Emerging Issues for Health Centers in State Telehealth Policy

By Heidi Emerson

Although telehealth is not a new concept, new technologies, greater comfort with technology, and changing payment models are driving increasing use by patients and providers. As a result, there has been new activity and interest in supporting the use of telehealth to expand access and improve care at health centers:

  • In a rural county in Georgia, Mercer University School of Medicine has coordinated a special program which was launched in the summer of 2015 with funding by the Governor’s budget.[1] In a county with no doctors or hospital, Community Health Care Systems, a health center in Sparta, has been using the program to conduct electronic home visits.
  • Ravenswood Family Dentistry, a health center in San Mateo, California, has been using teledentistry to provide dental exams to children at a Head Start center in an area where dental care is limited, or dentists do not accept new Denti-Cal patients.[2]
  • In Mississippi, a new rule that took effect on Dec. 1, 2015 has added language to allow FQHCs or look-alikes to be reimbursed an additional fee as an originating site.[3]  (Mississippi Regulations, 10/27/15)

These are only some examples of how state programs and policies facilitate the use of technology to deliver care at health centers. According to a legislative scan by the Center for Connected Health Policy (CCHP), over 200 pieces of legislation related to telehealth were introduced in the 2015 state legislative sessions.  In addition to legislation around reimbursement and payment, some of the other policies and programs that are being considered by states include the Interstate Medical Licensure Compact[4] passed by 12 states, and the Nurse Licensure Compact which preceded the physician compact by 15 years, with 25 states participating.[5] The Nurse Licensure Compact would allow nurses to practice in both their home state and other compact states with a multistate license.  The Medical Licensure Compact would streamline or expedite the licensing process for physicians practicing in multiple states.

Expansion of broadband networks to facilitate connections for telehealth are also being considered by states such as West Virginia.  Funding for the expansion of broadband access is also available as part of the Federal Communications Commission’s National Broadband Plan through the FCC’s Rural Health Care Program, and its Healthcare Connect Fund, created in 2012. [6]

According to a 2015 report released by the Robert Graham Center and the American Academy of Family Physicians (AAFP), reimbursement continues to be a major barrier for physicians in utilizing telehealth in their practices.[7]  In their survey of 1,557 physicians, among users of telehealth, the most common use was for referrals to specialists (68%) and mental health providers (28%).  For health centers, other challenges include the complexity of billing and reimbursement rules, shortages of providers, interoperability of data systems, and coding of telehealth claims and encounters, according to a report from CCHP that examined telehealth programs at 3 federally qualified health centers and 2 rural health centers in California.[8]

The National Conference of State Legislatures (NCSL) released a report that reviews telehealth policy trends and focuses on three issues: coverage and reimbursement, licensure, and safety and security.[9] Furthermore, the report provides a policy checklist for legislators on these three key issues, and suggests that other ways that states can support telehealth include state reforms that transform care delivery through state plan amendments, waivers and grants. Similar to other reports, other policy issues to consider are liability coverage, scope of practice, credentialing and privileging, prescribing and informed consent.

As we start 2016, it is likely that telehealth and telemedicine policy will be topics under consideration by both states and Congress. It is worth watching policies that will ease restrictions, promote reimbursement, and will allow the use of technology to expand access to both primary and specialty care. The integration of telehealth into practice can improve quality of care for the chronic and complex conditions of the vulnerable populations that health centers serve.

For other resources on state telehealth policies that impact health centers, please see NACHC’s 2013 report, and 2015 issue brief.


[1] http://www.georgiahealthnews.com/2015/11/struggling-rural-county-vanguard-telemedicine-revolution/?ref=ft

[2] http://centerforhealthreporting.org/article/teledentistry-could-boost-access-california%E2%80%99s-poor-kids

[3] https://www.medicaid.ms.gov/providers/administrative-code/final-administrative-code-filings/

[4] For more information: http://www.fsmb.org/policy/publications-media/news-releases; http://www.licenseportability.org/

[5] For more information: https://www.ncsbn.org/nurse-licensure-compact.htm

[6] For more information, see also: https://transition.fcc.gov/national-broadband-plan/health-care-broadband-in-america-paper.pdf

[7] Family Physicians and Telehealth: Findings from a National Survey, Robert Graham Center, October 30, 2015. Accessed at: http://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/RGC%202015%20Telehealth%20Report.pdf

[8] Community Health Centers and Telehealth: A Cost Analysis Report and Recommendations. Center for Connected Health Policy, July 2015.

[9] Telehealth Policy Trends and Considerations, National Conference of State Legislatures, December 2015. Accessed at: http://www.ncsl.org/research/health/telehealth-policy-trends-and-considerations.aspx

State Affairs: A Year In Review

As the year comes to a close, and many states are gearing up for the 2016 legislative session, our team at State Affairs reflects on the highlights of the year. Apart from the various changes that came about due to the most recent November elections, the key issues involving or impacting health centers have been around coverage options for the uninsured, payment reform, state funding for health centers, and community partnerships.

Medicaid Expansion

As of December 2015, 30 states and the District of Columbia have expanded coverage for individuals with incomes under 133% of federal poverty level.  In 2014, 26 states had expanded coverage. In FY 2015, New Hampshire and Indiana had 1115 waivers approved and Pennsylvania decided to move to traditional expansion rather than implementation of its previously approved 1115 waiver. In FY 2016, Alaska’s governor decided to accept federal funding to expand Medicaid, and Montana’s 1115 waiver was approved. At the close of this year, four additional states have been discussing potential ways to increase coverage in their states: South Dakota, Utah, Wyoming, and Louisiana.

What’s Not New?

Similar to other waivers, Montana includes cost-sharing, such as some premiums and co-pays for individuals with incomes at or below 100% FPL. To date, CMS has not approved any waivers that allow individuals below 100% FPL to be dis-enrolled from coverage, even if they fail to pay premiums.

Although some states have been discussing the addition of work requirements or high cost-sharing for eligible individuals, CMS has not approved waivers with these elements to date.

What’s New?

Indiana and Montana both include a provision that “locks out” individuals with incomes above 100% FPL who fail to pay premiums for a specified period of time.

Montana’s waiver will be the first to use a third-party administrator to run the program.

States that have already expanded are planning to submit new waiver requests, and may include additional restrictions such as increased cost-sharing, premiums, life time enrollment limits, and changes in benefits. Michigan’s waiver to allow the continuation of their expansion program was approved, and includes new elements that include healthy behavior incentives.  States to watch in 2016 include Ohio, Arizona, Kentucky and New Hampshire.

Payment Reform

To help health centers assess their current readiness for engagement in payment reform, NACHC contracted with JSI in to develop the Payment Reform Readiness Assessment Tool. This year, NACHC was excited to launch a web-based version of the tool to facilitate an experience that is more user-friendly and accessible. Contact Kersten Lausch at klausch@nachc.org to learn more.

NACHC’s State Affairs team hosted a webinar series on payment reform for health centers. Recordings of these webinars can be accessed below.

In 2015, California approved legislation, sponsored by the California Primary Care Association, to authorize a voluntary 3-year alternative payment methodology (APM) pilot for FQHCs in the state. The PPS-equivalent capitation payment model is intended to provide health centers with greater flexibility to deliver care to each patient in a manner that best meets his or her needs.

State Funding

According to NACHC’s Annual PCA Policy Survey, for FY2015, twenty-nine states reported that their state provides direct funding for health centers for a total of $305 million as compared to thirty-one states providing approximately $400 million in FY2014. Looking towards the future, twenty-four PCAs were able to provide estimates of their funding for SFY2016, and of those twenty-four, nine are expecting an increase in funding, seven are expecting funding levels to stay the same, and eight are expecting a decrease in funding.

Health Center-Hospital Partnerships

Our Partnership project with America’s Essential Hospitals and George Washington University launched their website: www.safetynetpartnership.org earlier this year. On this website, you will find information about the four local communities that worked with the National Partnership in 2014-15 on a common priority area and leveraging health center-hospital collaboration to implement, respond to, or influence policy. Check out the website to learn more about the innovative and important work these local partnerships are doing around increasing access to coverage, increasing access to specialty care, and outreach and enrollment in Medicaid and in the Marketplace.

It has been a busy year in state health policy, and we are looking forward to working with you and supporting you in your efforts in 2016.  Thank you for the work you do for health centers and your communities! Wishing you happiness and health in the New Year and beyond!

NACHC State Affairs: Dawn McKinney, Heidi Emerson, Luke Ertle, and Kersten Burns Lausch

Research Department: A Year In Review


The NACHC Research Department has had another busy and productive year! Here is a quick recap of just some of the research- and data-driven resources we have put together, as well as some exciting projects we have been working on:

The Role of Community Health Centers in Lowering Preventable Emergency Department Use

This fact sheet notes the substantial proportion of emergency department (ED) visits in the US that are preventable and identifies some of the most common barriers that lead to increased preventable emergency department use. In addition, it highlights the vital role played by the health center model of care in eliminating such barriers, noting that the average cost of a health center visit is one-sixth the average cost of an ED visit

Qualified Health Plans and Health Centers: A Primer

This primer provides a brief explanation of qualified health plans and points to the numerous ways health centers serve as key partners for QHPs. It also provides new data on health centers’ experiences with QHPs and the patients enrolled in them, including loss of patient QHP coverage. Key QHP contracting tips for health centers are provided as well.

Health Centers Provide Cost Effective Care

This popular fact sheet was revamped this year with a more infographic style and some new data. This resource highlights health centers’ lower average costs of care compared to all physician settings, despite serving more complex patients. It also presents research findings that health centers produce savings for the health care system while also generating jobs and stimulating economic activity in low income communities across the country.

National Health Center Week Infographics

Two new infographics were developed to celebrate National Health Center Week 2015. One, titled Health Centers: Paving the Road to Good Health, uses data and research-driven facts to illustrate the unique characteristics of health centers and their patients as well as the many ways in which health centers successfully deliver and improve care compared to other providers. A second, customizable infographic made it possible for individual health centers to tell their health center story against a backdrop of facts about the national health center movement’s 50 year history and growth.

Assessing and Addressing the Social Determinants of Health to Position Health Centers for Value Based Payment

The NACHC Research Department has worked with the Association of Asian Pacific Community Health Organizations (AAPCHO), the Oregon Primary Care Association (OPCA), and the Institute for Alternative Futures (IAF) to develop a protocol that allows health centers to collect and respond to patient-level data on the social determinants of health.  Click here to view the tool and more information.

Expanding Health Center Patient-Centered Research Capacity

The NACHC Research Department has worked with a host of partners to build health centers’ capacity to engage in patient-centered outcomes research by developing a free curriculum and collaborative learning community.  The curriculum includes twelve webinars that walks through the steps needed to produce a research proposal, including developing a research question, calculating sample sizes, analyzing data, developing budgets, and writing a proposal.  View the recorded webinars here.

All of us here in the Research Department are honored to be applying research to empower health centers and the communities they serve—thank you for the opportunity and for a wonderful 2015!

Wishing you a happy and healthy 2016,

The NACHC Research Department:  Michelle Proser, Michelle Jester, & Caitlin Crowley

Regulatory Affairs: A Year in Review

NACHC’s Regulatory Affairs Department has seen a lot of action over the last year, with many important regulations and guidances released and the addition of new staff.  Below are some of our highlights from 2015:

  • We welcomed a new Director of Regulatory Affairs! As many of you know, Roger Schwartz, the former Director of the Regulatory Affairs Department retired at the beginning of the year and we welcomed Colleen Meiman on as the new Director.  She jumped right into the new role on Day One and, as you’ll see, we have kept her busy all year.  We are all glad to have her on board!
  • We redesigned the NACHC process for soliciting input on proposed regulations and guidances, such as:
    • expanding timeframes and opportunities for health centers and PCAs to suggest and respond to draft comments
    • creating a new webpage with information on the regulatory process, links to documents currently open for public comment, and links to NACHC comments to previous documents, searchable by topic area
  • We submitted formal comments to the Department of Health and Human Services (HHS) on a wide variety of policy areas, including:
    • The rules governing Medicaid Managed Care Plans: this is the first proposed rule on Medicaid Managed Care plans that CMS has released in years and covers policies guiding all areas of Medicaid Managed Care, including contract reviews and setting rates.
    • The mega-guidance on the 340B Drug Discount Program: this much anticipated guidance on the 340B program proposed to make major changes to the program in the agency’s first-ever guidance on the program,  including creating a new patient definition and other important program policies. We expect this “mega-guidance” to be finalized in the upcoming year.
    • The rules governing the Marketplaces in 2017: this is CMS’ annual guidance on the Marketplace Exchanges, which provides the policies that Exchanges and Qualified Health Plans must follow to participate in the Marketplaces, including issues such as essential community providers (ECPs), the role of Navigators and Certified Assistance Counselors, and network adequacy.
  • We have been working directly with the Administration to raise concerns about, and secure improvements, in:
    • changes to the HPSA scoring and Shortage Designation processes
    • the new format for the Medicare Cost Report, expected to be released in 2016
    • Medicaid payment approaches, including ensuring states are appropriately paying Medicaid PPS rates and the Medicaid wrap around
    • Addressing the 340B registration process to address the challenges and issues we have heard from health centers

It has been a busy, but important year in Regulatory Affairs and we expect 2016 to be just the same.  We thank you all for your time and attention in helping to formulate NACHC’s position on these rules and regulations and look forward to working with you in the New Year.   Happy Holidays! – Colleen and Susan

Positive Outcomes for Medicaid Expansion Demonstration in Cleveland

By Kersten Lausch

Research demonstrating the value of Medicaid expansion continues to grow. The following is an overview of a recent study that examined how the MetroHealth Care Plus program in Cuyahoga County, Ohio impacted patient care. [Note: Unfortunately, access to the full text of Cebul et al.’s article in Health Affairs requires paid subscription or purchase.]

What is Care Plus?
In February 2013, prior to Ohio’s decision to expand Medicaid, CMS approved a Medicaid waiver that enabled a county-owned hospital (MetroHealth System) and two local FQHCs (Care Alliance and Neighborhood Family Practice) in Cuyahoga County to offer Medicaid-like coverage to residents (ages 18-64) with incomes at or below 133 percent of the federal poverty line. To finance Care Plus, the hospital used the $36 million annual subsidy it receives from Cuyahoga County taxpayers and drew down enhanced federal Medicaid matching dollars.

Over the next 11 months, Care Plus provided coverage to 28,294 patients who were able to receive benefits without co-pays through the program’s defined network, which included the three partner organizations and other community providers (e.g., community mental health centers). Care Plus patients formally transitioned to Ohio’s expanded Medicaid program on January 1, 2014.

What did the study find?
Between 2012 and 2013, Cebul and colleagues found that patients enrolled in Care Plus had better care and health outcomes than those who remained uninsured. For example, the researchers found that, compared to those who were continuously uninsured, Care Plus patients with diabetes improved over 13 percentage points on the diabetes composite standard (a combined metric for assessing quality of diabetes care).

The researchers also found that the total cost of care for patients enrolled in Care Plus was 28.7 percent below the budget cap set by CMS for the program to remain budget neutral.

What supported these outcomes?
In addition to giving patients access to care, Cebul et al. concluded that the program’s defined provider network and delivery system innovations helped to support the quality and cost outcomes. Specifically, all three partner organizations:

  • Used the same electronic health records platform;
  • Had patient-centered medical home-recognized primary care practices; and
  • Publicly reported performance in a regional health improvement collaborative.

The article by Cebul and colleagues was published in July’s Health Affairs issue, which was dedicated to the 50th anniversary of Medicaid. Several articles within the issue feature the substantial role played by health centers. For more information, read our post “Health Affairs’ July Issue Commemorating 50 Years of Medicaid Highlights Significant Role Played by Health Centers.”