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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.

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Presentation on theme: "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."— Presentation transcript:

1 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

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
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 [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 [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 , ]

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 , ]

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 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 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 , Sec. 1834(m), 42 U.S.C. 1395m(m), 2003

11 Medicare - Covered Services
Home Health Services Sec 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 (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 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 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 Telehealth.-- Telehomecare encounters do not meet the definition of a visit set forth in regulations at 42 CFR (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: 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 # (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 , and protected under the MN Data Practices Act according to MN Statutes, Section , 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 # , issued August 5, 2003) MN Statute, Section 256B.0625 MN Statute, Chapter 256L

42 MA, MinnesotaCare - Resources
Minnesota Health Care Programs (MHCP) Provider Manual, Chapter 24 on-line at: DHS Bulletin # : 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
DHS Bulletin # : Alternative Care Program Restructures Nursing and Nursing Support Services (issued February 14, 2002) DHS Bulletin # : Counties Exempt from Liability When Offering Cash Payments (issued October 16, 2000)

51 Minnesota - Policy Why should we move in this direction?
enhances quality; additional studies needed, thus far results and conclusions supportive enhances the quality of care and client outcomes reduces liability; professional and paraprofessional cost-effective; when funding streams are integrated will align the incentives addresses human resource shortages and targets human and professional resources more efficiently and effectively

52 Conclusion Where do we need to be going together?
"it's not if, but when" technology is driving a changing paradigm in how care is delivered think of technology as an integral component of care delivery; it is the missing link advocate for technology across delivery system use technology to gain practice and experience; develop standards

53 AC Data: Participation by Age


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