State of New Hampshire

OFFICE OF PROFESSIONAL LICENSURE AND CERTIFICATION

DIVISION OF HEALTH PROFESSIONS

121 South Fruit Street, Suite 303

Concord, N.H. 03301-2412

Telephone 603-271-2152 · Fax 603-271-6702

OFFICE OF PROFESSIONAL LICENSURE AND CERTIFICATION

GUIDANCE ON TELEHEALTH DURING THE COVID-19 STATE OF EMERGENCY

Reference Number: SFY 2020-03

Authorized by: Lindsey B. Courtney, Interim Executive Director

Division/Board/Council/Commission: Office of Professional Licensure and Certification, Division of Health Professions

Effective Date: March 18, 2020

Subject: Telehealth guidance

Description: Guidance concerning telehealth services under Emergency Order #8

Pursuant to the Governor’s Emergency Order #8 under Executive Order 2020-04, and upon authorization by the Department of Health and Human Services, the Office of Professional Licensure and Certification issues the following guidance to medical providers. In response to the outbreak of COVID-19, effective immediately, the Governor has ordered “[a]ll medical providers [ . . .] be allowed to perform health care services through the use of all modes of telehealth, including video and audio, audio-only, or other electronic media, to treat the residents of the state of NH for all medically necessary services.”

The State’s temporary expansion of telehealth services applies to all medical providers including, but not limited to, those professions licensed, certified, or registered by the Office of Allied Health Professionals, Board of Medicine, Board of Nursing, Board of Psychology, Board of Mental Health Practice, Board of Licensing for Alcohol and Other Drug Use Professionals, Board of Licensed Dietitians, and the Board of Dental Examiners. To the extent a practice act or administrative rule limits or otherwise sets forth the parameters under which telehealth services may be provided that may conflict with this Order, Executive LINDSEY B. COURTNEY Interim Executive Director OPLC Telehealth Guidance Reference No. 2020-03 Order #8 overrides such references until the Order is rescinded or until the State of Emergency is terminated, whichever happens first.

For general questions regarding this notification, please contact:

Lindsey B. Courtney, JD

Interim Executive Director

Office of Professional Licensure and Certification

121 South Fruit Street

Concord, NH 03301

lindsey.courtney@oplc.nh.gov

SAMHSA Releases Taking Care of Your Behavioral Health Fact Sheet: Tips For Social Distancing, Quarantine, and Isolation during an Infectious Disease Outbreak

In the event of an infectious disease outbreak, local officials may require the public to take measures to limit and control the spread of the disease. This tip sheet provides information about social distancing, quarantine, and isolation. The government has the right to enforce federal and state laws related to public health if people within the country get sick with highly contagious diseases that have the potential to develop into outbreaks or pandemics. This tip sheet, produced by the Substance Abuse and Mental Health Services Administration (SAMHSA), describes feelings and thoughts you may have during and after social distancing, quarantine, and isolation. It also suggests ways to care for your behavioral health during these experiences and provides resources for more help.

https://www.samhsa.gov/sites/default/files/tips-social-distancing-quarantine-isolation-031620.pdf

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

MEDICARE TELEMEDICINE HEALTH CARE PROVIDER FACT SHEET

Mar 17, 2020 

• Telehealth

Medicare coverage and payment of virtual services

INTRODUCTION:

Under President Trump’s leadership, the Centers for Medicare & Medicaid Services (CMS) has broadened access to Medicare telehealth services so that beneficiaries can receive a wider range of services from their doctors without having to travel to a healthcare facility. These policy changes build on the regulatory flexibilities granted under the President’s emergency declaration. CMS is expanding this benefit on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans – particularly those at high-risk of complications from the virus that causes the disease COVID-19  – are aware of easy-to-use, accessible benefits that can help keep them healthy while helping to contain the community spread of this virus.   

Telehealth, telemedicine, and related terms generally refer to the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Innovative uses of this kind of technology in the provision of healthcare is increasing.  And with the emergence of the virus causing the disease COVID-19, there is an urgency to expand the use of technology to help people who need routine care, and keep vulnerable beneficiaries and beneficiaries with mild symptoms in their homes while maintaining access to the care they need. Limiting community spread of the virus, as well as limiting the exposure to other patients and staff members will slow viral spread.

EXPANSION OF TELEHEALTH WITH 1135 WAIVER: Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020.  A range of providers, such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers, will be able to offer telehealth to their patients.  Additionally, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

Prior to this waiver Medicare could only pay for telehealth on a limited basis:  when the person receiving the service is in a designated rural area and when they leave their home and go to a clinic, hospital, or certain other types of medical facilities for the service. 

Even before the availability of this waiver authority, CMS made several related changes to improve access to virtual care.  In 2019, Medicare started making payment for brief communications or Virtual Check-Ins, which are short patient-initiated communications with a healthcare practitioner. Medicare Part B separately pays clinicians for E-visits, which are non-face-to-face patient-initiated communications through an online patient portal.

Medicare beneficiaries will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. This will help ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home, without having to go to a doctor’s office or hospital which puts themselves and others at risk.

TYPES OF VIRTUAL SERVICES:

There are three main types of virtual services physicians and other professionals can provide to Medicare beneficiaries summarized in this fact sheet:  Medicare telehealth visits, virtual check-ins and e-visits.

MEDICARE TELEHEALTH VISITS:  Currently, Medicare patients may use telecommunication technology for office, hospital visits and other services that generally occur in-person. 

• The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  Distant site practitioners who can furnish and get payment for covered telehealth services (subject to state law) can include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals. 
• It is imperative during this public health emergency that patients avoid travel, when possible, to physicians’ offices, clinics, hospitals, or other health care facilities where they could risk their own or others’ exposure to further illness.  Accordingly, the Department of Health and Human Services (HHS) is announcing a policy of enforcement discretion for Medicare telehealth services furnished pursuant to the waiver under section 1135(b)(8) of the Act.  To the extent the waiver (section 1135(g)(3)) requires that the patient have a prior established relationship with a particular practitioner, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

KEY TAKEAWAYS:

• Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to patients in broader circumstances.
• These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
• Starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for professional services furnished to beneficiaries in all areas of the country in all settings.
• While they must generally travel to or be located in certain types of originating sites such as a physician’s office, skilled nursing facility or hospital for the visit, effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for Medicare telehealth services furnished to beneficiaries in any healthcare facility and in their home.
• The Medicare coinsurance and deductible would generally apply to these services. However, the HHS Office of Inspector General (OIG) is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
• To the extent the 1135 waiver requires an established relationship, HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

VIRTUAL CHECK-INS: In all areas (not just rural), established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. We expect that these virtual services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation. 

Medicare pays for these “virtual check-ins” (or Brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would generally apply to these services.

Doctors and certain practitioners may bill for these virtual check in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012). The practitioner may respond to the patient’s concern by telephone, audio/video, secure text messaging, email, or use of a patient portal.  Standard Part B cost sharing applies to both. In addition, separate from these virtual check-in services, captured video or images can be sent to a physician (HCPCS code G2010).

KEY TAKEAWAYS:

• Virtual check-in services can only be reported when the billing practice has an established relationship with the patient. 
• This is not limited to only rural settings or certain locations.
• Individual services need to be agreed to by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient agreement. 
• HCPCS code G2012: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
• HCPCS code G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.
• Virtual check-ins can be conducted with a broader range of communication methods, unlike Medicare telehealth visits, which require audio and visual capabilities for real-time communication.

E-VISITS:  In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.

Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

• 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes
• 99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes
• 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

• G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes
•  G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes
• G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.

KEY TAKEAWAYS:

• These services can only be reported when the billing practice has an established relationship with the patient. 
• This is not limited to only rural settings. There are no geographic or location restrictions for these visits.
• Patients communicate with their doctors without going to the doctor’s office by using online patient portals.
• Individual services need to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation. 
• The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable.
• The Medicare coinsurance and deductible would generally apply to these services.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA):  Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.  For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html

Summary of Medicare Telemedicine Services

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Brought to you by the NHADACA Ethics Committee

COVID-19 Public Health Emergency Response and 42 CFR Part 2 Guidance We emphasize that, under the medical emergency exception, providers make their own determinations whether a bona fide medical emergency exists for purposes of providing needed treatment to patients.

COVID-19 Public Health Emergency Response and 42 CFR Part 2 Guidance In response to the Novel Coronavirus Disease (COVID-19) pandemic, the Substance Abuse and Mental Health Services Administration (SAMHSA) is providing this guidance to ensure that substance use disorder treatment services are uninterrupted during this public health emergency. SAMHSA understands that, in accordance with the Centers for Disease Control and Prevention guidelines on social distancing, as well as state or local government-issued bans or guidelines on gatherings of multiple people, many substance use disorder treatment provider offices are closed, or patients are not able to present for treatment services in person. Therefore, there has been an increased need for telehealth services, and in some areas without adequate telehealth technology, providers are offering telephonic consultations to patients. In such instances, providers may not be able to obtain written patient consent for disclosure of substance use disorder records. The prohibitions on use and disclosure of patient identifying information under 42 C.F.R. Part 2 would not apply in these situations to the extent that, as determined by the provider(s), a medical emergency exists. Under 42 U.S.C. §290dd-2(b)(2)(A) and 42 C.F.R. §2.51, patient identifying information may be disclosed by a part 2 program or other lawful holder to medical personnel, without patient consent, to the extent necessary to meet a bona fide medical emergency in which the patient’s prior informed consent cannot be obtained. Information disclosed to the medical personnel who are treating such a medical emergency may be re-disclosed by such personnel for treatment purposes as needed. We note that Part 2 requires programs to document certain information in their records after a disclosure is made pursuant to the medical emergency exception. We emphasize that, under the medical emergency exception, providers make their own determinations whether a bona fide medical emergency exists for purposes of providing needed treatment to patients.  Learn More

New Hampshire Medicaid Telehealth Fact Sheet during COVID-19 State of Emergency Declaration March 18, 2020 This guidance is being issued in light of the State of Emergency, and the Governor’s March 18, 2020 Emergency Order #8 temporarily expanding telehealth services during the COVID-19 State of Emergency Declaration.

This expansion and guidance is only in effect for the duration of the State of Emergency. In order to protect the public’s health and mitigate exposure to, and the spread of, COVID-19, Governor Sununu has signed an emergency order, effective immediately, that expands the coverage of telehealth for Commercial insurance and Medicaid including for Managed Care Organizations (MCOs) in regards to eligible providers, originating site, and modality of telehealth platform.

Telehealth reimbursement typically requires live video and audio, however, during the declared state of emergency period related to COVID-19 in New Hampshire, audio only telehealth is eligible for reimbursement.

Eligible Providers:

• Physicians/Physician Assistants/APRNs/Clinical Nurse Specialists/Nurse Midwives Certified Registered Nurse Anesthetists Clinical Psychologists, Clinical Social Workers,
• Master’s Level Psychiatric Nurses School Psychologists licensed by the Board of Psychologists Pastoral psychotherapists,
• Marriage and Family Therapists,
• Clinical Mental Health Counselors LADCs, MLADCs, CRSWs,
• Applied Behavioral Analysts Providers licensed by the Board of Mental Health Practice Community Mental Health Programs designated by the Department of Health and Human Services.

Dentists Registered Dietitians or Nutritional Professionals Originating Sites: There are no restrictions, and may include a private residence.

Reimbursement: Medicaid pays the same rate as if the service was provided face-to-face. Billing for the service delivered should follow routine practices as if the service was provided face-to-face, with the addition of a modifier GT indicating the service was provided via telehealth and indicate place of service (POS 02: Telehealth). There is no additional payment to originating sites. Documentation standards follow the regular standards as if the service was delivered face-to-face. Confidentiality and Privacy Protection

Considerations: On March 17th, 2020, the Office for Civil Rights at the U.S. Department of Health and Human Services announced discretion in enforcement of HIPAA rules during the national declaration of a state of emergency related to COVID-19 in order to allow or expanded use of telehealth. In addition to HIPPA compliant telehealth platforms, practitioners may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype. Facebook Live, Twitch, TikTok, and similar video communication applications that are public facing, should not be used. Telephone only audio may also be used. If you have questions regarding please call the New Hampshire Medicaid Provider Call Center 866-291- 1674 or 223-4774, or email NHProviderRelations@conduent.com. Attachment: March 18, 2020 Emergency Order.

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https://www.governor.nh.gov/news-media/emergency-orders/documents/emergency-order-8.pdf

COVID 19 (Coronavirus) is currently top of mind for most of us.  We want to assure you that NHADACA and NHTIAD is taking action to both fully maintain operations. As always, our members, colleagues, and our communities are our top priorities.   On March 16, Governor Sununu announced a state of emergency due to COVID-19 with a memo outlining the recommendations of NH Right to Know law RSA 91-A.- you may read those details attached.  Additionally, you will find practical tips from SAMHSA with additional resources listed.  On March 10, Beacon Health made announcements about billing for covered services delivered telephonically such as video/telephonic counseling (when clinically appropriate) to reduce risk.  Billing will be accepted as of April 1 for dates of service beginning from March 12.  

We understand the complications this outbreak may bring in carrying out the work all of us are doing.   Many employers have already implemented the CDC social distancing protocols and we are learning more about how to navigate these challenges every day.  In order to focus on disease prevention efforts and reduce the spread of the virus, the Right to Know NH RSA 91-A enables sharing of this important information.   According to guidance issued in March 2020 by OSHA on Preparing Workplaces for COVID-19, everyone should engage in frequent and thorough hand washing. You should make sure to have a place available where you can wash your hands. If soap and running water are not immediately available, have readily available alcohol-based hand rubs containing at least 60% alcohol.  To summarize, CDC has identified following these steps to minimize risks to exposure;

1. Have you visited a doctor’s office or medical facility in last 14 days?

2. Have you had any contact with someone who has been diagnosed with Covid-19 in last 14 days

3. In the past 14 days, you have traveled to (or been in close contact with someone who has traveled to) China, Iran, South Korea, Italy, or any other high-risk country as identified by the CDC

4.  If you believe you have been exposed to the coronavirus or if you are experiencing symptoms consistent with COVID-19 (including fever, cough, sore throat, and/or difficulty breathing), contact your health care provider to schedule a test, practice self-quarantining, handwashing, and limiting contact with others.

Review the guidance released by the Centers for Disease Control and Prevention (CDC) on how to protect yourself from the coronavirus

Relying on the expertise of the CDC and our local health officials, we are committed to sharing information as soon as we have it to protect the health and wellbeing of our members, colleagues, and communities. 

Helpful Links and other resources:

• CDC information on managing anxiety and stress during this time
• COVID-19 Guidance for Opioid Treatment Programs from SAMHSA
• Coronavirus (COVID-19): What the CDC Is Recommending to HIV/AIDS Clinicians via TheBodyPro
• Contact your liability insurance carrier for additional information relevant to your practice and work setting

Most kind regards from everyone at NHADACA and NHTIAD

Dear NHADACA / NHTIAD Community,

All NHADACA trainings and events through the end of April will be converted to remote attendance via Zoom or cancelled.  In the next few weeks, we will evaluate doing the same for May and June.  We are working diligently to consult presenters on the applicability of their training to an online format, update the website, notify registrants, and process credits & refunds.  We are doing our best to respond to your health and credentialing needs, and as soon as possible we will also start working from home ourselves.  We will still have access to emails and phone messages, but it may take slightly longer to get back to you (at least initially).  Please check our website for trainings that are cancelled, but remember we are still working on March & April and will update May and June as soon as we can.

Most sincerely yours,

Dianne Pepin Castrucci, MLADC

Effective Immediately, and for a period of 30 days from today, ALL TESTING SERVICES ARE HALTED throughout the United States and Canada.

Within the past 24 hours, the US Centers for Disease Control (CDC) have issued updated guidance on measures to be taken to reduce the spread of the COVID-19 disease.  In particular, the CDC lowered the number of people that should be able to congregate in the same space from 50 to 10 in the United States. 

Given this new guidance, Prometric has determined it is necessary and appropriate to close our test centers in the United States and Canada for a period of 30 days, starting today on March 17.  This dramatic step is necessary in order to comply with this new federal guidance as well as to further protect the health and well-being of the individual test takers and the staff that provide services at each of our testing locations.  We anticipate re-opening our test centers effective April 16, however, please note that the specific date will be dependent on circumstances that are changing daily.

Operations teams are actively reaching out to individuals with testing appointments today and throughout the closure period, in an effort to prevent them from unnecessarily appearing at the testing centers.  We will be taking measures to reschedule those impacted appointments into a new date after the planned re-opening and will be communicating that information to the impacted individuals.  We will work closely with the test takers to find new appointment dates and times that work for their schedules, and we will be waiving any rescheduling fees.