Following the release of the Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine by the Federation of State Medical Boards in April 2014[1], the Center for Connected Health Policy (CCHP) and the American Telemedicine Association (ATA) released telemedicine reports, providing insights into the state of telemedicine adoption, reimbursement barriers and physician licensing requirements throughout the United States.

A few preliminary comments....These reports provide a great resource for those researching the regulatory environment surrounding telemedicine and telehealth. But, it is important to remember that the laws and policies in this area change frequently throughout the US. The three reports cover most of the same areas, although they are presented differently. The report from the Center for Connected Health sets out eleven policy areas that are generally crucial when providers are formulating a telemedicine based business model. The American Telemedicina Association reports provide some very helpful charts comparing the laws of the various states. It is also important to remember that other regulatory requirements impact the practice of telemedicine, such as state and federal data privacy and security laws as well as general medical practice requirements (e.g., record keeping).

If you have questions regarding any telemedicine related issues, please contact us today.


Center for Connected Health Policy Report on State Telehealth Policies and Reimbursement Schedules: A Comprehensive Plan of the 50 States and District of Columbia (Sept. 2014)[2]

In its second annual report, the CCHP looked at the Medicaid reimbursement policies and telemedicine laws in all 50 states. As CCHP notes, some "states have incorporated policies into law, while others have addressed issues such as definition, reimbursement policies, licensure requirements, and other important issues in their Medicaid Program Guidelines." This is a good reminder to those interested in operating in this space must take care to review all appropriate laws and guidance documents prior to starting their telemedicine based practice or otherwise offering healthcare services via telemedicine. For example, some technologies may seen appropriate until a board of medicine takes action against a provider. See e.g., Can Doctor’s Use Skype for Telemedicine? Not in Oklahoma.

CCHP observed the following major trends regarding reimbursement for live video, store-and-forward and remote patient monitoring:
  • In comparison to forty-four states last year, currently forty-six state Medicaid programs reimburse for some form of live video. Washington DC’s Medicaid program is also now required to reimburse for live video as a result of recent legislation.
  • Ten state Medicaid programs offer some reimbursement for store-and-forward (states that only reimbursed for tele-radiology are not included in this count).
  • Thirteen state Medicaid programs offer reimbursement for remote patient monitoring compared to ten states at the time this report was first published in 2013.
  • Three state Medicaid programs (Alaska, Minnesota and Mississippi) reimburse for all three.
In reviewing state telemedicine policies, the survey focused on eleven policy areas:
  • Definition of the term telemedicine/telehealth
  • Reimbursement for live video
  • Reimbursement for store-and-forward
  • Reimbursement for remote patient monitoring (RPM)
  • Reimbursement for email/phone/fax
  • Consent issues
  • Location of service provided
  • Reimbursement for transmission and/or facility fees
  • Online prescribing
  • Private payer laws
  • Cross-state licensure
These policy areas are important to understand when developing a telemedicine based practice, evaluating offering services to existing patients via telemedicine, or developing a telemedicine compliance program. Physicians and physician extenders (e.g., nurse practitioners, registered nurses, and others) who wish to practice across state lines must also pay close attention to the licensure requirements keeping in mind that the law is based on the physical location of the patient and not the provider.

American Telemedicine Association Report on Physician Practice Standards & Licensure [3]

This report evaluated the physician licensure laws in the states for both in-state and out-of state practice. The report also looked at the physician-patient encounter requirements when using telemedicine, telepresenter requirements that may be more stringent as compared to in-person services, and informed consent requirements. The report provides a summary chart grading each state on a A - F scale.

American Telemedicine Association Report on Coverage & Reimbursement [4]

Payment and coverage remains one of the biggest obstacles to the widespread adoption of telemedicine. In this report, the ATA "extracts and compares telemedicine coverage and reimbursement standards for every state in the U.S." Notably, as the ATA explained:
  • Of the 21 states that have telemedicine parity laws for private insurance, only 15 of them and D.C. scored the highest grades indicating policies that authorize state-wide coverage, without any provider or technology restrictions. Over half of the country, 29 states, ranked the lowest with failing scores for having no parity law in place.
  • Forty-seven state Medicaid programs have some type of coverage for telemedicine. Only five states and D.C. scored the highest grades by offering more comprehensive coverage, with few barriers for telemedicine-provided services . Connecticut, Hawaii, Idaho, Iowa, Nevada, Rhode Island, Utah and West Virginia ranked the lowest with failing scores in this area.
  • One disappointing observation includes the lack of coverage and reimbursement for telemedicine under state employee health plans. Eighty-two percent of the country is ranked the lowest with failing scores including Arkansas which will only cover the use of store-and-forward for diabetic retinopathy screening, and Nebraska which requires their plans to cover autism treatment via telemedicine.
  • Regarding Medicaid regulations, states are slowly moving away from the traditional hub-and-spoke model and allowing a variety of technology applications. Twenty-three states and D.C. do not specify a patient setting or patient location as a condition for payment of telemedicine. Aside from this, 21states recognize the home as an originating site, while 13 states recognize schools and/or school-based health centers as an originating site. Utah ranks the lowest with only one eligible originating site
  • South Dakota has the highest ranking for Medicaid operations because its program covers telemedicine when providers use interactive audio-video, store-and-forward, remote patient monitoring, e-mail, fax, or phone mail. Fifty-seven percent of the country ranked the lowest with failing scores either because they only cover synchronous only or provide no coverage for telemedicine at all. Idaho, Missouri, North Carolina and South Carolina prohibit the use of cell phone video to facilitate a telemedicine encounter.[5]

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[1] Federation of State Medical Boards, Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine (April 2014), available at https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/FSMB_Telemedicine_Policy.pdf.

[2] Center for Connected Health Policy, State Telehealth Policies and Reimbursement Schedules: A Comprehensive Plan of the 50 States and District of Columbia (Sept. 2014), available at https://cchpca.org/sites/default/files/resources/Fifty%20State%20Medicaid%20Report.09.2014_1.pdf.

[3] American Telemedicine Association, Physician Practice Standards & Licensure (Sept. 2014), available at https://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis--physician-practice-standards-licensure.pdf?sfvrsn=6.

[4] American Telemedicine Association, Coverage & Reimbursement (Sept. 2014), available at https://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf?sfvrsn=6.

[5] Id. at 2-3.
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Posted by Tatiana Melnik on October 28, 2014.