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#NASHPCONF20 Highlighted States’ Creativity in Addressing Equity, Bolstering Health Care, and Preserving Safety Nets during COVID-19

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Last week, over 1,000 state health policy leaders and others from every state joined the National Academy for State Health Policy’s (NASHP) first-ever virtual state health policy conference to discuss a path forward during an unrelenting pandemic and profound budget challenges. As one state official noted, “This was a chance to lift my eyes from the day-to-day challenges and look at the big picture.”

Several common themes emerged from the discussions. First, we saw the resiliency and creativity of state policymakers as they struggle with the day-to-day challenges of addressing the pandemic and safeguarding public health. We saw their insistence that action must replace words to address the horrific racial disparities in health care.

During the sessions, attendees reinforced the need for data and evidence to inform policies and for continued vigilance to ensure health care is available and affordable for all. Frustrated by the lack of federal action, particularly around costs, states are exploring new models to make prescription drugs affordable now and new initiatives to benchmark total cost-of-care spending, limit cost growth, and address health care consolidation.

The NASHP conference reinforced how much the work state leaders do every day matters. They make the right things happen that support our heroic frontline workers, they work hard behind the scenes to ensure health care is safe, accessible, and affordable, and they quietly keep things running while chaos and crisis make headlines.

The pandemic has challenged state leaders to find new ways to deliver care to those with substance use disorders, children with special health care needs, and others who rely on home- and community-based services. State officials shared their strategies to:

  • Support essential health workers who provide critical care;
  • Deploy state employees to staff hotlines to bolster contact tracing and provide other support to populations at high risk of infection; and
  • Continue regulatory flexibility to support telehealth to allow states to determine appropriate utilization and reimbursement strategies.

The conference gave leaders an opportunity to brainstorm about the pandemic’s impact on nursing home and other congregate care facilities and the need to re-double efforts to build more robust home- and community-based care options. Throughout the conference, attendees noted that many of these issues are not new – but the urgency now to address them will stimulate action.

In his opening day remarks, Massachusetts Gov. Charlie Baker praised the work of states and noted that the pandemic challenges state policymakers to find new ways to change how health care is delivered and to recognize that health care must also address the social determinants of health.

A striking theme throughout the three-day conference was the emergence of new partnerships and the breaking down of silos within state government to allow staffs from different agencies to quickly join forces in a common effort to make needed changes. Collaboration replaced competition as states faced both the pandemic and its devasting impact on state budgets – a trend speakers hoped would survive the pandemic.

We hope state leaders who are working under extraordinary pressure during this unique period in our nation’s history were a bit re-energized as they returned to work, knowing new challenges lie ahead. This pandemic will pass and in its wake will be innovation and creativity that will inform future policy. Getting there isn’t easy, but the NASHP conference reinforced how much the work state leaders do every day matters. They make the right things happen that support our heroic frontline workers, they work hard behind the scenes to ensure health care is safe, accessible, and affordable, and they quietly keep things running while chaos and crisis make headlines. They hold firm to their values and tell truth to power no matter what the consequences.

We hope to meet in person at next year’s conference in Washington, DC with tales to tell of how you made progress on equity, ensured that the safely net was there in tough budget times, and how you managed to pull out from the shadows of a long pandemic. Be well, take care of yourselves, and thank you for your continued leadership and devotion to the important work you do.

States Redesign Home Visiting Programs for a Telehealth World during COVID-19

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As families face immense stress from the pandemic, states have rapidly reworked their home visiting programs to continue to support women and children. Because face-to-face services, including case management and family support and counseling, are no longer an option, health departments now deliver these vital services by telehealth. But with this new operating platform, states have needed to quickly address issues such as privacy requirements and billing, reimbursement, and enrollment processes as they launch their telehealth services.

Recently, the Centers for Medicare & Medicaid Services (CMS) released a toolkit in response to COVID-19 with guidance and steps for state Medicaid programs as they transition services to telehealth. The updated CMS guidance allows for greater flexibilities, including reimbursement for telephonic visits. To streamline the process, CMS stipulated that “no federal approval is needed for state Medicaid programs to reimburse for telehealth services in the same manner or at the same rate paid for face-to-face services, visits, or consultations.” However, a state plan amendment (SPA) is necessary to accommodate any revisions to payment methodology to account for telehealth costs. 

Additionally, the Office of Civil Rights at the Department of Health and Human Services issued guidance that allows for enforcement discretion for noncompliance with the Health Insurance Portability and Accountability Act (HIPAA) regulatory requirements related to providers and telehealth, such as using non-HIPAA-compliant systems, such as the free version of Zoom.

How Michigan Converted its Home Visiting Service

Michigan, a state with a robust home visiting program prior to COVID-19, took quick action to support home visiting staff and the families they served to ensure continuation of services during the pandemic. The Maternal and Infant Health Program (MIHP) is administered and financed by the state Medicaid agency and is the largest home visiting program in the state. MIHP is available to all pregnant women enrolled in Medicaid and their infants up to age 12 months, with some exceptions. The program promotes healthy pregnancies and positive birth outcomes through a standardized, systemwide process of case management. When Michigan Gov. Gretchen Whitmer announced a state of emergency and stay-at-home orders in March 2020, the program quickly moved its home visiting services to telehealth. 

The Michigan Department of Health and Human Services (MDHHS) updated guidance on telehealth visits for Medicaid beneficiaries. The provider bulletin allows for greater flexibilities on distant and originating sites and outlines the billing codes and modifiers providers should use. The MIHP operations team took numerous steps to ensure a smooth transition to telehealth services for their providers and families, including: 

  • Both the state Medicaid agency and the MIHP operations team had early and continued communication with providers, including making staff available to answer questions and provide support.
  • The MIHP program created additional guidance specifically for MIHP providers. The guidance includes instructions on how to obtain and properly document verbal consent, billing procedures and codes specific to the MIHP program, and documentation procedures for all virtual visits. 
  • MDHHS held a provider webinar with detailed information related to telemedicine flexibility, including information targeted to MIHP providers and others.
  • MIHP operations conducted a provider survey about how MIHP programs were continuing to provide services during this time, which netted a near 100 percent provider response rate. The survey revealed that a large majority of agencies adjusted successfully and quickly to the telehealth service delivery model. In addition, only a small number of agencies suspended services temporarily, primarily due to agencies shifting resources to cover COVID-19 emergency functions.

As states begin to reopen, many home visiting programs will begin to consider returning to face-to-face visits exclusively or as a part of their support programs. Considerations for the role of telehealth in home visiting is expected to factor into state decisions. While it is unclear how state home visiting programs will transition, some groups including The National Alliance of Home Visiting Models have encouraged all home visiting programs to continue to use telehealth to ensure the safety of women and their families, as well as home visitors. With the greater flexibilities allowed by CMS, states have the option to continue using telehealth for their home visiting programs during the pandemic. This allows for the continuation of important services for women and children and helps decrease the spread of COVID-19. 

States will be weighing a number of considerations as they begin to open, including the benefits of telehealth for home visits and the costs associated with telehealth compared to in-person visits. These new policies will be important to monitor and will have implications for longer-term and possibly permanent use of telehealth to deliver essential services to families. 

Additional Resources: 

Strengthening Workforce Capacity: State Actions to Address Opioid Use Disorder during COVID-19

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During the COVID-19 pandemic, the opioid epidemic has quietly raged on, requiring states to fight a costly, two-front war. While states have rallied to ensure that opioid use disorder (OUD) treatment remains accessible, organizational and workforce challenges persist and the resources and revenue needed to address them are rapidly changing.

Gaps in treatment infrastructure and behavioral health workforce shortages have historically challenged states’ OUD treatment delivery. In the midst of the pandemic, states are optimizing current flexibility and supports for their behavioral health workforces to help maintain treatment access during the COVID-19 pandemic, while also monitoring how or whether these new strategies will be maintained in the future.

Here are some approaches states are taking to increase access to treatment and address workforce shortages by expanding job descriptions, offering flexible training, and changing licensing requirements:

Modifying licensure requirements. Licensing requirements for providers vary significantly by state, creating barriers for out-of-state practitioners to providing services across state lines. Expanding out-of-state license recognition and preventing licensure lapses can help ensure and expand access to treatment, promote adoption of telehealth services, and address provider shortages.

  • New Hampshire, New York, and Pennsylvania have all expanded the ability of out-of-state providers to deliver services within their states through executive orders. New Hampshire allows out-of-state providers to deliver medically necessary services both in person and via telehealth. Similarly, Pennsylvania has issued temporary licenses for out-of-state medical providers and has expedited issuance of temporary licensing. New York has allowed providers licensed in other states and Canada to practice in the state without penalty due to lack of licensure.
  • States may also consider delaying the expiration of provider licenses during the pandemic to remove any potential barriers providers may have to delivering services. Following an executive order that extended license expiration dates across provider types, Maryland’s Behavioral Health Administration (BHA) released guidance on licensure extension and new licensure processing specific to behavioral health providers. Professional licenses that would have expired during the period of the current emergency will be extended for 30 days after the emergency order is lifted, though the BHA continues to process licensure and re-licensure applications that are mailed or submitted electronically.

Leveraging licensed providers. As states face workforce shortages that are amplified by COVID-19, officials may find opportunities to leverage licensed providers in unique capacities, particularly in the provision of OUD treatments.

  • In Massachusetts, under order of the commissioner of public health, pharmacists may now administer medications for opioid use disorder (MOUD) in clinical settings, a policy shift designed to allow nursing staff who ordinarily handle such responsibilities to be reassigned to treat COVID-19 patients.
  • The Ohio’s Board of Pharmacy has adopted temporary regulatory guidance to allow authorized prescribers in opioid treatment programs (OTP) to delegate buprenorphine administration to registered nurses (RNs) and licensed practical nurses (LPNs).

Providing buprenorphine waiver trainings. States have been working to encourage and train providers to become “waivered” or licensed to prescribe buprenorphine long before this pandemic began, and several organizations are now taking advantage of increased flexibility in provider schedules to provide training. Anticipating that overdoses may increase during the pandemic, states can encourage provider engagement with these and similar programs to grow their waivered workforce.

  • California Bridge, a program supported in part by the California Department of Health Care Services (DHCS), is offering free online buprenorphine trainings that emphasize the immediate needs of vulnerable individuals during COVID-19.
  • Get Waivered, a non-profit program promoting and providing emergency department (ED) provider training, is offering a “Get Waivered Remote” training aimed at ED providers and medical students, recognizing that with clinics operating at limited capacity during the COVID-19 pandemic, EDs may become a more necessary point of care for people with OUD. This training is free and fully remote.

Supporting behavioral health workforces. As with other frontline workers, behavioral health staff working in residential care, institutional settings, and in direct contact with patients are experiencing significant stress working during the pandemic. To support staff without creating new programs and resulting budget demands, states may consider developing resources to support the mental health needs of both licensed and unlicensed workforces.

While these steps in response to COVID-19 are designed to address concerns about treatment access during the pandemic – sometimes, explicitly – policymakers are also considering the long-term service and budget implications of these changes. In a time of historically reduced state revenues, leaders will be considering how policy shifts and adjustments made during this pandemic can or should be adapted for the post-pandemic treatment of OUD, with likely fewer resources to do so.

States Establish New Telehealth Policies to Safeguard Well-Child Care and Immunizations

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The COVID-19 pandemic has reduced access to children’s preventive care across the country, with some providers reporting a 70 to 80 percent decrease in well-child visits, and far fewer children receiving vital in-person services, such as immunizations. Some primary care practices also have limited their services or shut down to comply with mandatory social distancing policies. To ensure children and families are able to stay safe and receive appropriate care, states are providing new guidance for telehealth visits.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT), the required Medicaid benefit for comprehensive and preventive health care services for children and youth up to age 21, includes well-child visits and immunizations. Well-child visits are necessary to prevent disease, administer scheduled immunizations, track healthy growth and development, identify health concerns early when they are easier and less costly to treat, and address parental and caregiver concerns.

In addition to a drop in well-child visits because of the pandemic, the US Centers for Disease Control and Prevention (CDC) released data showing that provider requests for childhood immunizations began dropping within a week of the national emergency declaration, signaling an immediate decline in routine immunizations for children. Several states, including California, Indiana, Kentucky, New Hampshire, North Carolina, South Carolina, Tennessee, and Washington State, have issued specific bulletins with information on EPSDT/well-child visits, including clarification of what services can be delivered via telehealth and billing guidance, so that these services can be provided during the pandemic to maintain healthy child development.

The Centers for Medicare & Medicaid Services (CMS) has also provided states with overarching telehealth guidance to promote access to care. Through executive orders and legislative authority, many states are ensuring telehealth services are easily accessible and that patients are not deterred from seeking necessary care during the pandemic that they would otherwise be unable to receive in person. States are also working to ensure that telehealth policies do not exacerbate existing disparities in care. Some examples of general state telehealth policy changes include:

  • Arkansas and Missouri recently relaxed the requirement that telehealth visits must only be conducted with previously established patients.
  • Arizona mandated that cost sharing for telehealth visits should be lower than in-person visits.
  • Oregon stipulated that cost sharing for telehealth services should not be greater than that for in-person visits.

While expanded telehealth policies increase access to primary care virtually during the pandemic, limiting in-person visits can reduce children’s ability to receive timely immunizations. Childhood immunizations are a cost-effective way to prevent disease, and vaccines are one of the most important public health tools to ensure health in a community, however, overall immunization rates are decreasing during the pandemic. The American Academy for Pediatrics (AAP) guidance encourages providers to prioritize in-person newborn care and well-child visits and immunizations for infants and children up to 24 months, and new CDC data shows a less prominent decline in immunizations for children under 24 months compared to children over 24 months. To address these immunization lags and promote access to other important preventive care, states have released guidance based on the needs of their own populations and their own provider capacity. For example:

  • Indiana and Kentucky’s policies for EPSDT visits note that providers need to complete the components of the visit that could not be done via telehealth (e.g., immunizations) in a follow-up visit within six months of the end of the public health emergency.
  • South Carolina and Tennessee’s guidance notes that when pediatric well care is provided via telehealth, the providers must inform the Medicaid enrollee (or parent/guardian) of any immunizations that would normally be administered and schedule a time to administer the vaccines as soon as possible after the telehealth visit. The providers bill for administering the immunization whenever it is delivered outside of the telehealth visit, such as on a different day, at a separate location, or through a drive-up immunization model.
  • Several states, including Maine, are encouraging practices to schedule well-child visits and administer immunizations in the morning and sick visits in the afternoon to keep the healthy and sick segregated. Other guidance to maintain well-child visits includes separating patients spatially, by placing patients with sick visits in different areas of the clinic or a different location from patients who are present for well visits.
  • Washington, DC and North Carolina’s guidance recommends providers utilize telehealth visits wherever possible, and that the subsequent, in-person follow-up visit should be as soon as is safe, based on the provider’s discretion. Washington, DC’s guidance also notes that if possible, pediatric immunizations, vital signs for infants up to 12 months, blood lead level screenings for children under 26 months, and infant anemia screening should not be delayed.

States also choose the billing codes and modifiers to track telehealth well-child visits and the subsequent follow-up visits for immunizations and other in-person services. For example:

  • Alabama directs providers to use code 02 in the place of service field to indicate telemedicine and use the modifier CR, for a “catastrophic event.”
  • Washington State providers must use EPSDT codes plus the CR modifier. For in-person follow-up appointments to complete the EPSDT visit, providers should use code 99429 with the CR modifier.
  • Kentucky providers should use 02 in the place of service field, and no modifiers are needed. For vaccine administration, providers bill code 90460 at the time of vaccine administration.
  • Alaska providers should use 02 in the place of service field, and modifiers 95, GT, or GQ to indicate a telehealth visit.

Well-child visits are an important vehicle for providers to assess healthy child development. There are many potential long-term implications of the pandemic on these visits, including primary care practices permanently shutting down due to lack of funding. Limited workforce capacity may lead to potential pent-up demand for pediatric preventive services resulting in:

State Medicaid and public health agencies are working closely to follow guidance from the Department of Health and Human Services (HHS), CMS, and CDC, with guidance from the AAP and American Academy of Family Physicians (AAFP) to ensure well-child visits are as uninterrupted as possible, so children can receive preventive services like immunizations, and subsequent vaccine-preventable outbreaks do not occur.

The National Academy for State Health Policy is continuing to monitor state and federal guidance to support states in ensuring children stay healthy during this pandemic and beyond.

This blog is supported by the David and Lucille Packard Foundation and the Centers for Disease Control and Prevention (CDC). To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.

Infographic: How State Medicaid Programs Can Use Telehealth to Serve Pregnant Women during COVID-19

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This infographic highlights what states need to consider when providing pregnancy-related services to Medicaid enrollees through telehealth during the pandemic. Links to more tools and resources are listed below the infographic. 

States can use the following flexibilities and tools to increase access to pregnancy-related services via telehealth:

States’ Recent 1115 Waiver Applications Include Provisions to Support Children during the Pandemic

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More than a dozen states have recently submitted 1115 waiver applications that have the potential to safeguard access to care and increase support for children during the COVID-19 pandemic.

If approved, these 1115 waivers would be retroactively to March 1, 2020, and expire “no later than 60 days after the end of the public health emergency.” The Centers for Medicare & Medicaid Services (CMS) created an 1115 waiver template for states to use when requesting authority to address the impact of COVID-19 on their Medicaid programs. The National Academy for State Health Policy (NASHP) April 6, 2020, blog, State Medicaid Strategies to Maintain Access to Care for Children with Special Health Care Needs during the Pandemic, outlines steps states are taking to support children with special health care needs using 1135 and 1915(c) Appendix K emergency waiver authorities.

Of the COVID-related 1115 waiver applications reviewed by NASHP, several contain provisions related to children. The 1115 waiver provisions listed below represent a selection of key strategies for serving children during the COVID-19 pandemic that other states may want to consider for their Medicaid programs, including payments to foster caregivers, reimbursement of family caregivers, and telephonic and virtual care coordination services.

Payments to foster caregivers: Children in foster care are more likely to experience physical and mental health challenges compared to children in the general population. During the COVID-19 pandemic, children in foster care may not be able to access their typical support services through schools and specialty physical and mental health providers. Arkansas, for example, is acknowledging the importance of providing stability and support to these vulnerable children by requesting authority through a 1115 waiver, to provide an additional monthly payment to all foster caregivers (“licensed foster parents, relative caregivers, and fictive kin”) for providing at-home care for children in their care. These monthly payments would be designed to “prevent negative impacts to physical and mental health during emergency period.”

Reimbursement for family caregivers: Both Georgia and New Hampshire have included provisions in their 1115 COVID-19 waiver requests asking for Medicaid reimbursement of family caregivers for caring for youth with special health care needs. Georgia’s 1115 waiver request would add a family caregiver service to its Georgia Pediatric Program in the event that licensed professional nurses (LPNs) are not available to provide the child’s needed services. New Hampshire’s 1115 waiver request asks to waive CFR 440.167 and allow family members to perform and be reimbursed for personal care services. Both of these approaches allow children who receive services in their homes to remain in a home setting and potentially reduce the need for hospital or nursing facility placement during a time when these facilities are being overwhelmed with COVID-19 patients.

Care coordination through telehealth for Medicaid managed care organizations (MCOs): Care coordination services are critical for children with special health care needs and are important services to improve health outcomes, reduce caregiver and patient burden, decrease health care costs, and strengthen systems of care for children with chronic and complex conditions. Currently, New Mexico’s Medicaid MCOs are required to conduct many care coordination activities (including initial screenings, needs assessments, and nursing facility level of care determinations) via home visits involving face-to-face interactions. As a result of COVID-19, New Mexico is requesting in its 1115 waiver application to allow its MCOs to continue to conduct their care coordination supports virtually – by telephone or, if possible, using video technology. This provision may help ensure that these valuable supports and services are continued and that children and youth with special health care needs (CYSHCN), in particular, are maintaining access to their care coordinators and care coordination services.

The National Academy for State Health Policy will continue to closely follow CMS responses to these waiver submissions and track any additional state 1115 waiver actions in response to the COVID-19 pandemic.

As states look for ways to ensure their systems are designed to support children during the pandemic, especially those with special health care needs, the National Standards for Systems of Care for CYSHCN can be a helpful resource. The standards address the core components of the structure and process of an effective system of care for CYSHCN such as access to care, eligibility and enrollment, and care coordination.

Many state waiver proposals during the pandemic are designed to improve aspects of the health care delivery system that are addressed by the National Standards, such as acknowledging the critical role families play in caring for children and children with special health care needs and allowing for flexibility in how care coordination is provided to best meet the needs of families and children. The standards can provide states with a framework to help ensure that key provisions and health care system components and protections are maintained during a time of disruption in the traditional health care delivery system.

New State Insurance Requirements in Response to COVID-19

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COVID-19 has upended health care systems and states are revising health insurance rules to make sure consumers can maintain their health insurance coverage and access needed health care services during the pandemic. The chart below details recent state actions that:

  • Limit consumer out-of-pocket costs for testing, treatment and out-of-network care;
  • Facilitate access to and delivery of care, including rapid transfers to appropriate care settings without lengthy reviews and telehealth expansion;  
  • Enable consumers to maintain coverage despite economic hardship and COVID-19 diagnosis by relaxing premium payment requirements and waiving penalties; and
  • Ease prescription refills and allow drug substitutes (formulary exemptions). 

For more information, read the NASHP blog, States Protect Consumers’ Coverage and Improve COVID-19 Care Delivery through Insurance Reforms.

Questions Remain as States Look to Evidence-Based Research to Inform Adoption of Telehealth

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In response to the COVID-19 epidemic, health systems are increasing their use of virtual tools and telehealth at unprecedented speed and insurers are expanding coverage for the services. These tools have great potential to help consumers access services that may be difficult to do so in-person and help physicians manage patients’ care remotely. 

As the pandemic drives rapid development and deployment of these tools to meet pressing needs, policymakers need to consider how best to use these technologies in the long term. 

Over the past several months, the National Academy for State Health Policy (NASHP) convened the Telehealth Affinity Group of state policymakers to examine emerging evidence from the Patient Centered Outcomes Research Institute (PCORI) on the use of telehealth to transform health care delivery. Past discussions have highlighted some of the promise and challenges of telehealth tools, including:

In February, before the pandemic hit the United States, the affinity group met to discuss three PCORI studies. Their discussions offer insights for policymakers and health systems to weigh, along with lessons learned from the current telehealth deployment, as long-term telehealth policies are adapted and implemented. 

Clear evidence of effectiveness is ideal, but not always available when needed. While policymakers acknowledge the importance of evidence-based research, it is impractical to wait for multi-year, in-depth studies to release results before implementing a new technology. The current pandemic is a unique example, but even prior to COVID-19, state policymakers recognized that there were situations in which, for financial and practical reasons, virtual tools that deliver medical services needed to be leveraged. State agencies often operate with constrained resources and are frequent innovators that adopt novel approaches, especially if there is promise that the approach will be cost-effective or the best solution available to address an urgent need.  

Rapidly changing technology may limit relevance of some telehealth research. Technology is rapidly changing, as is user familiarity with technological tools. As a result, well-crafted research to test the ease of use and the likelihood that a specific technological tool can lead to a promising health outcome can be irrevalent by the time the results are released. For instance, a study that examined technology requiring in-home installation and specialized training for participants in 2014-2016 found that patients who received the intervention reported higher levels of anxiety than those in the control group. The study’s results might be different if conducted today with the newest smart phone devices many people use daily. While it was not reported in the study, affinity group members speculated the invasive nature of the technology partially contributed to the elevated anxiety levels of the intervention group. 

While the findings of these point-in-time studies may still generally apply, the constant nature of technical change makes it difficult to justify investment in technology that could change in just a few years even if there had been more conclusive evidence that interventions had been effective. However, as technology improves and patient familiarity with various technologies grows, it is possible that both patient ability and willingness to adopt technologies will improve enabling better results from use of technological interventions.

Questions remain about how efficiently telehealth expands provider networks. A primary concern of policymakers is ensuring access to providers, particularly in rural or underserved areas, but is telehealth effective in expanding provider networks? To date, the studies reviewed by the group offer interesting uses of telehealth technology and the effect of those technologies on patient behaviors, but there is often little examination of effect of the intervention on network availability. For example, members questioned how telehealth interventions could serve to help address workforce needs, including efficient distribution of limited provider resources, especially across both rural and urban settings. 

Ultimately, state health policymakers want to find ways to provide lower-cost and/or better-quality services to patients. This a challenge that research into the use of technology interventions in clinicial care may not be able to immediately provide. And, examining the lessons from rapid acceleration of telehealth use during the COVID-19 pandemic may not be able to answer that question either. 

NASHP will continue to discuss emerging PCORI research and telehealth policies in the coming months. To learn more, read our prior blogs State Officials Consider Patient Preferences when Evaluating Telehealth Evidence and States Explore Emerging Evidence to Learn New, Innovative Uses of Telehealth. 

States Rapidly Build their Telehealth Capacity to Deliver Opioid Use Disorder Treatment

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States are turning to telehealth to minimize direct contact between patients, providers, and other staff during the COVID-19 pandemic. For opioid use disorder (OUD) treatment, this shift represents a significant departure from how these services have been historically delivered and requires rapid organizational changes.

State policymakers are quickly restructuring OUD treatment, including the administration of medications for opioid use disorder (MOUD) that include buprenorphine and methadone, and addressing barriers to telehealth for OUD by coordinating with providers to streamline processes and adapt to a rapidly changing landscape in accordance with federal guidance. 

The shift toward telehealth represents a significant clinical practice change, one that highlights longstanding concerns about the quality of care delivered via telehealth – particularly safety and confidentiality concerns around prescribing medications for opioid use disorder without drug screens and physical exams.

State Strategies

Supporting providers to increase telehealth access. Recent guidance from the Drug Enforcement Agency (DEA) waived the need for an in-person evaluation in order for a provider to prescribe buprenorphine for the first time, underscoring the urgency to gain capacity for telehealth services by OUD providers.

  • The Maryland Health Care Commission has developed a Telehealth Virtual Resource Center to encourage the adoption and use of telehealth. The resource center provides technology tips for providers and includes a telehealth readiness assessment for ambulatory services to improve the delivery of telehealth services.
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) temporarily opened the door for providers to prescribe buprenorphine for new patients via telephone, with the DEA following suit for audio only calls, provided that the telephone call aligns with adequate levels of care. Tennessee, for example, is now permitting telephonic sessions in a TennCare (Medicaid) enrollee’s home when that member has concerns about COVID-19.
  • Many states are following suit. The New Jersey Division of Medical Assistance and Health Services (DMAHS) has also permitted providers to utilize telephonic or audio-only technology for the delivery of telehealth service, as long as the technology meets the state’s standard of care. New Jersey also removed the face-to-face requirement for federally qualified health centers, enabling them to bill at the full rates for a virtual encounter when utilizing telephonic technology to deliver telehealth services.
  • In an effort to increase utilization of telehealth services, the Washington Health Care Authority has purchased a limited number of Zoom licenses for providers to utilize to administer telehealth services. The licenses will be prioritized for providers who have greatest need, including providers who prescribe MOUD.
  • While Zoom can provide Health Insurance Portability and Accountability Act (HIPAA) compliant products (with an executed Business Associate Agreement), states should be aware that Zoom has experienced a drastic increase in usage, which has exposed privacy issues within the platform’s design. US Sen. Richard Blumenthal of Connecticut recently sent a letter to Zoom, outlining these privacy concerns.

Payment: States are quickly updating billing procedures and reimbursement rates to support their transition to telehealth.

  • Rhode Island provides in-depth guidance on Medicaid billing for telehealth fee-for-service and managed care providers, including behavioral health providers, to streamline reimbursement. The resource outlines billing codes to be utilized for service delivery by physicians, nurse practitioners, counselors, and peers.
  • Kentucky’s Cabinet for Health and Family Services for Medicaid has also provided billing guidance to providers, highlighting that targeted case management, peer support services, and community services are now eligible for delivery via telehealth.
  • Washington has ensured payment parity for telehealth services and in-person services, increasing behavioral health telehealth rates to match those for in-person services.

 What Happens to Telehealth after the Pandemic?

The trajectory of policy change over the course of the pandemic has been to ease restrictions and remove barriers to the provision of OUD services via telehealth. The long-term implications remain to be seen, but the shift toward telehealth represents a significant clinical practice change, one that highlights longstanding concerns about the quality of care delivered via telehealth – particularly safety and confidentiality concerns around prescribing MOUD without urine drug screens and physical exams. Ultimately, in order to maintain patient safety while continuing to use telehealth models, states may need to consider how to address limiting telehealth services while retaining patients.

Providing OUD treatment through telehealth has fiscal effects as well. Incentivizing and easing telehealth now via strategies that raise reimbursement rates for telehealth services to create parity or add new services altogether will be reflected in Medicaid budgets downstream – especially if those services continue beyond this emergency. States may need to adapt regulations, reconsider reimbursement rates for OUD services and capitation, and potentially amend managed care contracts to reflect significant shifts in service delivery.

The COVID-19 pandemic has forced states and providers into wildly new territory in order to ensure that patients continue to have access to life-saving OUD services. While states have adapted extraordinarily quickly and are developing creative solutions to ensure continued access to OUD treatment, the removal of barriers during this emergency may have important ramifications on the future of telehealth policy.

States Protect Consumers’ Coverage and Improve COVID-19 Care Delivery through Insurance Reforms

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As COVID-19 diagnoses grow, states are making rapid-fire adjustments so consumers can access the care they need. One key strategy has been promoting health insurance enrollment to protect consumers from potentially exorbitant medical bills. Recognizing more protection is needed, state insurance regulators are also making sure consumers maintain their coverage, find appropriate care, and are protected from exorbitant or surprise medical bills. 

Enabling Continuity of Coverage, despite Life Disruptions

Maintenance of health insurance coverage will be a challenge for many, especially for the recently unemployed who face sudden income uncertainty or even loss of employer-provided health insurance. Several states are mandating or requesting that insurers refrain from terminating health plans. While some states define specific conditions under which carriers must suspend terminations – for example, Arkansas prohibits terminations in the case of job loss or COVID-19 diagnosis – others, including Colorado, Indiana, and Maine, apply broadly in the case of non-payment of premiums during the public health emergency. 

These policies do not absolve consumers of their responsibility to pay their premiums, but rather grant a needed reprieve (usually up to 60 days) during which consumers are required to contact their insurers to figure out a payment strategy. Several states also recommend that insurers consider waving any late fees or penalties for non- or late payment, recognizing that additional fees put undue burden on already strained households. 

States are also working to provide flexibility to businesses to help them retain their ability to offer coverage during lean times. Such flexibilities include waiving minimum participation rates, eliminating “hours worked” and minimum contribution requirements, and opening enrollment to individuals who may have declined coverage during a company’s typical open enrollment period. 

Directing Consumers to Appropriate Care and Services

As health systems become increasingly strained, it is more important that ever to ensure that consumers are directed to the most appropriate care settings. Health insurers have a direct communication channel to their enrollees and serve an important role in helping direct consumers to care. Most states have requested insurers to help keep consumers properly informed during the pandemic. Such measures include posting updated information about COVID-19 on insurer websites, establishing robust communication channels so insurers can rapidly respond to consumer inquiries, and expanding nurse help-lines to aid in triaging care. 

Encouraging Remote Care via Telehealth

Both state and federal leaders have recognized the importance of telehealth to help mitigate the spread COVID-19 by enabling consumers to solicit services from home, regulators can enable immediate self-quarantine of individuals suspected of infection, while also helping preventing needless exposure for those at risk of infection. States are recommending that insurers bolster their available telehealth workforce, including staff available to handle behavioral health services. While some states already enforce parity laws for telehealth delivery, meaning that telehealth services are reimbursed at the same rate as in-person services, some states are newly requiring parity for telehealth, if only for the limited duration of this public health emergency.

To ease widespread implementation of telehealth services, the Department of Health and Human Services Office of Civil Rights (OCR) has temporarily relaxed privacy and security requirements to enable widespread access to telehealth tools during this emergency. In tandem, states have enacted or recommended policies to bolster insurer capacity to offer telehealth services. These include suggestions for how insurers could relax restrictions that normally prohibit utilization of telehealth including:

  • Waiving requirements for an in-person consultation prior to rendering of telehealth services;
  • Allowing services to be delivered straight to a consumers’ homes (versus a certified point of care); and 
  • Removing prohibitions on the use of common technologies, such as FaceTime, Skype, or telephone (without video), which are normally restricted due to privacy concerns.

Several states, including Connecticut, Delaware, and Iowa, are also encouraging insurers to offer telehealth services at reduced or zero-dollar cost sharing to further incentivize consumers to use telehealth services. Massachusetts has mandated telehealth coverage for COVID-19 related services with no cost-sharing.

Expediting Access to Necessary Services

Insurers and providers have established processes used to assess if an enrollee is receiving appropriate, covered services to treat an illness. These processes include pre-authorization requirements and utilization reviews that are conducted before a service is performed. However, these checks can impose administrative burdens and affect the timeliness of care, which together adds additional strain to health care providers. Several states have existing laws that put time limits on approvals to help expedite services, however, under the current state of emergency many are recommending that insurers waive or suspend use of these tools (e.g., prior authorizations, utilization review). For example, Colorado and Georgia explicitly call for elimination of pre-authorization requirements to transition patients to in-home or acute care settings, which would help maneuver patients out of limited hospital beds to alternative care settings. Such changes will help expedite care and alleviate strained administrative systems, which, in turn, allows systems to better serve patients. 

Protecting Patients from High Medical Bills

Recognizing that even the insured are likely to face some medical costs related to COVID-19, states led the way in issuing guidance to recommend that insurers cover testing without cost sharing for consumers. The federal government followed by enacting the Families First Coronavirus Response Act that requires insurers to cover testing for COVID-19, but concerns remain that consumers may be billed for COVID-19-related treatment.  A few states, including Massachusetts and New Mexico, have mandated coverage of COVID-19 treatment and others, including Florida, Georgia, and Kansas, have requested that insurers consider such steps. Several major insurers have stepped forward and announced they will cover COVID-19 treatments at low-to-no cost, even without a mandate. However, variation exists over what kind of treatments will be covered and how care delivery settings may affect coverage. 

As discussed in the recent National Academy for State Health Policy (NASHP) blog, States Act to Increase Medicaid/Marketplace Coverage to Insulate Consumers from COVID-19 Care Costs, rapid evolution of health care settings and limitations on available workforces put consumers at particular risk to receive care out-of-network, which could lead to surprise medical or balance bills. For example, hospitals and new makeshift facilities are bringing in new providers to address surplus demand, but new providers may serve as contractors, in which case they may not technically be considered part of a hospital’s network. States have put forth a number of solutions to mitigate these issues – ranging from urging carriers to review and modify networks to meet increased demand to clear mandates that insurers cover out-of-network providers at in-network rates if conditions make it difficult to seek in-network care. 

Massachusetts has enacted some of the strictest consumer protections, mandating in-network coverage of acute care services related to COVID-19 treatment and prohibiting providers from balancing billing consumers for the cost of out-of –network services. Massachusetts also specifies reimbursement rates for services delivered by out-of-network providers – the in-network rate when the insurer has a an existing agreement with the hospital at which the provider is practicing, and 135 percent of the Medicare rate if no such agreement exists. 

Collectively, these changes will help protect consumers during this extraordinary time. However, as this crisis continues, these policies could have significant long-term ramifications for insurance markets as insurers absorb the new costs related to these mandates. NASHP will continue to monitor these changes, including long-term impact.

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