California law defines telehealth as the “the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers."
See Business and Professions Code 2290.5
Who decides whether or not to provide services via telehealth?
Generally, the health care provider determines if a benefit or service is clinically appropriate to be provided via a telehealth modality, subject to consent by the patient.
Who can use telehealth to provide health care services?
The health care provider rendering Medi-Cal covered benefits or services provided via a telehealth modality must meet the requirements of Business and Professions Code (B&P Code), Section 2290.5(a)(3) or be a provider type otherwise designated by DHCS to provide telehealth, pursuant to Welfare and Institutions Code 14132.725 (b)(2)(A). Providers billing for services delivered via telehealth must be enrolled as Medi-Cal providers.
For policy and billing information specific to FQHCs, RHCs or IHS-MOA clinics, providers may refer to the Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) and Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics sections in the appropriate Part 2 manual, as well as any relevant guidance issued during the COVID-19 PHE.
Are providers able to use telehealth to establish a new patient-provider relationship?
Video synchronous interaction: Providers (including FQHCs/RHCs) may establish a relationship with new patients via synchronous video telehealth visits.
Note: In specialty mental health services, the establishment of care for a new patient refers to the mental health assessment done by a licensed clinician. For the purpose of substance use treatment in Drug Medi-Cal and Drug Medi-Cal Organized Delivery System, the establishment of care for a new patient refers to the American Society of Addiction Medicine Criteria Assessment.
Audio-only synchronous interaction: Providers may not establish a relationship with new patients via audio-only synchronous telehealth (i.e., over the phone), except for in the following instances: (1) When the visit is related to sensitive services as defined in subsection (n) of Section 56.06 of the Civil Code*; (2) When the patient requests an audio-only modality or attests they do not have access to video, and when established in accordance with department specific requirements and consistent with federal and state laws, regulations, and guidance.
Asynchronous store and forward: Only FQHC and RHC providers may establish a new patient via asynchronous store and forward, subject to certain conditions: (1) the patient is physically present at an FQHC or RHC, or at an intermittent site of the FQHC or RHC, at the time the service is provided; (2) the individual who creates the patient records at the originating site is an employee or contractor of the FQHC or RHC, or other person lawfully authorized by the FQHC or RHC to create a patient record; (3) the FQHC or RHC determines that the billing provider is able to meet the applicable standard of care; (4) an FQHC patient who receives telehealth services shall otherwise be eligible to receive in-person services from that FQHC pursuant to Health Resources and Services Administration (HRSA) requirements.
* “Sensitive services" means all health care services related to mental or behavioral health, sexual and reproductive health, sexually transmitted infections, substance use disorder, gender-affirming care, and intimate partner violence, and includes services described in Sections 6924, 6925, 6926, 6927, 6928, 6929, and 6930 of the Family Code, and Sections 121020 and 124260 of the Health and Safety Code, obtained by a patient at or above the minimum age specified for consenting to the service specified in the section.
Are providers who offer one modality of telehealth (e.g., audio-only synchronous telehealth) required to offer other telehealth modalities (e.g., video synchronous telehealth)?
Over time, but no sooner than January 1, 2024, Medi-Cal will require providers to phase-in an approach that provides patients the choice of a video telehealth modality when care is provided via telehealth. Specifically, if a provider offers audio-only telehealth services, the provider will also be required to provide the option for video services. The Department will issue guidance on this requirement in 2023, which will consider availability of broadband access and Medi-Cal providers’ access to requisite technologies.
Does a licensed provider need to be with the patient if the home is the originating site?
No, unless the distant site provider determines it is medically necessary for a health care provider to be with the patient. Please see the Medi-Cal Provider Manuals for Rural Health Clinics/Federally Qualified Health Centers and Indian Health Services MOA 638 clinics for requirements specific to the originating site.
If I have privileges and credentials at my hospital, do I need privileges and credentials at the originating hospital to care for a patient at that hospital?
Issues of privileges and credentialing for distant physicians to care for patients via telehealth are determined by the policies of the originating hospital. However, state law –
see Business and Professions Code section 2290.5 (h) - and federal regulations –Title 42 of the Code of Federal Regulations, Part 482.12, 482.22 and 485.616 - allow hospitals to accept the privileges and credentials for providers at distant hospitals.
Does Medi-Cal allow out-of-state providers to render services via telehealth?
A licensed health care provider rendering Medi-Cal covered benefits or services via a telehealth modality must be licensed in California, enrolled as a Medi-Cal rendering provider or non-physician medical practitioner (NMP), and affiliated with an enrolled Medi-Cal provider group. The enrolled Medi-Cal provider group for which the health care provider renders services via telehealth must meet all Medi-Cal program enrollment requirements and must be located in California or a border community.
For policy and billing information specific to FQHCs, RHCs or IHS-MOA clinics, providers may refer to the Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) and Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics sections in the appropriate Part 2 manual , as well as any relevant guidance issued during the COVID-19 PHE.
A person who is licensed as a health care practitioner in another state and is employed by a tribal health program does not need to be licensed in California to perform services for the tribal health program in California or a border community (Business and Professions Code section 719).
What resources are available to providers?
Please
see the DHCS Telehealth Resources webpage for helpful information for providers.
The California Telehealth Resource Center (CTRC) is a federally designated resource center dedicated to helping providers implement and sustain telehealth programs. Services include: program needs assessment for implementation or expansion, equipment selection, telehealth presenter training; operational workflow; contracting with specialists; billing; and credentialing and staff roles. In addition, CTRC also produces a Telehealth Program Developer Kit that can be downloaded from the CTRC website. It provides a step-by-step guide to help providers develop a telehealth program.
The Center for Connected Health Policy (CCHP) is a federally designated national telehealth resource center on policy. The CCHP works closely with all telehealth resource centers in the United States and provides technical assistance to state agencies and lawmakers on telehealth policy. For recent information on telehealth legislation and policy, visit the CCHP website.
What types of services provided via telehealth does Medi-Cal cover?
Medi-Cal covers synchronous telehealth (e.g., video synchronous interaction and audio-only synchronous interaction) and asynchronous telehealth (e.g., store and forward and e-consults) across multiple services and delivery systems, including physical health, dental, specialty and non-specialty mental health, and SUD services (State Plan Drug Medi-Cal and Drug Medi-Cal Organized Delivery System / DMC-ODS). Medi-Cal covers synchronous and asynchronous telehealth services delivered through telehealth in 1915(c) waiver programs, Targeted Case Management (TCM) Program and Local Education Agency Medi-Cal Billing Option Program (LEA-BOP). Services delivered via telehealth must meet the procedural definitions and components of the CPT or HCPCS code. Medi-Cal also covers remote patient monitoring (RPM); see question below for more detail.
Please see the Frequently Asked Questions for Medi-Cal Special Programs for information specific to those programs.
Does Medi-Cal pay the same rate for services provided through telehealth as it pays for the same service provided in-person (i.e., payment parity)?
Yes. Medi-Cal pays the same rate for professional medical services provided by telehealth as it pays for services provided in-person. Please see the Payments and Claims section on this page.
How do I get paid for telehealth services?
Medi-Cal will only pay providers if they perform a medically necessary professional service for the patient that meets the definition of the code billed, is clinically appropriate based upon evidence-based medicine and/or best practices to be delivered via telehealth, and meets patient consent and medical confidentiality requirements.
See the Medi-Cal Telehealth Provider Manual or other appropriate DHCS provider guidance for limitations and guidance on telehealth billing.
E-Consults: A health care provider at the distant site may bill for an e-consult with the CPT Codes listed in the
Medi-Cal Telehealth Provider Manual when the benefits or services delivered meet the procedural definition and components of the CPT code for e-consults as defined by the AMA as well as any requirements described in the Medi-Cal provider manual. The e-consult policy is not applicable for FQHCs, RHCs or IHS-MOA clinics. For policy and billing information specific to FQHCs, RHCs or IHS-MOA clinics, providers may refer to the Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) and Indian Health Services (IHS), Memorandum of Agreement (MOA) 638, Clinics sections in the appropriate Part 2 manual.
Note: Medi-Cal covered benefits or services provided in-person with the patient do not use telehealth modifiers and are billed according to standard Medi-Cal policies.
Does Medi-Cal pay for originating site and transmission fees?
Medi-Cal pays an originating site fee per transmission to the provider at the originating site for coordinating services via telehealth, via synchronous and/or asynchronous, to a distant site. The maximum is once per day per patient using HCPCS code Q3014. The originating site fee is not available for audio-only synchronous interaction.
Medi-Cal pays both the originating site and the distant site a transmission fee up to 90 minutes per beneficiary per day for services provided using a two-way, real time interactive visual telecommunications system (synchronous). The HCPCS code is T1014. Transmission fees are not available for audio-only synchronous interaction.
The originating site fee and transmission fees are not available to FQHCs, RHCs or IHS-MOA clinics.
Questions about claims and billing may be directed to Telephone Service Center (TSC) at (800) 541-5555 (outside of California, please call (916) 636-1980.
Are there any restrictions on the type of setting for the originating or distant site?
No. Medi-Cal does not limit the type of setting where telehealth services may be provided to a patient by a health care provider. For example, the type of setting where a patient may be seen (i.e., “originating site") includes, but is not limited to a medical office, community clinic, or the patient's home. Medi-Cal does not place limits on the type of distant sites, but requires providers to ensure and maintain patient privacy in any location from where they are delivering services.
Please see the Medi-Cal Provider Manuals for Rural Health Clinics/Federally Qualified Health Centers and Indian Health Services MOA 638 clinics for requirements specific to the originating site in those settings.
Does Medi-Cal reimburse for exam room expenses and/or pay for equipment to set-up telehealth operations?
Medi-Cal does not pay for telehealth equipment purchases. Please see previous question regarding originating site fees.
Does Medi-Cal cover remote patient monitoring (telemonitoring)?
Yes, effective July 1, 2021, remote physiologic monitoring (RPM), also known as remote patient monitoring, was implemented for fee-for-service and managed care beneficiaries. RPM services are provided for established patients ages 21 and older and are reimbursable when ordered by and billed by physicians or other qualified health professionals (QHP).
Do Medi-Cal Managed Care Plans (MCPs) cover telehealth services?
Yes, Medi-Cal managed care plans have the same baseline telehealth coverage and reimbursement policies as Medi-Cal FFS. Plans may opt to provide additional coverage and benefits beyond what is required by the FFS program.
Does Medi-Cal cover telehealth services provided in Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Indian Health Services (IHS) clinics?
Yes, allowable costs associated with telehealth services may be included in the clinic's Prospective Payment System (PPS) rate; however, FQHCs, RHCs, and IHS clinic PPS sites may not bill for originating site or transmission fees. Please see the Provider Manuals for RHCs/FQHCs and IHS MOA 638 clinics for scenarios about billing for services provided by telehealth.
Who can I call if I have questions about submitting claims?
Questions about Fee-for-Service claims and billing may be directed to Telephone Service Center (TSC) at (800) 541-5555 or via email to Medi-CalOutreach@Xerox.com. For managed care billing questions, contact the Medi-Cal managed care plan.
Does the patient need to consent prior to receiving services by telehealth?
Yes. State law requires the health care provider initiating the use of telehealth to obtain written or verbal consent once before the initial delivery of telehealth services. Medi-Cal has developed
Telehealth Patient Consent Language, which includes language outlining a beneficiary’s right to in-person services, the voluntary nature of consent, the availability of transport to access in-person services if needed, and potential limitations/risks of receiving services via telehealth. Patient consent can be completed verbally or in writing. Patients who consent to synchronous video must separately consent to synchronous audio-only services.
How should providers document consent?
Health care providers may document consent either by having the beneficiary sign a paper or electronic form that can be included in the patient’s medical record or by having the provider note consent in the patient’s medical record.
Are providers required to use the model language published by DHCS?
No – this is meant to support compliance with statute. Please refer to AB-32 Telehealth (2021-2022)Sec.2-Section 14132.725 of the Welfare and Institutions Code.
All the following shall be communicated by a health care provider to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth to a Medi-Cal beneficiary:
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an explanation that beneficiaries have the right to access covered services that may be delivered via telehealth through an in-person, face-to-face visit;
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an explanation that use of telehealth is voluntary and that consent for the use of telehealth can be withdrawn at any time by the Medi-Cal beneficiary without affecting their ability to access covered Medi-Cal services in the future;
- an explanation of the availability of Medi-Cal coverage for transportation services to in-person visits when other available resources have been reasonably exhausted;
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the potential limitations or risks related to receiving services through telehealth as compared to an in-person visit, to the extent any limitations or risks are identified by the provider.
Are group practices and systems able to obtain consent for future services with different providers rendered via telehealth during the beneficiary’s first visit within the practice/system (vs. before receiving telehealth services from each individual provider)?
A health care provider must communicate to a Medi-Cal beneficiary, in writing or verbally, on at least one occasion prior to, or concurrent with, initiating the delivery of one or more health care services via telehealth. Group practices need to obtain and document a patient's initial consent for purposes of telehealth services prior to the initiation of health care services via telehealth. If consent is documented by the group practice, it is not necessary for each provider rendering health care services via telehealth to document consent.
What are common benefits, and risks or limitations, related to receiving services through telehealth?
Benefits:
- It is easier, more convenient, and more efficient to receive medical care and treatment
- Patients can communicate with providers without the necessity of an in-office appointment.
Limitations or Risks:
- Delays in medical evaluation/treatment or a failure to obtain needed treatment could occur if an in-person follow-up visit is required.
- The electronic equipment could fail during a telehealth visit.
I do not want to receive services by telehealth. Where can I find more information on transportation support services for in-person visits?
Medi-Cal offers
transportation to and from appointments for services covered by Medi-Cal. This includes transportation to medical, dental, mental health, or substance use disorder appointments, and to pick up prescriptions and medical supplies, if they attest that all other available resources have been reasonably exhausted.
Are minors able to give consent (written, verbal) without a parent or guardian?
Minors who receive confidential care, including sexual health, reproductive health, mental health under the Minor Consent Program, may consent to receive the same services via telehealth that are appropriate for telehealth. More information is available on the Minor Consent Program.
