Interim Guidance for the Use of Telemedicine, Teledentistry, and Telehealth for HIV Core and Support Services - Users Guide and FAQs

Including Emergency Guidance for Use During the COVID-19 State Public Health Emergency (PHE)

The purpose of this guide is to offer further clarification on DSHS’ guidance on telemedicine, teledentistry, and telehealth as well as the modifications to federal and state law and DSHS Ryan White policies enacted during the Public Health Emergency (PHE) due to COVID-19.
 

What is Telemedicine?

• Telemedicine is when a physician or a licensed medical professional operating under the supervision of a physician delivers any type of medical service, examination, or consultation via electronic means rather than in person.
• Mental health counseling services offered by a licensed provider via electronic means is considered telemedicine and not telehealth.
• Telemedicine is defined and regulated by law.
   

What is Teledentistry?

• Teledentistry is when a dentist or a licensed health professional operating under the supervision of a dentist delivers any type of dental service via electronic means rather than in person.
• Teledentistry is defined and regulated by law.
   

What is Telehealth?

• Telehealth is when a licensed or certified health professional who is not required to practice under the supervision of a physician delivers services via electronic means rather than in person.
• Telehealth is defined and regulated by law.
   

What Ryan White services can be delivered remotely?

• The Health Resources and Services Administration’s (HRSA) Policy Clarification Notice (PCN) update to 16-02 focuses on the delivery of Outpatient Ambulatory Health Services and Medical Case Management via electronic means, but also encourages the use of telehealth to deliver services related to HIV diagnosis, care and support.
• DSHS permits any Ryan White-funded service to be delivered using telemedicine, teledentistry, or telehealth.
• Services that do not fall under the legal definition of telemedicine, teledentistry, or telehealth and can be delivered or performed by staff who do not need to have licensure or accreditation (ex., Medical Case Management, Non-Medical Case Management, Emergency Financial Assistance, Referral for Healthcare) should follow DSHS’ guidance for telehealth, regardless of if those services are listed in the Ryan White taxonomy under Core Medical or Support Services.
   

What systems can I use to deliver services remotely?

• Any HIPAA-compliant telemedicine platform is strongly recommended for telemedicine or telehealth. The Texas Medical Association (TMA) and the US Department of Health and Human Services (DHHS) both offer sample lists of HIPAA compliant platforms.
• A vendor Business Associate Agreement (BAA) is required to ensure the safety of Protected Health Information (PHI) when using electronic communications and platforms.
• The declared COVID-19 PHE allows the following modifications:
  • The telephone (audio only) can be used for medical visits
  • Platforms with audio and video that are not encrypted but are not public-facing are permitted
• Subrecipients that have platforms that are HIPAA-compliant should continue to use them if they are able to.
• Subrecipients using non-HIPAA-compliant platforms during the PHE should look for an encrypted platform to seamlessly continue remote services after the PHE has ended; DSHS will not permit use of non-compliant systems for Ryan White services after the PHE has been rescinded.
   

Do I need to document client permission to access services electronically?

• A signed (electronic signature permitted) informed consent listing the specific parameters and risks of telemedicine, teledentistry, or telehealth should be received from the client. TMA provides a sample informed consent.
• DSHS allows the following modifications during the PHE:
  • Use of a client’s verbal consent if this is documented in the client’s record that the benefits and risks of telemedicine, teledentistry, and telehealth were explained to the client.
  • A good faith effort must be made to obtain the patient’s written or electronic acknowledgement by the usual methods.
  • This modification applies to services provided through DSHS’ Ryan White Program.
     

How do I document the services I provide via electronic means?

• Subrecipients should document telemedicine, teledentistry, or telehealth services the same way they would document a comparable in-person service.
• The declared COVID-19 PHE allows the following modification:
  • The requirement to keep complete and accurate medical records has been waived if the strict compliance to this requirement would prevent, hinder, or delay timely delivery of necessary medical services in relation to efforts to cope with the declared disaster.
• Subrecipients who are able to document telemedicine services without compromising client access should continue to do so.
• This exemption has been declared by the Governor and the Texas Medical Board (TMB) for telemedicine; providers not regulated by TMB and reporting to another licensing board should check with that entity for direction.
• For guidance on security measures for accessing client electronic or paper records while working remotely outside the office during the PHE, see DSHS PHI Protocols in Response to COVID-19.
   

Do I still have to follow the Ryan White Standards of Care when using telemedicine, teledentistry, or telehealth and during COVID-19?

• All Core Medical and Support Services provided via telemedicine and telehealth must follow the DSHS Standards of Care.
• State law dictates that a health service provided via telemedicine or teledentistry is subject to the standard of care that would apply to same health care service or procedure in an in-person setting.
• DSHS has the following modifications during the PHE:
  • For OAHS and/or MCM: If a client is being seen for urgent or acute care rather than routine HIV care or if there is limited access to any specific service or a barrier to meeting any specific quality indicator, the provider should document this in their note for consideration of being excluded from the indicator.
  • Most indicators have a timeline criterion of “at least once during the measure period” and as the duration or full impact of COVID-19 on systems of care are not known at this time, this may change.
  • Subrecipients should document any barriers to following the DSHS Standards of Care as applicable in the client record for visits completed during the state of the PHE.
     

How do I get paid for services I deliver through telemedicine, teledentistry, or telehealth?

• The DSHS Ryan White Program will reimburse for all services on the taxonomy delivered through telemedicine, teledentistry, and telehealth as long as they meet the requirements in the DSHS Telemedicine, Teledentistry, and Telehealth guidance including:
  • All applicable state and federal law and modifications due to COVID-19
  • DSHS Ryan White Standards of Care for the service being provided
  • Any deviations from the DSHS Standards of Care are documented in the client file
• Check with each on-Ryan White funding source or third-party payer before enacting any modification to their usual operating procedures so that billings or claims are not denied due to lack of compliance. The Texas Department of Insurance (TDI) has issued modifications for payment of telemedicine or telehealth services during the PHE.
• Teledentistry is allowable per State law as of September 1, 2021 and will be reimbursable through public benefits programs, Medicaid, and many other private third-party payers as of January 1, 2022. Providers should ensure that any teledentistry services billed to Ryan White are in compliance with payer of last resort requirements.
• While behavioral health services have been allowable by telephone (audio only) for some time, counseling delivered by telephone is reimbursable by Medicaid and other public benefits programs as of June 15, 2021.
• Services such as preventive health and wellness; case management and care coordination; occupational, physical, and speech therapy; nutritional counseling; assessment (nursing); substance use treatment, and home telemonitoring services delivered via telehealth are reimbursable by Medicaid and other public benefits programs as of June 15, 2021.
• As private insurers often follow Medicaid rules, providers should check with other insurers to determine when and if they intend to begin reimbursing for these services.
   

Do these guidelines apply to all of my clients?

• The modifications regarding HIPAA apply across the federal level for all services subject to federal privacy laws.
• The modifications enacted by the Governor’s Office and Texas Medical Board (TMB) apply to services that are clinical/medical and regulated by TMB. Check with other applicable licensing boards for their modifications.
• Note that all other information in this guide and the DSHS Telemedicine and Telehealth Guidance is intended for use by the DSHS Ryan White Program. Other grantors and third-party payers may adhere to or recognize different rules or regulations.
   

Questions from the Field

Please submit questions regarding DSHS telemedicine or telehealth guidance to Loretta Holland, HIV Care Services Consultant (loretta.holland@dshs.texas.gov)
 

Q1. If only non-clinical (not medical) services are provided via telehealth, is there an expectation that an agency has a medical director or designated physician?

No, the intention is to ensure that a staff person who has supervisory authority oversees the tele system of care directs quality control; ensures compliance with DSHS telemed/health guidelines, state law, and internal agency policies; and is generally responsible for oversight of tele service delivery. For non-medical programs, this could be a Program Director or equivalent.