California Reimbursement for Telehealth

While Medicare reimbursement for telemedicine has garnered a lot of attention, many states also have extensive laws about telehealth reimbursement. For example, California laws provide for significant telehealth reimbursement.

While this is not an exhaustive list of California law regarding telehealth, some statutory authority relevant to reimbursement includes:

• Cal Ins Code 10123.85 (no disability insurance contract for hospital, medical or surgical coverage shall require face-to-face contact for services appropriately provided through telemedicine)

• Cal Ins Code 10123.13 (requires every insurer issuing group of individual policies of disability insurance that cover medical, hospital, or surgical expenses, including telemedicine, to reimburse each claim as soon as practical but no later than 30 working days after receipt of the claim).

• Cal Health & Safety Code 1375.1 (requires all health care service plans under the Knox-Keene Act to have a procedure for prompt payment or denial of claims, including telemedicine claims).

• Cal Health & Safety Code 1374.13 (amends Medi-Cal contracts with healthcare service plans to add coverage of telemedicine and make any capitation rate adjustments).

• Cal Health & Safety Code 14132.72 (provides reimbursement for telemedicine by Medi-Cal for healthcare services otherwise covered through Medi-Cal (but excludes phone and fax)).

California Health & Safety Code Section14132.72 provides:

(a) For purposes of this section, the definitions in subdivision (a) of Section 2290.5 of the Business and Professions Code shall apply.

(b) It is the intent of the Legislature to recognize the practice of telehealth as a legitimate means by which an individual may receive health care services from a health care provider without in-person contact with the provider.

(c) In-person contact between a health care provider and a patient shall not be required under the Medi-Cal program for services appropriately provided through telehealth, subject to reimbursement policies adopted by the department to compensate a licensed health care provider who provides health care services through telehealth that are otherwise reimbursed pursuant to the Medi-Cal program.

(d) Nothing in this section or the Telehealth Advancement Act of 2011 shall be construed to conflict with or supersede the provisions of Section 14091.3 of this code or any other existing state laws or regulations related to reimbursement for services provided by a noncontracted provider.

(d) The department shall not require a health care provider to document a barrier to an in-person visit for Medi-Cal coverage of services provided via telehealth.

(e) For the purposes of payment for covered treatment or services provided through telehealth, the department shall not limit the type of setting where services are provided for the patient or by the health care provider.

(f) Nothing in this section shall be interpreted to authorize the department to require the use of telehealth when the health care provider has determined that it is not appropriate.

(g) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, and make specific this section by means of all-county letters, provider bulletins, and similar instructions.

Always contact a telemedicine attorney who can counsel you on structuring a telehealth, telepsychology, telepsychiatry, or other telemedicine venture in your state.

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