate for dates of service on or after July 1, 2021. The department may establish a fee schedule for applicable health care services delivered via remote patient monitoring.

SOURCE: AB 133, Sec. 380 (2021 Session). Accessed Aug. 2021.

Medi-Cal provider rates are included for 4 remote physiological monitoring codes (99453, 99454, 99457, 99458). It is possible Medi-Cal is considering these codes Communication Technology Based Services (CTBS) consistent with Medicare.

SOURCE: Medi-Cal Rates Information. Aug. 2021. Accessed Aug. 2021.


CONDITIONS

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PROVIDER LIMITATIONS

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OTHER RESTRICTIONS

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Colorado

Last updated 08/18/2021

POLICY

Telehealth monitoring is available for members who are eligible …

POLICY

Telehealth monitoring is available for members who are eligible through the Home Health benefit and should not be billed as telemedicine.

SOURCE: CO Department of Health Care Policy and Financing.  “Telemedicine Billing Manual” 4/21.  (Accessed Aug. 2021).

The CO Medical Assistance Program will reimburse for home health care or home and community-based services through telemedicine at a flat fee set by the state board.

SOURCE: CO Revised Statutes 25.5-5-321 (Accessed Aug. 2021)

Home care agencies and home care placement agencies must allow for supervision in person or be telemedicine or telehealth.  Any rules adopted by the board shall be in conformity with applicable federal law and must take into consideration the appropriateness, suitability and necessity of the method of supervision permitted.

SOURCE: CO Revised Statutes 25-27.5-104 & SB 20-212 (2020 Session) (Accessed Aug. 2021).

The Home Health Agency shall create policies and procedures for the use and maintenance of the monitoring equipment and the process of telehealth monitoring. The Home Health Agency shall provide monitoring equipment that possesses the capability to measure any changes in the monitored diagnoses and meets all the safety requirements in the regulation. Home Health Telehealth services are covered for clients receiving Home Health Services for telehealth monitoring.

SOURCE: 10 CO Code of Regulation 2505-10 8.520.5.D (Accessed Aug. 2021).

CO Medicaid reimburses telehealth remote monitoring services including installation and on-going remote monitoring of clinical data through technologic equipment in order to detect minute changes in the member’s clinical status that will allow Home Health agencies to intercede before a chronic illness exacerbates requiring emergency intervention or inpatient hospitalization.

SOURCE: CO Medical Assistance Program, Home Health Billing Manual, (4/21), (Accessed Aug. 2021).

CO Medicaid covers home health telehealth, which includes frequent and ongoing self-monitoring of members through equipment left in the member’s home which is designed to measure the common signs and symptoms of disease exacerbation before a crisis occurs allowing for timely intervention and symptom management.

SOURCE: CO Department of Health Care Policy and Financing.  “Home Health Telehealth”.  (Accessed Aug. 2021).


CONDITIONS

  • A member is eligible only if they meet the following criteria:
  • Member must receive Home Health services from provider who has opted to provide telehealth services
  • Member must require frequent and on-going monitoring/management of their disease or condition
  • Member’s home environment must be compatible with the use of the equipment
  • Member or caregiver must be willing and able to comply with vital sign self-monitoring
  • Member must have one or more of the following diagnoses:
    1. Congestive Heart Failure
    2. Chronic Obstructive Pulmonary Disease
    3. Asthma
    4. Diabetes
    5. Other diagnosis or condition deemed appropriate by the Department or its designee

SOURCE: CO Department of Health Care Policy and Financing.  “Home Health Telehealth”.  (Accessed Aug. 2021).

The following requirements must be met:

  • Client is receiving services from a home health provider for at least one of the following: congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes, pneumonia; or other diagnosis or medical condition deemed eligible by the Department or its Designee.
  • Client requires ongoing and frequent, minimum of 5 times weekly, monitoring to manage their qualifying diagnosis, as defined and ordered by a physician or podiatrist;
  • Client has demonstrated a need for ongoing monitoring as evidenced by having been hospitalized two or more times in the last twelve months for conditions related to the qualifying diagnosis; or, if the client has received home health services for less than six months, the client was hospitalized at least once in the last three months, an acute exacerbation of a qualifying diagnosis that requires telehealth monitoring, or new onset of a qualifying disease that requires ongoing monitoring to manage the client in their residence;
  • Client or caregiver misses no more than 5 transmissions of the provider and agency prescribed monitoring events in a thirty-day period; and
  • Client’s home environment has the necessary connections to transmit the telehealth data to the agency and has space to set up and use the equipment as prescribed.

SOURCE: 10 CO Code of Regulation 2505-10 8.520.5.D (Accessed Aug. 2021).


PROVIDER LIMITATIONS

Any home health agency is eligible to provide services.  A specific list of agencies is provided.

SOURCE:  CO Department of Health Care Policy and Financing.  “Home Health Telehealth”.  (Accessed Aug. 2021).

Acute home health agencies and long-term home health agencies are reimbursed for the initial installation and education of telehealth monitoring equipment and can be billed once per client per agency. The agency can also bill for every day they receive and review the client’s clinical information.

No prior authorization needed, but agencies should notify the Department or its designee when a client is enrolled in the service.

SOURCE: CO Medical Assistance Program, Home Health Billing Manual, (4/21), (Accessed Aug. 2021).


OTHER RESTRICTIONS

Home Health services are covered under Medicaid only when all of the following are met:

  1. Services are medically necessary.
  2. Services are provided under a plan of care as defined at Section 8.520.1 DEFINITIONS.
  3. Services are provided on an intermittent basis, as defined at Section 8.520.1, DEFINITIONS.
  4. The client meets one of the following:
    1. The only alternative to Home Health services is hospitalization or emergency room care; or
    2. Client’s medical records indicate that medically necessary services should be provided in the client’s home instead of other out-patient setting, according to one or more of the following guidelines:
      1. The client, due to illness, injury or disability, is unable to travel to an outpatient setting for the needed service;
      2. Based on the client’s illness, injury, or disability, travel to an outpatient setting for the needed service would create a medical hardship for the client;
      3. Travel to an outpatient setting for the needed service is contraindicated by a documented medical diagnosis;
      4. Travel to an outpatient setting for the needed service would interfere with the effectiveness of the service; or
      5. The client’s medical diagnosis requires teaching which is most effectively accomplished in the client’s place of residence on a short-term basis.
  5. The client is unable to perform the health care tasks for him or herself, and no unpaid family/caregiver is able and willing to perform the tasks; and
  6. Covered service types are those listed in Service Types, Section 8.520.5.

SOURCE: 10 CO Code of Regulation 2505-10 8.520.4.A. (Accessed Aug. 2021).

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Connecticut

Last updated 06/30/2021

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Effective Now Until June 30, 2023

Notwithstanding the provisions …

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Effective Now Until June 30, 2023

Notwithstanding the provisions of section 19a-906 of the general statutes and subdivision (1) of this subsection, a telehealth provider that is an in-network provider or a provider enrolled in the Connecticut medical assistance program that provides telehealth services to a Connecticut medical assistance program recipient, may, during the period beginning on the effective date of this section and ending on June 30, 2023, use any information or communication technology in accordance with the directions, modifications or revisions, if any, made by the Office for Civil Rights of the United States Department of Health and Human Services to the provisions of the Health Insurance Portability and Accountability Act of 1996 P.L. 104-191, as amended from time to time, or the rules and regulations adopted thereunder.

SOURCE: HB 5596 (2021 Session). (Accessed June 2021).


TRANSMISSION FEE

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PROVIDER LIMITATIONS

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Delaware

Last updated 07/09/2021

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No Reference Found

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District of Columbia

Last updated 08/25/2021

POLICY

There is no reimbursement for remote patient monitoring.

SOURCE: …

POLICY

There is no reimbursement for remote patient monitoring.

SOURCE: DC Municipal Regulation. Title 29, Ch. 9, Sec. 910.29, & Physicians Billing Manual.  DC Medicaid. Mar. 18, 2021, Sec. 15.9.7. P. 67 (Accessed Aug.. 2021)  & DC Dept. of Healthcare Finance. Telehealth Provider Guidance. July 30, 2021, p. 6.  (Accessed Aug.. 2021).


CONDITIONS

No Reference Found.


PROVIDER LIMITATIONS

No Reference Found.


OTHER RESTRICTIONS

No Reference Found.

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Florida

Last updated 07/17/2021

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No Reference Found

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PROVIDER LIMITATIONS

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PROVIDER LIMITATIONS

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Georgia

Last updated 10/01/2021

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No Reference Found

CONDITIONS

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PROVIDER LIMITATIONS

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No Reference Found


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PROVIDER LIMITATIONS

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OTHER RESTRICTIONS

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Hawaii

Last updated 09/28/2021

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Hawaii Medicaid is required to cover appropriate telehealth services …

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Hawaii Medicaid is required to cover appropriate telehealth services (which includes store-and-forward and remote patient monitoring) equivalent to reimbursement for the same services provided in-person.

SOURCE: HI Revised Statutes § 346-59.1.  (Accessed Sept. 2021).


CONDITIONS

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PROVIDER LIMITATIONS

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OTHER RESTRICTIONS

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Idaho

Last updated 08/10/2021

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No Reference Found

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PROVIDER LIMITATIONS

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No Reference Found


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PROVIDER LIMITATIONS

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Illinois

Last updated 08/25/2021

POLICY

IL Medicaid will cover home uterine monitoring with prior …

POLICY

IL Medicaid will cover home uterine monitoring with prior approval and when patient meets specific criteria.  Payment is only for the items and not for the service.

SOURCE: IL Dept. of Healthcare and Family Services, Handbook for Durable Medical Equipment, Chapter M-200, Policy and Procedures for Medical Equipment and Supplies, p. 56 (Sept. 2015). (Accessed Aug. 2021).


CONDITIONS

Only for home uterine monitoring.

  • Home uterine monitoring
  • Must be at least 24 weeks gestation; gestation of less than 24 weeks may require additional information
  • Hospitalized for preterm labor at 24-36 weeks
  • Cessation of labor accomplished by administration of tocolytics (terbutaline, procardia, etc.)
  • Discharged to home on oral or subcutaneous tocolytics
  • Multiple gestation pregnancy
  • History of preterm labor and delivery
  • Cervical status change (lengthening or dilation)
  • Cervical effacement
  • Contraction threshold
  • Gravida/para

Pregnancy-Induced Hypertension Monitor

  • Covered for diagnosis of pregnancy-induced hypertension, previous pregnancy induced hypertension or pre-eclampsia
  • Hospitalizations for symptoms related to pregnancy induced; i.e., hypertension, headaches, edema in face, hands and feet
  • Blurred vision
  • Right upper quadrant pain
  • 24-hour urine results greater than 300 mg of total protein
  • Antihypertensive medications
  • Pre-pregnancy and current blood pressure readings.

Will not be covered for patients with a diagnosis of chronic hypertension.

SOURCE: IL Dept. of Healthcare and Family Services, Handbook for Durable Medical Equipment, Chapter M-200, Policy and Procedures for Medical Equipment and Supplies, p. 56 (Sept. 2015). (Accessed Aug. 2021).


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Indiana

Last updated 08/24/2021

POLICY

Indiana Code requires Medicaid to reimburse providers who are …

POLICY

Indiana Code requires Medicaid to reimburse providers who are licensed as a home health agency for telehealth services.

SOURCE: IN Code, 12-15-5-11(c). (Accessed Aug. 2021).


CONDITIONS

The member must be receiving services from a home health agency.  Member must initially have two or more of the following events related to one of the conditions listed below within the previous twelve months:

  • Emergency room visit
  • Inpatient hospital stay

An emergency room visit that results in an inpatient hospital admission does not constitute two separate events.

The two qualifying events must be for the treatment of one of the following diagnoses:

  • Chronic obstructive pulmonary disease
  • Congestive heart failure
  • Diabetes

SOURCE: IN Admin Code, Title 405, 5-16-3.1(d) & IN Medicaid Telemedicine and Telehealth Module, Oct. 1, 2019, published Mar. 30, 2021, p. 7. (Accessed Aug. 2021).


PROVIDER LIMITATIONS

Reimbursement for home health agencies under certain conditions.  A registered nurse must perform the reading of transmitted health information provided from the member in accordance with the written order of the physician.

SOURCE: IN Admin Code, Title 405, 5-16-3.1(d)(5) (Accessed Aug. 2021).


OTHER RESTRICTIONS

Treating physician must certify the need for home health services and document that there was a face-to-face encounter with the individual.

SOURCE: IN Admin Code, Title 405, 5-16-3.1(e) (Accessed Aug. 2021).

Prior authorization is required for all telehealth services and must be submitted separately from other home health service prior authorization requests.  Services may be authorized for up to 60 days.  See Telehealth Module for additional requirements.

Member must also be receiving or approved for other IHCP home health services.

SOURCE: IN Medicaid Telemedicine and Telehealth Module, Oct. 1, 2019, published Mar. 30, 2021 p. 6-7. (Accessed Aug. 2021).

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Iowa

Last updated 10/11/2021

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Managed care plans in Iowa’s Healthy and Well Kids …

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Managed care plans in Iowa’s Healthy and Well Kids in Iowa (Hawki) program, may cover telehealth and telemonitoring services, but do not appear to be mandated.

SOURCE: IA Hawki Benefits. (Accessed Oct. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

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Kansas

Last updated 08/27/2021

POLICY

Kansas Medicaid will reimburse for home telehealth. The policy …

POLICY

Kansas Medicaid will reimburse for home telehealth. The policy states:

“Home telehealth uses real-time, interactive, audio/video telecommunication equipment to monitor patients in the home setting, as opposed to a nurse visiting the home. This technology may be used to monitor the beneficiary for significant changes in health status, provide timely assessment of chronic conditions and provide other skilled nursing services.”

SOURCE:  Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, p. 8-29 (Aug. 2021) (Accessed Aug. 2021).

Home and Community Based Services for the Frail Elderly

“Home Telehealth is a remote monitoring system that enables the participant to effectively manage one or more diseases and catch early signs of trouble so intervention can occur before the participant’s health declines. The provision of Home Telehealth involves participant education specific to one or more diseases (e.g. COPD, CHF, hypertension, and diabetes), counseling, and nursing supervision.

SOURCE:  Kansas Medical Assistance Program, Provider Manual, HCBS Frail Elderly, p. 8-17. (May 2019) (Accessed Aug. 2021).


CONDITIONS

See manual for the codes to use for the provision of telehealth visits to provide long-term care home health services and to assist beneficiaries in managing their diabetes.

SOURCE:  Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, p. AIII-3-AIII-6. (Aug. 2021). (Accessed Aug. 2021).

Home and Community Based Services for the Frail Elderly

Telehealth services (including remote patient monitoring) are provided on an individualized basis for participants who have an identified need in their ISPOC. Participant options and information are provided and discussed during the development of the Integrated Service Plan of Care (ISPOC).  The participant can qualify if either of the following apply:

  • The participant is in need of disease management consultation and education AND has had two or more hospitalizations, including emergency room (ER) visits, within the previous year related to one or more diseases.
  • The participant is using MFP to move from a nursing facility back into the community.

SOURCE:  Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, HCBS Frail Elderly, p. 8-17 & 8-18, (May 2019). (Accessed Aug. 2021).  


PROVIDER LIMITATIONS

Home Telehealth services must be provided by a registered nurse or licensed practical nurse. Agencies may bill skilled nursing services on the same date of service as telehealth services.

SOURCE:  Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, p. 8-29 (Aug. 2021). (Accessed Aug. 2021). 

 Home and Community Based Services for the Frail Elderly

Must be delivered by a registered nurse or licensed practical nurse with RN supervision.  Providers can include home health agencies or county health departments with system equipment capable of monitoring participant vital signs daily.  This includes (at a minimum) heart rate, blood pressure, mean arterial pressure, weight, oxygen saturation, and temperature. Also, the provider must have the capability to ask the participant questions which are tailored to his or her diagnosis. The provider and equipment must have needed language options such as English, Spanish, Russian, and Vietnamese.

SOURCE:  Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, HCBS Frail Elderly, p. 8-18-19, (May 2019), (Accessed Aug. 2021).


OTHER RESTRICTIONS

Providers must submit literature to the fiscal agent’s Provider Enrollment team pertaining to the telecommunication equipment the agency has chosen that will allow thorough physical assessments such as: assessment of edema, rashes, bruising, skin conditions, and other significant changes in health status.

Providers must satisfy all the enrollment/demonstration requirements. See manual for specific demonstration criteria.

Providers are eligible for reimbursement of home telehealth services that meet the following criteria:

  • Prescribed by a physician or allowed nonphysician practitioner;
  • Considered medically necessary;
  • Signed beneficiary consent for telehealth services;
  • Skilled nursing service;
  • Does not exceed program limitations (two visits per week for non-Home and Community Based Services beneficiaries)

Prior authorization required.

SOURCE:  Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, p. AIII-19. (Aug. 2021). (Accessed Aug. 2021).

Home Telehealth Limitations

  • Providers must bill T1030 and T1031 with place of service 02 for home telehealth skilled nursing visits. These codes are per visit.
  • PAs are entered for no more than 60 days. Home telehealth services cannot be approved for durations of more than 60 days. Additional documentation may be required to support continuation of home telehealth service requests that exceed 60 days.
  • Telehealth visits must be provided by a registered nurse or licensed practical nurse.
  • Telehealth visits must use face-to-face, real-time, interactive video contact to monitor beneficiaries in the home setting as opposed to a nurse visiting the home. This technology can be used to monitor a beneficiary’s health status and to provide timely assessments of chronic conditions and other skilled nursing services.
  • HCBS beneficiaries eligible for face-to-face skilled nursing visits provided by a home health agency may receive home telehealth visits with documentation of medical necessity and prior authorization (PA).  The PA must include units to cover the duration and frequency of home telehealth visits. Oral medication administration or monitoring is not considered skilled care.
  • Oral medication administration or monitoring is not considered skilled care.

SOURCE:  Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, p. AIII-8. (Aug. 2021). (Accessed Aug. 2021).

 Home and Community Based Services for the Frail Elderly

See HCBS Frail Elderly provider manual for documentation requirements.

SOURCE:  Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, HCBS Frail Elderly, p. 8-19 & 8-20  (May 2019), (Accessed Aug. 2021).

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Kentucky

Last updated 09/15/2021

POLICY

Remote patient monitoring shall not be an eligible telehealth …

POLICY

Remote patient monitoring shall not be an eligible telehealth service within the fee-for-service Medicaid program unless that service is:

  • Expanded pursuant to subsection (4) of this section;
  • Otherwise included as a part of a department approved value based payment arrangement; or
  • Otherwise included as a value added service or payment arrangement.

A managed care organization may reimburse for remote patient monitoring as a telehealth service if expanded pursuant to subsection (4) of this section or provided as a:

  • Value based payment arrangement; or
  • Value added service or payment arrangement.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Sept. 2021).

Health care providers performing a telehealth or digital health service shall, as appropriate for the service, provider, and recipient, utilize the following modalities of communication delivered over a secure communications connection that complies with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA):

  • Live or real-time audio and video synchronous telehealth technology;
  • Asynchronous store-and-forward telehealth technology;
  • Remote patient monitoring using wireless devices, wearable sensors, or implanted health monitors;
  • Audio-only telecommunications systems; or
  • Clinical text chat technology when:
    • Utilized within a secure, HIPAA compliant application or electronic health record system;

and

    • Meeting:
      • The scope of the provider’s professional licensure; and
      • The scope of practice of the provider; and
      • Comply with the following federal laws to prevent waste, fraud, and abuse relating to telehealth:
        • False Claims Act, 31 U.S.C. § 3729-3733;
        • Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b); and
        • Physician Self-Referral, Section 1877 of the Social Security Act

SOURCE: KY 900 KAR 12:005 Emergency Rule & Ordinary Rule. (Accessed Sept. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Louisiana

Last updated 08/30/2021

POLICY

Under the Community Choices Waiver, Louisiana Medicaid will reimburse …

POLICY

Under the Community Choices Waiver, Louisiana Medicaid will reimburse for telecare, including:

  • Activity and Sensor Monitoring,
  • Health status monitoring, and
  • Medication dispensing and monitoring.

Monthly telecare services consist of:

  • Delivering, furnishing, maintaining and repairing/replacing equipment on an ongoing basis. This may be done remotely as long as all routine requests are resolved within three business days;
  • Monitoring of recipient-specific service activities by qualified staff;
  • Training the recipient and/or the recipient’s responsible representative in the use of the equipment;
  • Cleaning and storing equipment;
  • Providing remote teaching and coaching as necessary to the recipient and/or caregiver(s); and
  • Analyzing data, developing and documenting interventions by qualified staff based on information/data reported.

Personal Emergency Response System (PERS) is also reimbursed under Community Choices Waiver, which sends alerts when emergency services are needed by the recipient.

Activity and Sensor Monitoring

This service is a computerized system that monitors the recipient’s in-home movement and activity for health, welfare and safety purposes.  At a minimum the system must:

  • Monitor the home’s points of egress;
  • Detect falls;
  • Detect movement or lack of movement;
  • Detect whether doors are opened or closed; and
  • Provide a push button emergency alert system.

Some systems also monitor the home’s temperature.

Health Status Monitoring

This service collects health-related data to assist the health care provider in assessing the recipient’s health condition and in providing recipient education and consultation. Could be beneficial for patient with chronic conditions for monitoring weight, oxygen saturation measurements and vital signs.

Medication Dispensing and Monitoring

A remote monitoring system that is individually pre-programmed to dispense and monitor the recipient’s compliance with medication therapy.  The provider or caregiver is notified when there are missed doses or non-compliance with medication therapy.

SOURCE: LA Dept. of Health and Hospitals, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.1, p. 33-35 (as revised on Mar. 16, 2021). (Accessed Aug. 2021).

Standards

Assistive Devices and Medical Supplies Provided by a Durable Medical Equipment (DME) provider that:

  • Is enrolled to provide DME; and
  • Has enrolled in Medicaid as an Assistive Devices and Medical Supplies CCW provider (Provider Type 17);

OR

Provided by a home health agency provider that:

  • Is licensed to provide home health services;
  • Is Medicare certified; and
  • Has enrolled in Medicaid as an OAAS – Community Choices Waiver assistive devices provider (Provider Type 17).

For personal emergency response systems (PERS), these services are provided by a provider that:

  • Is enrolled in Medicaid as a PERS provider; and
  • Has furnished verification (copy of letter from the manufacturer written on the manufacturer’s letterhead stationary) that the provider is an authorized dealer, supplier or manufacturer of a PERS product.

The PERS provider must install and support PERS equipment in compliance with all of the applicable federal, state, parish and local laws and regulations, as well as meet manufacturer’s specifications, response requirements, maintenance records, and recipient education.

SOURCE: LA Dept. of Health and Hospitals, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.6, p. 74 and 84 (As revised on Mar. 2, 2020). (Accessed Aug. 2021).


CONDITIONS

Health status monitoring:

May be beneficial to individuals with congestive heart failure, diabetes or pulmonary disease.

Services must be based on a verified need of the beneficiary and the service must have a direct or remedial benefit with specific goals and outcomes.

SOURCE: LA Dept. of Health and Hospitals, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.1, p. 34-35 (As revised on Mar. 2, 2020). (Accessed Aug. 2021).


PROVIDER LIMITATIONS

Telecare providers must meet the following requirements:

  • Be UL listed/certified or have 501(k) clearance;
  • Be web-based;
  • Be compliant with the requirements of the Health Insurance Portability and Accountability Act (HIPAA);
  • Have beneficiary specific reporting capabilities for tracking and trending;
  • Have a professional call center for technical support based in the United States; and
  • Have on-going provision of web-based data collection for each beneficiary, as appropriate. This includes response to beneficiary

SOURCE: LA Dept. of Health and Hospitals, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.6, p. 84 (As revised on Mar. 2, 2020). (Accessed Aug. 2021). 


OTHER RESTRICTIONS

Limitations

  • Services must be based on verified need and have a direct or remedial benefit with specific goals and outcomes.
  • Benefit must be determined by an independent assessment on any item that costs over $500 and on all communication devices, mobility devices, and environmental controls.
  • Independent assessments must be performed by individuals who have no fiduciary relationship with the manufacturer, supplier, or vendor of the item.
  • All items must reduce reliance on other Medicaid State Plan or waiver services
  • All items must meet applicable standards of manufacture, design and installation
  • The items must be on the Plan of Care developed by the support coordinator and are subject to approval by OAAS Regional Office or its designee.
  • A beneficiary will not be able to simultaneously receive telecare activity and sensor monitoring services and traditional PERS services.

Where applicable, beneficiaries must use Medicaid state plan services, Medicare, or other available payers first. The beneficiary’s preference for a certain brand or supplier is not grounds for declining another payer in order to access waiver services.

SOURCE: LA Dept. of Health and Hospitals, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.1, p. 35 & 32 (As revised on Mar. 16, 2021). (Accessed Aug. 2021).

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Maine

Last updated 08/05/2021

POLICY

Telemonitoring Services are the use of information technology to …

POLICY

Telemonitoring Services are the use of information technology to remotely monitor a member’s health status through the use of clinical data while the member remains in the residential setting. Telemonitoring may or may not take place in real time.

SOURCE: MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.01, p. 5 (Aug. 11, 2019). (Accessed Aug. 2021).

“Telemonitoring,” as it pertains to the delivery of MaineCare services, means the use of information technology to remotely monitor a patient’s status via electronic means, allowing the provider to track the patient’s health data over time. Telemonitoring may be synchronous or asynchronous.

SOURCE: ME Statute Sec. 22:855.3173-H(E) & LD 791 (2021 Session). (Accessed Aug. 2021).

ME Medicaid provides coverage for telemonitoring services (which may or may not take place in real time) under certain circumstances.

Covered telemonitoring services include:

  • Evaluation of the member to determine if telemonitoring services are medically necessary;
  • Evaluation of Member to ensure cognitively and physically capable of operating equipment;
  • Evaluation of residence to determine suitability for telemonitoring services;
  • Education and training;
  • Remote monitoring and tracking of data by a RN, NP, PA or physician and response with appropriate clinical interventions;
  • At least monthly telephonic services;
  • Maintenance of equipment; and
  • Removal/disconnection of equipment when telemonitoring services are no longer necessary or authorized

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.04. p. 6-7. (June 15, 2020). (Accessed Aug. 2021).

Home and Community Benefits for the Elderly and for Adults with Disabilities

Real time remote support monitoring is covered under Home and Community Benefits for the Elderly and for Adults with Disabilities.  Services may include a range of technological options including in-home computers, sensors and video camera linked to a provider that enables 24/7 monitoring and/or contact as necessary.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19.04-2, p. 23 (May 2, 2021). (Accessed Aug. 2021).


CONDITIONS

In order to be eligible for telemonitoring a member must:

  • Be eligible for home health services;
  • Have a current diagnosis of a health condition requiring monitoring of clinical data at a minimum of five times per week, for at least one week;
  • Have documentation in the patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room or have continuously received Telemonitoring Services during the past calendar year and have a continuing need for such services, as documented by an annual note from a health care provider;
  • Have telemonitoring services included in the Member’s plan of care;
  • Reside in a setting suitable to support telemonitoring equipment; and
  • Have the physical and cognitive capacity to effectively utilize the telemonitoring equipment or have a caregiver willing and able to assist with the equipment.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.02. p.3-4 (June 15, 2020). & MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p.10-11. (Aug. 11, 2019). (Accessed Aug. 2021).

Home and Community Benefits for the Elderly and for Adults with Disabilities Final approval must be obtained from the Department, Office of Aging and Disability Services upon a recommendation by the ASA or SCA. In making such a recommendation the ASA or the SCA must consider and document the following information:

  • Number of hospitalizations in the past year;
  • Use of emergency room in the past year;
  • History of falls in the last six months resulting from injury;
  • Member lives alone or is home alone for significant periods of time;
  • Service access challenges and reasons for those challenges;
  • History of behavior indicating that a member’s cognitive abilities put them at a significant risk of wandering; and
  • Other relevant information.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19.04-2, p. 13 (May 2, 2021). (Accessed Aug. 2021).


PROVIDER LIMITATIONS

Telemonitoring only reimbursed when provided by a certified Home Health Agency.  See regulations for specific requirements of Home Health Agencies utilizing telemonitoring services.

SOURCE:  MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 16. (Aug. 11, 2019). (Accessed Aug. 2021). 

In order to be reimbursed for services, Health Care providers:

  • Must be enrolled as MaineCare providers in order to be reimbursed for services;
  • Be a certified Home Health Agency pursuant to the MaineCare Benefits Manual Ch. II Section 40 (“Home Health Services”);
  • The Provider ordering the service must be a Provider with prescribing privileges (physician, nurse practitioner or physician’s assistant);
  • Must document that they have had a face-to-face encounter with the member before a physician may certify eligibility for services under the home health benefit. This may be accomplished through interactive telehealth services, but not by telephone or e-mail.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.01. p.1 & 4 (June 15, 2020). (Accessed Aug. 2021).


OTHER RESTRICTIONS

Telemonitoring services are intended to collect a member’s health-related data, such as pulse and blood pressure readings, that assist healthcare providers in monitoring and assessing the member’s medical conditions.

A note, dated prior to the beginning of service delivery, and demonstrating the necessity of home telemonitoring services, must be included in the member’s file. In the event that services begin prior to the date recorded on the provider’s note, services delivered in that month will not be covered.

SOURCE:  Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 16. (Aug. 11, 2019). (Accessed Aug. 2021). 

Services shall not be duplicate of any other services.  See regulation for examples of duplication.

SOURCE:  Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.06.p. 17.  (Aug. 11, 2019). (Accessed Aug. 2021).  

See regulation for list of non-covered services.

SOURCE:  Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.07. p. 18-19. (Aug. 11, 2019). (Accessed Aug. 2021).

Department required to adopt regulations that comply with the following:

  • May not include any requirement that a patient have a certain number of ER visits or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s eligibility for telemonitoring services;
  • Except as provided in the last bullet point (see below), must include qualifying criteria for a patient’s eligibility of telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an ER
  • Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth;
  • Must include requirements for providers providing telehealth and telemonitoring services; and
  • Must allow at least some portion of case management services covered by the MaineCare program to be delivered through telehealth, without requiring qualifying criteria regarding a patient’s risk of hospitalization or admission to an emergency room.

SOURCE: ME Statute Sec. 3173-H & LD 1974 (2020 Session). (Accessed Aug. 2021).

A health care provider must document that a face-to-face encounter with the member occurred before they are eligible for a home health benefit.  This can occur through interactive telehealth services, but not by telephone or e-mail.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03. p. 4. (June 15, 2020). (Accessed Aug. 2021). 

Home and Community Benefits for the Elderly and for Adults with Disabilities

Use of remote monitoring requires sufficient Back Up Plans and the SCA will be responsible for ensuring that the member has at least two adequate back-up plans prior to making a referral for this service.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 13 (May 2, 2021). (Accessed Aug. 2021).

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Maryland

Last updated 08/31/2021

POLICY

Recently Passed Legislation

Remote patient monitoring services means the …

POLICY

Recently Passed Legislation

Remote patient monitoring services means the use of synchronous or asynchronous digital technologies that collect or monitor medical, patient–reported, and other forms of health care data for Program recipients at an originating site and electronically transmit that data to a distant site provider to enable the distant site provider to assess, diagnose, consult, treat, educate, provide care management, suggest self–management, or make recommendations regarding the Program recipient’s health care.

SOURCE: MD Health General Code 15-141.2 (As amended by HB 123/SB 3 (2021 Session). Accessed Aug. 2021.

Existing MD Medicaid guidance and regulation limits reimbursement for remote patient monitoring to certain chronic conditions.  Preauthorization requirements also apply.

SOURCE:  Remote Patient Monitoring.  MD Department of Health.  (Accessed Aug. 2021). 

No reimbursement for home health monitoring services is included under telehealth manual.

SOURCE: MD Medicaid Telehealth Program. Telehealth Provider Manual. Updated April 2020. p. 3, (Accessed Aug. 2021).


CONDITIONS

Recently Passed Legislation

Telehealth definition includes remote patient monitoring. The Program is required to reimburse a health care provider for the diagnosis, consultation, and treatment of a Program recipient for a health care service covered by the Program that can be appropriately provided through telehealth regardless of patient and provider location.

From July 1, 2021, to June 30, 2023, when appropriately provided through telehealth, the Program shall provide reimbursement in accordance on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

  • Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
  • Any room and board fees.

The Department may adopt regulations to carry out this section.

SOURCE: MD Health General Code 15-141.2 (a-b, h)  (As amended by HB 123/SB 3 (2021 Session). Accessed Aug. 2021.

Existing guidance states Medicaid recipients diagnosed with one of the following conditions qualify:

  • Chronic Obstructive Pulmonary Disease
  • Congestive Heart Failure
  • Diabetes (Type 1 or 2)

The participant must be enrolled in Medicaid, consent to RPM, have an internet connect and capability to use monitoring tools and have one of the following scenarios within the most recent 12-month period:

  • Two hospital admissions with the same qualifying medical condition as the primary diagnosis
  • Two emergency room department visits with the same qualifying medical condition as the primary diagnosis
  • One hospital admission and one emergency department visit with the same qualifying medical condition as the primary diagnosis.

SOURCE:  MD Home Health Transmittal No. 64.  Jan. 10, 2018.  (Accessed Aug. 2021).


PROVIDER LIMITATIONS

Recently Passed Legislation

The Department may specify in regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients via telehealth. If the Department specifies by regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this subsection, the regulations shall include all types of health care providers that appropriately provide telehealth services.

The Program is not required to reimburse a health care provider for a health care service delivered in person or through telehealth that is:

  • Not a covered health care service under the Program; or
  • Delivered by an out–of–network provider unless the health care service is a self–referred service authorized under the Program.

SOURCE: MD General Health Code 15-141.2(g-h). (As amended by HB 123/SB 3 (2021 Session). (Accessed Aug. 2021).

Eligible Providers:

  • Home Health Agencies
  • Hospitals
  • Clinics
  • Federally Qualified Health Centers
  • Managed Care Organizations
  • Health Professionals (Physicians, Nurses, Physician Assistants)

SOURCE:  Remote Patient Monitoring.  MD Department of Health.  (Accessed Aug. 2021).


OTHER RESTRICTIONS

Preauthorization required.

The RPM reimbursement rate is an all-inclusive rate of $125 per 30 days of monitoring which covers equipment installation, participant education for using the equipment, and daily monitoring of the information transmitted for abnormal data measurements.

Reimbursement does not include RPM equipment, upgrades to RPM equipment or internet service for participants.

SOURCE:  MD Home Health Transmittal No. 64.  Jan. 10, 2018.  (Accessed Aug. 2021).

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Massachusetts

Last updated 09/01/2021

POLICY

No Reference Found

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

POLICY

No Reference Found


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Michigan

Last updated 09/02/2021

POLICY

“Remote patient monitoring means digital technology to collect medical …

POLICY

“Remote patient monitoring means digital technology to collect medical and other forms of health data from an individual in 1 location and electronically transmit that information via a health insurance portability and accountability act of 1996, Public Law 104-191 compliant, secure system to a health care provider in a different location for assessment and recommendations.”

The Department of Health and Human Services must provide coverage for remote patient monitoring services through the medical assistance program and Healthy Michigan program.

SOURCE: MI Compiled Laws Sec. 400.105g (Accessed Sept. 2021).

Remote Patient Monitoring (RPM) is a covered service under Michigan Compiled Law (MCL) 400.105g. RPM means using digital technology to collect medical and other forms of health data from an individual in one location and electronically transmit that information via a secure, HIPAA-compliant system to a health care provider in a different location for assessment and recommendations. RPM is covered for both acute and chronic conditions.

SOURCE: Medical Services Administration (MSA) Bulletin 21-24 Aug. 2021. (Accessed Sept. 2021).


CONDITIONS

RPM devices include (1) non-invasive remote monitoring devices that measure or detect common physiological parameters, and (2) non-invasive monitoring devices that wirelessly transmit the beneficiary’s medical information to their health care provider or other monitoring entity. The device must be reliable and valid, and the beneficiary must be trained or sufficiently knowledgeable in the proper use/wearing of the device to ensure appropriate recording of medical information. Medical information may include, but is not limited to, blood pressure and heart rate and rhythm monitoring.

SOURCE: Medical Services Administration (MSA) Bulletin 21-24 Aug. 2021. (Accessed Sept. 2021).


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

All RPM devices, including mobile medical applications, must meet the U.S. Food & Drug Administration (FDA) definition of a medical device. Personal tablets, computers, cell phones, software intended for administrative support or support of healthy lifestyles/general wellness, and electronic health records are not medical devices or durable medical equipment and are not covered as part of RPM services.

Reimbursement for the device used for remote monitoring, and programming of the device, is generally included in the reimbursement of RPM services and not separately reimbursable. For items or devices separately reimbursed to a medical supplier, such as personal use continuous glucose monitoring systems (CGMs), refer to the Medical Supplier chapter of the MDHHS Medicaid Provider Manual.

SOURCE: Medical Services Administration (MSA) Bulletin 21-24 Aug. 2021. (Accessed Sept. 2021).

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Minnesota

Last updated 09/11/2021

POLICY

Telemonitoring (Remote Physiological Monitoring Services)

MHCP covers telemonitoring services …

POLICY

Telemonitoring (Remote Physiological Monitoring Services)

MHCP covers telemonitoring services for MHCP members in fee-for-service programs.

Telemonitoring services are the remote monitoring of data related to a member’s vital signs or biometric data by a monitoring device or equipment that transmits the data electronically to a provider for analysis. Telemonitoring is a tool that can assist the provider in managing a member’s complex health needs.

SOURCE: MN Statute Sec. 256B.0625 Subd. 3(h) As Amended by HF 33 (2021 Session). (Accessed Sept. 2021). MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telemedicine), As revised Sept. 2, 2021. (Accessed Sept. 2021). 

There is reimbursement for “tele-homecare” under Elderly Waiver (EW) and Alternative Care (AC) programs.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Elderly Waiver (EW) and Alternative Care (AC) Program, As revised November 6, 2020, (Accessed Sept. 2021).

Prior authorization for home care services is required for all tele-home-care visits.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Home Care Svcs., As revised Feb. 10, 2021 (Accessed Sept. 2021).


CONDITIONS

MHCP covers telemonitoring services for members in high-risk, medically complex patient populations. These members have medical conditions like congestive heart failure, chronic obstructive pulmonary disease (COPD) or diabetes.

MHCP covers telemonitoring services based on the following medical necessity criteria:

  • The telemonitoring service is medically appropriate based on the member’s medical condition or status.
  • The member is cognitively and physically capable of operating the monitoring device or equipment, or the member has a caregiver who is willing and able to assist with the monitoring device or equipment.
  • The member resides in a setting that is suitable for telemonitoring and not in a setting that has health care staff on site.
  • The prescribing provider has identified and documented how telemonitoring services would likely prevent the member’s admission or readmission to a hospital, emergency room or nursing facility.
  • The results of the telemonitoring services are directly used to impact the plan of care.

Any service that does not meet medical necessity criteria will not be covered.

Bill on 837P claim format. Refer to the MN–ITS 837P Professional User Guides.

Submit claims for telemonitoring services using the CPT or HCPC code that describes the services rendered. Prior-authorization is not needed.

Provider must bill for at least 16 days of data collection within a 30 day period.

SOURCE: MN Statute Sec. 256B.0625 Subd. 3(h) As Amended by HF 33 (2021 Session). (Accessed Sept. 2021). MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telemedicine), As revised Sept. 2, 2021. (Accessed Sept. 2021). 


PROVIDER LIMITATIONS

The assessment and monitoring of the health data transmitted by telemonitoring must be performed by the following licensed health care professionals:

  • Advanced practice registered nurse
  • Physician
  • Physician assistant
  • Podiatrist
  • Registered nurse
  • Respiratory therapist
  • A licensed professional working under the supervision of a medical director (for example, an LPN)

Only MDs and practitioners may bill for remote patient monitoring (RPM) services.

SOURCE: MN Statute Sec. 256B.0625 Subd. 3(h) As Amended by HF 33 (2021 Session). (Accessed Sept. 2021). MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telemedicine), As revised Sept. 2, 2021. (Accessed Sept. 2021). 


OTHER RESTRICTIONS

Data must be collected and transmitted rather than self-reported to the provider. The device must be defined by the FDA as a medical device.

Independent diagnostic testing facilities are not able to bill for RPM services.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telemedicine), As revised Sept. 2, 2021. (Accessed Sept. 2021). 

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Mississippi

Last updated 08/13/2021

POLICY

Private payers, MS Medicaid and employee benefit plans are …

POLICY

Private payers, MS Medicaid and employee benefit plans are required to provide coverage for remote patient monitoring services for Mississippi-based telehealth programs affiliated with a Mississippi health care facility.

A one-time telehealth installation/training fee is also reimbursed.

SOURCE: MS Code Sec. 83-9-353. (Accessed Aug. 2021).

The Division of Medicaid defines remote patient monitoring as using digital technologies to collect medical and other forms of health data from individuals in one location and electronically transmit that information securely to healthcare providers in a different location for interpretation and recommendation.

The Division of Medicaid reimburses for remote patient monitoring:

  • Of devices when billed with the appropriate code, and
  • For disease management:
  • A daily monitoring rate for days the beneficiary’s information is reviewed.
  • Only one (1) unit per day is allowed, not to exceed thirty-one (31) days per month.
  • An initial visit to install the equipment and train the beneficiary may be billed as a set-up visit.
  • Only one set-up is allowed per episode even if monitoring parameters are added after the initial set-up and installation.
  • Only one (1) daily rate will be reimbursed regardless of the number of diseases/chronic conditions being monitored.

The Division of Medicaid does not reimburse for the duplicate transmission or interpretation of remote patient monitoring data.

The Division of Medicaid does not cover remote patient monitoring for disease management as
outlined in Miss. Admin. Code Part 225, Rule 2.3.B. for a beneficiary who is a resident of an
institution that meets the basic definition of a hospital or long-term care facility.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 2.1 & 2.4 & 2.5. (Accessed Aug. 2021). 

Continuous Glucose Monitoring

A continuous glucose monitoring service is reimbursed when when medically necessary, prior authorized by the UM/QIO, Division of Medicaid or designee, ordered by the physician who is actively managing the beneficiary’s diabetes and the beneficiary meets specific criteria.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 4.3. (Accessed Aug. 2021).


CONDITIONS

The Division of Medicaid covers remote patient monitoring, for disease management when medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), Division of Medicaid or designee, ordered by a physician, physician assistant, or nurse practitioner for a beneficiary who meets the following criteria:

  • Has been diagnosed with one (1) or more of the following chronic conditions of diabetes, congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD), heart disease, mental health, sickle cell;
  • Is capable of using the remote patient monitoring equipment and transmitting the necessary data or has a willing and able person to assist in completing electronic transmission of data.

The Division of Medicaid covers remote patient monitoring of devices when medically necessary, ordered by a physician, physician assistant or nurse practitioner which includes, but not limited to:

  • Implantable pacemakers,
  • Defibrillators,
  • Cardiac monitors,
  • Loop recorders,
  • External mobile cardiovascular telemetry, and
  • Continuous glucose monitors.

SOURCE: MS Admin. Code 23, Part 225, Rule. 2.3. (Accessed Aug. 2021).

To qualify for RPM services, patients must meet all of the following criteria:

  • Be diagnosed in the last 18 months with one or more chronic condition, which include, but are not limited to, sickle cell, mental health, asthma, diabetes, and heart disease; and
  • The patient’s healthcare provider recommends disease management services via remote patient monitoring.

SOURCE: MS Code Sec. 83-9-353. (Accessed Aug. 2021).

Continuous Glucose Monitoring

Must have an established diagnosis of type I or type II diabetes mellitus that is poorly controlled as defined below:

  • Unexplained hypoglycemic episodes,
  • Nocturnal hypoglycemic episode(s),
  • Hypoglycemic unawareness and/or frequent hypoglycemic episodes leading to impairments in activities of daily living,
  • Suspected postprandial hyperglycemia,
  • Recurrent diabetic ketoacidosis, or
  • Unable to achieve optimum glycemic control as defined by the most current version of the American Diabetes Association (ADA).

Patient must also:

  • Be able, or have a caregiver who is able, to hear and view CGM alerts and respond appropriately.
  • Has documented self-monitoring of blood glucose at least four (4) times per day.
  • Requires insulin injections three (3) or more times per day or requires the use of an insulin pump for maintenance of blood glucose control.
  • Requires frequent adjustment to insulin treatment regimen based on blood glucose testing results,
  • Had an in-person visit with the ordering physician within six (6) months prior to ordering to evaluate their diabetes control and determined that criteria (1-4) above are met,
  • Has an in-person visit every six (6) months following the prescription of the CGM to assess adherence to the CGM regimen and diabetes treatment plan.

CGM service only when the blood glucose data is obtained from a Federal Drug Administration (FDA) approved Class III, durable medical equipment (DME) medical device for home use.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 4.3. (Accessed Aug. 2021).


PROVIDER LIMITATIONS

Remote patient monitoring services must be delivered by an enrolled Medicaid provider acting within their scope-of-practice and license and in accordance with state and federal guidelines.  Must be ordered by a physician, physician assistant or nurse practitioner.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 2.2 & 2.3. (Accessed Aug. 2021).

A health insurance or employee benefit plan can limit coverage to health care providers in a telemedicine network approved by the plan.

SOURCE: MS Code Sec. 83-9-353(18). (Accessed Aug. 2021). 

Continuous Glucose Monitoring

Continuous glucose monitoring services must be delivered by an enrolled Medicaid provider acting within their scope-of-practice and license and in accordance with state and federal guidelines.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 4.2. (Accessed Aug. 2021).


OTHER RESTRICTIONS

A remote patient monitoring prior authorization request form may be required for approval of telemonitoring services.  If prior authorization is required, the law lists certain requirements for the form.

The law lists specific technology requirements.

SOURCE: MS Code Sec. 83-9-353(6) as amended by HB 200, (2021 Session). (Accessed Aug. 2021).

Providers of remote patient monitoring services must have protocols in place to address all of
the following:

  • A mechanism for monitoring, tracking and responding to changes in a beneficiary’s clinical condition, and
  • A process for notifying the prescribing physician of significant changes in the beneficiary’s clinical signs and symptoms.

See admin code for list of requirements for prior authorization form.

Remote patient monitoring services must be provided in the beneficiary’s private residence.

SOURCE: MS Admin. Code 23, Part 225, Rule. 2.2 & 2.3. (Accessed Aug. 2021).

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Missouri

Last updated 02/28/2021

POLICY

Subject to appropriations, the department shall establish a statewide …

POLICY

Subject to appropriations, the department shall establish a statewide program that permits reimbursement under the MO HealthNet program for home telemonitoring services.

“Home telemonitoring service” shall mean a health care service that requires scheduled remote monitoring of data related to a participant’s health and transmission of the data to a health call center accredited by the Utilization Review Accreditation Commission (URAC).

SOURCE: MO Revised Statute Sec. 208.686. (Accessed Aug. 2021).


CONDITIONS

Eligible conditions:

  • Pregnancy
  • Diabetes
  • Heart disease
  • Cancer
  • Chronic obstructive pulmonary disease
  • Hypertension
  • Congestive heart failure
  • Mental illness or serious emotional disturbance
  • Asthma
  • Myocardial infarction; or
  • Stroke

The beneficiary must also exhibit two or more the following risk factors:

  • Two or more hospitalizations in the prior twelve-month period;
  • Frequent or recurrent emergency department admissions;
  • A documented history of poor adherence to ordered medication regimens;
  • A documented history of falls in the prior 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; or
  • A documented history of consistently missed appointments with health care providers

SOURCE: MO Revised Statute Sec. 208.686.(Accessed Aug. 2021).

Personal Emergency Response Systems is available under the Developmental Disabilities Waiver.  This service may also include electronic support systems using video, web-cameras, or other technology. However, use of such systems may be subject to due process review. Assistive technology shall not include household appliances or items that are intended for purely diversional or recreational purposes. Assistive technology should be evidenced based, and shall not be experimental.  Electronic support systems using video, web-cameras, or other technology is only available on an individual, case-by-case basis when an individual requests the service and the planning team agrees it is appropriate and meets the health and safety needs of the individual.  See manual for more details.

SOURCE: MO HealthNet, Provider Manual, Developmental Disabilities Waiver Manual, Section 13, p. 30-31 (Mar. 1, 2021). (Accessed Aug. 2021).


PROVIDER LIMITATIONS

The program must ensure the home health agency or hospital shares telemonitoring clinical information with participant’s physician.

SOURCE: MO Revised Statute Sec. 208.686. (Accessed Aug. 2021)


OTHER RESTRICTIONS

If, after implementation, the department determines that the program established under this section is not cost effective, the department may discontinue the program and stop providing reimbursement under the MO HealthNet program for home telemonitoring services.  The department shall promulgate rules and regulations to implement the provisions of this section.

SOURCE: MO Revised Statute Sec. 208.686. (Accessed Feb. 2021).

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Montana

Last updated 09/08/2021

POLICY

No Reference Found

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

POLICY

No Reference Found


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Nebraska

Last updated 08/02/2021

POLICY

Telemonitoring: The remote monitoring of a client’s vital signs, …

POLICY

Telemonitoring: The remote monitoring of a client’s vital signs, biometric data, or subjective data by a monitoring device which transmits such data electronically to a health care practitioner for analysis and storage.

Medicaid will reimburse for telemonitoring when all of the following requirements are met:

  • Telemonitoring is covered only when the services are from the originating site;
  • The client is cognitively capable to operate the equipment or has a willing and able person to assess in the transmission of electronic data;
  • The originating site has space for all program equipment and full transmission capability;
  • The provider maintains a client’s record supporting the medical necessity of the service, all transmissions and subsequent review received from the client, and how the data transmitted from the client is being utilized in the continuous development and implementation of the client’s plan of care.

Paid at daily per diem-rate and includes:

  • Healthcare practitioner review and interpretation of client data;
  • Equipment and all supplies, accessories, and services necessary for proper functioning and use of equipment;
  • Medically necessary visits to the home by a health care practitioner;
  • Training on the use of the equipment and completion of necessary records.

No additional or separate payment is allowed.

SOURCE: NE Admin. Code Title 471 Sec. 1-004.01(F) & 1-004.07, Ch. 1, p. 7 & 9.  (Accessed Aug. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Nevada

Last updated 07/28/2021

POLICY

No Reference Found

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

POLICY

No Reference Found


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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New Hampshire

Last updated 07/26/2021

POLICY

“Remote patient monitoring” means the use of electronic technology …

POLICY

“Remote patient monitoring” means the use of electronic technology to remotely monitor a patient’s health status through the collection and interpretation of clinical data while the patient remains at an originating site. Remote patient monitoring may or may not take place in real time. Remote patient monitoring shall include assessment, observation, education and virtual visits provided by all covered providers including licensed home health care providers.

Remote patient monitoring shall only be covered in the event that the patient has already established care at an originating site via face-to-face in-person service;  A provider shall not be required to establish care via face-to-face in-person service when:

  • The provider is a Department of Veteran Affairs (VA) practitioner or VA-contracted practitioner not required to obtain a special registration pursuant to 21 U.S.C. section 831(h);
  • The patient is being treated by, and is physically located in a correctional facility administered by the state of New Hampshire or a New Hampshire county;
  • The patient is being treated by, and is physically located in a doorway as defined in RSA 167:4-d, II(c);
  • The patient is being treated by and is physically located in a state designated community mental health center pursuant to RSA 135; or
  • The patient is being treated by, and physically located in, a hospital or clinic registered in a manner fully consistent with 21 U.S.C. section 823(f); and

by which an individual shall be construed to prohibit the Medicaid program from providing coverage for only those services that are medically necessary and subject to all other terms and conditions of the coverage.

SOURCE: NH Revised Statutes 167:4-d (Accessed Jul. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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New Jersey

Last updated 07/21/2021

POLICY

Insurers and NJ Medicaid must provide reimbursement for telemedicine …

POLICY

Insurers and NJ Medicaid must provide reimbursement for telemedicine or telehealth on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when services are delivered through in-person contact and consultation. Remote patient monitoring is included within definition of telehealth.

SOURCE: NJ Statute C.30:4D-6k. (Accessed Jul. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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New Mexico

Last updated 07/19/2021

POLICY

No Reference Found

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

POLICY

No Reference Found


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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New York

Last updated 07/15/2021

POLICY

RPM included within definition of “telehealth” in statute requiring …

POLICY

RPM included within definition of “telehealth” in statute requiring Medicaid Reimburse telehealth delivery of services.

Subject to the approval of the state director of the budget, the commissioner may authorize the payment of medical assistance funds for demonstration rates or fees established for home telehealth services provided pursuant to subdivision three-c of section thirty-six hundred fourteen of the public health law.

Subject to federal financial participation and the approval of the director of the budget, the commissioner shall not exclude from the payment of medical assistance funds the delivery of health care services through telehealth, as defined in subdivision four of section two thousand nine hundred ninety-nine-cc of the public health law.

SOURCE: Social Services Law Title 11, Article 367-u & NY Public Health Law Article 29 – G Section 2999-cc. (Accessed Jul. 2021).

Remote patient monitoring (RPM) uses digital technologies to collect medical data and other personal health information from members in one location and electronically transmit that information securely to health care providers in a different location for assessment and recommendations. Monitoring programs can collect a wide range of health data from the point of care, such as vital signs, blood pressure, heart rate, weight, blood sugar, blood oxygen levels and electrocardiogram readings. RPM may include follow-up on previously transmitted data conducted through communication technologies or by telephone.

Follow-up is included in the monthly time component.

Remote patient monitoring services are billed using CPT code “99091” and should not be billed more than once per member per month. Billing should occur on the last day of each month in which RPM is used. A fee of $48.00 per month will be paid for RPM for a minimum of 30 minutes per month spent collecting and interpreting a member’s RPM data.

FQHCs that have opted out of APGs are unable to bill for RPM services.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 4 & 11-12. (Accessed Jul. 2021).


CONDITIONS

Medical conditions that may be treated/monitored by means of RPM include, but are not limited to:

  • Congestive heart failure
  • Diabetes
  • Chronic obstructive pulmonary disease
  • Wound care
  • Polypharmacy
  • Mental or behavioral problems
  • Technology-dependent care, such as continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 4. (Accessed Jul. 2021).


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

The following considerations apply to RPM:

  1. Medical conditions that may be treated/monitored by means of RPM include, but are not limited to, congestive heart failure, diabetes, chronic obstructive pulmonary disease, wound care, polypharmacy, mental or behavioral problems, and technology-dependent care such as continuous oxygen, ventilator care, total parenteral nutrition or enteral feeding.
  2. RPM must be ordered and billed by a physician, nurse practitioner or midwife, with whom the member has or has entered into a substantial and ongoing relationship. RPM can also be provided and billed by an Article-28 clinic, when ordered by one of the previously mentioned qualified practitioners.
  3. Members must be seen in-person by their practitioner, as needed, for follow-up care.
  4. RPM must be medically necessary and shall be discontinued when the member’s condition is determined to be stable/controlled.
  5. Payment for RPM while a member is receiving home health services through a Certified Home Health Agency (CHHA) is pursuant to PHL Section 3614 (3-c)(a) – (d) and will only be made to that same CHHA.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 35, Number 2, February 2019, p. 4-5. (Accessed Jul. 2021).

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North Carolina

Last updated 07/12/2021

POLICY

“Remote Patient Monitoring is the use of digital devices …

POLICY

“Remote Patient Monitoring is the use of digital devices to measure and transmit personal health information from a beneficiary in one location to a provider in a different location. Remote patient monitoring enables providers to collect and analyze information such as vital signs (blood pressure, heart rate, weight, blood oxygen levels) in order to make treatment recommendations. There are two types of remote patient monitoring addressed within this policy:

  • Self-Measured and Reported Monitoring: When a beneficiary uses a digital device to measure and record their own vital signs, then transmits the data to a provider for evaluation.
  • Remote Physiologic Monitoring: When a beneficiary’s physiologic data is wirelessly synced from a beneficiary’s digital device where it can be evaluated immediately or at a later time by a provider.”

NC Medicaid reimburses for remote patient monitoring for self-measured blood pressure monitoring and remote physiologic monitoring. See manual for coverage criteria. See Appendix A of manual for covered remote monitoring codes.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 2, & 7, Nov. 15, 2020. (Accessed Jul. 2021).

SMBPM is a beneficiary’s regular use of a personal blood pressure monitoring device to assess and record blood pressure across different points in time outside of a clinical setting, typically at home. This service is available for new or established patients.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 16, Nov. 15, 2020. (Accessed Jul. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

Providers that may bill NC Medicaid for remote patient monitoring include physicians, nurse practitioners; psychiatric nurse practitioner; certified nurse midwives; and physician’s assistants.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 15, Nov. 15, 2020. (Accessed Jul. 2021).


OTHER RESTRICTIONS

Remote patient monitoring requires use of a device that is defined by the FDA as a medical device. Some forms of remote patient monitoring, such as remote physiologic monitoring (detailed below), require a device that is wirelessly synced where the provider can evaluate the data in real or near-real time. All remote patient monitoring must be conducted in a HIPAA compliant manner, particularly with respect to protecting transmission of patient health data.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, p. 8, Nov. 15, 2020. (Accessed Jul. 2021).

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North Dakota

Last updated 07/08/2021

POLICY

Home health services include telemonitoring.

Home Health Telemonitoring will …

POLICY

Home health services include telemonitoring.

Home Health Telemonitoring will be covered within the same limits noted above. Home Telemonitoring is not allowed for the initial Home Health evaluation visit or for the discharge visit. In addition, Home Health Telemonitoring is limited to no more than forty percent (40%) of the total visits during each certification period.

SOURCE: North Dakota Department of Human Services: General Information for Providers. North Dakota Medicaid and Other Medical Assistance Programs.  (Apr. 2021) P. 59 & 62 (Accessed Jul. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Ohio

Last updated 07/06/2021

POLICY

Telehealth is the interaction with a patient via synchronous, …

POLICY

Telehealth is the interaction with a patient via synchronous, interactive, real-time electronic communication that includes both audio and video elements; OR

The following activities that are asynchronous or do not have both audio and video elements:

  • Telephone calls
  • Remote patient monitoring
  • Communication with a patient through secure electronic mail or a secure patient portal

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 2/8/2021 & OAC 5160-1-18.  (Accessed Jul. 2021).

Remote physiologic monitoring codes 99453, 99454, 99457, and 99458 are listed as a covered telehealth service.

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 2/8/2021. (Accessed Jul. 2021).

Federally Qualified Health Center and Rural Health Clinics

Remote patient monitoring will be paid through FFS as a covered non-FQHC/RHC service under the clinic provider type 50 (using ODM’s payment schedules).

SOURCE: The Ohio Department of Medicaid.  Telehealth Billing Guide.  Revised 2/8/2021.  (Accessed Jul. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Oklahoma

Last updated 06/29/2021

POLICY

“Remote patient monitoring” means the use of digital technologies …

POLICY

“Remote patient monitoring” means the use of digital technologies to collect medical and other forms of health data (e.g. vital signs, weight, blood pressure, blood sugar) from individuals in one (1) location and electronically transmit that information securely to health care providers in a different location for assessment and recommendations.

Health care services delivered by telehealth such as remote patient monitoring, store-and-forward, or any other telehealth technology must be compensable by OHCA in order to be reimbursed.

Services provided by telehealth must be billed with the appropriate modifier.

The cost of telehealth equipment and transmission is not reimbursable by SoonerCare.

SOURCE: OK Admin. Code Sec. 317:30-3-27(a) & (e). (Accessed Jun. 2021).

Continuous glucose monitoring (CGM)

CGM means a minimally invasive system that measures glucose levels in subcutaneous or interstitial fluid. CGM provides blood glucose levels and can help members make more informed management decisions throughout the day.

CGM must be determined by a provider to be medically necessary and documented in the member’s plan of care as medically necessary and used for medical purposes. A request by a medical provider for CGM in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity. CGM devices must be approved by the U.S. Food and Drug Administration (FDA) as non-adjunctive and must be used for therapeutic purposes. Devices may only be used for members within the age range for which the devices have been FDA approved.

CGM patients must have an in-person or telehealth visit within 6 months between the treating provider, member and/or family to evaluate their diabetes control.

SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Jun. 2021).


CONDITIONS

Continuous glucose monitoring (CGM)

Member must have a diagnosis that correlates to the use of CGM.

SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Jun. 2021).


PROVIDER LIMITATIONS

Continuous glucose monitoring (CGM)

Prescription must be made by a physician, physician assistant, or an advanced practice registered nurse.

SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Jun. 2021).


OTHER RESTRICTIONS

No Reference Found

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Oregon

Last updated 06/30/2021

POLICY

To encourage the efficient use of resources and to …

POLICY

To encourage the efficient use of resources and to promote cost-effective procedures in accordance with ORS 413.011 (1)(L), the Oregon Health Authority shall reimburse the cost of health services delivered using telemedicine, including but not limited to:

  • Health services transmitted via landlines, wireless communications, the Internet and telephone networks;
  • Synchronous or asynchronous transmissions using audio only, video only, audio and video and transmission of data from remote monitoring devices; and
  • Communications between providers or between one or more providers and one or more patients, family members, caregivers or guardians.

The authority shall pay the same reimbursement for a health service regardless of whether the service is provided in person or using any permissible telemedicine application or technology.

SOURCE: OR Statute Ch. 414 & House Bill 2508 (2021 Session), (Accessed Jun. 2021).

Oregon will reimburse “dental care providers” for ‘remote patient monitoring’, which is defined as “personal health and dental information is collected by dental care providers in one location then transmitted electronically to a dentist in a distant site location for use in care”

SOURCE: OR OAR 410-123-1265, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Teledentistry. (Effective Jan. 1, 2021). (Accessed Jun. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Pennsylvania

Last updated 10/12/2021

POLICY

Telemedicine, for purposes of Medicaid payment, does not include …

POLICY

Telemedicine, for purposes of Medicaid payment, does not include telephone, asynchronous or store and forward technology or facsimile machines, electronic mail systems or remote patient monitoring devices. However, these technologies may be utilized as a part of the provision of a MA-covered service.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-21-06, p. 2, Sept. 30, 2021 (Accessed Oct. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Rhode Island

Last updated 06/25/2021

POLICY

No Reference Found

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

POLICY

No Reference Found


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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South Carolina

Last updated 06/19/2021

POLICY

An order or referral is required for South Carolina …

POLICY

An order or referral is required for South Carolina Medicaid Telemonitoring services.

SOURCE: SC Health and Human Svcs. Dept. Provider Administrative and Billing Manual, p. 11-12 (Oct. 2020). (Accessed Jun. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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South Dakota

Last updated 09/13/2021

POLICY

The Office of Adult Services and Aging defines “telehealth …

POLICY

The Office of Adult Services and Aging defines “telehealth services” as a home-based health monitoring system used to collect and transmit an individual’s clinical data for monitoring and interpretation.

SOURCE: SD Regulation 67:40:19:01(21) (Accessed Sept. 2021).

The initial order encounter for home health services may occur through telehealth.

SOURCE: SD Medicaid Billing and Policy Manual: Home Health Services, p. 3 (Mar. 2021). (Accessed Sept. 2021).

SD Medicaid does not cover remote monitoring.

SOURCE: SD Medicaid Billing and Policy Manual: Physician Services, p. 9 (Aug. 2021), (Accessed Sept. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Tennessee

Last updated 06/14/2021

POLICY

“Remote patient monitoring services” means using digital technologies to …

POLICY

“Remote patient monitoring services” means using digital technologies to collect medical and other forms of health data from a patient and then electronically transmitting that information securely to healthcare providers in a different location for interpretation and recommendation.

A health insurance entity may consider any remote patient monitoring service a covered medical service if the same service is covered by Medicare. The appropriate parties may negotiate the rate for these services in the manner in which is deemed appropriate by the parties

SOURCE: TN Code Annotated, Sec. 56-7-1011, (Accessed Jun. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Texas

Last updated 09/22/2021

POLICY

Home telemonitoring service means “a health service that requires …

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).

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Utah

Last updated 06/09/2021

POLICY

Home telemetry for outpatient long-term cardiac monitoring is allowed …

POLICY

Home telemetry for outpatient long-term cardiac monitoring is allowed with prior authorization. Criteria include:

  • Must be ordered by a neurologist
  • Member must have had a stroke or TIA with no identifiable cause
  • Member should have already had 24-hour monitoring done previously
  • Member should not be currently taking anti-coagulated or Warfarin for any other reason
  • Member should not have a known contraindication for Warfarin
  • Outpatient long-term cardiac monitoring may only be authorized for the 30-day test
  • Data from the test must be reviewed and interpreted by a cardiologist

SOURCE: Utah Medicaid Provider Manual: Physician Manual, p. 22 (May 2021).  (Accessed May 2021).


CONDITIONS

Only for patients with a long-term cardiac health issue.

SOURCE: Utah Medicaid Provider Manual: Physician Manual, p. 22 (May 2021).  (Accessed May 2021).


PROVIDER LIMITATIONS

Test must be ordered by a neurologist and reviewed and interpreted by a cardiologist.

SOURCE: Utah Medicaid Provider Manual: Physician Manual, p. 23 (Jan. 2021).  (Accessed Feb. 2021).


OTHER RESTRICTIONS

No Reference Found

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Vermont

Last updated 06/02/2021

POLICY

See Health Care Administrative Rule 3.101 on Telehealth for …

POLICY

See Health Care Administrative Rule 3.101 on Telehealth for requirements of telemonitoring.

Home Telemonitoring is a health service that allows and requires scheduled remote monitoring of data related to an individual’s health, and transmission of the data from the individual’s home to a licensed home health agency. Scheduled periodic reporting of the individual’s data to a licensed physician is required, even when there have been no readings outside the parameters established in the physician’s orders. In the event of a measurement outside of the established individual’s parameters, the provider shall use the health care professionals noted above to be responsible for reporting the data to a physician.

SOURCE: VT Agency of Human Services. Home Health Agency, Assistive Community Care and Enhanced Residential Care Supplement.  Sec. 1.3.11 Telemonitoring, p. 7 (Apr. 2, 2021), (Accessed May 2021).

“Telemonitoring” means a health service that enables remote monitoring of a beneficiary’s health- related data by a home health agency done outside of a conventional clinical setting and in conjunction with a physician’s plan of care.

VT Medicaid covers telemonitoring for specific conditions when data is reviewed by certain types of licensed professionals (see below requirements).

SOURCE: VT Health Care Administrative Rule 3.101.  (Nov. 19, 2020), (Accessed May 2021).

VT Medicaid is required to cover home telemonitoring services performed by home health agencies or other qualified providers for beneficiaries who have serious or chronic medical conditions that can result in frequent or recurrent hospitalizations and emergency room admissions.

“Home telemonitoring service” means a health service that requires scheduled remote monitoring of data related to a patient’s health, in conjunction with a home health plan of care, and access to the data by a home health agency or other qualified provider as defined by the Agency of Human Services.

SOURCE: VT Statutes Annotated Title 33 Sec. 1901g(a). (Accessed May 2021).


CONDITIONS

The Agency shall provide coverage for home telemonitoring for one or more conditions or risk factors for which it determines, using reliable data, that home telemonitoring services are appropriate and that coverage will be budget-neutral. The Agency may expand coverage to include additional conditions or risk factors identified using evidence-based best practices if the expanded coverage will remain budget-neutral or as funds become available.

SOURCE: VT Statutes Annotated Title 33 Sec. 1901g(a). (Accessed May 2021).

To be covered, services shall be:

  • Clinically appropriate for delivery through telemonitoring,
  • Medically necessary, and
  • Be limited to a Congestive Heart Failure diagnosis.

For telemonitoring services, beneficiaries shall:

  • Have Medicaid as their primary insurance or Medicaid and dually enrolled in Medicare with a non-homebound status,
  • Have a Congestive Heart Failure diagnosis,
  • Be clinically eligible for home health services, and
  • Have a physician’s plan of care with an order for home telemonitoring services

SOURCE:  VT Health Care Administrative Rules 13.174.003 (3.101.4), Telehealth, (Accessed May 2021).


PROVIDER LIMITATIONS

The Agency of Human Services shall provide Medicaid coverage for home telemonitoring services performed by home health agencies or other qualified providers as defined by the Agency of Human Services for Medicaid beneficiaries who have serious or chronic medical conditions that can result in frequent or recurrent hospitalizations and emergency room admissions.

A home health agency or other qualified provider shall ensure that clinical information gathered by the home health agency or other qualified provider while providing home telemonitoring services is shared with the patient’s treating health care professionals. The Agency of Human Services may impose other reasonable requirements on the use of home telemonitoring services.

SOURCE: VT Statutes Annotated Title 33 Sec. 1901g(a). (Accessed May 2021).

Qualified telemonitoring providers shall:

  • Use the following licensed health care professionals to review data:
    • Registered nurse (RN)
    • Nurse Practitioner (NP)
    • Clinical nurse specialist (CNS)
    • Licensed practical nurse (LPN) under the supervision of a RN or physician assistant (PA), and
  • Follow data parameters established by a licensed physician’s plan of care, and
  • Meet or exceed applicable federal and state legal requirements of medical and health information privacy, including compliance with HIPAA.

SOURCE:  VT Health Care Administrative Rules 13.174.003 (3.101.4), Telehealth, (Accessed May 2021).

Home Telemonitoring is a health service that allows and requires scheduled remote monitoring of data related to an individual’s health, and transmission of the data from the individual’s home to a licensed home health agency. Scheduled periodic reporting of the individual’s data to a licensed physician is required, even when there have been no readings outside the parameters established in the physician’s orders. In the event of a measurement outside of the established individual’s parameters, the provider shall use the health care professionals noted above to be responsible for reporting the data to a physician.

SOURCE: VT Agency of Human Services. Home Health Agency, Assistive Community Care and Enhanced Residential Care Supplement.  Sec. 1.3.11 Telemonitoring, p. 7 (Apr. 2021). (Accessed May 2021).


OTHER RESTRICTIONS

No Reference Found

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Virginia

Last updated 09/20/2021

POLICY

Face-to-face encounters may occur through telemedicine, which is defined …

POLICY

Face-to-face encounters may occur through telemedicine, which is defined as the two-way, real time interactive electronic communication between the member and the Provider located at a site distant from the member. This electronic communication must include, at a minimum, the use of audio and video equipment. Telemedicine shall not include by telephone or email.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual, Home Health Manual, Covered Services and Limitations. p. 5 (July 2021). (Accessed Sept. 2021).

VA Medicaid reimburses for Continuous Glucose Monitoring.

SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Clarification of Existing Medicaid Coverage of Continuous Glucose Monitoring for Members in Medicaid/FAMIS/FAMIS MOMS Fee-for-Service Programs. (Oct. 2016) (Accessed Sept. 2021).

The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services.  Such plan shall include a provision for payment of medical assistance for remote patient monitoring services provided via telemedicine for specific conditions (see section below).

“Remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload.

SOURCE: VA Code Annotated Sec. 32.1-325 (Accessed Sept. 2021).


CONDITIONS

The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services.  Such plan shall include:

  • A provision for payment of medical assistance for remote patient monitoring services provided via telemedicine for:
    • High-risk pregnant persons;
    • Medically complex infants and children; Transplant patients;
    • Patients who have undergone surgery, for up to three months following the date of such surgery; and
    • Patients with a chronic health condition who have had two or more hospitalizations or emergency department visits related to such chronic health condition in the previous 12 months.

“Remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload.

SOURCE: VA Code Annotated Sec. 32.1-325 (Accessed Sept. 2021).

Coverage Continuous Glucose Monitoring is limited to members with:

  • Type 1 diabetes
  • Type 2 diabetes (when over 16 years old)
  • Pregnant women who are injecting insulin with either Type 1 or 2.

Service authorization is required. Additional requirements apply.

SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Clarification of Existing Medicaid Coverage of Continuous Glucose Monitoring for Members in Medicaid/FAMIS/FAMIS MOMS Fee-for-Service Programs. (Nov. 2016) (Accessed Sept. 2021).


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No reference found.

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Washington

Last updated 09/08/2021

POLICY

Home Health Services

“Telemedicine means the use of tele-monitoring …

POLICY

Home Health Services

“Telemedicine means the use of tele-monitoring to enhance the delivery of certain home health skilled nursing services through:

  • The collection of clinical data and the transmission of such data between a patient at a distant location and the home health provider through electronic processing technologies. Objective clinical data that may be transmitted includes, but is not limited to, weight, blood pressure, pulse, respirations, blood glucose, and pulse oximetry; or
  • The provision of certain education related to health care services using audio, video, or data communication instead of a face-to-face visit.”

SOURCE: WA Admin. Code Sec. 182-551-2010. (Accessed Sept. 2021).

HCA covers the delivery of home health services through telemedicine for clients who have been diagnosed with an unstable condition who may be at risk for hospitalization or a more costly level of care.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 32, (Apr. 2021), (Accessed Sept. 2021).


CONDITIONS

Home Health Services

The client must have a diagnosis or diagnoses where there is a high risk of sudden change in medical condition which could compromise health outcomes.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 32, (Sept. 2021), (Accessed Sept. 2021).


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

Home Health Services

HCA pays for one telemedicine interaction, per eligible client, per day, based on the ordering licensed practitioner’s home health plan of care.

To receive payment for the delivery of home health services through telemedicine, the services must involve:

  • A documented assessment, identified problem, and evaluation, which includes:
    • Assessment and monitoring of clinical data including, but not limited to, vital signs, pain levels and other biometric measures specified in the plan of care. Also included is an assessment of response to previous changes in the plan of care.
    • Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care
  • Implementation of a documented management plan through one or
    more of the following:

    • Education regarding medication management as appropriate, based on the findings from the telemedicine encounter
    • Education regarding other interventions as appropriate to both the patient and the caregiver
    • Management and evaluation of the plan of care, including changes in visit frequency or the addition of other skilled services
    • Coordination of care with the ordering licensed provider regarding findings from the telemedicine encounter
    • Coordination and referral to other medical providers as needed
    • Referral to the emergency room as needed

HCA does not pay for the purchase, rental, repair, or maintenance of telemedicine equipment and associated costs of operation of telemedicine equipment.

HCA does not require prior authorization for the delivery of home health services through telemedicine.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 33-34, (Apr. 2021), (Accessed Sept. 2021).

Home health monitoring is not covered in Applied Behavior Analysis Program for clients Age 20 or younger.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Applied Behavior Analysis for Clients 20 and Younger, p. 33 (Mar. 2021). (Accessed Sept. 2021).

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West Virginia

Last updated 09/13/2021

POLICY

No reimbursement. WV Medicaid only reimburses for real time …

POLICY

No reimbursement. WV Medicaid only reimburses for real time communications.

SOURCE: WV Dept. of Health and Human Svcs. Medicaid Provider Manual, Chapter–519.17 Practitioner Services: Telehealth Services. (Revised Mar. 1, 2020) (Accessed Sept. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Wisconsin

Last updated 09/07/2021

POLICY

Except as provided by the department by rule, remote …

POLICY

Except as provided by the department by rule, remote patient monitoring of a Medical Assistance recipient in which the medical data pertains to a Medical Assistance recipient must be reimbursed.

Except as provided by the department by rule, services that are covered under Medicare for which the federal department of health and human services provides Medical Assistance federal financial participation and that are remote physiologic monitoring shall be reimbursed.

SOURCE: WI Statute Sec. 49.45 (61).  (Accessed Sept. 2021).

No reimbursement. Services must be functionally equivalent to face-to-face.

SOURCE: WI ForwardHealth Online Handbook. Topic #510 Telehealth. (Accessed Sept. 2021).


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Wyoming

Last updated 09/03/2021

POLICY

No Reference Found

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

POLICY

No Reference Found


CONDITIONS

No Reference Found


PROVIDER LIMITATIONS

No Reference Found


OTHER RESTRICTIONS

No Reference Found

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Medicaid & Medicare

Remote Patient Monitoring

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