Section 52.16 - Access to Covered Services through Telehealth(1) A Carrier shall provide coverage for Health Care Services delivered via Telehealth by a contracted Network Provider if: (a) the Health Care Services are covered by way of in-person consultation or delivery; and(b) the Health Care Services may be appropriately provided through the use of Telehealth.(2) A Carrier shall not meet Network adequacy through significant reliance on Network Providers who deliver Health Care Services via Telehealth only and shall not be considered to have an adequate Network if patients are not able to access appropriate in-person services in a timely manner upon request. Coverage shall not be limited to services delivered by Providers who are contracted through third-party Telehealth vendors.(3) A Carrier may undertake Utilization Review, including preauthorization, to determine the appropriateness of Telehealth as a means of delivering a Health Care Service; provided, however, that the determination shall be made in the same manner as if the service was delivered in person.(4) A Carrier shall not be required to reimburse a Health Care Professional for a Health Care Service that is not a covered benefit under the plan. A Carrier shall not be required to reimburse a Health Care Professional not contracted under a closed Network plan except as provided for under subclause (4) of subsection (a) of section 6 of chapter 176O.(5) A Health Care Professional shall not be required to document a barrier to an in-person Visit in or shall the type of setting where Telehealth services are provided be limited for Health Care Services provided via Telehealth; provided, however, that a patient may decline receiving services via Telehealth in order to receive in-person services.(6) A Carrier's coverage may provide for patient Cost-sharing (copayment, coinsurance, deductible) for services delivered during a Telehealth Visit; provided that the patient Cost-sharing does not exceed the deductible, copayment, or coinsurance applicable to the same services provided during an in-person Visit with a Health Care Provider.(7) Carriers shall ensure that the in-Network rate of reimbursement for services delivered during a Telehealth Visit with Health Care Professionals of covered Behavioral Health Services when provided via interactive audio-video technology or audio-only telephone shall be no less than the rate of payment for the same Behavioral Health Service provided via an in-person Visit with a Health Care Provider.(8) The rate of payment for services delivered during a Telehealth Visit when provided via synchronous interactive audio-video technology or audio-only telephone may be greater than the rate of payment for the same service delivered by other Telehealth modalities.(9) Coverage that reimburses a Health Care Professional with a Global Payment shall account for the provision of Telehealth services when setting the global payment reimbursement amount.(10) Carriers will contractually require that Health Care Professionals use Telehealth technology that conforms to applicable federal and state health information privacy and security standards as well as standards for informed consent. As long as the technology meets these standards, a Carrier shall not limit the use of a Telehealth communications platform that conforms to such standards.(11) Carriers are to include information within Network Directories about which Providers are available to deliver services via Telehealth. A Carrier should forward its comprehensive Telehealth plan to the Division, and such plan will subsequently be forwarded as part of the biennial managed care Accreditation process. The Telehealth plan should include the following: (a) The communications that will be used with Providers to specify the service and documentation standards that a Provider will need to meet in order for services provided by Telehealth to be covered by the Carrier;(b) A statement that restricts covered Telehealth Visits to those that are compatible with state/federal privacy standards;(c) A list of the services that will not be covered when provided to a covered person via Telehealth, and an explanation for why these services are not covered;(d) An explanation of how and when Cost-sharing (copayments, coinsurance, and deductibles) will apply for Telehealth services, and if Cost-sharing is waived, a description of the exact circumstances under which the Cost-sharing will be waived.(e) A statement of how the Carrier intends to reimburse Providers for the following Telehealth services: 1. Behavioral Health Services;2. Primary Care Services; and3. Chronic Disease Management services; and4. All other services, including those provided by Asynchronous Telehealth.(f) An identification of the billing codes, location codes or other codes that the Carrier intends to use to reimburse Providers for Telehealth services, including the following: 1. when Telehealth may be used for follow-ups that may be considered less than a Visit, a description of how the Carrier intends to reimburse Providers for these follow-up Telehealth services; and2. physical exams, including those that have both Telehealth and in-person components.Amended by Mass Register Issue 1345, eff. 8/11/2017.Amended by Mass Register Issue 1509, eff. 11/24/2023.