HBA-JEK C.S.S.B. 789 77(R) BILL ANALYSIS Office of House Bill AnalysisC.S.S.B. 789 By: Moncrief Public Health 5/7/2001 Committee Report (Substituted) BACKGROUND AND PURPOSE Texas faces unique challenges with its health care system. The state has experienced a larger population increase than any other state in the nation in the past decade, especially in its Hispanic and aging babyboomer populations. Rural Texas has difficulty recruiting doctors, and several counties in Texas do not even have a physician. Telemedicine has the potential to bring health services to rural and underserved communities. C.S.S.B. 789 sets forth provisions regarding the reimbursement and the regulation of telemedicine medical services in Texas. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that rulemaking authority is expressly delegated to the Health and Human Services Commission in SECTION 1 (Section 531.0216, Government Code), SECTION 2 (Section 531.02161, Government Code), SECTION 3 (Section 531.0217, Government Code), SECTION 15 (Section 57.0475, Utilities Code), SECTION 17 (Section 32.053, Human Resources Code), and SECTION 21, to the Telecommunications Infrastructure Fund Board in SECTION 2 (Section 531.02161, Government Code) and SECTION 15 (Section 57.0475, Utilities Code), to the Texas Board of Mental Health and Mental Retardation in SECTION 18 (Section 533.102, Health and Safety Code), and to the Texas State Board of Medical Examiners in SECTION 3 (Section 531.0217, Government Code), and SECTION 9 (Section 6, Article 21.53F, Insurance Code) of this bill. ANALYSIS C.S.S.B. 789 amends the Government Code to require the Health and Human Services Commission (HHSC) and the Telecommunications Infrastructure Fund Board (TIF board) by joint rule to establish and adopt minimum standards for an operating system used in the provision of telemedicine medical services (telemedicine) by a health care facility participating in the state Medicaid program no later than October 1, 2001. The bill sets forth requirements for minimum standards for the system (SECTIONS 2 and 20). The bill requires HHSC no later than January 1, 2002, to require by rule each human services agency that administers a part of the Medicaid program to provide Medicaid reimbursement for a telemedicine medical service that is initiated by or provided by a physician (SECTIONS 3 and 21). C.S.S.B. 789 prohibits HHSC from reimbursing a health care facility for telemedicine provided to a Medicaid recipient unless the facility complies with the minimum standards adopted by HHSC and the TIF board. The bill requires HHSC by rule to consult with the Texas Department of Health (TDH) and the telemedicine advisory committee to develop a procedure to deny reimbursement for a health care service that, based on credible, clinical evidence, is shown to be medically inappropriate. C.S.S.B. 789 requires HHSC by rule to establish pilot programs in designated areas under which HHSC, in administering government-funded health programs, may reimburse a health professional participant in the pilot program for telehealth services and by rule to establish a separate provider identifier for telemedicine providers. The bill requires HHSC to report to the speaker of the house of representatives and the lieutenant governor on the effects of telemedicine on the Medicaid program in the state no later than December 1 of each evennumbered year, and authorizes HHSC to adopt rules as necessary to implement provisions related to telemedicine reimbursement (SECTION 1). C.S.S.B. 789 provides that HHSC shall require facilities and providers of telemedicine medical services to make a good faith effort to identify and coordinate with existing providers to preserve and protect existing health care systems and medical relationships in an area. The bill requires HHSC to require a patient's primary care physician or provider to be notified of the telemedicine medical service for the purpose of sharing information if the patient consents to the notification. The bill requires HHSC in consultation with the Texas State Board of Medical Examiners (TSBME) to monitor and regulate the use of telemedicine to ensure compliance with these provisions, and authorizes HHSC to use a corrective action plan to ensure compliance (SECTION 3). C.S.S.B. 789 amends the Government and Insurance codes to authorize TSBME, in consultation with HHSC, to adopt rules as necessary to establish supervisory requirements for a service delegated to and performed by an individual who is not a physician, to define those situations when a face-to-face consultation with a physician is required after a telemedicine medical service. The bill authorizes TSBME in consultation with the commissioner of insurance to adopt rules necessary to ensure adequate supervision of health professionals who are not physicians and who provide telemedicine, to establish the maximum number of health professionals who are not physicians that a physician may supervise through telemedicine, and to require a face-to-face consultation between a patient and a physician providing telemedicine within a certain number of days following an initial telemedicine service only if the physician has never seen the patient (SECTIONS 3 and 9). The bill amends the Government Code to provide that the advisory committee established by HHSC is to coordinate state telemedicine efforts and assist HHSC in evaluating, monitoring, and coordinating telemedicine services and reimbursement. The bill provides that the telemedicine provisions do not affect any requirement relating to a federally qualified health center, a rural health clinic, or physician delegation of the authority to carry out or sign prescription drug orders to an advanced practice nurse or physician assistant (SECTION 3). C.S.S.B. 789 amends the Health and Safety Code to provide that a health plan provider that is providing state child health plan (CHIP) covered benefits to a child must permit benefits to be provided through telemedicine in accordance with policies developed by HHSC. The bill sets forth benefits for which the policies must provide and requires HHSC to consult with the telemedicine advisory committee in developing the polices (SECTION 4). C.S.S.B. 789 amends the Utilities Code to require the TIF board to establish an assistance program to provide education concerning the telecommunications infrastructure fund and to facilitate access to funds and programs by health care facilities and physicians (SECTION 12). The bill requires the TIF board to use money in the qualifying entities account for funding an automated system to integrate client services and eligibility requirements for health and human services across agencies (SECTION 13). This requirement expires September 1, 2003 (SECTION 23). The bill requires the TIF board and HHSC jointly to adopt rules prescribing the criteria that certain health care facilities must meet to be eligible to receive a grant from the TIF board and sets forth requirements regarding the criteria (SECTION 15). On customer request, the bill requires an electing company to provide private network services to a project that would have been eligible to be funded by the telecommunications infrastructure fund under provisions existing January 1, 2001 (SECTION 16). C.S.S.B. 789 amends the Human Resources Code to require HHSC to establish a home telemedicine pilot program under which certain Medicaid recipients receive home health care services through home telemonitoring systems. The bill sets forth provisions regarding the eligibility criteria, the locations, the reimbursement levels, and the services provided through the pilot program. In designing and implementing the pilot program, HHSC is required to ensure that a participant receives the necessary equipment, training, and instruction and that a participant's satisfaction and the quality of services is frequently monitored and evaluated. The bill requires HHSC to adopt rules necessary for implementing the pilot program and to submit a report to the legislature regarding the program by December 1, 2004. The pilot program expires September 1, 2005 (SECTION 17). C.S.S.B. 789 amends the Health and Safety Code to require the Texas Board of Mental Health and Mental Retardation (MHMR board) and the Texas Department of Mental Health and Mental Retardation (MHMR) to develop and implement a pilot program (jail diversion program) in one rural area and one urban area designed to incorporate audiovisual telecommunications systems to divert persons with mental illness from the criminal justice system, to provide access to appropriate mental health services to persons who have entered the criminal justice system, and to increase the awareness of law enforcement officers and officials to mental health issues that may bring persons with mental illness into the criminal justice system. The bill requires HHSC to employ to the greatest extent practicable available electronic information systems for the jail diversion program. The bill requires MHMR and participating legal and mental health entities to enter into an agreement regarding the jail diversion program and the duties of each participating entity. The bill requires a participating county to be responsible for establishing the diversion team as prescribed by the department. The bill requires the jail diversion program to incorporate prebooking diversion and postbooking diversion in court and in jail. The bill specifies that the jail diversion program must provide for the electronic transmission of information concerning all admissions to jails participating in the program to an information system at a local mental health authority. The bill requires the MHMR board to evaluate the jail diversion program and to report to the governor, lieutenant governor, and speaker of the house of representatives not later than November 1 of each even-numbered year. The jail diversion program expires September 1, 2005 (SECTION 18). The bill requires the commissioner of human services to appoint not later than the 30th day after the effective date of this bill a program administrator to administer a pilot program that uses teledentistry and other methods of delivering dental services to provide dental services to students in one public school district in the state (teledentistry program). C.S.S.B. 789 sets forth the conditions under which, for purposes of the teledentistry program, a licensed dentist may delegate orally, in writing, or through advanced audio and video telecommunications services a service, task, or procedure to a dental hygienist under his or her supervision. The bill requires the program administrator to establish an advisory committee for the teledentistry program within 30 days of being appointed (SECTIONS 19 and 22). The bill sets forth provisions regarding the development and implementation of the teledentistry program. The bill specifies that only a teledentistry dental service initiated by or provided by a licensed dentist in this state may be reimbursed under the Medicaid program at the same rate as the Medicaid program reimbursements for a comparable in-person dental service. The bill prohibits a request for reimbursement from being denied solely because an in-person consultation between a dentist or other dental professional and a patient did not occur. The bill also prohibits a teledentistry dental service from being provided under the teledentistry program if an in-person consultation with a dentist is reasonably available to a student. The program administrator is required to use the results of the teledentistry program to determine the efficacy and the effectiveness of teledentistry. The bill requires the program administrator to report on the teledentistry program to the legislature no later than December 31, 2002. The teledentistry program expires and the advisory committee is abolished December 31, 2002 (SECTION 19). EFFECTIVE DATE On passage, or if the Act does not receive the necessary vote, the Act takes effect September 1, 2001. COMPARISON OF ORIGINAL TO SUBSTITUTE C.S.S.B. 789 differs from the original bill by establishing a home telemedicine pilot program, jail diversion pilot program for persons with mental illness, and a teledentistry pilot program for implementation in a school (SECTIONS 17-19). The substitute adds provisions regarding telemedicine medical services for children through the state child health plan (CHIP) (SECTION 4). The substitute requires the Health and Human Services Commission (HHSC) and the Telecommunications Infrastructure Fund Board (TIF board) by joint rule to establish and adopt minimum standards for an operating system used in the provision of telemedicine medical services by a health care facility participating in the state Medicaid program (SECTIONS 2 and 20). The substitute prohibits HHSC from reimbursing a health care facility for telemedicine medical services provided to a Medicaid recipient unless the facility complies with these minimum standards. The substitute requires HHSC by rule to consult with the Texas Department of Health (TDH) and the telemedicine advisory committee (committee) to develop a procedure to deny reimbursement for a medical service that is shown to be medically inappropriate. The substitute removes provisions requiring HHSC to consult with TDH and the committee to establish procedures to identify clinical evidence supporting delivery of health care services using a telecommunications system and establish pilot studies for telemedicine medical service delivery, and annually review reimbursement for health care services. (SECTION 1). The substitute sets forth eligibility criteria for grants for telemedicine medical services to health care facilities (SECTION 15). C.S.S.B. 789 requires the TIF board to use money in the qualifying entities account for funding an automated system to integrate client services and eligibility requirements for health and human services across agencies (SECTIONS 13 and 23). The substitute adds that a telemedicine patient's consent is necessary to require the patient's primary care provider to be notified of the telemedicine services provided. The substitute modifies the duties of the telemedicine advisory committee (SECTION 3). C.S.S.B. 789 requires the Texas State Board of Medical Examiners, in consultation with the commissioner of insurance, to adopt rules to ensure adequate supervision of health professionals who are not physicians and who provide telemedicine medical services, to establish the maximum number of health professionals who are not physicians that a physician may supervise through a telemedicine medical service, and to require a face-to-face consultation between a patient and a physician providing a telemedicine medical service if the physician has never seen the patient (SECTION 9). The substitute modifies the conditions under which an electing company is required to provide private network services to telecommunications infrastructure projects (SECTION 16). The substitute removes provisions authorizing the appropriate licensing agency for a person providing telehealth services to adopt rules, in consultation with the commissioner of insurance, to ensure that appropriate care is provided and to prevent abuse and fraud.