As part of Executive Order No. 7F issued on March 18, Connecticut Governor Ned Lamont authorized the Commissioner of the Department Social Services (DSS) to “temporarily waive any requirements” set forth in state law, regulations, rules, policies or other directives concerning telehealth as is necessary to enable the Medicaid program “to cover applicable services provided through audio-only telehealth services.”  As a result, DSS will be able to expand Medicaid coverage for telehealth services that are provided by phone, and not just audio-video technology.

DSS Guidance – Provider Bulletin 2020-14

Contemporaneous with the issuance of Governor Lamont’s Executive Order, DSS issued Provider Bulletin 2020-14 to address the expansion of telemedicine services for Medicaid beneficiaries in Connecticut.  Bulletin 2020-14 updates two prior Bulletins issued on March 13, which are reviewed below.  DSS also updated its Telemedicine FAQs on March 18.

Pursuant to Provider Bulletin 2020-14, for dates of services from March 18 through the end of the COVID-19 emergency declaration in Connecticut, the following services can be provided by telehealth by providers currently authorized to furnish the services in-person:

• All of the following children’s behavioral health (BH) rehabilitation services:
  • Home-based models (codes H2019 & T1017 and modifiers for Intensive In-Home Child and Adolescent Psychiatric Services (IICAPS));
  • Emergency Mobile Psychiatric Services (EMPS) (codes S9484 & S9485); and
  • Extended Day Treatment (EDT), non-group services (code H2012)
• Autism spectrum disorder treatment services (97153 & H2014)
• Targeted case management (T1017)
• Case management (T1016)
• Family therapy without the patient (90846)

Additionally, as of March 18, to the extent permitted by other federal and state requirements, opioid treatment programs are permitted to fulfill the face-to-face requirements with a physician, APRN or physician assistant via telemedicine as part of induction services, as long as a nurse is in the same location as the recipient patient.

Billing of Audio-Only Services

Under Provider Bulletin 2020-14, certain evaluation and management services and behavioral health services can be provided via audio-only technology (telephone) to established patients (i.e., not new patients) of a provider, and the patient need not have COVID-19 symptoms to be eligible.  E&M services should be billed using CPT codes 99442 and 99443.  Behavioral health services should be billed using CPT codes 98967 and 98968.  The initial induction of medication for purposes of Medication Assisted Treatment (MAT) cannot be provided via audio-only technology.

Providers eligible to furnish audio-only E&M services include physicians, APRNs, PAs, CNMs, free-standing medical clinics (not school-based), behavioral health clinics (including enhanced care clinics), outpatient hospital behavioral health clinics, public and private psychiatric outpatient hospital clinics, FQHCs, and family planning clinics.

Providers eligible to furnish audio-only behavioral health services include all providers eligible to furnish audio-only E&M services (except that only behavioral health FQHCs are eligible and family planning clinics and CNMs are not eligible), plus rehabilitation clinics, independent licensed behavioral health clinicians (licensed psychologists, licensed clinical social workers (LCSWs), licensed marital and family therapists (LMFTs), licensed professional counselors (LPCs), and licensed alcohol and drug counselors (LADCs)).

For both E&M and behavioral health services rendered by telephone, providers can only bill for services to established patients, and may only bill for services that would be covered in person but for the current COVID-19 pandemic.  DSS also notes – in an update to prior guidance requiring written informed consent – that providers should obtain verbal consent when conducting audio-only telehealth services, and should document such consent in the medical record.  Providers must also have procedures to verify provider and patient identities, adhere to all coding requirements and federal and state billing regulations, and must completely document all services provided (including by noting that the service was furnished by telephone).  There is no restriction on the location of the provider when furnishing telehealth services, except as stated in prior DSS bulletins and any future DSS bulletins to be issued.

HIPAA

Finally, Provider Bulletin 2020-14 updates DSS’ prior guidance on HIPAA compliance when providing telehealth services by citing to the notification issued by the Department of Health and Human Services on March 17 regarding enforcement discretion for telehealth remote communications during the COVID-19 public health emergency.  DSS indicates that providers should consult that notification regarding their obligations under HIPAA, and by inference this suggests that providers in Connecticut can use technologies listed in the notification to provide telehealth services for the duration of the COVID-19 pandemic despite the fact that they may not fully comply with HIPAA (e.g., technologies like FaceTime and Skype).  This provides additional flexibility for Medicaid providers and beneficiaries to ensure access to care during the pandemic. Prior DSS Guidance on Telehealth

On March 13, DSS issued two successive Provider Bulletins expanding coverage and access to telehealth services for Medicaid beneficiaries.  DSS first issued Provider Bulletin 2020-09, which implements “full coverage of specified synchronized telemedicine” under Medicaid and CHIP for dates of services on and after March 13, 2020.  DSS then immediately issued Provider Bulletin 2020-10, which removes certain restrictions contained in 2020-09 during the period starting from March 13, 2020 until the end of the COVID-19 emergency.

Pursuant to the March 13 DSS guidance, synchronized telemedicine is defined to refer to “an audio and video telecommunication system with real-time communication between the patient and practitioner.”  Notably, in these Bulletins DSS conditioned coverage on the use by a provider of “a HIPAA-compliant, real time audio and video communication system” and specifically notes that “certain popular video chatting software programs are not HIPAA-compliant.”  The Bulletins were issued before the federal government released a notification that it would be exercising its enforcement discretion to not penalize providers for using such “popular video chatting software programs” that are not fully HIPAA-compliant, and DSS subsequently updated its guidance to defer to the federal guidance in Provider Bulletin 2020-14.

Under the March 13 DSS Bulletins, certain medical and behavioral health services will be fully covered when medically necessary, provided via HIPAA-compliant technology, and otherwise comply with Medicaid program requirements, including the services listed below:

• Behavioral Health Services:
  • Psychotherapy services, including CPT codes 90832, 90833, 90834, 90836, 90837, 90838, 90847.  There is no restriction on the site at which the Medicaid member receives individual therapy, family therapy, or psychotherapy with medication management.
  • Psychiatric Diagnostic Evaluations, including CPT codes 90791 and 90792.
    • NOTE: During the period starting from March 13 until the end of the COVID-19 public health emergency, there are no originating site restrictions on the receipt of psychiatric diagnostic evaluations, per Provider Bulletin 2020-10.
  • Medication Assisted Treatment.
    • Note that certain originating site restrictions apply as further set forth in Bulletin 2020-09.
  • Medication Management Services, including CPT codes 99211, 99212, 99213, 99214, and 99215.
• Medical Services:
  • Select patient E&M services, including CPT codes 99211, 99212, 99213, 99214, and 99215.
  • Pre- and post-surgical consultations related to surgical services approved by DSS via prior authorization and provided by an out-of-state provider, as long as the provider is also licensed in Connecticut.
  • Per Provider Bulletin 2020-10, there are no originating site restrictions for the provision of otherwise covered medical services via telehealth.
  • Additionally, during the period starting from March 13 until the end of the COVID-19 public health emergency, DSS has added “new patient” E/M services as coverable via telehealth using CPT codes 99201-99205.
• Refer to Bulletin 2020-09 for a full list of covered services.

Bulletin 2020-09 specifically advises federally qualified health centers (FQHCs) that they can bill their encounter rate when an approved medically necessary telemedicine service is rendered.  FQHCs cannot bill an encounter rate when they are the originating site only, i.e. when no services were rendered to the member other than providing the space and technology for a distant site provider to render telehealth services.

DSS notes that “all applicable federal and state requirements” for “equivalent in-person services apply for telemedicine services.” DSS also states that:

• Medicaid providers are “prohibited from saving recordings of telehealth video-conferencing sessions”;
• Providers must obtain “informed consent in writing” from each member before providing telehealth services and annually thereafter (please note, however, that DSS subseuqnetly indicated that a provider can obtain verbal consent prior to starting telemedicine services until the end of the COVID-19 emergency);
• If the member is a minor, a parent or legal guardian must be present for telehealth services in the same manner that one would be for an in-person visit;
• Medicaid patients must be in a secure and private location; and
• There is no new prior authorization requirement for telehealth services.

Finally, on March 13 DSS provided the following guidance on billing and documentation of telehealth services for Medicaid members:

• Payments rates are the same as for in-person services;
• Documentation must be maintained by both the distant site provider and the originating site provider (if any);
• Claims cannot be submitted if telehealth services are not provided or completed (e.g., due to technical issues); and
• All distant site providers must append the applicable telehealth modifier to the claim for services: “GT” if the member’s originating site is a health care facility or office, or “95” when the member is at home.

Medicaid providers would be well-advised to closely review Bulletins 2020-14, 2020-10 and then 2020-09, as well as the DHHS notification referenced in Bulletin 2020-14, in connection with establishment of telehealth programs amidst the COVID-19 pandemic.