Recent actions in two different states provide a good example of how different state Medicaid policies can vary widely and how the state telehealth policy landscape continues to be an ever-evolving environment. We often see that while one state is expanding their telehealth policy, another is imposing new requirements that may limit the availability of services via telehealth. Although the subjects of the policies within these two example states may not be the same, it does still demonstrate that states are continuing to work on, and refine, their telehealth policies.
The first example is a state expanding their current policies. Earlier this month, the North Dakota Health and Human Services (HHS) FamilyFirst Services allowed Parent-Child Interaction Therapy (PCIT) to be done via telehealth by an approved provider. PCIT is a treatment designed to improve a parent-child relationship and reduce disruptive behaviors in young children. The focus tends to be on children ages 2 to 7 years old, and parents typically receive weekly PCIT sessions with a licensed therapist as the parent plays and interacts with their child. Previously, North Dakota FamilyFirst Services had limited PCIT to only in-person services. However, in the announcement, the director of North Dakota Children and Family Services notes, “Telehealth delivery maintains the integrity of the PCIT model while increasing flexibility and reach.” The North Dakota HHS announcement provides more information on how families can apply for such services (which has no cost).
At the other end of the spectrum, where telehealth utilization policies are being limited, we have North Carolina. Last month HB 696 was signed into law which among other things, required the North Carolina Department of Health and Human Services (DHHS) to implement the following regarding Medicaid coverage for Applied Behavioral Analysis (ABA) Therapy for the North Carolina Medicaid coverage of Research-Based Behavioral Health Treatment for Autism Spectrum Disorder (ASD):
- Prohibit services provided by a paraprofessional via telehealth;
- Require patient assessments to be conducted in-person;
- Allow services involving the observation and direction of a paraprofessional to be conducted via telehealth and limit these telehealth services to no more than 50% of the services provided to a beneficiary;
- Allow parent, guardian and caregiver training to be provided via telehealth with no in-person requirement; and
- Board Certified Behavior Analysts and Qualified Autism Services Practitioner Supervisors are not permitted to enroll in the North Carolina Medicaid program as out of state providers.
These new provisions have raised concerns regarding the future availability of services to treat Medicaid enrollees with ASD. At this time, DHHS has not promulgated regulations or guidance on how these provisions will be implemented, but in a recent article, at least one CEO of a company providing ABA services noted that interest in providing services to North Carolina may slow until more details are released regarding how DHHS will implement the new policies. However, the same CEO also noted that his company, at least, intends to adapt to the challenges presented by the newly passed policies.
Perhaps more concerning to some telehealth service organizations in North Carolina is the blanket prohibition of out-of-state Board-Certified Behavior Analysts and Qualified Autism Services Practitioner Supervisors from enrolling in North Carolina Medicaid. In the last few years, some Medicaid programs have raised concern regarding out-of-state telehealth providers treating their program enrollees, even when they are licensed by the state. A common concern some Medicaid programs have is that enrollees may never see a provider in-person if they are only utilizing telehealth providers from out-of-state. Some states address this concern by requiring a provider to have a physical business location within the state, or requiring some relationship be established with an in-state provider where the patient can be referred to for care. As an example, California Medicaid requires an enrolled Medicaid provider to be affiliated with an enrolled California Medicaid provider group that is located in the state or a border community. In addition, subject to very limited exceptions for some provider types [mental health] established by California Medicaid, all health care providers must meet Established Place of Business (EPOB) requirements (California Code of Regulations, Title 22, section 51000.60). As a result, the EPOB requirement does not allow enrollment of fully remote, non-California based health care providers who offer services exclusively through telehealth modalities or at an administrative location that does not meet all EPOB and/or other Medi-Cal provider enrollment requirements (CA Dept of Health Care Services, Medi-Cal Part 2 General Medicine Manual, p. 5).
Prior to the pandemic, some state Medicaid programs had already begun clarifying or phasing out in-state requirements of their enrolled providers, although in many states the issue was still vague or not explicitly addressed in the context of telehealth. However, with the increased use of telehealth brought on by the pandemic, as well as the more favorable policies towards its use, some states are now revisiting these policies.
It should be noted that the provider location requirements for Medicaid enrollment are not about licensure, but rather about the provider’s location (as most Medicaid policies still require in-state licensure). Most states at this time are unlikely to have a prohibition on a Medicaid program requiring the provider be within the state’s borders as long as they are licensed in-state. However, even without the Legislature enacting this change in the case of North Carolina, state Medicaid programs may be able to enact such a requirement on their own, or such requirements may have been preexisting that applied prior to the increasing prevalence of out-of-state telehealth providers. For instance, while California’s policy generally restricts out-of-state telehealth providers with no in-state address or provider relationship, they did create an exception a few years ago for fully remote mental health providers. The aforementioned California policy is an example of a Medicaid program instituting such a change without being directed by passage of state legislation.
From these state examples discussed, we can clearly see that the state telehealth policy landscape remains a dynamic and ever-evolving space, with the distinct possibility that some policies may indeed have a more limiting effect on how broadly telehealth may be used within a given state. To keep abreast of changes similar to those discussed here, CCHP tracks pending legislation and regulations as well as state Medicaid policies on our Policy Finder, which is continuously being updated by the CCHP team. |
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