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ARIZONA STATE SENATE
Fifty-Fifth Legislature, First Regular Session
telehealth; health care providers; requirements
Purpose
Outlines telehealth procedures and requirements relating to coverage of services, network adequacy, delivery of health care, health care providers and interstate health care services. Establishes the Telehealth Advisory Committee on Telehealth Best Practices (Advisory Committee) and the Acute Care Services Pilot Program.
Background
Telemedicine is the practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the patient, including audio or video communications sent to a health care provider for diagnostic or treatment consultation. Before a health care provider delivers health care through telemedicine, the treating health care provider must obtain verbal or written informed consent from the patient or the patient's health care decision maker, with certain exceptions (A.R.S. §§ 36-3601 and 36-3602).
All contracts and policies issued, delivered or renewed in Arizona must provide coverage for health care services that are provided through telemedicine if the health care service would be covered were it provided through an in-person consultation between the subscriber and a health care provider. A corporation, health care services organization (HCSO), disability insurer, group disability insurer and blanket disability insurer may not limit or deny the coverage of health care services provided through telemedicine and must apply only the same limits or exclusions on a health care service provided through telemedicine that are applicable to an in-person consultation for the same health care service (A.R.S. §§ 20-841.09; 20-1057.13; 20-1376.05; and 20-1406.05).
An employee who may be entitled to workers' compensation must submit to medical examination, if and when requested by the Industrial Commission of Arizona (ICA), the employee's employer or the insurance carrier. The request for the medical examination must fix a time and place with regard to the convenience of the employee and their physical condition and ability to attend (A.R.S. § 23-1026).
On March 25, 2020, Governor Douglas A. Ducey issued an executive order requiring all health insurance plans regulated by the Department of Insurance and Financial Institutions (DIFI) to provide coverage for all healthcare services provided through telemedicine if the healthcare service would be covered were it provided through an in-person visit between the enrollee and a healthcare provider (Executive Order 2020-15).
If the modification of telehealth services leads to an increase in utilization of telehealth services, there may be a fiscal impact to the state General Fund.
Provisions
Coverage of Telehealth Services
1. Prohibits a corporation, HCSO, disability insurer, group disability insurer and blanket disability insurer (health insurer) from limiting or denying the coverage of health care services provided through telehealth, including ancillary services.
2. Defines telehealth for the purposes of health care services coverage to include:
a) the use of an audio-only telephone encounter between a subscriber who has an existing relationship with a health care provider or provider group if:
i. an audio-visual telehealth encounter is not reasonably available due to the subscriber's lack of technology or telecommunications infrastructure limits, as determined by the health care provider; and
ii. the telehealth encounter is initiated at the request of the subscriber or authorized by the subscriber before the telehealth encounter; and
b) the use of an audio-only encounter between the subscriber and health care provider, regardless of whether there is an existing relationship between the health care provider or provider group, if the telehealth encounter is for a behavioral health or substance use disorder service and the outlined conditions apply.
3. Allows a corporation, disability insurer, group disability insurer and blanket disability insurer to 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 recommends not be provided through telehealth based on peer-reviewed clinical publications or research.
4. Allows a HCSO to 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 peer-reviewed clinical publications or research, recommends not be provided through telehealth.
5. Requires a health insurer to reimburse health care providers at the same level of payment for equivalent services as identified by the diagnostic and procedure codes, whether provided through telehealth or in-person care, unless the telehealth encounter is provided through a telehealth platform that is sponsored or provided by the health insurer.
6. Prohibits a health insurer from requiring a health care provider to use a telehealth platform that is sponsored or provided by the health insurer.
7. Requires a health care provider, to qualify for the same level of payment, to make telehealth services generally available to patients through the interactive use of audio, video or other electronic media.
8. Requires the health care provider, at the time of the telehealth encounter, to access available clinical information and records that are appropriate to evaluate the patient's condition.
9. Requires the health care provider to inform the subscriber before the telehealth encounter if there is a charge for the encounter.
10. Allows a health insurer to establish reasonable requirements and parameters for telehealth services, including documentation, fraud prevention, identity verification and recordkeeping.
11. Prohibits the requirements and parameters established by a health insurer from being more restrictive or less favorable to health care providers or subscribers than are required for health care services delivered in-person.
12. Stipulates that telehealth services may be provided and must be covered regardless of where the subscriber is located or the type of site.
13. Excludes outlined emergency services from the coverage a contract may limit.
14. Requires services provided through telehealth or resulting from a telehealth encounter to comply with any practice guidelines developed by the Advisory Committee.
15. Excludes the sole use of voice mail from the definition of telehealth.
Network Adequacy
16. Prohibits a health insurer from using contracted telehealth providers to meet network adequacy standards required by state or federal law.
17. Stipulates that a health insurer's contracted health care provider network is not considered adequate if enrollees are unable to access appropriate nonemergency in-person health care services from the network's contracted health care providers in a timely manner.
18. Requires a health insurer that waives a copayment, coinsurance or other cost sharing measure that impacts a health care provider's reimbursement to reimburse the health care provider for the cost sharing measure to ensure that the health care provider receives the full contracted rate.
19. Requires a health insurer to provide notice in its provider network directories that all enrollees have the right to request and receive appropriate nonemergency in-person health care services from the network's health care providers in a timely manner.
Telehealth Delivery of Health Care
20. Defines telehealth, for statutes governing the practice of telehealth, as the:
a) interactive use of audio, video or other electronic media, including asynchronous store-and-forward technologies and remote patient monitoring technologies, for the practice of health care, assessment, diagnosis, consultation or treatment and the transfer of medical data; and
b) use of an audio-only telephone encounter between the patient or client and health care provider if an audio-visual telehealth encounter is not reasonably available due to the patient's preference, functional status or lack of technology or any telecommunications infrastructure limits, as determined by the health care provider.
21. Allows verbal or written informed consent to be obtained by electronic means before a health care provider delivers health care through telehealth.
22. Prohibits a health care provider regulatory board or agency from enforcing any statute, rule or policy that would require a licensed health care provider who is authorized to write prescriptions to require an in-person examination of a patient before issuing a prescription, except as specifically prescribed by federal law.
23. Allows a physical or mental health status examination to be conducted during a telehealth encounter.
Telehealth Health Care Providers
24. Requires a health care provider to make a good faith effort in determining whether a health care service should be provided through telehealth instead of in person.
25. Requires a health care provider to use their clinical judgement when considering whether the nature of the services necessitates physical interventions and close observation and the circumstances of the patient, including diagnosis, symptoms, history, age, physical location and access to telehealth.
26. Requires a health care provider to make a good faith effort in determining the communication medium of telehealth and, if practicable, the telehealth communication medium that allows the health care provider to most effectively assess, diagnose and treat the patient.
27. Allows the factors the health care provider may consider in determining the communication medium to include the patient's lack of access to or inability to use technology or any limits in telecommunication infrastructure necessary to support interactive telehealth encounters.
28. Prohibits the health care provider from considering the provider's personal preference or convenience in determining the communication medium of telehealth.
Interstate Telehealth Services
29. Allows a health care provider who is not licensed in Arizona to provide telehealth services to a person located in Arizona if the health care provider:
a) registers with Arizona's applicable health care provider regulatory board or agency that licenses comparable health care providers in Arizona on an application that contains:
i. the health care provider's name;
ii. proof of the health care provider's professional licensure, including all jurisdictions the provider is licensed and the license numbers;
iii. the health care provider's address, email address and telephone number, including information if the provider needs to be contacted urgently;
iv. evidence of professional liability insurance coverage; and
v. designation of a duly appointed statutory agent for service of process in Arizona;
b) pays the applicable registration fee;
c) holds a current, valid and unrestricted license to practice in another state that is substantially similar to a license issued in Arizona to a comparable health care provider and is not subject to any past or pending disciplinary proceedings in any jurisdiction;
d) acts in full compliance with all applicable laws and rules of Arizona, including scope of practice and telehealth requirements;
e) complies with all existing requirements of Arizona and any other state in which the health care provider is licensed regarding maintaining professional liability insurance, including coverage for telehealth services provided in Arizona;
f) consents to Arizona's jurisdiction for any disciplinary action or legal proceeding related to the health care provider's acts or omissions;
g) follows Arizona's standards of care for that particular licensed health profession;
h) annually updates the health care provider's registration for accuracy; and
i) submits to the applicable health care provider regulatory board or agency a report with the number of patients the provider served in Arizona and the total number and type of encounters in Arizona for the preceding year.
30. Exempts, from interstate telehealth registration requirements, a health care provider who is not licensed to provide health care services in Arizona but holds an active license to provide health care services in another jurisdiction and who provides telehealth services to a person located in Arizona if either of the following applies:
a) the health care provider provides fewer than 10 telehealth encounters in a calendar year; or
b) the services are provided under one of the following circumstances:
i. in response to an emergency medication condition;
ii. in consultation with a health care provider who is licensed in Arizona and has the ultimate authority over the patient's diagnosis and treatment;
iii. to provide after-care specifically related to a medical procedure that was delivered in-person in another state; or
iv. to a person who is a resident of another state and the telehealth provider is the primary care provider or behavioral health provider located in the person's residence.
31. Requires a health care provider, within five days after any restriction is placed on the health care provider's license or any disciplinary action is initiated or imposed, to notify the applicable health care provider regulatory board or agency.
32. Allows the regulatory board or agency registering a health care provider to use the National Practitioner Databank to verify the submitted information.
33. Prohibits a registered interstate health care provider from opening an office in Arizona or providing in-person health care services to persons located in Arizona without first obtaining a license through the applicable health care provider regulatory board or agency.
34. Stipulates that a health care provider who fails to comply with the applicable laws and rules of Arizona is subject to investigation and disciplinary action by the applicable health care provider regulatory board or agency.
35. Allows disciplinary action by the applicable health care provider regulatory board or agency in Arizona to include revoking the health care provider's practice privileges in Arizona and referring the matter to the licensing authority in Arizona or states where the health care provider possesses a professional license.
36. Determines that the venue for any action arising from a violation of interstate telehealth services is the patient's county of residence in Arizona.
Telehealth Advisory Committee on Telehealth Best Practices
37. Establishes the Advisory Committee consisting of the following members:
a) one physician who is licensed by the Arizona Medical Board (AMB);
b) one physician who is licensed by the Arizona Board of Osteopathic Examiners (ABOE) in Medicine and Surgery and is practicing primary care in Arizona;
c) two advanced practice registered nurses who are licensed by the Arizona Board of Nursing;
d) one physician who is licensed by the AMB or the ABOE in Medicine and Surgery and who specializes in pain management;
e) one psychiatrist who is licensed by the AMB or the ABOE in Medicine and Surgery;
f) one psychologist who is licensed by the Arizona Board of Psychologist Examiners;
g) two behavioral health professionals who are licensed by the Arizona State Board of Behavioral Health Examiners, one of whom is employed by an outpatient treatment center;
h) one physician who is licensed by the Arizona Naturopathic Physicians Medical Board;
i) two dentists who are licensed by the Arizona Dental Board;
j) one health care professional whose primary area of focus is treating persons with developmental disabilities;
k) one health care professional whose primary area of focus is industrial injuries;
l) one speech-language pathologist who is licensed by the Arizona Department of Health Services (DHS);
m) one occupational therapist who is licensed by the Arizona Board of Occupational Therapy Examiners;
n) one hospital administrator;
o) one physician assistant who is licensed by the Arizona Regulatory Board of Physician Assistants;
p) one representative of the Arizona Commission for the Deaf and Hard of Hearing;
q) two representatives of health care insurers;
r) one optometrist who is licensed by the Arizona Board of Optometry; and
s) one representative from:
i. the Arizona Health Care Cost Containment System;
ii. DHS;
iii. the Department of Economic Security;
iv. DIFI; and
v. the ICA.
38. Requires the Advisory Committee to review national and other standards for telehealth best practices and relevant peer-reviewed literature.
39. Allows the Advisory Committee to conduct public meetings at which testimony may be taken regarding the efficacy of various communication mediums and the types of services and populations for which telehealth is appropriate.
40. Requires the Advisory Committee, by September 1, 2021, to submit a report to the Governor, the President of the Senate and the Speaker of the House of Representatives with recommendations, including best practice guidelines for telehealth use by health care providers.
41. Requires the Advisory Committee to update the Advisory Committee's best practice guidelines and recommendations when applicable.
42. Terminates the Advisory Committee on July 1, 2029.
Acute Care Services Pilot Program
43. Requires DHS, by September 1, 2021, to develop a three-year pilot program that allows the delivery of acute care services to patients in the patient's home by licensed hospitals in Arizona working in coordination with licensed home health professionals.
44. Requires the pilot program to be designed in a manner and in coordination with the Acute Care at Home Program authorized by the Centers for Medicare and Medicaid Services.
45. Terminates the pilot program on December 31, 2024.
DIFI Reporting Requirements
46. Requires DIFI, by January 1, 2023, to report to the President of the Senate and the Speaker of the House of Representatives the number of telehealth encounters based on claims data received by health insurers and health plans for services provided in Arizona in the preceding year, including:
a) the number of telehealth encounters in Arizona involving out-of-state providers;
b) the types of services provided through telehealth encounters; and
c) an analysis of implications on the cost of services or access to services based on available data.
47. Requires any personally identifiable health information to be redacted from the DIFI report.
Workers' Compensation Medical Examination
48. Requires a request for an employee's medical examination to include whether the medical examination could be conducted through telehealth.
49. Allows a medical examination to be conducted via telehealth with the consent of both the employee and the requesting party.
Definitions
50. Excludes, from the definition of telehealth, the use of a fax machine, instant messages, voice mail or email.
51. Removes the definition of telemedicine.
52. Modifies the definition of unprofessional conduct to allow the physical or mental health status examination required prior to prescribing, dispensing or furnishing a prescription medication or prescription-only device to be conducted through telehealth with clinical evaluation that is appropriate for the patient and the condition with which the patient presents, rather than during a real-time telemedicine encounter with audio and video capability.
53. Modifies the definition of unethical conduct to allow, in the course of dispensing drugs pursuant to diagnosis by mail or the internet, knowingly dispensing a drug on a prescription order written pursuant to a physical or mental health status examination that was conducted through telehealth and is consistent with federal law, rather than during a real-time telemedicine encounter with audio and video capability.
54. Modifies the definition of health care provider to include certain licensed or permitted persons and health care institutions.
55. Includes the use of telehealth in the definition of direct client contact.
56. Removes the definition of telepractice relating to the Arizona State Board of Behavioral Health Examiners.
57. Defines relevant terms.
Miscellaneous
58. Makes technical and conforming changes.
59. Becomes effective on the general effective date.
House Action
HHS 2/1/21 DPA 8-0-0-1
3rd Read 2/11/21 37-22-1
Prepared by Senate Research
March 15, 2021
MG/ML/gs