NYS Medicaid Coverage of Telehealth
This is an archived page and information may be outdated.
Visit the NYS Medicaid Telehealth web page for the current telehealth guidance.
- Overview also available in Portable Document Format (PDF)
Federally Qualified Health Centers
October 2019
Overview of Telehealth Expansion
Telehealth Expansion
- Telehealth is defined as the use of electronic information and communication technologies to deliver health care to patients at a distance.
- Originating Site: Where the member is located at the time health care services are delivered.
- Distant Site: Any secure location where the telehealth provider is located while delivering health care services by means of telehealth.
- A Special Edition Medicaid Update was issued in February 2019.
- The expanded telehealth policy is effective January 1, 2019 for Medicaid fee–for–service (FFS) and March 1, 2019 for Medicaid Managed Care (MMC).
- Nothing precludes implementation by the MMC Plans prior to January 1, 2019.
| Medicaid Reimbursement Policy as of March 2015 | Modalities, Originating Sites and Distant Sites Have Been Expanded and Include the Following (in addition to those listed in Column One) | |
|---|---|---|
| Eligible Modalities |
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| Eligible "Originating" Sites (Location of Patient) |
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| Eligible "Distant" Sites (Location of Consulting Practitioner) |
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| Eligible Telehealth Practitioner–Types |
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Telehealth Practitioner Requirements
- Practitioners providing services via telehealth must be licensed or certified, currently registered in accordance with NYS Education Law or other applicable law, and enrolled in NYS Medicaid.
- Telehealth services must be delivered by providers acting within their scope of practice.
- Reimbursement will be made in accordance with existing Medicaid policy related to supervision and billing rules and requirements.
- Providers must be credentialed at both the distant site and the originating site in order to provide telehealth services.
Credentialing and Privileging
- The Article 28 hospital acting as an originating site may rely on the credentialing and privileging decisions of the distant site hospital when granting or renewing privileges to a health care practitioner who is a member of the clinical staff at the distant site hospital.
- The distant site hospital collects and evaluates all credentialing information and performs all required verification activities, and acts on behalf of the originating site hospital for such credentialing purposes.
- The distant site reviews (at least every two years) the credentials, privileges, physical and mental capacity and competence of the telehealth provider and reports the results of the review to the originating site.
- The originating site also reviews (at least every two years) the performance of these privileges and provides the distant site hospital with the performance evaluation for use in the distant site´s periodic appraisal of the telemedicine practitioner.
Confidentiality
- All services must be performed on dedicated secure transmission linkages that meet the minimum federal and state requirements.
- HIPAA requires that a written “business associate agreement” (BAA) or contract that provides for privacy and security of protected health information be in place between the telehealth provider and the supporting telehealth vendor.
- All confidentiality requirements that apply to medical records apply to services delivered by means of telehealth.
- The medical record must document the physical location of the patient as well as the physical location of the distant site practitioner.
Consent
- Providers must document in the medical record that the Medicaid member has consented to the six questions under Part E of the February 2019 Medicaid Update on telehealth.
- Providers must have written protocols and procedures on how practitioners shall provide the Medicaid member with basic information about the services they will be receiving via telehealth and the member shall provide their consent to participate in services utilizing this technology.
Failure to Transmission
- All telehealth providers must have a written procedure detailing a contingency plan in the case of a failure of transmission or other technical difficulty that renders the service undeliverable via telehealth.
- Policies and procedures must be available upon audit.
- If the service is undelivered due to a failure of transmission or other technical difficulty, a claim should not be submitted to Medicaid.
Modifiers
To Be Used When Billing for Telehealth Services
| Modifier | Description | Note/Example |
|---|---|---|
| 95 | Synchronous telemedicine service rendered via real–time interactive audio and video telecommunication system | Note: Modifier 95 may only be appended to the specific services covered by Medicaid and listed in Appendix P of the AMA´s CPT Professional Edition 2018 Codebook. The CPT codes listed in Appendix P are for services that are typically performed face–to–face but may be rendered via a real–time (synchronous) interactive audio–visual telecommunication system. |
| GT | Via interactive audio and video telecommunication systems | Note: Modifier GT is only for use with those services provided via synchronous telemedicine for which modifier 95 cannot be used. |
| GQ | Via asynchronous telecommunications system | Note: Modifier GQ is for use with Store and Forward technology |
| 25 | Significant, separately identifiable evaluation & management (E&M) service by the same physician or other qualified health care professional on the same day as a procedure or other service | Example: The member has a psychiatric consultation via telemedicine on the same day as a primary care E&M service at the originating site. The E&M service should be appended with the 25 modifier. |
Place of Service Code
To Be Used When Billing for Telehealth Services
| POS Code | Description |
|---|---|
| 2 | The location where health services and health related services are provided or received, through telehealth telecommunication technology. When billing telehealth services, providers must bill with place of service code 02 and continue to bill modifier 95, GT or GQ. |
Specific Billing Rules for FQHCs
FQHCs That Opted Into APGs
- FQHCs that have "opted into" APGs should follow the billing guidance provided for sites billing under APGs.
Billing Entity
- A "billing entity" includes all entities billing under one Tax ID Number.
- Therefore if an FQHC has separate NPIs but operates under one TIN, the separate NPIs are considered a part of the same billing entity.
- If an FQHC provides services via telehealth to a Medicaid enrollee and acts as both the originating site and the distant site within the same FQHC organization, then only the originating site may submit a claim to receive the full PPS rate.
Administrative Expenses
- If an FQHC is acting as an originating site, then the FQHC offsite rate (4012) may be billed to recoup administrative expenses for the telehealth encounter.
Additional Services
- An FQHC can be reimbursed for providing a telehealth visit and an additional face–to–face visit in one day.
- The FQHC can bill the full PPS rate (4013) and the FQHC offsite rate (4012) if the FQHC is providing a separate and distinct service that is medically necessary in addition to the telehealth encounter.
- The 25 modifier must be used to indicate the separate and distinct encounter.
Integrated Settings
- The February 2019 NYS Medicaid Update on telehealth billing only applies to Article 28 licensed facilities.
- If an Article 28 is integrated with an Article 31 or an Article 32, then the regulatory authority will depend on where the patient is located.
- Article 31 and 32 facilities are governed by the Office of Mental Health and Office of Alcoholism and Substance Abuse Services respectively, and are subject to their telehealth regulation.
Wrap Around Payments
- Services provided via telehealth by an FQHC that would be reimbursed at the PPS rate (4013) are eligible for the wrap around payment.
- If the telehealth visit is for an offsite visit (4012), then a wrap around payment would not be billed.
Services Provided Outside of an FQHC
- The FQHC can bill the PPS rate (4013) if the Medicaid member is located in one of the following locations:
- An Article 28 licensed outpatient clinic
- An emergency room
- A practitioner´s private practice
- The FQHC can bill the PPS rate (4012) if the Medicaid member is located in one of the following locations:
- Their home or other similar residence such as a nursing facility or adult care facility
- A temporary location such as an educational setting, school–age program or child daycare center
- A skilled nursing facility if clinic services are not included in the skilled nursing home´s Medicaid rate
- The FQHC cannot bill if the Medicaid member is located in one of the following locations:
- An inpatient hospital
- A skilled nursing facility if clinic services are included in the nursing home´s rate
Medicaid/Medicare Dually Eligible Persons
- Claims for dually eligible individuals will follow the existing crossover process.
- Medicaid will pay the difference between the Medicare payment and the FQHC´s PPS rate (4013).
- If the service provided is not within the scope of services covered by Medicare (e.g. dental, store–and–forward) but is an eligible telehealth services under Medicaid, then the telehealth encounter can be billed to Medicaid.
- If Medicare only covers the service as a face–to–face encounter, then the telehealth encounter cannot be billed to Medicaid.
Medicare Telehealth Restrictions on FQHCs
- Medicare´s telehealth restrictions on FQHCs apply to the Medicaid telehealth program for services provided to dually eligible individuals.
- Medicare prohibits FQHCs from acting as distant sites.
- Medicare allows FQHCs to act as originating site only if:
- The FQHC is in a county outside of a Metropolitan Statistical Area (MSA), or;
- The FQHC is located in a rural Health Professional Shortage Area (HPSA).
- If an FQHC is serving a dually eligible individual as an originating or distant site inside an MSA or outside a rural HPSA, then the telehealth service will not be reimbursed by Medicaid.
Questions
- Questions regarding Medicaid FFS billing, should be directed to eMedNY Provider Services at (800) 343–9000.
- Policy questions regarding Medicaid FFS may be directed to the Office of Health Insurance Programs, Division of Program Development and Management at (518) 473–2160.
- Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan.
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