Audit of the Office of Medicaid (MassHealth)—Review of Telehealth Overview of Audited Entity

This section describes the makeup and responsibilities of the Office of Medicaid (MassHealth).

Overview

Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare for approximately 1.8 million low- and moderate-income children, families, seniors, and people with disabilities annually. In fiscal year 2021, MassHealth paid healthcare providers more than $18.1 billion, of which approximately 45% was funded by the Commonwealth. Medicaid expenditures represented approximately 40% of the Commonwealth’s total fiscal year 2021 budget.

Telehealth

On January 1, 2019, MassHealth published its All Provider Bulletin 281, which announced the beginning of its coverage of telehealth behavioral health services. The bulletin allows community health centers, community mental health centers, and outpatient substance use disorder treatment providers to deliver certain services via telehealth, including psychotherapy, counseling, clinical case management, and opioid treatment. Any covered service provided via telehealth must comply with the billing and program regulations that existed before MassHealth issued the bulletin. Further, the bulletin requires providers to use technology that complies with the federal Health Insurance Portability and Accountability Act to ensure privacy. It also requires them to use software that allows patients to communicate with them in real time, with video capabilities. The use of text messaging to provide services is unallowable. MassHealth pays its providers the same rate for telehealth and in-person services.

All documentation for telehealth services must be maintained in accordance with the program regulations specific to each claim. Further, providers must document additional information specific to the telehealth service rendered. For example, they must document the distant site, which is the location from which they provided the service, and the originating site, which is the location where the member received the service.

On March 10, 2020, in response to the 2019 coronavirus (COVID-19) pandemic, Governor Charlie Baker declared a state of emergency in the Commonwealth. As a result, MassHealth published All Provider Bulletin 289, which allows more types of providers to deliver services via telehealth. It states that MassHealth will “permit qualified providers to deliver clinically appropriate, medically necessary MassHealth-covered services to MassHealth members via telehealth (including telephone and live video)” as long as the providers meet the recordkeeping requirements outlined in the bulletin. The recordkeeping requirements in this bulletin (as well as All Provider Bulletins 291, 298, 303, and 314, which we reviewed during our audit) are the same as, or similar to, those in All Provider Bulletin 281. Although MassHealth does not require any specific software (such as Zoom or Microsoft Teams) to be used for these telehealth services, it does require providers to ensure that the same confidentiality measures are applied for telehealth that would be applied for in-person visits. (For example, providers must keep the member’s identity, appointment details, and associated health information confidential.) Additionally, MassHealth allows providers to use certain procedure codes for services delivered via telephone without video, but only if they are clinically appropriate² and medically necessary.³

For the period March 1, 2019 (when MassHealth began covering telehealth behavioral health) through August 31, 2019, the monthly average number of claims paid for telehealth behavioral health service was 127, with a monthly average amount of $2,513. During the same period, the monthly average number of claims paid for non-telehealth behavioral health service was 357,485, with a monthly average amount of $42,411,739.

From September 1, 2019 through February 28, 2020, the monthly average number of claims paid for telehealth behavioral health service was 84, with a monthly average amount of $6,619. During the same period, the monthly average number of claims paid for non-telehealth behavioral health service was 100,743, with a monthly average amount of $39,727,116.

From March 1, 2020 through August 31, 2020, the monthly average number of claims paid for telehealth behavioral health service was 85,445, with a monthly average amount of $6,339,299. During the same period, the monthly average number of claims paid for non-telehealth behavioral health service was 173,108, with a monthly average amount of $31,268,550.

From September 1, 2020 through February 28, 2021, the monthly average number of claims paid for telehealth behavioral health service was 86,449, with a monthly average amount of $6,270,112. During the same period, the monthly average number of claims paid for non-telehealth behavioral health service was 159,389, with a monthly average amount of $29,620,740.

Finally, from March 1, 2021 through June 30, 2021, the monthly average number of claims paid for telehealth behavioral health service was 50,574, with a monthly average amount of $3,463,881. During the same period, the monthly average number of claims paid for non-telehealth behavioral health service was 117,028, with a monthly average amount of $20,244,113.

A summary of these payments for Telehealth and Non-Telehealth Behavioral Health Services as outlined above is depicted in the chart below.

Payments for Telehealth and Non-Telehealth Behavioral Health Services

The 10 procedure codes with the highest amounts paid during the audit period are summarized below.

Procedure Code	Paid Amount	Number of Claims
90834—Psychotherapy Patient/Family, 45 Minutes	$33,479,690.86	463,209
H2015—Comprehensive Community Support Services	$25,100,346.33	177,298
T1015—Clinic Visit/Encounter, All Inclusive	$12,709,245.50	76,224
99214—Office/Outpatient Visit, Established	$5,850,578.36	114,912
99213—Office/Outpatient Visit, Established	$4,285,244.11	102,599
90832—Psychotherapy Patient/Family, 30 Minutes	$3,509,139.56	98,118
H2012—Behavioral Health Day Treatment, per Hour	$1,963,560.87	43,553
S9485—Crisis Intervention Mental Health Service	$1,163,595.78	2,318
H0032—Mental Health Service Plan Development	$982,432.37	6,678
H0004—Behavioral Health Counseling and Therapy	$919,215.95	14,976

 

By allowing these services to be provided via telehealth, MassHealth allows its members to receive care from providers they might not otherwise be able to see in person. Additionally, the expansion allows non-English-speaking members to receive care remotely from providers who can communicate in their languages. It also allows members with substance use disorders to receive treatment via telehealth from providers who offer medication-assisted treatment (i.e., treatment with medications like buprenorphine/naloxone, commonly known as Suboxone, or methadone).

Medicare Part B Telehealth Coverage

Medicare Part B is medical insurance coverage (one of the four parts of the federal Medicare program). Before the COVID-19 pandemic, it covered only some telehealth services, such as counseling; prescription management; and follow-up consultations for lab work, x-rays, and some surgeries. After the pandemic began, the federal Centers for Medicare & Medicaid Services expanded Medicare Part B coverage of telehealth to include additional services such as office visits, hospital outpatient visits, consultations, and psychiatric examinations.

Medicare pays the same rate for behavioral health claims whether the services are provided via telehealth or in person. Federal financial participation, the financial contribution given by the federal government to the state, is awarded to MassHealth for telehealth claims covered under Medicare and Medicaid. To receive this contribution, MassHealth must ensure that telehealth documentation, such as the identification of MassHealth members and their medical histories, is readily available and is maintained in accordance with federal regulations. Additionally, Section 75.403(g) of Title 45 of the Code of Federal Regulations states that costs must be adequately documented to be allowable under federal law.

Behavioral Health

Behavioral health services provided by MassHealth include both mental health and substance use disorder treatment. Types of behavioral health services that are covered by MassHealth include psychiatry, individual and group therapy, crisis intervention, drug screening, and mental health assessments, all based on members’ individual needs.

2.    To be considered clinically appropriate, services must meet certain professional medical standards, including being provided in a timely manner and performed in an appropriate setting.

3.    If a physician determines that a service is necessary to properly evaluate and treat a patient, the service is considered medically necessary.

Date published:	November 23, 2022