20-1057.13. Telehealth; coverage of health care services; definition

A. An evidence of coverage issued, delivered or renewed by a health care services organization in this state must provide coverage for health care services that are provided through telehealth if the health care service would be covered were it provided through an in-person encounter between the enrollee and a health care provider and provided to an enrollee receiving the service in this state.  The following requirements apply to coverage of telehealth services:

1. Except as otherwise provided in this subsection, a health care services organization may not limit or deny the coverage of health care services provided through telehealth, including ancillary services, and may apply only the same limits or exclusions on a health care service provided through telehealth that are applicable to an in-person encounter for the same health care service, except for procedures or services as identified by the diagnostic and procedure codes, for which the weight of evidence, based on practice guidelines, peer-reviewed clinical publications or research or recommendations by the telehealth advisory committee on telehealth best practices established by section 36-3607, determines not to be appropriate to be provided through telehealth.

2. Except as otherwise provided in this paragraph, a health care services organization shall reimburse health care providers at the same level of payment for equivalent services as identified by the healthcare common procedure coding system, whether provided through telehealth using an audio-visual format or in-person care. A health care services organization shall reimburse health care providers at the same level of payment for equivalent in-person behavioral health and substance use disorder services as identified by the healthcare common procedure coding system if provided through telehealth using an audio-only format.  This paragraph does not apply to a telehealth encounter provided through a telehealth platform that is sponsored or provided by the health care services organization. A health care services organization may not require a health care provider to use a telehealth platform that is sponsored or provided by the health care services organization as a condition of network participation. 

3. Before January 1, 2022, a health care services organization shall cover services provided through an audio-only telehealth encounter if that service is covered by medicare or the Arizona health care cost containment system when provided through an audio-only telehealth encounter.  Beginning January 1, 2022, a health care services organization shall cover services provided through an audio-only telehealth encounter if the telehealth advisory committee on telehealth best practices established by section 36-3607 recommends that the services may appropriately be provided through an audio-only telehealth encounter.

4. A health care provider shall bill for a telehealth encounter using the healthcare common procedure coding system and shall identify whether the telehealth encounter was provided in an audio-only or audio-video format.  To submit a claim for an audio-only service, the health care provider must make telehealth services generally available to patients through the interactive use of audio, video or other electronic media. 

5. At the time of the telehealth encounter, the health care provider shall access clinical information and records, if available, that are appropriate to evaluate the patient's condition.  The health care provider shall inform the enrollee before the telehealth encounter if there is a charge for the encounter.

6. A health care services organization may establish reasonable requirements and parameters for telehealth services, including documentation, fraud prevention, identity verification and recordkeeping, but such requirements and parameters may not be more restrictive or less favorable to health care providers or enrollees than are required for health care services delivered in person.

7. Covered telehealth services may be provided regardless of where the enrollee is located or the type of site.

8. Except in an emergency as prescribed in section 20-2803, the evidence of coverage may limit the coverage to those health care providers who are members of the health care services organization's provider network.

B. Subsection A of this section does not:

1. Limit the ability of health care services organizations to provide incentives to enrollees that are designed to improve health outcomes, increase adherence to a course of treatment or reduce risk.

2. Prevent health care services organizations from offering network contracts to health care providers who employ value-based purchasing or bundled payment methodologies if otherwise allowed by law or prevent health care providers from voluntarily agreeing to enter into such contracts with a health care services organization.

C. This section does not relieve a health care services organization from an obligation to provide adequate access to in-person health care services.  Network adequacy standards required by federal or state law may not be met by a health care services organization through the use of contracted health care providers who provide only telehealth services and do not provide in-person health care services in this state or within fifty miles of the border of this state. 

D. This section does not prevent a health care services organization from imposing deductibles or copayment or coinsurance requirements for a health care service provided through telehealth if the deductible, copayment or coinsurance does not exceed the deductible, copayment or coinsurance applicable to an in-person encounter for the same health care service.  If the health care services organization waives a deductible or copayment or coinsurance requirement that impacts a health care provider's contracted reimbursement rate, the health care services organization shall reimburse the health care provider for the cost of the deductible or copayment or coinsurance requirement to ensure that the health care provider receives the contracted reimbursement rate if the service is covered and the claim meets other requirements of the network participation agreement.

E. Services provided through telehealth or resulting from a telehealth encounter are subject to all of this state's laws and rules that govern prescribing, dispensing and administering prescription pharmaceuticals and devices and shall comply with Arizona licensure requirements and any practice guidelines of the telehealth advisory committee on telehealth best practices established by section 36-3607 or, if not addressed, the practice guidelines of a national association of medical professionals promoting access to medical care for consumers via telecommunications technology or other qualified medical professional societies to ensure quality of care.

F. This section does not apply to limited benefit coverage as defined in section 20-1137.

G. For the purposes of this section, "telehealth":

1. Means the interactive use of audio, video or other electronic media, including asynchronous store-and-forward technologies and remote patient monitoring technologies, for the purpose of diagnosis, consultation or treatment.

2. Includes:

(a) The use of an audio-only telephone encounter between an enrollee who has an existing relationship with a health care provider or provider group if both of the following apply:

(i) An audio-visual telehealth encounter is not reasonably available due to the enrollee's functional status, the enrollee's lack of technology or telecommunications infrastructure limits, as determined by the health care provider.

(ii) The telehealth encounter is initiated at the request of the enrollee or authorized by the enrollee before the telehealth encounter.

(b) The use of an audio-only encounter between the enrollee and a health care provider, regardless of whether there is an existing relationship with the health care provider or provider group, if the telehealth encounter is for a behavioral health or substance use disorder service and both items of subdivision (a) of this paragraph apply.

3. Does not include the sole use of a fax machine, instant messages, voice mail or email.