Nation’s telemedicine laws a patchwork of parity and Medicaid policies

The American Telemedicine Association (ATA) has compiled a report listing laws that allows readers to compare telemedicine policies affecting coverage and reimbursement among the 50 states and the District of Columbia (D.C.).  The ATA analysis considered policies based on health plan parity and Medicaid conditions of payment.  Although it found widespread differences among the states, in particular when it examined 13 additional indicators within the parity and conditions of payment categories, it gave five states and D.C. overall ratings of A. Thirty states received B ratings and 13 received C ratings.  Two states–Connecticut and Rhode Island–received grades of F.


Telemedicine parity laws are those that require private insurers to cover telemedicine-provided services comparable to that of in-person services. Twenty-three states and D.C. have full parity laws in effect. Sixteen of those states and D.C. received the highest grades in the private insurance parity category because they provide statewide coverage and do not impose provider or technology restrictions.  Forty-eight Medicaid programs provide some type of Medicaid coverage, but only four, along with D.C., received the highest parity grades.  Twenty-four states provide some telemedicine coverage under state employee health plans and 21 extend coverage under parity laws.  However, 58 percent of the country received failing grades for parity among state employee health plans because they offered no or only limited coverage for telehealth.

Medicaid conditions of payment

Payment for telemedicine services is traditionally conditioned on the services being provided to patients in specific settings or locations, such as physicians’ offices and hospitals, and ignoring more convenient locations such as patient homes, community mental health centers, and federally qualified health centers.  However, according to the ATA compilation, 24 states do not condition payment on patient settings or location.  In addition to these, 25 states recognize the home as an originating site for telemedicine services; 16 recognize schools and/or school-based health centers as originating sites.

States that cover telemedicine services generally do so when they are provided by a physician.  Only 15 states and D.C. did condition payment on a specific provider type.  A handful of states covered services provided by podiatrists, optometrists, or behavioral analysts.  With respect to physician-provided services, most states cover office visits or consultation, but few cover ultrasounds or echocardiograms.

Eighty-two percent of states cover telemedicine services without geographic or distance restrictions.  On the other hand, 57 percent of states received failing scores in the eligible technologies indicator category because they provide no coverage for telemedicine or only cover synchronous technologies, such as videoconferencing that occurs in real time, as opposed to other technologies, such as store-and-forward, in which still images are transmitted.  In addition to the policies discussed above,  the analysis also looked specifically at policies concerning mental and behavioral health services, rehabilitation services, home health services, informed consent, and the use of telepresenters.

High-ranking states

D.C., Maine, New Hampshire, New Mexico, Tennessee, and Virginia received overall grades of A.  They were found to offer broad coverage and employ innovative payment or service delivery models.  Maine is one of eight states to reimburse for telerehabilitative services within the home health benefit, even though those services are covered when provided in-person.   New Mexico offers true parity and is one of only three states to cover services provided by a behavioral analyst, which is necessary in the treatment of autism spectrum disorders.  Virginia is one of only three states to have extended coverage to its dual-eligible population through the CMS Capitated Financial Alignment Model for Medicare-Medicaid enrollees. Although Alaska received an overall grade of B, it was the only state to receive the highest ranking for services provided under the home health benefit.

The report cautions that its ranking are based on paper laws through April 2015, and that actual telemedicine practices may differ within the states.  The ATA also issued a related report comparing state physician practice standards and licensure.

251 patient organizations join in support of 21st Century Cures

More than 250 patient organizations have joined together to support the 21st Century Cures Act (H.R. 6) in a letter to the House Energy and Commerce Committee. “The bill is based on the hard work and thoughtful recommendations of the entire health community,” the organizations wrote, “and we thank you for your tireless work to incorporate our feedback into the legislation.”

The organizations, which include the American Kidney Fund, the Epilepsy Foundation, Mental Health America, the U.S. Pain Foundation, and other groups representing a diverse range of patients and caregivers, applauded the bipartisan bill for its patient focus, writing, “Just as Democrats and Republicans have come together to craft a bipartisan bill that cleared the Energy and Commerce Committee with a unanimous vote, so, too, do we affirm our support of this game-changing legislation.”

21st Century Cures

The proposed legislation would “accelerate the discovery, development, and the delivery of 21st century cures” by providing funding to the National Institutes of Health (NIH) to strengthen the agency and expand its research. The legislation would also relax privacy regulations under the Health Insurance Portability and Accountability Act (HIPAA) (P.L. 104-191) to allow research data to be more easily shared. Price transparency would also be furthered by the publishing of Medicare pricing data for outpatient hospitals and ambulatory surgical centers.

Previously, the American Hospital Association (AHA) expressed its support of the relaxation of HIPAA privacy requirements, describing it as a step toward the furthering of information sharing and the clinical success of value-focused entities like the accountable care organizations created under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), as current privacy rules function as a barrier to clinical integration (see American hospitals are thrilled and sick with ‘21st Century Cures’ bill, Health Law Daily, May 13, 2015). The AHA also applauded the legislation’s efforts toward price transparency but stated that publishing Medicare pricing data may provide a misleading picture of pricing under Medicare.

Highlight on Nevada: Governor signs post-acute care study bill into law

A bill signed into law by Nevada governor Brian Sandoval calls for the establishment of a legislative committee to study the quality and funding of post-acute care in Nevada. Assembly Bill No. 242 creates a subcommittee to oversee an interim study that will examine alternatives to institutionalization as a means of providing post-acute care in Nevada. The committee will be composed of legislators selected from the Nevada Senate Standing Committee on Health and Human Services and the Nevada Assembly Standing Committee on Heath and Human Services and will consider such alternatives as home- and community-based services.

The law, which originated in the Nevada Legislative Committee on Senior Citizens, Veterans, and Adults with Special Needs, and was sponsored by the Assembly Committee on Health and Human Services, requires the study to review the funding and quality of post-acute care options in Nevada. It must include a consideration of alternatives to traditional institutionalization for post-acute care such as home- and community-based waiver programs. The study must review the costs and savings of such alternatives and provide an analysis of the benefits and detriments on the quality of life for persons receiving the post-acute care services. Additionally, the study must include information about the post-acute care quality measures that are required to be reported to Medicare, Medicaid, and the state of Nevada. The law also requires the committee to detail the state and federal funding procedures for post-acute care and report on Nevada’s current post-acute care funding formula. Any recommendations that the committee would like to submit to the legislature must be approved by a majority of the committee members.

Under Section 1915(c) of the Social Security Act, states have the option of providing long-term care in home- and community-based settings (HCBS) through the Medicaid HCBS Waiver Program. Additionally, sections 2401 to 2406 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) provide incentives to assist states in increasing the availability of HCBS through Medicaid. Such programs can provide both standard medical services and non-medical services. Examples of covered standard medical services could include case management services, homemaker assistance, personal care, habilitation, adult day health services, and respite care. States may also propose other services that will assist in keeping individuals at home and in their communities rather than in institutional settings. Nevada currently offers its own Home and Community Based Waiver Program (HCBW) and the Community Options Program for the Elderly that provide non-medical services to elderly individuals to assist them in remaining in their homes as an alternative to nursing homes.

The Nevada post-acute care study suggests that the state may be following a national trend toward providing more HCBS rather than institutionalized care as a means of controlling costs while keeping patients at home. A 2013 report by the American Association of Retired Persons (AARP) that examined state studies of HCBS programs concluded that most states found a lower, per-individual cost of providing such services as compared with providing traditional institutional care.

The Nevada Health Care Association (NVHCA) expressed strong support for the post-acute care study. Nevada Business Magazine is reporting that Daniel Mathis, President and CEO of the NVHCA stated, “The study is quite comprehensive, and it’s a positive move in improving care in the state.” He was further reported as stating,  “Importantly, it reviews state and federal funding for post-acute care, including the funding formula used in the state. This is critical to improving quality measurements and the overall level of care in Nevada.”

Governor Sandoval signed the legislation into law on June 1, 2015, and it goes into effect on July 1, 2015. The results of the study and recommendations for legislation must be presented by the committee to the Director of the Legislative Counsel Bureau for submission to the following year’s legislative body.

Senators agree on over-the-counter contraception, but not on cost sharing

Senator Patty Murray (D-Wash), Ranking Member of the Senate Health, Education, Labor, and Pensions (HELP) Committee, has introduced a bill that would require insurance companies to provide coverage for any birth control pills that the FDA may approve for over-the-counter (OTC) sales. Murray’s Affordability is Access Act would maintain the FDA’s sole authority to determine the safety and effectiveness of drugs and make them available over-the-counter, as well as prevent retailers from interfering with a customer’s access to any oral contraceptive that the FDA has approved or regulated for routine, daily use. The bill comes on the heels of the Allowing Greater Access to Safe and Effective Contraception Act, introduced by Senators Cory Gardner (R-Colo) and Kelly Ayotte (R-NH), which would provide incentives to manufacturers of oral contraceptives to seek over-the-counter status, but would not require insurance coverage.

Over-the-counter contraception

Emergency oral contraception in the form of Plan B® and Plan B One-Step® is currently available OTC. However, the proposed bills would encourage the OTC delivery of safe and effective birth control pills for routine, daily use. According to Gardner, “Most other drugs with such a long history of safe and routine use are available for purchase over the counter, and contraception should join them.” Although it is unusual for insurance companies to cover OTC medication, it is not unprecedented; some insurance companies, for example, may cover Prilosec®, a heartburn drug, in certain circumstances.

Competing bills

Gardner and Ayotte’s plan would limit OTC accessibility to adults aged 18 or over. It would allow for priority review and waive the FDA filing fee for prescription to OTC applications. It would also repeal the ACA’s prohibition on health savings accounts, but it would not require insurers to cover the medication. Murray’s bill would not impose an age minimum. According to Murray, “affordability and access go hand in hand.” Critics of the Republican bill note that oral contraception can cost $600 a year, making it unaffordable for many. Murray’s bill would build on the Patient Protection and Affordable Care Act’s (ACA’s) (P.L. 111-148) contraception mandate. “Anyone will tell you that if something is too expensive, it doesn’t matter how easy it is to get,” Murray stated. “It might as well be on the moon.”