20-1406.05. Telehealth; coverage of health care services; definition

A. All policies issued, delivered or renewed by a group disability insurer or a blanket disability insurer 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 insured and a health care provider and provided to an insured receiving the service in this state.  The following requirements apply to coverage of telehealth services:

1. Except as otherwise provided in this subsection, a group or blanket disability insurer 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 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 group or blanket disability insurer 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 group or blanket disability insurer 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 group or blanket disability insurer.  A group or blanket disability insurer may not require a health care provider to use a telehealth platform that is sponsored or provided by the group or blanket disability insurer as a condition of network participation.

3. Before January 1, 2022, a group or blanket disability insurer shall cover services provided through an audio-only telehealth encounter if that service is reimbursed by medicare or the Arizona health care cost containment system when provided through an audio-only telehealth encounter.  Beginning January 1, 2022, a group or blanket disability insurer 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 insured before the telehealth encounter if there is a charge for the encounter.

6. A group or blanket disability insurer 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 insureds than are required for health care services delivered in person.

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

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

B. Subsection A of this section does not:

1. Limit the ability of group or blanket disability insurers to provide incentives to insureds that are designed to improve health outcomes, increase adherence to a course of treatment or reduce risk.

2. Prevent group or blanket disability insurers 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 group or blanket disability insurer.

C. This section does not relieve a group or blanket disability insurer 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 group or blanket disability insurer 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 group or blanket disability insurer 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 group or blanket disability insurer waives a deductible or copayment or coinsurance requirement that impacts a health care provider's contracted reimbursement rate, the group or blanket disability insurer 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 insured 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 insured's functional status, the insured'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 insured or authorized by the insured before the telehealth encounter.

(b) The use of an audio-only encounter between the insured 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.