Medicaid Clinical Coverage Policies Proposed Changes Incorporate Pandemic Lessons Learned

Telehealth became the star of the pandemic by keeping people in services despite having to quarantine at home.  North Carolina quickly ramped up their telehealth policies through a temporary waiver of federal rules and providers accordingly increased their telehealth capacity.  The list of qualified professionals who can provide certain services, particularly telehealth, was also expanded temporarily.  Both of these have the potential to expand access to needed services for individuals with Medicaid and Health Choice.  The outstanding question has been what portion of the temporary flexibilities would become permanent.  NC DHHS is taking steps  to determine this through proposed changes to Medicaid Clinical Coverage Policies and is requesting feedback.  Many of these policies are related to behavioral health, intellectual and developmental disabilities and substance use disorders.  The US Department of Health and Human Services has extended the public health emergency that allows states to have waivers and flexibilities in place as the country continues to grapple with the pandemic.  The July 25^th deadline  has now been extended 90 days to October 25, 2020.  US DHHS has indicated there will be no further extension.  That makes it all the more important for North Carolina to formalize permanent changes to incorporate those flexibilities that have improved access to care during the pandemic.    

According to NC DHHS, the proposed revision to Clinical Coverage Policy 1-H: Telehealth, Virtual Patient Communications and Remote Patient Monitoring is “intended to provide overarching guidance related to the delivery of services via telehealth, virtual patient communications and remote patient monitoring that are not otherwise included in a program or service-specific clinical coverage policy.”  Comments are due on this proposed policy change by August 15^th.  Other proposed policy changes have deadlines for feedback ranging from August 15^th to September 22^nd.

The revised Clinical Coverage Policy 1-H would adopt the following changes:

• Redefines telehealth to include all forms of two-way, real-time audio telecommunications, such as telemedicine, telepsychiatry, teletherapy, etc. The telepsychiatry codes that were in the previous version of 1-H will be included in a forthcoming revised 8-C clinical coverage policy.
• Adds coverage for virtual patient communications (telephone and online digital evaluation and management, interprofessional consultation) and remote patient monitoring codes. 
• Eliminates restriction on “video cell phone interactions;” telehealth can occur over a HIPAA compliant platform on any device with audio/visual capabilities.
• Eliminates restrictions on originating sites: an originating site can be the patient’s home and there are no distance requirements between originating and distant sites.
• Eliminates requirements for referring providers.
• Expands eligible provider types (varies by service).
• Eliminates consulting provider language; medical examinations can occur without oversight from a consulting provider.

In addition, it is proposed that Clinical Coverage Policy 8-A, Enhanced Mental Health and Substance Abuse Services, will be permanently amended to expand the list of eligible providers to include Licensed Professional Counselor Associate or Licensed Clinical Mental Health Counselor Associate, Licensed Marriage and Family Therapist Associate and Licensed Clinical Social Worker Associate and to enable Mobile Crisis Management and Diagnostic Assessment to be delivered via telehealth.  Many other Clinical Coverage Policies will now have provisions related to telehealth.  Services such as Health and Behavior Intervention, Facility-Based Crisis Service for Children and Adolescents, Outpatient Behavioral Health Services provided by direct-enrolled providers, Research-Based Behavioral Health Treatment for ASD, and Peer Support Services.

A few of the rules (Community Support Team, Inpatient Behavioral Health Services, Mental Health/Substance Abuse Targeted Case Management, Assertive Community Treatment Program) are updating terminology to comply with recent legislative changes to professional designations, e.g. Licensed Professional Counselors are now Licensed Clinical Mental Health Counselors and a Certified Substance Abuse Counselor (CSAC) has been amended to be a Certified Alcohol and Drug Counselor (CADC). 

NCQA Updates HEDIS Measures for Telehealth:

Another sign that the country is embracing progress in telehealth is the new Healthcare Effectiveness Data and Information Set (HEDIS) measures from the National Committee for Quality Assurance (NCQA).  NCQA, a leading accreditation agency for organizations such as managed care organizations, has adjusted 40 measures to incorporate telehealth.  Eight of those measures are related to behavioral health services.  Measures such as antidepressant medication management; follow-up after hospitalization for mental illness; follow-up after emergency department visit for mental illness; and diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications now address telehealth provisions of the service. 

Changes to Innovations Waiver and other I/DD Services:

Intellectual and Developmental Disability Clinical Coverage Policies also have some proposed changes because of temporary flexibilities that were provided.  In addition to adding telehealth provision for  Research-Based BH Treatment for ASD, Therapeutic Leave for ICF-IID facilities would be permanently extended from 60 days to 90 days.  To support this extension, providers will be required to check in with the individual every 15 days and maintain coordination of care responsibilities. 

More extensive proposed changes are being suggested for the Innovations Waiver, Clinical Coverage Policy 8-P.  Comments for the proposed changes to the Innovations Waiver are due by September 18^th.  Some of the proposed revisions include:

• Eliminating Intensive In-Home Supports and Personal Care as services under the Innovations Waiver;
• Provision for the Tribal Option for the Innovations Waiver by including language related to care coordination that involves Cherokee Indian Hospital Authority, the plan under the Tribal Option;
• Adding a list of definitions;
• Adding telehealth, virtual patient communications and remote monitoring as an option for some services and adding parameters around monitoring systems;
• Adding Tenancy Support Services under Community Navigator;
• Adding vocational services and Social Determinants of Health to the Individualized Staffing Plans;
• Allowing a Doctor of Osteopathic Medicine to order assistive technology services;
• Requiring that service documentation occur within seven days of the date of service;
• Defining community-based employment-focused skill development under Community Networking;
• Adding specificity to Day Supports;
• Adding language around the Employer of Record model used in Financial Support Services and related background checks;
• Allowing LME/MCOs to approve short-term use of Alternative Family Living (AFL) staff to provide day services;
• Adding specificity to Supported-Employment services;
• Clarifying that adults are aged 22 and older;
• Specifying that the SIS is “only one measure of an individual’s support needs. The SIS results may be considered in determining the amount of services approved but are not binding, and all other evidence of the beneficiary’s support needs must also be considered.”;
• Changing Individual budgets language to state they are guidelines and are “not a binding limit on the amount of services that can be requested or approved.”;
• Allowing for certain circumstances when the $135,000 waiver limit can be exceeded and parameters around requesting a Intensive Review;
• Adding Supported Living to services that can be self-directed.