This document includes Senate Committee Amendments incorporated into the bill on Mon, Feb 13, 2017 at 5:19 PM by lpoole.
This document includes Senate Committee Amendments incorporated into the bill on Wed, Feb 15, 2017 at 9:31 AM by lpoole.
This document includes Senate 2nd Reading Floor Amendments incorporated into the bill on Wed, Feb 22, 2017 at 3:01 PM by lucydaynes.
1 2
3
4
5
6
7 LONG TITLE
8 General Description:
9 This bill amends the Medical Assistance Act, the Public Employees' Benefit and
10 Insurance Program Act, and the Insurance Code to provide coverage, and coverage
11 transparency, for certain telehealth services.
12 Highlighted Provisions:
13 This bill:
14 ▸ defines terms;
15 ▸ amends the Medical Assistance Act regarding reimbursement for telemedicine
16 services;
17 ▸ amends the Insurance Code to require insurer transparency regarding telehealth
18 reimbursement;
19 ▸ amends the Public Employees' Benefit and Insurance Program Act (PEHP)
20 regarding reimbursement for telemedicine services;
21 ▸ requires the Department of Health and PEHP to report to a legislative interim
22 committee and a task force regarding telehealth services;
23 ▸ requires a legislative study; Ŝ→ and ←Ŝ
24 ▸ describes responsibilities of a provider offering telehealth services Ŝ→ [
24a ←Ŝ
25 Ŝ→ [
26 conjunction with telehealth services.
27 Money Appropriated in this Bill:
28 None
29 Other Special Clauses:
30 None
31 Utah Code Sections Affected:
32 AMENDS:
33 26-18-13, as enacted by Laws of Utah 2008, Chapter 41
34 31A-22-613.5, as last amended by Laws of Utah 2015, Chapters 257 and 283
35 Ŝ→ [
36 ENACTS:
37 26-18-13.5, Utah Code Annotated 1953
38 26-59-101, Utah Code Annotated 1953
39 26-59-102, Utah Code Annotated 1953
40 26-59-103, Utah Code Annotated 1953
41 26-59-104, Utah Code Annotated 1953
42 26-59-105, Utah Code Annotated 1953
43 49-20-414, Utah Code Annotated 1953
44
45 Be it enacted by the Legislature of the state of Utah:
46 Section 1. Section 26-18-13 is amended to read:
47 26-18-13. Telemedicine -- Reimbursement -- Rulemaking.
48 (1) (a) [
49 telemedicine is considered [
50 and a patient under the state's medical assistance program if:
51 (i) the communication by telemedicine meets the requirements of administrative rules
52 adopted in accordance with Subsection (3); and
53 (ii) the health care services are eligible for reimbursement under the state's medical
54 assistance program.
55 (b) This Subsection (1) applies to any managed care organization that contracts with
56 the state's medical assistance program.
57 (2) The reimbursement rate for telemedicine services approved under this section:
58 (a) shall be subject to reimbursement policies set by the state plan; and
59 (b) may be based on:
60 (i) a monthly reimbursement rate;
61 (ii) a daily reimbursement rate; or
62 (iii) an encounter rate.
63 (3) The department shall adopt administrative rules in accordance with Title 63G,
64 Chapter 3, Utah Administrative Rulemaking Act, which establish:
65 (a) the particular telemedicine services that are considered [
66 encounters for reimbursement purposes under the state's medical assistance program; and
67 (b) the reimbursement methodology for the telemedicine services designated under
68 Subsection (3)(a).
69 Section 2. Section 26-18-13.5 is enacted to read:
70 26-18-13.5. Mental health telemedicine services -- Reimbursement -- Reporting.
71 (1) As used in this section:
72 (a) "Mental health therapy" means the same as the term "practice of mental health
73 therapy" is defined in Section 58-60-102.
74 (b) "Mental illness" means a mental or emotional condition defined in an approved
75 diagnostic and statistical manual for mental disorders generally recognized in the professions of
76 mental health therapy listed in Section 58-60-102.
77 (c) "Telehealth services" means the same as that term is defined in Section 26-59-102.
78 (d) "Telemedicine services" means the same as that term is defined in Section
79 26-59-102.
80 (2) This section applies to:
81 (a) a managed care organization that contracts with the Medicaid program; and
82 (b) a provider who is reimbursed for health care services under the Medicaid program.
83 (3) The Medicaid program shall reimburse for personal mental health therapy office
84 visits provided through telemedicine services at a rate set by the Medicaid program.
85 (4) Before December 1, 2017, the department shall report to the Legislature's Public
86 Utilities, Energy, and Technology Interim Committee and Health Reform Task Force on:
87 (a) the result of the reimbursement requirement described in Subsection (3);
88 (b) existing and potential uses of telehealth and telemedicine services;
89 (c) issues of reimbursement to a provider offering telehealth and telemedicine services;
90 (d) potential rules or legislation related to:
91 (i) providers offering and insurers reimbursing for telehealth and telemedicine services;
92 and
93 (ii) increasing access to health care, increasing the efficiency of health care, and
94 decreasing the costs of health care; and
95 (e) the department's efforts to obtain a waiver from the federal requirement that
96 telemedicine communication be face-to-face communication.
97 Section 3. Section 26-59-101 is enacted to read:
98
99 26-59-101. Title.
100 This chapter is known as the "Telehealth Act."
101 Section 4. Section 26-59-102 is enacted to read:
102 26-59-102. Definitions.
103 As used in this chapter:
104 (1) "Asynchronous store and forward transfer" means the transmission of a patient's
105 health care information from an originating site to a provider at a distant site Ŝ→ [
106 connection that complies with state and federal security and privacy laws
107 (2) "Distant site" means the physical location of a provider delivering telemedicine
108 services.
109 (3) "Originating site" means the physical location of a patient receiving telemedicine
110 services.
111 (4) "Patient" means an individual seeking telemedicine services.
112 (5) "Provider" means an individual who is:
113 (a) licensed under Title 26, Chapter 21, Health Care Facility Licensing and Inspection
114 Act;
115 (b) licensed under Title 58, Occupations and Professions, to provide health care; or
116 (c) licensed under Title 62A, Chapter 2, Licensure of Programs and Facilities.
117 (6) "Synchronous interaction" means real-time communication through interactive
118 technology that enables a provider at a distant site and a patient at an originating site to interact
119 simultaneously through two-way audio and video transmission.
120 (7) "Telehealth services" means the transmission of health-related services or
121 information through the use of electronic communication or information technology.
122 (8) "Telemedicine services" means telehealth services:
123 (a) including:
124 (i) clinical care;
125 (ii) health education;
126 (iii) health administration;
127 (iv) home health; or
128 (v) facilitation of self-managed care and caregiver support; and
129 (b) provided by a provider to a patient through a method of communication that:
130 (i) (A) uses asynchronous store and forward transfer; or
131 (B) uses synchronous interaction; and
132 (ii) meets industry security and privacy standards, including compliance with:
133 (A) the federal Health Insurance Portability and Accountability Act of 1996, Pub. L.
134 No. 104-191, 110 Stat. 1936, as amended; and
135 (B) the federal Health Information Technology for Economic and Clinical Health Act,
136 Pub. L. No. 111-5, 123 Stat. 226, 467, as amended.
137 Section 5. Section 26-59-103 is enacted to read:
138 26-59-103. Scope of telehealth practice.
139 (1) A provider offering telehealth services shall:
140 (a) at all times:
141 (i) act within the scope of the provider's license under Title 58, Occupations and
142 Professions, in accordance with the provisions of this chapter and all other applicable laws and
143 rules; and
144 (ii) be held to the same standards of practice as those applicable in traditional health
145 care settings;
146 (b) in accordance with Title 58, Chapter 82, Electronic Prescribing Act, before
147 providing treatment or prescribing a prescription drug, establish a diagnosis and identify
148 underlying conditions and contraindications to a recommended treatment after:
149 (i) obtaining from the patient or another provider the patient's relevant clinical history;
150 and
151 (ii) documenting the patient's relevant clinical history and current symptoms;
152 (c) be available to a patient who receives telehealth services from the provider for
153 subsequent care related to the initial telemedicine services, in accordance with community
154 standards of practice;
155 (d) be familiar with available medical resources, including emergency resources near
156 the originating site, in order to make appropriate patient referrals when medically indicated;
157 and
158 (e) in accordance with any applicable state and federal laws, rules, and regulations,
159 generate, maintain, and make available to each patient receiving telehealth services the patient's
160 medical records.
161 (2) A provider may not offer telehealth services if:
162 (a) the provider is not in compliance with applicable laws, rules, and regulations
163 regarding the provider's licensed practice; or
164 (b) the provider's license under Title 58, Occupations and Professions, is not active and
165 in good standing.
166 Section 6. Section 26-59-104 is enacted to read:
167 26-59-104. Enforcement.
168 (1) The Division of Occupational and Professional Licensing created in Section
169 58-1-103 is authorized to enforce the provisions of Section 26-59-103 as it relates to providers
170 licensed under Title 58, Occupations and Professions.
171 (2) The department is authorized to enforce the provisions of Section 26-59-103 as it
172 relates to providers licensed under this title.
173 (3) The Department of Human Services created in Section 62A-1-102 is authorized to
174 enforce the provisions of Section 26-59-103 as it relates to providers licensed under Title 62A,
175 Chapter 2, Licensure of Programs and Facilities.
176 Section 7. Section 26-59-105 is enacted to read:
177 26-59-105. Study by Public Utilities, Energy, and Technology Interim Committee
178 and Health Reform Task Force.
179 The Legislature's Public Utilities, Energy, and Technology Interim Committee and
180 Health Reform Task Force shall receive the reports required in Sections 26-18-13.5 and
181 49-20-414 and study:
182 (1) the result of the reimbursement requirement described in Sections 26-18-13.5 and
183 49-20-414;
184 (2) practices and efforts of private health care facilities, health care providers,
185 self-funded employers, third-party payors, and health maintenance organizations to reimburse
186 for telehealth services;
187 (3) existing and potential uses of telehealth and telemedicine services;
188 (4) issues of reimbursement to a provider offering telehealth and telemedicine services;
189 and
190 (5) potential rules or legislation related to:
191 (a) providers offering and insurers reimbursing for telehealth and telemedicine
192 services; and
193 (b) increasing access to health care, increasing the efficiency of health care, and
194 decreasing the costs of health care.
195 Section 8. Section 31A-22-613.5 is amended to read:
196 31A-22-613.5. Price and value comparisons of health insurance.
197 (1) (a) This section applies to all health benefit plans.
198 (b) Subsection (2) applies to:
199 (i) all health benefit plans; and
200 (ii) coverage offered to state employees under Subsection 49-20-202(1)(a).
201 (2) (a) The commissioner shall promote informed consumer behavior and responsible
202 health benefit plans by requiring an insurer issuing a health benefit plan to:
203 (i) provide to all enrollees, prior to enrollment in the health benefit plan, written
204 disclosure of:
205 (A) restrictions or limitations on prescription drugs and biologics including:
206 (I) the use of a formulary;
207 (II) co-payments and deductibles for prescription drugs; and
208 (III) requirements for generic substitution;
209 (B) coverage limits under the plan;
210 (C) any limitation or exclusion of coverage including:
211 (I) a limitation or exclusion for a secondary medical condition related to a limitation or
212 exclusion from coverage; and
213 (II) easily understood examples of a limitation or exclusion of coverage for a secondary
214 medical condition; [
215 (D) whether the insurer permits an exchange of the adoption indemnity benefit in
216 Section 31A-22-610.1 for infertility treatments, in accordance with Subsection
217 31A-22-610.1(1)(c)(ii) and the terms associated with the exchange of benefits; and
218 (E) whether the insurer provides coverage for telehealth services in accordance with
219 Section 26-18-13.5 and terms associated with that coverage; and
220 (ii) provide the commissioner with:
221 (A) the information described in Subsections 31A-22-635(5) through (7) in the
222 standardized electronic format required by Subsection 63N-11-107(1); and
223 (B) information regarding insurer transparency in accordance with Subsection (4).
224 (b) An insurer shall provide the disclosure required by Subsection (2)(a)(i) in writing to
225 the commissioner:
226 (i) upon commencement of operations in the state; and
227 (ii) anytime the insurer amends any of the following described in Subsection (2)(a)(i):
228 (A) treatment policies;
229 (B) practice standards;
230 (C) restrictions;
231 (D) coverage limits of the insurer's health benefit plan or health insurance policy; or
232 (E) limitations or exclusions of coverage including a limitation or exclusion for a
233 secondary medical condition related to a limitation or exclusion of the insurer's health
234 insurance plan.
235 (c) An insurer shall provide the enrollee with notice of an increase in costs for
236 prescription drug coverage due to a change in benefit design under Subsection (2)(a)(i)(A):
237 (i) either:
238 (A) in writing; or
239 (B) on the insurer's website; and
240 (ii) at least 30 days prior to the date of the implementation of the increase in cost, or as
241 soon as reasonably possible.
242 (d) If under Subsection (2)(a)(i)(A) a formulary is used, the insurer shall make
243 available to prospective enrollees and maintain evidence of the fact of the disclosure of:
244 (i) the drugs included;
245 (ii) the patented drugs not included;
246 (iii) any conditions that exist as a precedent to coverage; and
247 (iv) any exclusion from coverage for secondary medical conditions that may result
248 from the use of an excluded drug.
249 (e) (i) The commissioner shall develop examples of limitations or exclusions of a
250 secondary medical condition that an insurer may use under Subsection (2)(a)(i)(C).
251 (ii) Examples of a limitation or exclusion of coverage provided under Subsection
252 (2)(a)(i)(C) or otherwise are for illustrative purposes only, and the failure of a particular fact
253 situation to fall within the description of an example does not, by itself, support a finding of
254 coverage.
255 (3) The commissioner:
256 (a) shall forward the information submitted by an insurer under Subsection (2)(a)(ii) to
257 the Health Insurance Exchange created under Section 63N-11-104; and
258 (b) may request information from an insurer to verify the information submitted by the
259 insurer under this section.
260 (4) The commissioner shall:
261 (a) convene a group of insurers, a member representing the Public Employees' Benefit
262 and Insurance Program, consumers, and an organization that provides multipayer and
263 multiprovider quality assurance and data collection, to develop information for consumers to
264 compare health insurers and health benefit plans on the Health Insurance Exchange, which
265 shall include consideration of:
266 (i) the number and cost of an insurer's denied health claims;
267 (ii) the cost of denied claims that is transferred to providers;
268 (iii) the average out-of-pocket expenses incurred by participants in each health benefit
269 plan that is offered by an insurer in the Health Insurance Exchange;
270 (iv) the relative efficiency and quality of claims administration and other administrative
271 processes for each insurer offering plans in the Health Insurance Exchange; and
272 (v) consumer assessment of each insurer or health benefit plan;
273 (b) adopt an administrative rule that establishes:
274 (i) definition of terms;
275 (ii) the methodology for determining and comparing the insurer transparency
276 information;
277 (iii) the data, and format of the data, that an insurer shall submit to the commissioner in
278 order to facilitate the consumer comparison on the Health Insurance Exchange in accordance
279 with Section 63N-11-107; and
280 (iv) the dates on which the insurer shall submit the data to the commissioner in order
281 for the commissioner to transmit the data to the Health Insurance Exchange in accordance with
282 Section 63N-11-107; and
283 (c) implement the rules adopted under Subsection (4)(b) in a manner that protects the
284 business confidentiality of the insurer.
285 Section 9. Section 49-20-414 is enacted to read:
286 49-20-414. Mental health telemedicine services -- Reimbursement -- Reporting.
287 (1) As used in this section:
288 (a) "Mental health therapy" means the same as the term "practice of mental health
289 therapy" is defined in Section 58-60-102.
290 (b) "Mental illness" means the same as that term is defined in Section 26-18-13.5.
291 (c) "Network provider" means a health care provider who has an agreement with the
292 program to provide health care services to a patient with an expectation of receiving payment,
293 other than coinsurance, copayments, or deductibles, directly from the managed care
294 organization.
295 (d) "Telehealth services" means the same as that term is defined in Section 26-59-102.
296 (e) "Telemedicine services" means the same as that term is defined in Section
297 26-59-102.
298 (2) This section applies to the risk pool established for the state under Subsection
299 49-20-201(1)(a).
300 (3) The program shall reimburse a network provider for personal mental health therapy
301 office visits provided through telemedicine services at a rate set by the program.
302 (4) Before December 1, 2017, the program shall report to the Legislature's Public
303 Utilities, Energy, and Technology Interim Committee and Health Reform Task Force on:
304 (a) the result of the reimbursement requirement described in Subsection (3);
305 (b) existing and potential uses of telehealth and telemedicine services;
306 (c) issues of reimbursement to a provider offering telehealth and telemedicine services;
307 and
308 (d) potential rules or legislation related to:
309 (i) providers offering and insurers reimbursing for telehealth and telemedicine services;
310 and
311 (ii) increasing access to health care, increasing the efficiency of health care, and
312 decreasing the costs of health care.
313 Ŝ→ [
314 58-82-201. Electronic prescriptions -- Restrictions -- Rulemaking authority.
315 (1) Subject to the provisions of this section, a practitioner shall:
316 (a) provide each existing patient of the practitioner with the option of participating in
317 electronic prescribing for prescriptions issued for the patient, if the practitioner prescribes a
318 drug or device for the patient on or after July 1, 2012; and
319 (b) offer the patient a choice regarding to which pharmacy the practitioner will issue
320 the electronic prescription.
321 (2) A practitioner may not issue a prescription through electronic prescribing for a
322 drug, device, or federal controlled substance that the practitioner is prohibited by federal law or
323 federal rule from issuing through electronic prescribing.
324 (3) A pharmacy shall:
325 (a) accept an electronic prescription that is transmitted in accordance with the
326 requirements of this section and division rules; and
327 (b) dispense a drug or device as directed in an electronic prescription described in
328 Subsection (3)(a).
329 (4) The division shall make rules to ensure that:
330 (a) except as provided in Subsection (6), practitioners and pharmacies comply with this
331 section;
332 (b) electronic prescribing is conducted in a secure manner, consistent with industry
333 standards; and
334 (c) each patient is fully informed of the patient's rights, restrictions, and obligations
335 pertaining to electronic prescribing.
336 (5) An entity that facilitates the electronic prescribing process under this section shall:
337 (a) transmit to the pharmacy the prescription for the drug prescribed by the prescribing
338 practitioner however, this Subsection (5)(a) does not prohibit the use of an electronic
339 intermediary if the electronic intermediary does not over-ride a patient's or prescriber's choice
340 of pharmacy;
341 (b) transmit only scientifically accurate, objective, and unbiased information to
342 prescribing practitioners; and
343 (c) allow a prescribing practitioner to electronically override a formulary or preferred
344 drug status when medically necessary.
345 (6) The division may, by rule, grant an exemption from the requirements of this section
346 to a pharmacy or a practitioner to the extent that the pharmacy or practitioner can establish, to
347 the satisfaction of the division, that compliance with the requirements of this section would
348 impose an extreme financial hardship on the pharmacy or practitioner.
349 Ŝ→ [(7) A practitioner treating a patient through telehealth services, as described in Title 26,
350 Chapter 59, Telehealth Act, may not issue a prescription through electronic prescribing for a
351 drug or treatment to cause an abortion] ←Ŝ Ŝ→ [, except in cases of rape, incest, or if the life of the
352 mother would be endangered without an abortion] ←Ŝ Ŝ→ [.] ←Ŝ] ←Ŝ
Legislative Review Note
Office of Legislative Research and General Counsel