MaineCare Guidance Relating to Telehealth and COVID-19

MaineCare Guidance Relating to Telehealth and COVID-19

As we respond to COVID-19, we encourage MaineCare providers to consider utilizing telehealth services for the delivery of MaineCare-covered services when appropriate and necessary. MaineCare has long had a robust telehealth policy and has recently created additional flexibility for its usage. Please read this message in its entirety to understand your options and additional resources.

Utilizing Telehealth to Satisfy Face-to-Face Requirements in MaineCare Policies

Telehealth allows providers to deliver services to individuals remotely so that providers can monitor and address health conditions. This can be done through Interactive Telehealth Services, which are real time, interactive visual and audio telecommunications; or telephonically when Interactive Telehealth Services are unavailable.

With few exceptions such as personal care services and ambulance, telehealth can be used to satisfy the MaineCare face-to-face requirements when telehealth delivery of the service is of comparable quality to in-person service delivery. Providers are also required to ensure they are complying with all federal, state, and local regulations that apply, including HIPAA requirements, when network services are used.

Member & Service Criteria for Telehealth Eligibility

The significant majority of medically necessary MaineCare-covered service may be delivered via Interactive Telehealth Services if the following requirements are met:

1. The member is otherwise eligible for the covered service, as described in the appropriate section of the MaineCare Benefits Manual; and,
2. The covered service delivered by Interactive Telehealth Services is of comparable quality to what it would be if it were delivered in person.

If a member is eligible to receive the underlying covered service, and if delivery of the covered service via telehealth is medically appropriate as determined by the health care provider, the member is eligible to receive telehealth services. For services that traditionally have not been considered medically appropriate or of comparable quality via telehealth (e.g. Intensive Outpatient Treatment (IOP) or Home & Community Based Treatment (HCT)), providers are encouraged to consider alternative treatment options that could be more appropriately delivered via telehealth (e.g. 1:1 counseling visits). 

Delivery of Telehealth via Telephone

In addition to Interactive Telehealth Services, telephones are an acceptable mode to deliver telehealth if Interactive Telehealth Services are unavailable, and if Telephonic Service is medically appropriate for the underlying covered service.

Prior Authorization (PA) Requirements

Prior Authorization (PA) is only required for Interactive Telehealth Services if a PA is required for the underlying covered service. In these cases, the PA relates to the underlying covered service, not to the telehealth mode of delivery.

Telehealth and Pharmacy – NEW!

Through emergency rules, going forward the Department will allow for prescribing through telehealth. 

Telehealth Sites

Two distinct sites are necessary for delivering interactive telehealth. The first site – called the Originating Site – is where the MaineCare member is located when receiving the service. The second site – the Receiving Site – is where the provider who is administering the covered service or consultation is located.

The Originating Site can be a member’s home, nursing facility, long-term care facility, or other health care facility, with telehealth capabilities.

Telehealth Provider Eligibility

To receive reimbursement for telehealth services, a health care provider must be:

• Acting within the scope of his or her license,
• Enrolled as a MaineCare provider, and;
• Otherwise eligible to deliver the underlying covered service according to the requirements of the applicable section of the MaineCare Benefits Manual.  

Billing for Telehealth

In general, services must be billed in accordance with applicable sections of the MaineCare Benefits Manual. Providers must submit claims in accordance with Department billing instructions. The same procedure codes and rates apply to the underlying covered service as if those services were delivered face-to-face. When billing for Interactive Telehealth Services, health care providers at the Receiving (provider) Site should bill for the underlying covered service using the same process they would if it were delivered face-to-face; with the addition of a GT modifier to the claim.

Reimbursement for Originating Sites

In general, when a member is receiving telehealth services, any health care provider who is present with the member at the Originating Site (where the member is, e.g. a nursing facility or the member’s home), may not bill for assisting the health care provider delivering the covered telehealth service from the remote Receiving Site. However, if a health care provider at an Originating site is not providing clinical services but is making a room and telecommunications equipment available, that health care provider may bill MaineCare for an originating facility fee using code Q3014 for the service of coordinating the telehealth service.

Telehealth Resources for Providers

Providers who need assistance with implementing and/or have general billing questions regarding telehealth services are encouraged to contact the Northeast Telehealth Resource Center (NETRC) by email: netrc@mcdph.org or 1-800-379-2021. Specific questions can also be submitted to NETRC at https://www.netrc.org/contact.php. Many other helpful telehealth resources are available on NETRC’s website including NETRC’s Telehealth Toolkit for COVID-19.

MaineCare providers with telehealth questions related to MaineCare-specific billing and/or policies should contact their provider relations specialist or call Provider Services at 1-866-690-5585.

MaineCare encourages providers who would like to learn more about telehealth to participate in the National Consortium of Telehealth Resource Center’s webinar on March 17^th related to telehealth and COVID-19.