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Reimbursement for Telehealth and Provider and Facility Guidelines

Reimbursement for Telehealth

Reimbursement for Medicaid-covered services, including those delivered via telehealth, must satisfy federal requirements of efficiency, economy and quality of care. States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telehealth. For example, states may reimburse the physician or other practitioner at the distant site and reimburse a facility fee to the originating site. States can also reimburse any additional costs such as technical support, transmission charges, and equipment. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state. If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service.

State Flexibility in Covering/Reimbursing for Telehealth and the Application of General Medicaid Requirements to Coverage of Services Delivered via Telehealth

States have broad discretion in designing their approaches to telehealth since telehealth is a delivery method, not a benefit type. Telehealth is viewed as an alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient). As such, states have the option/flexibility to determine whether (or not) to cover telehealth; what types of telehealth to cover; where in the state it can be covered; how it is provided/covered; what types of telehealth practitioners/providers may be covered/reimbursed, as long as such practitioners/providers are "recognized" and qualified according to Medicaid statute/regulation; and how much to reimburse for services delivered using telehealth, as long as such payments do not exceed Federal Upper Limits. For more information, please review the resource Reimbursement for Medicaid for Services Delivered Via Telehealth

If the state decides to cover telehealth, but does not cover certain practitioners/providers of telehealth or its telehealth coverage is limited to certain parts of the state, then the state is responsible for assuring access and covering face-to-face visits/examinations by these "recognized" practitioners/providers in those parts of the state where telehealth is not available.

Therefore, the general Medicaid requirements of comparability, statewideness, and freedom of choice do not apply with regard to telehealth services.

Provider and Facility Guidelines

Medicaid guidelines require all providers to practice within the scope of their State Practice Act or other applicable state requirements. Some states have enacted legislation that requires providers using telehealth technology across state lines to have a valid state license in the state where the patient is located. Any such requirements or restrictions placed by the state are binding under current Medicaid rules