Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, 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 September 1, 2022, telemedicine and telehealth benefit information will be updated for Texas Medicaid.
Note: Telehealth includes teledentistry services.
Overview of Benefit Changes
Major changes to the benefit information include the following:
- Described and defined audio-only services
- Clarified that coverage of behavioral health (BH) audio-only services is not optional for health plans
- Added language regarding when audio-only services may be authorized for use
- Added language regarding the use of the 93 and FQ modifiers
- Reorganization of information about specific telemedicine and telehealth services within the Texas Medicaid Provider Procedures Manual handbooks
Definitions of Terminology
Telemedicine and telehealth services have the meaning assigned by Texas Occupations Code §111.001. The following are definitions of terms used in telemedicine and telehealth services:
- Telecommunications - the exchange of information by electronic and electrical means
- Platform - the technology, system, software, application, modality, or other method through which a health professional remotely interfaces with a client when providing a health care service or procedure as a telemedicine medical service or telehealth service
- Audiovisual technology- synchronous audiovisual technology or store-and-forward technology in conjunction with synchronous audio-only technology
- Synchronous audiovisual technology - an interactive, two-way audio and video telecommunications platform that meets the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA)
- Synchronous audio-only technology, also called synchronous telephone (audio-only) technology - an interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of HIPAA
- Store-and-forward technology - a telecommunications platform that stores and transmits, or grants access to, a client’s clinical information for review by a health professional at a different physical location from the client
- In person (or in-person) - within the physical presence of another person
Services Provided through Synchronous Audio-Only Technology
Synchronous telephone (audio-only) technology between the provider and the client in another location may be used to provide telemedicine and telehealth services within fee-for-service (FFS) Medicaid. Providers must ensure both the covered service and the delivery method are authorized by the Texas Health and Human Services Commission (HHSC).
Telemedicine and telehealth services provided through synchronous telephone (audio-only) technology must be billed with the appropriate modifier (93 or FQ), unless the procedure code indicates telephone (audio-only) delivery in the code description.
Behavioral Health Services
Behavioral health services provided through synchronous audio-only technology require the provider to obtain informed consent from the client, client’s parent, or the client’s legally authorized representative (LAR) before rendering a behavioral health service through a synchronous telephone (audio-only) technology platform, except when doing so is not feasible or could result in death or injury to the client. Verbal consent is permissible and must be documented in the client’s medical record.
Telemedicine and telehealth behavioral health services provided through synchronous telephone (audio-only) technology must be billed with a modifier. Procedure codes that indicate telephone (audio-only) delivery in the description do not need to be billed with a modifier.
Additional Guidelines for Telemedicine and Telehealth Services
The following delivery methods may be used to provide telemedicine and telehealth services within FFS Medicaid:
- Synchronous audiovisual technology between the distant-site provider and the client in another location
- Synchronous telephone (audio-only) technology between the distant-site provider and the client in another location
- Store-and-forward technology, in conjunction with synchronous telephone (audio-only) technology between the distant-site provider and the client in another location.
Not all Medicaid-covered services are authorized by HHSC for telemedicine or telehealth delivery in FFS. Providers must ensure that HHSC both allows the Medicaid-covered service to be delivered through telemedicine or telehealth and authorizes the delivery method.
For example, if a service is authorized for telemedicine delivery only when using synchronous audiovisual technology, that service may not be delivered using store-and-forward technology, store-and-forward technology in conjunction with synchronous telephone (audio-only) technology, synchronous telephone (audio-only) technology, or asynchronous audio-only technology.
Reminder: Texas Medicaid managed care organiziations (MCOs) must consider reimbursement for all medically necessary Medicaid-covered services that are provided using telemedicine or telehealth. Providers should refer to individual MCO policies for additional coverage information.
Conditions for Reimbursement
Telemedicine and telehealth services that may be reimbursed are those that meet the following conditions when delivered using any of the methods noted above:
- Are designated for reimbursement by HHSC
- Meet criteria, including clinical effectiveness, cost-effectiveness, and other criteria, as determined by HHSC
- Are provided by a Texas Medicaid enrolled provider
- Are both in compliance with Chapter 111 of the Texas Occupations Code and within standards established by the respective licensing or certifying board of the professional providing the service
- May not be denied solely because an in-person healthcare service between a provider and client did not occur
- May not be limited by requiring the provider to use a particular technology platform to receive reimbursement for the service
- Other conditions for reimbursement applicable to services provided may vary by service type. Providers may refer to the appropriate Texas Medicaid Provider Procedures Manual handbook for additional information.
Beginning September 1, 2022, procedure codes that are benefits for providers delivering services through telemedicine or telehealth will be outlined in the respective Texas Medicaid Provider Procedures Manual handbooks.
Note: During a Declaration of State of Disaster, HHSC may issue direction to providers regarding the use of telemedicine or telehealth services, including the use of a synchronous telephone (audio-only) platform to provide covered services outside of the allowances described in this article. A Declaration of State of Disaster is when an executive order or proclamation is issued by the governor declaring a state of disaster in accordance with Section 418.014 of the Texas Government Code.
Additional Guidelines for Telemedicine Services
All physicians must comply with 22 Texas Administrative Code §174.5 when issuing prescriptions through telemedicine.
For more information, call the TMHP Contact Center at 800-925-9126.