State Telehealth Coverage and Reimbursement Announcements

March 24, 2020

MEMORANDUM

On March 19, Governor Pritzker issued an Executive Order, while the Department of Healthcare and Family Services (HFS) issued Emergency Rules (89 Ill. Adm. Code 140.403(e)) and a Provider Notice, all focused on telehealth coverage and reimbursement.

The Executive Order requires commercial insurers regulated by the Dept. of Insurance to cover costs of all clinically appropriate, medically necessary telehealth services rendered by in-network providers.  The Executive Order does not apply to out-of-network telehealth services. In addition to telehealth platforms stipulated in the Illinois Insurance Code (215 ILCS 5/356z.22) services may be delivered via video (e.g., FaceTime, Facebook Messenger video chat, Google Hangouts video, Skype) or telephonically (e.g., landline or cellular).

Insurers may establish “reasonable requirements and parameters” for services, including documentation and recordkeeping, but may not be more restrictive than the Medicaid Emergency Rules (outlined in 89 Ill. Adm. Code 140.403(e)).  Utilization review requirements cannot be unnecessary, duplicative or unwarranted, while treatment limitations cannot be more stringent than in-person service requirements. Cost-sharing (copayments, deductibles, or coinsurance) cannot be implemented for in-network providers, unless a patient enrolled in a high-deductible health plan has not yet met their deductible and the service is not “preventative care” as defined by the U.S. Treasury; however, the definition of preventative care recently has been expanded to include COVID-19-related services.

Eligible distant site providers are listed in the Order and must be licensed or authorized to practice in Illinois, in addition to details on broadened confidentiality allowances for mental health and developmental disabilities patients. As “requirements and parameters” of commercial coverage may not be more restrictive or less favorable than the HFS Emergency Rules, all providers must be paid at the same reimbursement rate as in-person services.

The Medicaid Emergency Rules (89 Ill. Adm. Code 140.403(e)) and Provider Notice stipulate that HFS  will reimburse medically necessary and clinically appropriate telehealth for patients with Medicaid fee-for service (FFS) and Managed Medicaid (HealthChoice Illinois). Providers will be paid at the same reimbursement rate as in-person services with dates of service after March 9.

The distant site provider can be any enrolled provider with the appropriate license or certification, while originating sites can include a patient’s place of residence or temporary location in or outside the state of Illinois. Originating sites will be eligible for a facility fee when it is a certified eligible facility or provider organization that acts as the location for the patient at the time a telehealth service is rendered. In addition to the existing service delivery definitions in the Rule, telehealth can be delivered through a communication system that is synchronous (live) and “of an amount and nature that would be sufficient to meet the key components and requirements of the same service” when delivered in-person. The distant site provider and originating site provider eligible for a facility fee must maintain adequate documentation of the telehealth services provided in accordance with the record requirements of the Rule (89 Ill. Adm. Code 140.403(d)).

During the public health emergency, HFS will cover additional services that do not meet the Rule definition of “telehealth services,” but would be considered services delivered via telehealth, such as e-visits and virtual check-ins. HFS has provided the following temporary reimbursement allowances:

•  Virtual check-ins with a physician, advance practice nurse or physician assistant are brief (5- 10 min) via telephone or other communication device, used to decide whether an office visit or other service is necessary. Report using Evaluation and Management codes (99441, 99442, and 99443); documentation must still be maintained by providers in the record to meet all HCPCS or CPT codes;
• “E-visits” are non- face-to-face communications initiated by patients via online patient portals, and reported using HCPCS codes G0261, G2062, G2063;
• Both virtual and e-visits require the patient be an established patient to the provider, and reimbursement will be based on the Practitioner Fee Schedule; and
• Behavioral health services (mental health and substance use disorder) described in Sections 140.6(m) and 140.403 of the Rule can be delivered via audio or video interaction, except for Mobile Crisis Response and Crisis Stabilization.

Contact us with questions or comments for IHA.