It’s been a week filled with last-minute government pivots to avoid interruptions of care. Literally less than 12 hours before the end of the public health emergency (PHE), Connecticut’s Department of Social Services (CT DSS) released revisions to its telehealth guidance for Medicaid recipients. Earlier this week, the Drug Enforcement Agency also issued a last-minute announcement regarding telehealth.
On March 27, 2023, CT DSS issued telehealth guidance that stunned many in the provider community. One of the biggest issues with the guidance was the new requirement that, as of May 12, 2023, CT-licensed Medicaid providers offering telehealth services must be physically in the state of CT to deliver telehealth services to Medicaid patients.
During the pandemic, many CT-based providers hired CT-licensed clinicians living in other states to provide telehealth services. Especially in behavioral health, there simply were not enough CT-based clinicians to meet the need for care. After three years of adapting to care delivery in a pandemic, many organizations came to rely on these out of state clinicians to meet patient needs.
Another issue with the original guidance was that all CT Medicaid enrolled billing entities must have a physical location in Connecticut. Many CT-licensed providers, especially behavioral health providers, went 100% remote during the pandemic. They gave up physical office spaces to adapt to the changing needs.
Additionally, DSS’s informed written consent requirement provided few details on the form or format of the consent or whether providers could rely at all on consent obtained verbally during the PHE.
There were many other questions and issues but the above were the most commonly cited concerns with the March 27, 2023 telehealth guidance.
Immediately after CT DSS issued its original guidance, providers began lodging complaints. For weeks, DSS promised clarification. DSS issued its clarification on afternoon of May 11, 2023 in the form of revised guidance, a revised table of telehealth eligible services and Frequently Asked Questions (FAQs) with answers to 26 specific questions. Better late than never!
Location of the Provider
In both the revised guidance and the FAQs, CT DSS acknowledged that out-of-state providers offering services through in-state Medicaid enrolled providers may provide telehealth services while outside of CT. To be permissible, the in-state Medicaid enrolled provider must be able to provide access to in-person services when medically necessary or requested by the Medicaid patient. And of course, the out-of-state provider must hold a Connecticut license to practice.
The FAQs say that an “[i]n-state enrolled CMAP providers may contract with out-of-state practitioners to provide 100% telehealth services to HUSKY members.” While DSS does not explicitly mention employees, I read the “contract” language as applying to employees of an in-state enrolled provider as well. Excluding employees simply would not make sense. If using out-of-state employees, it may be best to have a contract with those employees.
Physical Office Space
DSS confirmed that a physical location in CT is required and provided examples of appropriate and inappropriate in-state physical locations in #17 of the FAQs. It describes as appropriate “[a] location in CT. . . including but not limited to rented/shared/owned/ WeWork space where the provider has a room or set of rooms to see the member in-person and can maintain the member’s privacy and confidentiality during the visit.” It also finds acceptable the use of a colleague’s office space.
Unacceptable physical locations are those where the provider “does not have consistent access for on-demand use” and where the provider cannot maintain privacy and confidentiality. Further, DSS finds the sporadic use of the home or office space of friends or family when the provider lives outside of CT and provides only telehealth services to be unacceptable.
Consent
DSS clarified in its revised guidance that the provider can choose the method and format of the informed consent. The original guidance allows for electronic written consent. In its FAQs, DSS offered a grace period of six months for implementation when an existing patient verbally consented to a telehealth service during the PHE and such consent is documented. DSS explained:
“Verbal consent obtained during the PHE, as evidenced by a documentation in the medical record, may remain in effect for up to six months after the end of the PHE, after which, providers must obtain” informed written consent.
Patients who did not consent to telehealth during the PHE must provide informed written consent before a provider can provide telehealth services. There is no grace period for these new telehealth relationships.
CMAP Changes
- Anything not listed in the updated CMAP table is not a telehealth eligible service.
- The code for initial psychiatric evaluations was added to the chart (90792) as eligible for video visits.
- Many of the established patient and service limitation requirements were removed for audio-only behavioral health services.
- There are different codes for medication management via video (99202-99205, 99211-99215) or via audio-only (99442-99443).
Other Notable Revisions/Clarifications
- For behavioral health audio-only services, the modifier FQ (not CR) must be used.
- DSS addressed billing when switching from video to audio-only due to technical difficulties. See #15 in the FAQs. Documentation must reflect the reason for the switch.
- The freestanding clinic requirement that either the practitioner or the patient must be present at the clinic for the telehealth service will not apply to behavioral health services provided by freestanding clinics.
Audio-only Services
The basic requirements for audio-only services have not changed since the last guidance and are worth repeating here. Audio-only services are covered only if the services:
- Are (1) clinically appropriate, as determined by the Commissioner, (2) it is not possible to provide comparable covered audiovisual telehealth services, and (3) provided to individuals who are unable to use or access comparable, covered audiovisual telehealth services (based on P.A. 21-133, now at Conn. Gen. Stat. §17b-245g); AND
- Meet any other restrictions/requirements outlined in the CMAP Telehealth Table attached to the guidance.
Be sure to check CT DSS’s website on telehealth often as things may be further updated. Just like the CT DSS FAQs that DSS regularly updated during the pandemic, I expect these FAQs to be updated frequently. It is important to comply with these requirements. CT DSS provides contact information at the end of the provider bulletin. Contact CT DSS with specific questions or concerns.