EmblemHealth members enrolled in either a Medicaid or Medicare-Medicaid plan are able to access telehealth services from approved home health care agencies as a covered benefit if the members are assessed by the home health care agency on an individual basis and the members meet specific criteria.
To be eligible, the member must have conditions needing frequent monitoring and be at-risk of acute or long-term care facility admission. (Congestive heart failure, asthma, cardiac conditions, chronic obstructive pulmonary disease (COPD), HIV and diabetes are the most frequent diagnoses for those currently receiving telehealth services. However, this is not an exhaustive list of conditions for which telehealth may be indicated. Each case is assessed individually to determine the appropriateness of telehealth monitoring.) Telehealth services may only be provided during an episode of home care. They must be an adjunct to nursing care and they do not replace physician-ordered nursing visits.
The home health care agency must submit a doctor's order to EmblemHealth along with the member's assessment in order to obtain prior approval to provide telehealth services to the member as a covered benefit.
EmblemHealth will cover telehealth services if they are deemed medically necessary. If a member enrolls in EmblemHealth while in receipt of telehealth services through Medicaid fee-for-service, we provide transitional care while we conduct our own assessment of the individual's care needs. Our review may include review of the original assessment or we may request a new assessment.
Only home care agencies approved by Medicaid as providers of telehealth are authorized to provide telehealth monitoring.
The home health care agency may then bill using HCPCS code T1014 for either the nursing visit or the installation, but not both. Authorization is given for 30 days. On day 30, another 30 days may be requested. If longer than 60 days are needed, the member must be reassessed.
The risk assessment tool completed by the home care agency incorporates the following information. The member:
- Is at risk for hospitalization or emergency care visits
- Lives alone
- Has a documented history of, or is at risk of, requiring unscheduled nursing visits or interventions
- Has a history of non-compliance in adhering to disease management recommendations
- Requires ongoing symptom management related to dyspnea, fatigue, pain, edema, or medication side effect or adverse effects
- Resides in a medically under-served, rural or geographically inaccessible area
- Requires frequent physician office visits
- Has difficulty traveling to and from home for medical appointments
- Has the functional ability to work with the telehealth monitoring equipment in terms of sight, hearing, manual dexterity, comprehension and ability to communicate
Glossary terms found on this page:
Formal acceptance as an inpatient by an institution, hospital or health care facility.
Services that have been approved for payment based on a review of EmblemHealth's policies.
Services that have been approved for payment based on a review of EmblemHealth's policies.
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition.
Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.
Care for a person with an emergency condition.
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.
Health care services rendered to a member in their home in lieu of confinement in a hospital or skilled nursing facility. Care must be under the supervision of a registered professional nurse. This type of care may include physical, occupational or speech therapy, medical supplies and medication prescribed by a doctor.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.
Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:
- It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
- It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
- It is in accordance with accepted standards of good medical practice in the community.
- It is furnished in a setting commensurate with the member's medical needs and condition.
- It cannot be omitted under the standards referenced above.
- It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
- It is not furnished primarily for the convenience of the member, the member's family or the provider.
- In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.
The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.
Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.
A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.