Wisconsin Medicaid Coverage of Telehealth Services

>Wisconsin Medicaid Coverage of Telehealth Services

Wisconsin Medicaid Coverage of Telehealth Services

WIAAP has been working with the Medicaid’s Telehealth Project Management Office to outline the many questions that surround provision of well child and other services via telehealth in light of the COVID-19 pandemic.

In particular, published guidance may be interpreted to indicate that well-child visits performed via phone or video (to the extent possible) will be covered by Medicaid in the same way that health supervision visits done “traditionally” (in-person, in-clinic) would be. Since that is not outlined specifically, however, many of our members — who are currently deeply uncertain about doing well-child visits via phone or video for fear of not being appropriately reimbursed — are looking for formal written guidance to that effect.

There is a formal policy in ForwardHealth Update 2020-15, published on 3/30/2020, that indicates:

“Beginning on March 12, 2020, and for the duration of the Wisconsin public health emergency for COVID-19, ForwardHealth will allow telehealth services utilizing interactive synchronous (real-time) technology, including audio-only phone communication, for currently covered services that can be delivered with functional equivalency to the face-to-face service. This applies to all service areas and all enrolled professional and paraprofessional providers allowable within current ForwardHealth coverage policy. Services that are not currently covered on a face-to-face basis are not covered via telehealth.”

While pediatricians can’t perform many aspects of a physical exam via telehealth to a patient’s home, we recognize that many of the most meaningful aspects of health supervision visits are through skilled questions and dialogue with families — which is indeed possible via telehealth. The term “functionally equivalent” then would apply to those services even if a face-to-face service even if a physical exam is not being conducted.

If immunizations or screening lab work was being deferred, the expectation is that those would be performed as soon as would be feasible, but it is at each provider’s discretion as to whether providing the core visit via telehealth suffices to meet the intention of Bright Futures. A provider may also decide whether a follow up physical exam will be necessary or whether it would not provide more than minimal additional information.

In other words, while ForwardHealth has not defined “functional equivalency to the face-to-face service” in detail, written correspondence between the Wisconsin AAP and Wisconsin Medicaid indicates the following:

“Telehealth may be appropriate for members who can stay near the device being used to provide telehealth services and participate in therapeutic or supportive activities with a provider who is not physically present. Telehealth may be appropriate for goals that can be accomplished through verbal and visual cueing. Telehealth is not appropriate for activities that require physical interaction or for goals that require hands-on support or physical prompting.

“At this time, DMS does not have plans to provide guidance on individual services and their functional equivalency via telehealth.

“Providers are expected to perform clinically appropriate services within their scope of practice and exercise professional judgment (emphasis theirs) in determining if services can be delivered effectively via telehealth, and bill accordingly. Telehealth may be appropriate for members who can stay near the device being used to provide telehealth services and participate in therapeutic or supportive activities with a provider who is not physically present. Telehealth may be appropriate for goals that can be accomplished through verbal and visual cueing. Telehealth is not appropriate for activities that require physical interaction or for goals that require hands-on support or physical prompting.”

Members can sign up for ForwardHealth Updates to be made aware of policy changes as they occur in real time.