COVID-19 Telehealth Policy Update to Behavioral Health Coverage

(Update: In response to feedback from providers after this bulletin was distributed on March, 28, 2020, SCDHHS is clarifying that the additional temporary flexibilities offered to providers in this bulletin are also available to the provider types listed as “LIPs” in this bulletin (licensed psychologists, LPCs, LMFTs, LISW-CPs and LPES) who are enrolled in the Medicaid program.)

On Friday, March 13, 2020, President Donald Trump declared a national emergency due to coronavirus disease 2019 (COVID-19) and Governor Henry McMaster declared a state of emergency for the state of South Carolina. As a part of the state’s preparation and response to COVID-19, the South Carolina Department of Health and Human Services (SCDHHS) is announcing additional temporary modifications to policies related to telehealth coverage.

Reimbursement for the telephonic services addressed below is available if the interaction with a Healthy Connections Medicaid member includes at least one telephonic component. Interactions that also include video interaction may also be billed, but other forms of electronic communication, such as email and instant and text messaging, are not eligible for reimbursement. Services provided pursuant to the current SCDHHS telemedicine coverage policy should continue to be billed according to those guidelines. SCDHHS will begin accepting claims for the changes noted below no later than April 15, 2020, for dates of services on or after this bulletin’s date. These changes will be in effect for the duration of the federally declared public health emergency unless rescinded or superseded by SCDHHS prior to the end of the emergency.

The telehealth policy modifications outlined below were developed in consultation with clinical professionals and thought leaders throughout the South Carolina provider community and are intended to balance immediate treatment needs that are not appropriate for deferral with the safety and efficacy of remote service delivery. In all circumstances, the services identified below must meet standard requirements for medical necessity.

This bulletin contains three sections. The first explains SCDHHS’ existing telemedicine benefit and flexibilities that were in-place prior to this bulletin. The second announces new and temporary flexibilities available to providers during the COVID-19 outbreak, which requires unprecedented social distancing. The third details guidelines to ensure quality of care. SCDHHS is regularly reviewing the clinical landscape and amending guidance based on feedback received from the provider community, beneficiaries and public health officials. Additional guidance and modifications to coverage policy may be communicated in future bulletins

Existing Behavioral Health Telemedicine Services

Prior to the constraints on the healthcare delivery system created by social distancing policies that are designed to slow the spread of COVID-19, SCDHHS’ State Plan covered a broad array of interventions offered using audio and visual (A/V) interactions and some telephonic interactions to ensure access to services in a variety of settings.

The following tables detail the telemedicine and telephonic services available and specific to behavioral health services and providers.

Community Mental Health Clinics (CMHC) Remote Services and Medical University of South Carolina (MUSC)

Legend for Tables: Advanced Practice Registered Nurse (APRN); Physician’s Assistant (PA); Registered Nurse (RN); Telephonic (TEL); Audio and Visual (A/V)

Private Provider Groups

Rehabilitative Behavioral Health Services (RBHS) and Licensed Independent Practitioners (LIPs)

Effective March 19, 2020, SCDHHS authorized reimbursement for LIPs (licensed psychologists, LPCs, LMFTs, LISW-CPs and LPES) who are enrolled in the Medicaid program to provide periodic check-ins and assessments with established patients. This coverage expansion is detailed in the Medicaid bulletin issued on March 19, 2020 and included codes 98966, 98967 and 98968. The coverage expansions below are in addition to coverage detailed in the March 19 bulletin. In lieu of the array of behavioral health screening and evaluation codes listed in the provider manual, these should be used as detailed in the March 19 bulletin.

Additional Flexibilities During COVID-19 Response

Telemedicine

Given the announcement schools will be closed for the month of April and the state’s intensifying social distancing efforts, SCDHHS is introducing additional telemedicine codes for providers enrolled under CMHC, RBHS or LIP categories. These additional codes are available to physicians, nurse practitioners, and physician assistants already authorized to render services and for the following provider types:

• Licensed Psychologist
• Licensed Professional Counselor
• Licensed Independent Social Worker
• Licensed Marriage and Family Therapist

Note that limitations and billing guidelines provided in this section apply only to those instances when these services are provided via telehealth. When the services below are provided in a manner consistent with current SCDHHS policy, such as care delivered face-to-face or through the therapeutic foster care system, existing limitations and billing requirements apply.

The services and limitations listed are for established patient relationships and may be delivered without regard to the patient’s location, using a synchronous audio-visual, telehealth delivery platform. These remote services are not reimbursable for individuals practicing under the supervision of a LIP provider. Providers should use a “GT” modifier when billing the codes and should reference their appropriate provider manual for other modifiers or coding guidance for the services listed below.

Administrative Flexibilities

SCDHHS has issued guidance to managed care organizations (MCO) to operate with necessary flexibility to ensure continuity of care with respect to prior authorization and documentation requirements for providers. SCDHHS will continue to monitor the provider community and address any issues between providers, beneficiaries and MCOs as needed.

In addition, the Centers for Medicare and Medicaid Services (CMS) has issued guidance on Health Insurance Portability and Accountability Act (HIPAA) enforcement discretion regarding services authorized for telemedicine, which is available here: https://www.hhs.gov/sites/default/files/hipaa-and-covid-19-limited-hipaa-waiver-bulletin-508.pdf

Finally, SCDHHS has submitted an 1135 waiver to CMS for a variety of administrative flexibilities.  SCDHHS will issue further bulletins as CMS acts on the waiver.

Limitations and Clarification

Providers engaging in telemedicine services are required to ensure that the quality of care delivered is the same as if engaging the patient in a face-to-face format. Beneficiaries that are unable to self-direct or engage with a telephone or audio-visual device without a provider’s presence may require face-to-face interactions to receive the therapeutic effect of the interventions detailed in this bulletin.

With the flexibilities noted above, several exclusions remain in place during the COVID-19 response to ensure that Medicaid reimbursement is available only when the quality of patient care remains at a clinically appropriate level including:

• Administration of injectable medication
• Inpatient services, such as those administered in a hospital inpatient psychiatric setting or Psychiatric Residential Treatment Facility (PRTF) cannot be provided in alternate settings and monitored remotely.
• Except where otherwise noted, providers that are not licensed or credentialed to practice independently are excluded. Remote supervision of some interventions provided by independent practitioners will be covered in future bulletins.
• Only individual services are eligible for telemedicine. Group or multi-family interventions are not reimbursable, nor are services with staff-to-beneficiary ratio is greater than one-to-one.
• Providers may not conduct interventions remotely with more than one individual concurrently and must conclude any intervention or visit with one patient before commencing an intervention or visit with the next.
• Providers must still follow the course of therapy and limitations detailed in the beneficiary’s individual plan of care.

Additional guidance regarding coverage policy will be communicated in future bulletins as needed. 

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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