Public Health Ethics Group Presentation

Alabama Remote Patient Monitoring (RPM) policy:

Conditions:

• Remote Patient Monitoring (RPM) services are available to Medicaid eligible persons with a need for daily monitoring and with a diagnosis of one or more of the following conditions:
• Diabetes
• Gestational Diabetes (effective 10/1/2022)
• Hypertension
• Congestive Heart Failure
• Pediatric Asthma (effective 10/1/2022)
• An order from the recipient’s primary care physician (PCP) is required prior to the start of rendering RPM service. Orders for RPM, along with the specific parameters for daily monitoring, must be obtained from the patient’s PCP prior to evaluation and admission. The order must be documented in the medical record. Orders must be signed and dated by the ordering practitioner and must be obtained annually. Referrals for RPM may be accepted from any source, including physicians, ACHN Care Coordinators, patient or caregiver, the Health Department, hospitals, home health agencies, or community-based organizations. A practitioner must obtain patient consent before furnishing or billing RPM services.

Provider limitations:

Services rendered by non-physician practitioners, i.e., physician assistants, certified registered nurse practitioner, etc., must adhere to applicable guidelines, policies and procedures. Refer to Administrative Code chapters 6: Physicians and 49: Certified Register Nurse Practitioner (CRNP) for additional information.

A provider who contracts with Medicaid as an RPM provider is added to the Medicaid system with the National Provider Identifiers provided to the Agency at the time application is made. Appropriate provider specialty codes are assigned to enable the provider to submit requests and receive reimbursements for RPM related claims.

Any provider that can and is willing to pay the Alabama State Share may enroll as an RPM provider. A Memorandum of Understand (MOU) must be executed between the Medicaid Agency and the RPM provider. The MOU will outline the financial and medical responsibilities for the Medicaid Agency and the RPM provider. [3]

Requirements for RPM include but not limited to:

• Ability to provide services statewide.
• Meet appropriate clinical staffing requirements.
• Provides and allows the recipients to keep user friendly, interactive audio and video technology monitoring equipment.
•  
• Accepts electronic submissions of referrals.
• Provides an in-home initial assessment.
• Transmits recipient data automatically in real time (a Medicare requirement).
• Reviews, intervenes and reports on the data promptly.
• Provides 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified health care professionals or clinical staff, to address urgent needs of recipients.
• Develops, monitors and updates a patient-centered care plan
• Ongoing, compliance monitoring.
• Program graduation, when appropriate.

Kentucky Remote Patient Monitoring (RPM) Policy:

Pursuant to Section 7 of this administrative regulation, remote patient monitoring shall be an eligible telehealth service within the fee-for-service and managed care Medicaid programs [5]. A recipient participating in a remote patient monitoring service shall:

• Have the capability to utilize any monitoring tools involved with the ordered remote patient monitoring service. For the purposes of this paragraph, capability shall include the regular presence of an individual in the home who can utilize the involved monitoring tools; and
• Have the internet or cellular internet connection necessary to accommodate any needed remote patient monitoring equipment in the home.

The department may restrict the remote patient monitoring benefit by excluding:

• Remote patient monitoring equipment;
• Upgrades to remote patient monitoring equipment; or
• An internet connection necessary to transmit the results of the services.

Health care providers performing a telehealth or digital health service shall, as appropriate for the service, provider, and recipient, utilize the following modalities of communication delivered over a secure communications connection that complies with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA):

• Live or real-time audio and video synchronous telehealth technology;
• Asynchronous store-and-forward telehealth technology [6];
• Remote patient monitoring using wireless devices, wearable sensors, or implanted health monitors;
• Audio-only telecommunications systems; or

Clinical text chat technology when:

• Utilized within a secure, HIPAA compliant application or electronic health record system; and
• Meeting:
  • The scope of the provider’s professional licensure; and
  • The scope of practice of the provider; and
  • Comply with the following federal laws to prevent waste, fraud, and abuse relating to telehealth:
  • False Claims Act, 31 U.S.C. § 3729-3733;
  • Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b); and
  • Physician Self-Referral, Section 1877 of the Social Security Act

Conditions:

Pursuant to Section 7 of this administrative regulation, remote patient monitoring shall be an eligible telehealth service within the fee-for-service and managed care Medicaid programs [7]. Conditions for which remote patient monitoring shall be covered include:

• Pregnancy;
• Diabetes;
• Heart disease;
• Cancer;
• Chronic obstructive pulmonary disease;
• Hypertension;
• Congestive heart failure;
• Mental illness or serious emotional disturbance;
• Myocardial infarction;
• Stroke; or
• Any condition that the department determines would be appropriate and effective for remote patient monitoring.

Except for a recipient participating due to a pregnancy, a recipient receiving remote patient monitoring services shall have two (2) or more of the following risk factors:

Two (2) or more inpatient hospital stays during the prior twelve (12) month period;

• Two (2) or more emergency department admissions during the prior twelve (12) month period;
• An inpatient hospital stay and a separate emergency department visit during the prior twelve (12) month period;
• A documented history of poor adherence to ordered medication regimens;
• A documented history of falls in the prior six (6) month period;
• Limited or absent informal support systems;
• Living alone or being home alone for extended periods of time;
• A documented history of care access challenges; or
• A documented history of consistently missed appointments with health care providers.
• A recipient may participate in a remote patient monitoring program as the result of a pregnancy if the provider documents that the recipient has a condition that would be improved by a remote patient monitoring service

Provider limitations:

Remote patient monitoring shall be ordered by:

• A physician:
• An advanced practice registered nurse;
• A physician assistant; or
• When operating within their scope of practice and licensure, the following behavioral health practitioners:
  • A psychiatrist;
  • A licensed psychologist;
  • A licensed psychological practitioner;
  • A certified psychologist with autonomous functioning;
  • A licensed clinical social worker;
  • A licensed marriage and family therapist;
  • A licensed professional art therapist;
  • A licensed clinical alcohol and drug counselor; or
  • A licensed behavior analyst.

• Providers who may provide remote patient monitoring services include [8]:
  • A home health agency;
  • A hospital;
  • A federally qualified health center;
  • A rural health center;
  • A primary care center;
  • A physician;
  • An advanced practice registered nurse;
  • A physician assistant;
  • A behavioral health multi-specialty group participating in the Medicaid Program pursuant to 907 KAR 15:010;
  • A behavioral health services organization participating in the Medicaid Program pursuant to 907 KAR 15:020 or 907 KAR 15:022;
  • A residential crisis stabilization unit participating in the Medicaid Program pursuant to 907 KAR 15:070;
  • A chemical dependency treatment center participating in the Medicaid Program pursuant to 907 KAR 15:080;
  • A community mental health center that is participating in the Medicaid Program in compliance with 907 KAR 1:044, 907 KAR 1:045, or 907 KAR 1:047; or
  • A certified community behavioral health clinic that is participating

  Other restrictions:

  The department may restrict the remote patient monitoring benefit by excluding [9]:

  • Remote patient monitoring equipment;
  • Upgrades to remote patient monitoring equipment; or
  • An internet connection necessary to transmit the results of the services.

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