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Benefits for Telemedicine Services to Change for Texas Medicaid December 1, 2020

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after December 1, 2020, benefits for telemedicine (physician-delivered) services will change for Texas Medicaid.

Refer to: The article titled,”Multiple Medicaid COVID-19 Flexibilities Extended Through November 30, 2020,” which was published on this website October 23, 2020, for information about the COVID-19 telemedicine flexibilities that are effective through November 30, 2020.

Overview of Benefit Changes

Major changes to this medical benefit include the following:

  • Reimbursing federally qualified health centers (FQHCs) for telemedicine services
  • Updated guidelines for school-based settings
  • Clarification of Texas Medicaid managed care organization (MCO) guidelines for telemedicine services

Telemedicine Benefits for FQHCs

FQHCs may be reimbursed for telemedicine services when services are provided in the office and outpatient settings.

Distant Site

FQHCs providing distant-site telemedicine services may be reimbursed for the following procedure codes:

Procedure Codes

G0466

G0467

G0468

G0469

G0470

T1015

Note: Telemedicine services should be billed using modifier 95.

FQHCs may be reimbursed the distant-site provider fee for telemedicine services at the Prospective Payment System (PPS) rate or Alternative Prospective Payment System (APPS) rate.

Patient Site

FQHCs may be reimbursed the facility fee (procedure code Q3014) as an add-on procedure code, which should not be included in any cost reporting that is used to calculate a PPS or APPS per visit encounter rate.

To receive reimbursement for more than one facility fee for the same client on the same date of service, an FQHC must submit documentation of medical necessity indicating that the client needed multiple distant-site provider consultations. A signed letter from the client's treating health-care provider at the FQHC stating that the client suffered an illness or injury requiring additional diagnosis or treatment by a distant-site provider will be sufficient to document the client's medical need for receiving multiple distant-site provider consultations on the same date of service.

If an FQHC is eligible for payment of both an encounter and a facility fee for the same client on the same date of service, the FQHC must submit a claim for the facility fee separate from the claim submitted for the encounter.

School-Based Setting

A health professional will no longer be required to be present with a client located in a school-based setting during a treatment delivered via telemedicine.

General Guidelines for Texas Medicaid MCOs

Texas Medicaid MCOs are prohibited from denying reimbursement for covered services solely because they are delivered remotely. MCOs must consider reimbursement for all medically necessary Medicaid-covered services provided via telemedicine and must consider clinical and cost-effectiveness to determine whether a telemedicine visit is appropriate.

Texas Medicaid MCOs must determine whether to reimburse for a telemedicine service based on the following considerations:

  • Medical necessity.
  • Clinical effectiveness.
  • The telemedicine service provided is cost-effective.
  • The telemedicine service is provided in accordance with the law and contract requirements applicable to the provision of the same health-care service provided in person.
  • The use of telemedicine promotes and supports patient-centered medical homes.

Texas Medicaid MCOs must consider reimbursement for all services that are currently a Medicaid benefit when provided via telemedicine, including the procedure codes that are identified in the table above.

All other medically necessary Medicaid-covered benefits provided via telemedicine must also be considered for reimbursement.

Texas Medicaid MCOs cannot deny, limit, or reduce reimbursement for a covered health-care service or procedure provided via telemedicine based on the provider's choice of telecommunications platform to provide the service or procedure.

Providers should refer to individual MCO policies for additional coverage information.

Refer to: The current Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook, subsection 3.2, “Telemedicine Services,” for information about the services that are currently a benefit when provided via telemedicine.

For more information, call the TMHP Contact Center at 800-925-9126.