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Telehealth in MN: Where We Are and Where We’re Going Minnesota Rural Health Conference Smart Health 2006: Focus On Tec

Telehealth in MN: Where We Are and Where We’re Going Minnesota Rural Health Conference Smart Health 2006: Focus On Technology July 18, 2006. Public Policy and Reimbursement Denise Kolb, Administrator Alternative Care Program Aging and Adult Services Division MN Department of Human Services.

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Telehealth in MN: Where We Are and Where We’re Going Minnesota Rural Health Conference Smart Health 2006: Focus On Tec

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  1. Telehealth in MN: Where We Are and Where We’re Going Minnesota Rural Health ConferenceSmart Health 2006: Focus On Technology July 18, 2006 Public Policy and Reimbursement Denise Kolb, Administrator Alternative Care Program Aging and Adult Services Division MN Department of Human Services

  2. Public Benefits and Covered Services • Federal benefits • Medicare - Part B Telehealth Services • Medicare - Part A (in policy) • Medicare - Part C (in policy) • State benefits • MN Medical Assistance (MA), MinnesotaCare • Mental Health Collaboratives • Alternative Care (AC) Program- covered services

  3. Federal Benefits - Medicare • Medicare • Policy on telehealth (telemedicine and telehomecare) • History of authority • Benefits Improvement and Protection Act, 2000 • Balanced Budget Act, 2001 • Medicare Improvement and Modernization Act, 2003 • Covered services • Part B Telehealth Services • Part A Home Health Services (in policy)

  4. Medicare - Policy • Telemedicine/telecommunications networks and techniques, when appropriately developed, have the potential for (1) increasing access to quality health care for rural and under served Medicare beneficiaries, (2) reducing distance and isolation as significant factors in patient/practitioner encounters, and (3) providing a baseline of information for ongoing evaluation of utilization and outcomes Operational Policy Letter #41, HCFA, DHHS, 1996 Part D, SEC. 1876.[42 U.S.C. 1395m(m)]

  5. Medicare - Policy • Telemedicine has also been recognized by many states as an important component in providing cost-effective, quality medical care for needy individuals under the Medicaid program. Some states report that telemedicine has reduced transportation expenses, increased beneficiary access to specialists and other providers, and improved quality of care and communication among providers Operational Policy Letter #41, HCFA, DHHS, 1996 Part D, SEC. 1876.[42 U.S.C. 1395m(m)]

  6. Medicare - Covered Services • The Balanced Budget Act (BBA) of 1997 authorized telehealth covered service effective January 1, 1999 [Sec. 4206(a),(b)] • limited to payment of physician services under Part B (Supplementary Medical Insurance for the Aged and Disabled) including: • consultation services only • prohibiting asynchronous store and forward systems • shared fee between referring and consulting providers Program Memorandum-CR 1650, HCFA, DHHS, 2001 Part B, Sec. 1834(m), 42 U.S.C. 1395j [42 CFR 410.78, 414.65]

  7. Medicare - Covered Services • BBA continued… • prohibiting fees for site and line charges • limited practitioners to physicians, nurse practitioners, physician assistants, nurse midwives, and clinical nurse specialists • limited to rural health professional shortage areas and counties not classified as a MSA • four year telemedicine demonstration project effective October 1, 2000 Program Memorandum-CR 1650, HCFA, DHHS, 2001 Part B, Sec. 1834(m), 42 U.S.C. 1395j [42 CFR 410.78, 414.65]

  8. Medicare - Covered Services • Benefits Improvement and Protection Act of 2000 (BIPA) authorized expansion of telehealth effective October 1, 2001 [Sec. 223] • originally consultations only, now expanded to include office and other outpatient visits, pharmacological management, and individual psychotherapy • added definitions and provisions allowing for asynchronous store and forward systems w/ limitations • established definitions and fee for originating sites • extended demonstration sites another four year period Amends Public Law 105-33 Part B, Sec. 1834(m) [42 CFR S410.78, S414.65], 2002

  9. Medicare - Covered Services • BIPA continued • originally limited practitioners to physicians, nurse practitioners, physician assistants, nurse midwives, and clinical nurse specialists, now expanded to clinical psychologists and clinical social workers (w/ limitations) • originally limited to rural health professional shortage areas, counties not classified as a MSA, and expanded to approved telemedicine demonstration sites regardless of location Amends Public Law 105-33 Part B, Sec. 1834(m) [42 CFR S410.78, S414.65], 2002

  10. Medicare - Covered Services • Medicare Improvement and Modernization Act of 2003, signed December 8, 2003 [Sec. 417.,418.] • provided extension of telehealth demonstration sites for an additional 4 year time period (8 years) • following report by January 2005, provides authority to designate skilled nursing facilities as originating sites • There currently is no specifically and separately covered services for telehomecare under the home health agency provisions. The method is supported in policy and allowable under the prospective payment system. Amends Public Law 105-33, Sec. 1834(m), 42 U.S.C. 1395m(m), 2003

  11. Medicare - Covered Services • Home Health Services Sec. 201.13 Telehealth.-- • A home health agency may adopt telehealth technologies that it believes promote efficiencies or improve quality of care. • However, telehomecare encounters do not meet the definition of a “visit” as set forth in 42 CFR 409.48(c). They may not be counted as covered home health visits or used as a qualifying service for home health eligibility. Medicare Home Health Agency Manual (HCFA Pub. 11)

  12. Medicare - Covered Services • Home Health Services Sec 201.13 Telehealth.-- • An HHA may not substitute telehealth services for Medicare-covered services ordered by a physician. However, if an HHA has telehealth services available to its clients, a doctor may take their availability into account when he or she prepares a plan of treatment (i.e., may write requirements for telehealth services into the POT). Medicare Home Health Agency Manual (HCFA Pub. 11)

  13. Medicare - Covered Services • Home Care Services Sec. 201.13 Telehealth.-- • Medicare eligibility and payment would be determined based on the patient’s characteristics and the need for and receipt of the Medicare covered services ordered by the physician. • If a physician intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health services to be furnished. Medicare Home Health Agency Manual (HCFA Pub. 11)

  14. Medicare - Covered Services • Home Care Services Sec. 201.13 Telehealth.-- • Telehomecare encounters do not meet the definition of a visit set forth in regulations at 42 CFR 409.48(c) and the telehealth services may not be counted as Medicare covered home health visits or used as qualifying services for home health eligibility. Medicare Home Health Agency Manual (HCFA Pub. 11)

  15. MN: Critical Issues in LTC • Increasing Need for Long-Term Care • Over-Reliance on Institutional Model • Need for More Community-based Options • Current and Future Worker Shortages • Empowering Consumers and Communities • New Regulation and Reimbursement

  16. Minnesota: Vision for Long-Term Care • A long-term care system that: • Supports innovation through new delivery and financing models, and through use of technology • Ensures efficiency and affordability and productivity, including labor-saving technology, among both public and private long-term care providers

  17. Minnesota Board on Aging • Health system reform: Simplify and coordinate the health care system to improve chronic disease management and the quality of long-term care, and reduce cost

  18. Minnesota Board on Aging • Move toward new health care models that improve chronic disease management—across specialties and providers. Build bridges between the “medical” and “support” elements of the care system • Promote policies and programs that increase the affordability and accessibility of basic health care

  19. Minnesota Board on Aging • Promote healthy lifestyles to improve individual health and to mitigate future demand for long-term care services • Expanding community-based health promotion programs into new communities and for underserved populations (e.g., Wisdom Steps)

  20. Minnesota Board on Aging • Promote availability and services provided through the Senior LinkAge Line™ and MinnesotaHelp.info™ as valuable resources for older Minnesotans and their families • Reduce health disparities through campaigns for high risk persons

  21. Minnesota Board on Aging • Technological change: Promote adoption of rapidly expanding technologies, particularly in the areas of communications and information management, to improve consumer access, service quality and system efficiency

  22. Minnesota Board on Aging • Encourage incentives to adopt new health care technologies that improve access to information and services • Eliminate barriers to adoption of new technologies that improve quality and reduce costs

  23. Minnesota Board on Aging • Articulate a clear vision of the uses of new technologies to enhance the well-being of older Minnesotans, including wider awareness and use of readily available technologies • Raise the visibility of community education programs regarding new technologies, such as Senior Surf Days

  24. Minnesota Board on Aging • Partner with Area Agencies on Aging (AAA) to promote appropriate adoption of new service technologies among OAA grantees. Use Title III funds in support of technology • Establish known points of access to new technologies for older persons through continued partnership with community hubs, such as libraries, community centers, and senior housing

  25. Minnesota Board on Aging • Support AAA efforts to update management information systems to improve programs and services • Explore expansion of inter-generational programs, such as telephone and computer mentoring and support

  26. State Benefits - Minnesota • MN Medical Assistance (MA) and MinnesotaCare (basic plan) • Tele-medicine consultation (July 1999) • Tele-home Care (October 2001) • Mental Health Services • Tele-medicine consultation • Alternative Care (AC) Program • Tele-home Care (March 2002) • Discretionary Services (October 2000)

  27. Minnesota - Policy • The use of technology can improve the quality of care, realize efficiencies, and be more effective in utilizing resources • Through the application of technology and greater use of telehealthcare options, practice experience can be gained • Support the use of technology to enhance service delivery and supportive services for clients to remain at home and in their community setting as long as possible

  28. State Benefits - Minnesota • Medicaid - MN Medical Assistance (MA) • State’s plan for MA • benefit set - (fee-for-service) • Pre-Paid Medical Assistance Program - (capitated monthly per member payment under contracted health plans) • MinnesotaCare • Basic, Basic Plus, Basic Plus One, Basic Plus Two • Expanded benefit set • (capitated monthly per member payment under contracted health plans; enrollee premium)

  29. MA, MinnesotaCare - Covered Services • Tele-Medicine requirements • Consultation services: • a service provided by a physician whose opinion or advice is requested by another provider • limited to physician services as defined by CPT codes • physician ordered MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  30. MA, MinnesotaCare - Covered Services • Consultation services (continued)… • documentation must include the request for consultation, need for consultation, and the resulting consultation opinion • billing with CPT code modifier • Refer to Chapter 6 of the Minnesota Health Care Programs (MHCP) Provider Manual on-line at: http://www.dhs.state.mn.us/main/groups/business_partners/documents/pub/dhs_id_008926.hcsp MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  31. MA, MinnesotaCare - Covered Services • Mental Health Services • Consultations • using videoconferencing and technology for consultations across regions; state hospitals, psychiatrists and psychologists • plan of treatment; medication adjustment, behavior management plan

  32. MA, MinnesotaCare - Policy • Tele-home care services provide skilled nurse visits delivered via technology to enhance service delivery options that help address client access to needed services related to shortages of healthcare professionals, logistical barriers, provider responsiveness, and continuity of care issues that may reduce the comprehensiveness and successful outcome of a supportive home and community-based service plan MHCP Provider Manual, Chapter 24

  33. MA, MinnesotaCare - Covered Services • Home care - Service definition • Skilled nurse visit delivered either in-home or via distance audio-visual interactive technology; service definition is the same • Both delivery options are conducted face-to-face with the client to accomplish a skilled service MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  34. MA, MinnesotaCare - Covered Services • Telehomecare requirements • Client eligible for MA, MinnesotaCare • Physician ordered; plan of treatment 60 days demonstrating medical necessity • Prior authorization of all visits MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  35. MA, MinnesotaCare - Covered Services • Telehomecare • Does not require the physical presence of the nurse in the home residence • Visit is performed via live, two-way audio-visual, interactive technology • Technology provides for complete visual and verbal communication between the professional and the client • Provides for accurate measurement and assessment of the client’s physical status using telephonic computerized equipment MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  36. MA, MinnesotaCare - Covered Services • Telehomecare • integral to the care needs and services delivered to the client • in conjunction with in-home services and nursing visits • provided in a home with capacity for adequate and safe operation of the equipment • It may be augmented by utilizing store-and-forward technologies, not in synchronous transmission, and not necessarily during the face-to-face visualization of the two parties. • Allowable settings include client’s place of residence, which may be a community setting MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  37. MA, MinnesotaCare - Service Delivery • Allowable settings: • Community settings may include adult foster care, assisted living, residential care, and residential facilities, such as group homes, chem dep rehabilitation programs, non-certified board and lodge homes eligible for Group Residential Housing (GRH) payments • Not available in nursing facilities, inpatient hospitals, intermediate care facilities, or certified board and care. Refer to DHS Bulletin #00-56-25 (issued April 9, 2000) MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  38. Service Delivery - MA, MinnesotaCare • Data Privacy Requirements - Recipient-specific identifiable data obtained through real time and store-and-forward technology must be maintained as health records according to MN Statute, section 144.335, and • protected under the MN Data Practices Act according to MN Statutes, Section 13.461, and • The Health Insurance Portability and Accountability Act of 2001

  39. Service Delivery - MA, MinnesotaCare • Information used for research, training, other unrelated care purposes must protect the identity of the consumer and utilize a release of information • Refer to Crane, L., et al. (2002). Protecting privacy when using telehealth technology in healthcare. North Charleston, SC; Advanced Technology Institute

  40. MA, MinnesotaCare - Provider Standards • Federal and State Quality Assurance Requirements: • Medicare certified home health agency, and • MN Dept. of Health (MDH) licensed under Class A, and then • State Benefits - MHCP Requirements • MN Dept. of Human Services (DHS) enrolled in state provider network as a Medicaid certified provider - type 60 • [all three must be satisfied for payment] MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  41. MA, Minnesota Care - Service Delivery • Telehomecare • limited to 2 encounters per day as prior authorized • provider claim is made using the same health care procedure code (HCPC) – T1030 with added (GT) modifier • payment rate is same as the face-to-face visit under T1030 (Refer to DHS Bulletin #03-56-10, issued August 5, 2003) MN Statute, Section 256B.0625 MN Statute, Chapter 256L

  42. MA, MinnesotaCare - Resources • Resources: • Minnesota Health Care Programs (MHCP) Provider Manual, Chapter 24 on-line at: http://www.dhs.state.mn.us/main/groups/business_partners/documents/pub/dhs_id_008994.hcsp • DHS Bulletin #01-56-21: OPTIONS SERIES: New Procedures for Skilled nurse, Telehomecare, and Therapy Assistants (issued September 14, 2001)

  43. Alternative Care (AC) - Covered Services Alternative Care (AC) Program • Telehomecare - skilled nursing visits • Discretionary Services - optional services implemented locally • telehomecare - paraprofessional visits MN Statute, Section 256B.0913

  44. Alternative Care (AC) - Policy Telehomecare • similar to MA, MinnesotaCare, however... • provides only: home and community-based service to address long term care needs, including • supportive services that assist eligible seniors to reside independently in their own home or community setting, and • supportive services to informal caregivers to support their efforts to care for seniors MN Statute, Section 256B.0913

  45. Alternative Care (AC) - Service Delivery • Covered Service - Telehomecare • visits by skilled nurse performed in conjunction with in-home services of a nurse • limited to one per day • same procedure code, modifier (T1030-GT) • payment rate is negotiated through local lead agency within the state’s upper service rate limit MN Statute, Section 256B.0913

  46. Alternative Care (AC) - Optional Services • Discretionary Services • New services locally designed and implemented • Technical assistance/approval through the department • Telehomecare • telehomecare by paraprofessional worker • intermittent, visual contacts • flexible and individualized to client needs; schedule, frequency, duration • contact guide/plan for the worker • with in-home supportive services; same worker MN Statute, Section 256B.0913

  47. Alternative Care (AC) - Optional Services • Discretionary Services • Tasks may include, but are not limited to; medication reminders, orientation to person, place, and time, self-care reminders and prompting (dressing, eating, grooming), safety checks, reassurances, general well-being (observation of circumstances that are not typical or are out of the ordinary) MN Statute, Section 256B.0913

  48. Alternative Care (AC) Program • Discretionary services • under the direction and supervision of registered nurse • workers are trained and oriented • telehomecare equipment • each client’s care needs/contact plan • schedule, guidelines, and parameters of contacts • guidelines for reporting to professional staff MN Statute, Section 256B.0913

  49. Alternative Care (AC) Program • Discretionary services • provider submits records and charges to the local lead agency for payment • units of service and payment rate are negotiated between the service provider and the local lead agency under an agreement or contract following review and approval by the department MN Statute, Section 256B.0913

  50. Alternative Care (AC) - Resources • Resources: • DHS Bulletin #02-25-02: Alternative Care Program Restructures Nursing and Nursing Support Services (issued February 14, 2002) • DHS Bulletin #00-25-10: Counties Exempt from Liability When Offering Cash Payments (issued October 16, 2000)

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