Healthcare FAQs

Why is this EO being introduced?

Telehealth has become increasingly important in the face of COVID-19 and expanding access to it is critical to face this ever-expanding crisis. By expanding access to telehealth, we can both allow people who are self-isolating to continue medical services from their home as well as free up space in hospitals and other health facilities for patients impacted by COVID-19 who require in-patient care.

What scenarios are insurers required to cover telehealth under this EO?

- The service is already a covered benefit when provided in-person to the patient; - The service is clinically appropriate and medically necessary; and, - The telehealth service is delivered by an in-network provider acting within their scope of practice, who is licensed, certified, registered, or authorized to practice in the State of Illinois.

What qualifies for the prior authorization prohibition in the EO?

All telehealth services provided by in-network providers that relate to COVID-19 are prohibited from prior authorization.

What telehealth requirements are set out for commercial insurers under this EO?

This EO Prohibits commercial health insurance issuers from setting requirements for telehealth services that are more restrictive or less favorable toward providers and insureds than those established for Medicaid during the COVID-19 public health emergency. The Medicaid requirements address matters including provider documentation and reimbursement.

Which services qualify for the cost-sharing prohibition?

This EO prohibits cost-sharing for telehealth services delivered by in-network providers, whether or not they relate to COVID-19. However, to comply with federal requirements, an enrollee in a high-deductible health plan still will pay cost-sharing for any services that the IRS does not consider preventive care until the enrollee has met their deductible.

Which insurance plans do these telehealth coverage requirements apply to?

• Comprehensive health insurance coverage (e.g. major medical and HMO not self-insured)
• Short-term limited duration health insurance coverage
• Fully insured student health insurance coverage
• Fully insured association health plans
• Fully insured dental benefits, vision benefits, long-term care benefits, accident-only policies, and specified disease policies.

What platforms are allowed to be utilized under the relaxed rules of the EO?

Any non-public facing remote communication method, such as telephone calls, Skype, Apple FaceTime, Google Hangouts, Facebook Messenger video chat, etc. This exception does not allow the use of public facing products such as Facebook Live, TikTok, or Twitch.

Why is this emergency rules change being implemented?

Telehealth has become increasingly important in the face of COVID-19 and expanding access to it is critical to face this ever-expanding crisis. By expanding access to telehealth, we can both allow people who are self-isolating to continue medical services from their homes and free up space in hospitals and other health facilities for COVID-19 patients who require in-person care. Expanding access to telehealth will also allow our residents to continue to receive regular services, such as wellness checks, therapy appointments, and more, while social distancing orders are in place.

What does this EO do?

Under the emergency rules, HFS will reimburse medically necessary and clinically appropriate telehealth and virtual care with dates of service on or after March 9, 2020 until the public health emergency no longer exists. The rules also require providers to be paid the same rate for telehealth services as services delivered by traditional in-person methods. Finally, the emergency rules expand the modes of communication that can be used for telehealth services.

What is the new definition of "originating site" under the proposed rules?

Originating sites are the places where the patient receives the telehealth service. Under the emergency rules, Medicaid members can receive services in a wider range of facilities including in their place of residence or other temporary location within or outside the state of Illinois. A physician or other licensed health care professional is not required to be present at all times with the patient during the services at the originating site.

What originating sites qualify for facility fees?

An originating site will be eligible for a facility fee when it is a certified eligible facility or provider organization that acts as the location of the patient at the time a telehealth service is rendered, including but not limited to: substance use treatment programs licensed by the Department of Human Services' Division Substance Use Prevention and Recovery (SUPR), Supportive Living Program providers, Hospice providers, Community Integrated Living Arrangement (CILA) providers, and providers who receive reimbursement for a patient's room and board.

What facilities are included as "distant sites" under the new rules?

A distant site refers to the location of the healthcare practitioner providing the telehealth services. The enrolled practitioner providing services within the scope of their license or applicable certification may do so without any geographic or facility restrictions for the services delivered via telehealth. The expansion of distant health providers now includes:

• a physician, physician assistant, podiatrist or advanced practice nurse who is licensed by the State of Illinois or by the state where the patient is located;
• a federally qualified health center as defined in Section 1905(l)(2)(B) of the federal Social Security Act;
• a Rural Health Clinic or Encounter Rate Clinic;
• a Licensed Clinical Psychologist (LCP);
• a Licensed Clinical Social Worker (LCSW);
• an Advanced Practice Registered Nurse certified in psychiatric and mental health nursing,
• a Local Education Agency
• a School Based Health Center as defined in 77 Ill Adm. Code, 641.10.
• a Physical, Speech, or Occupational therapist as defined in 140.457
• a Dentist
• a Local Health Department
• a community health agency
• a Community Mental Health Center or Behavioral Health Center
• a Hospital as defined in 148.25

How are behavioral health services affected?

Behavioral health services have been expanded under the rules change. More behavioral health services are available via telehealth (except for Mobile Crisis Response and Crisis Stabilization as defined in 140.453(d)(3). These services can be provided using audio-only real-time telephone interactions or video interaction in accordance with the new emergency rules.

What new modes of communication are covered under the emergency rules?

The type of technology used for telehealth has been expanded and includes a communication system where information exchanged between the physician or other qualified health care practitioner and the patient during the course of the telehealth service is of an amount and nature that would be sufficient to meet the key components and requirements of the same service when rendered via face-to-face interaction. This includes but is not limited to smart phones and tablets. The recent Telehealth EO (EO 2020-09) allows any non-public facing remote communication method, such as telephone calls, Skype, Apple FaceTime, Google Hangouts, Facebook Messenger video chat, etc to be used for telehealth. This exception does not allow the use of public facing products such as Facebook Live, TikTok, or Twitch.

What documentation is required under the emergency rules?

The distant site provider and originating site provider eligible for a facility fee must maintain adequate documentation of the telehealth services provided in accordance with the record requirements of HFS. Medical records documenting the telehealth services provided must be maintained by the originating and distant sites and shall include, but are not be limited to, the name and license number of the provider at the distant site, locations of the originating and distant sites, the date and the beginning and ending times of the telehealth service, the medical necessity for the telehealth service and the type of interactive telecommunication system utilized at the originating and distant sites.

What about virtual check-ins and e-visits?

Medicaid members may receive services via virtual check-ins that must be rendered by a physician or advance practice nurse, or physician assistant who can report evaluation and management (E/M) service to an established patient, not originating from a related E/M service provided to the patient within the previous 7 days nor leading to an E/M service or procedure within the next 24-hours or soonest available appointment. Furthermore, Patients may initiate services by E-visits, which are non-face-to-face communications using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. The communication can occur over a 7-day period.