Telemedicine, Teledentistry, and Telehealth for HIV Core and Support Services

1.0 Purpose

This guidance applies to Ryan White Part B or State Services subrecipients who use telemedicine, teledentistry, or telehealth to provide Core Medical or Support Services. The Health Resources and Services Administration’s (HRSA) Policy Clarification Notice (PCN) 16-02 encourages the use of telehealth to deliver services related to HIV diagnosis, care, and support. The Texas Department of State Health Services (DSHS) bases this guidance on the Texas Medicaid Telecommunications Policy, Volume 2, July 2023, as well as the Texas Administrative Code (TAC) and the Texas Occupations Code (OCC).
 

2.0 Definitions

Distant site – The physical location of the professional rendering the service.

Patient site – The physical location of the client. Locations may include:

• Client’s home or other location considered private and appropriate by the client; or
• Free-standing clinic or ambulatory care facility

Store and Forward Technology – A telecommunications platform meeting the privacy requirements of the Health Insurance Portability and Accountability Act (HIPAA) that stores and transmits or grants access to a person’s clinical information for review by a health professional at a different physical location than the person.

Synchronous – Interactive video connections transmitting information in both directions; this term refers to live, real-time, interactive patient and health professional interactions.

Telehealth – A health service, other than a telemedicine medical service or a teledentistry dental service, delivered by a health professional licensed, certified, or otherwise entitled to practice in Texas and acting within the scope of the health professional’s license, certification, or entitlement to a patient at a different physical location than the health professional using telecommunications or information technology.

Telemedicine – Health care services delivered by a physician licensed in Texas, or a health professional who acts under the delegation and supervision of a health professional licensed in Texas and within the scope of the health professional’s license, to a patient at a different physical location using telecommunications or information technology. In Texas, mental health services are regulated as telemedicine, even when provided by a professional who lacks prescriptive authority.

Teledentistry – Health care services delivered by a dentist, or a health professional acting under the delegation and supervision of a dentist, acting within the scope of the dentist’s or health professional’s license or certification to a patient at a different physical location than the dentist or health professional using telecommunications or information technology.
 

3.0 General Requirements

DSHS-funded Part B or State Services subrecipients using telemedicine, teledentistry, or telehealth to provide Core Medical or Support Services must adhere to the following requirements:

• TAC, OCC, and state licensing boards must permit medical or health services delivered through telemedicine, teledentistry, or telehealth;
• The subrecipient must establish safeguards to ensure confidentiality and privacy in accordance with state and federal laws;
• The documentation of services rendered must be the same as for a comparable in-person service; 
• In accordance with OCC §111.006, professionals providing a health care service or procedure as a telemedicine service, a teledentistry service, or a telehealth service are subject to the standard of care that applies to the provision of the same health care service or procedure in an in-person setting;
• Core medical and support services provided via telemedicine, teledentistry, and telehealth must follow the HIV Medical and Support Service Categories;
• When a nonphysician practitioner requires a supervising physician, the supervising physician must be in the same physical location as the nonphysician practitioner; and
• Only established patients may use virtual check-in and e-visits.
   

4.0 Telemedicine Services

Title 22, Part 9, Chapter 174 of the Texas Administrative Code regulates telemedicine. Subchapter A pertains to medical services. Subchapter B pertains to mental health services. Chapter 174 defines mental health services, even those delivered by providers without prescribing authority, as telemedicine, not telehealth. 

For the DSHS Ryan White Program, providers may deliver some Core Medical Services via telemedicine, including Outpatient Ambulatory Medical Services (OAHS), Home Health Care, Mental Health Services, and Substance Abuse – Outpatient Care.

Providers may establish the practitioner-patient relationship with telemedicine in accordance with rules adopted under OCC §111.006.
 

5.0 Teledentistry Services

Title 22, Part 5, Chapter 108 of the Texas Administrative Code regulates teledentistry. Subchapter A, Rule §108.16 establishes the standards for the practice of teledentistry.

DSHS permits the use of teledentistry to serve Ryan White clients as of September 1, 2021. Teledentistry is billable to Medicaid and other third-party providers as of January 1, 2022, and providers must bill third-party payers in accordance with Ryan White payer of last resort requirements. The only Ryan White Part B service category providers may deliver via teledentistry is Oral Health Services.

Providers may establish the practitioner-patient relationship with teledentistry in accordance with rules adopted under OCC §111.006.
 

6.0 Telehealth Services 

Title 3, Subtitle A, Chapter 111 of the Texas Occupations Code regulates telehealth.

Core Medical and Support Services providers may deliver via telehealth include, but are not limited to, Medical Case Management, Non-Medical Case Management, Referral for Health Care and Support Services, and Local AIDS Pharmaceutical Assistance.
 

7.0 Service Delivery

Subrecipients may use the following modalities to deliver telemedicine, teledentistry, and telehealth services:

• Synchronous audiovisual technology between the distant site professional and the client in another location;
• Synchronous audio-only technology between the distant site professional and the client in another location; and
• Store and forward technology in conjunction with synchronous audio-only technology between the distant site professional and the client in another location. The distant site professional must use one of the following:
  • Clinically relevant photographic or video images, including diagnostic images; or
  • The client’s relevant medical records, such as medical history, laboratory and pathology results, and prescriptive histories.
     

8.0 Informed Consent

Prior to rendering the first telemedicine, teledentistry, or telehealth service with a client, the professional obtains informed consent regarding the benefits and risks of telemedicine, teledentistry, and telehealth from the client prior to evaluation or treatment. The professional secures this even if the client has an established in-person relationship with the provider.
 

9.0 Client Health Information Security

Subrecipients must adhere to the following guidelines when providing telemedicine and telehealth services:

• Physicians must use HIPAA-compliant platforms to deliver telemedicine services;
• The physical environment of the client and the distant site professional must ensure the client’s protected health information (PHI) remains confidential;
• Subrecipients providing telehealth or telemedicine medical services maintain the confidentiality of PHI as required by Federal Register 42, Code of Federal Regulations (CFR) Part 2, 45 CFR Parts 160 and 164, OCC Chapters 111 and 159, and other applicable federal and state law;
• Subrecipients providing telehealth or telemedicine services comply with the requirements for authorized disclosure of PHI relating to clients in an ambulatory health setting;
• The distant site professional stores client health information generated or utilized during a telehealth, teledentistry, or telemedicine service securely in a client health record or electronic health record;
• When the distant site professional stores the patient’s health information in an electronic health record (EHR), the professional uses software which complies with HIPAA confidentiality and data encryption requirements, as well as with the United States Department of Health and Human Services (HHS) rules implementing HIPAA; and
• HHS requires a Business Associate Agreement (BAA) to ensure the safety of PHI when using electronic communications and telehealth platforms; DHHS delineates the information required in a BAA and offers a sample downloadable BAA. Please note the sample is an example only, and the provider’s legal counsel would need to review it.
   

Other Resources

• Telemedicine Guide Resources