POLICY
Home telemonitoring service means “a health service that requires scheduled remote monitoring of data related to a patient’s health and transmission of the data to a licensed home and community support services agency, a federally qualified health center, a rural health clinic, or a hospital”.
SOURCE: TX Government Code, Sec. 531.001(4-a) as amended by HB 2727 (2023 Session). (Accessed Aug. 2023).
HHSC reimburses eligible providers performing home telemonitoring services in the same manner as their other professional services described in §355.8021 of this title (relating to Reimbursement Methodology for Home Health Services).
SOURCE: TX Admin Code, Title 1, Sec. 355.7001(e). (Accessed Aug. 2023).
Home telemonitoring is a health service that requires scheduled remote monitoring of data related to a client’s health, and transmission of the data from the client’s home to a licensed home health agency or a hospital. The data transmission must comply with standards set by HIPAA.
Data parameters are established as ordered by a physician’s plan of care.
Data must be reviewed by a registered nurse (RN), NP, CNS, or PA, who is responsible for reporting data to the prescribing physician in the event of a measurement outside the established parameters.
The provision and maintenance of home telemonitoring equipment is the responsibility of the home health agency or the hospital. The one-time initial setup and installation of the equipment in the client’s home is a benefit when services are provided by a home health agency or an outpatient hospital. Monthly home monitoring services are a benefit when services are provided by a home health agency or an outpatient hospital.
Documentation supporting medical necessity for telemonitoring services must be maintained in the client’s medical record by the entity providing the service (home health agency or hospital) and is subject to retrospective review. All paid telemonitoring services not supported by documentation of medical necessity are subject to recoupment.
Home telemonitoring services may be approved for up to 180 days per prior authorization request.
Requests for additional home telemonitoring services received after the current prior authorization period ends will be denied for dates of service provided before the date the request was received. See manual for prior authorization requirements.
Note: Some variations in policies in the two cited manuals. Double-checked the manual for your specific situation.
SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 14-15 (Aug. 2023). TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Aug. 2023), p. 9-12. (Accessed Aug. 2023).
CSHCN Program
Telecommunication services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.
SOURCE: TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Aug. 2023), p. 13 (Accessed Aug. 2023).
CONDITIONS
Home telemonitoring is a benefit for clients who have been diagnosed with either diabetes or hypertension or both.
SOURCE: TX Medicaid Telecommunication Services Handbook, p. 14 (Aug. 2023). (Accessed Aug. 2023).
Home telemonitoring services are available only to Texas Medicaid clients who:
- are diagnosed with diabetes, hypertension, or any other conditions allowed by Texas Government Code §531.02164 and determined by HHSC to be cost effective and feasible; and exhibit two or more of the following risk factors (see below)
SOURCE: TX Admin Code. Title 1, Sec. 354.1434, (Accessed Aug. 2023).
Home telemonitoring services are available only to Texas Medicaid clients who:
- are diagnosed with diabetes, hypertension, or any other conditions allowed by Texas Government Code §531.02164 and determined by HHSC to be cost effective and feasible; and
- exhibit two or more of the following risk factors:
- Two or more hospitalizations in the previous 12-month period
- Frequent or recurrent emergency department visits
- A documented history of poor adherence to ordered medication regime
- A documented history of falls in the previous 6-month period
- Limited or absent informal support systems
- Living alone or being home alone for extended periods of time
- A documented history of care access challenges
SOURCE: TX Admin Code. Title 1, Sec. 354.1434, & TX Medicaid Telecommunication Services Handbook, p. 16 (Aug. 2023). (Accessed Aug. 2023).
Home telemonitoring services are reimbursed in accordance with Chapter 355 of this title (relating to Reimbursement Rates).
Home telemonitoring services are available to Texas Medicaid clients who are 20 years of age and younger, with one or more of the following conditions:
- end-stage solid organ disease;
- organ transplant recipient; or
- requiring mechanical ventilation.
SOURCE: TX Admin Code. Title 1, Sec. 354.1434, (Accessed Aug. 2023).
Home telemonitoring is a benefit for clients who have been diagnosed with either diabetes or hypertension or both.
Home telemonitoring services is also a benefit for clients who are 20 years of age and younger, with one or more of the following conditions:
- End-stage solid organ disease
- Organ transplant recipient
- Requiring mechanical ventilation
Prior authorization will be considered for clients who are 20 years of age and younger and have at least one of the following conditions:
- End-stage solid organ disease
- Organ transplant recipient
- Mechanical ventilation
SOURCE: TX Medicaid Telecommunication Services Handbook, p. 14; 16 (Aug. 2023). (Accessed Aug 2023).
The executive commissioner shall adopt rules for the provision and reimbursement of home telemonitoring services under Medicaid as provided under this section. See sections below for additional details.
For purposes of adopting rules under this section, the commissioner shall:
- Identify and provide home telemonitoring services to persons diagnosed with conditions for which the commission determines the provision of home telemonitoring services would be cost-effective and clinically effective;
- consider providing home telemonitoring services under Subdivision (1) to Medicaid recipients who:
- Are diagnosed with one or more of the following conditions:
- pregnancy;
- diabetes;
- heart disease;
- cancer;
- chronic obstructive pulmonary disease;
- hypertension;
- congestive heart failure;
- mental illness or serious emotional disturbance;
- asthma;
- myocardial infarction;
- stroke;
- end stage renal disease; or
- a condition that requires renal dialysis treatment; and
- Exhibit at least one of the following risk factors
- two or more hospitalizations in the prior 12-month period;
- frequent or recurrent emergency room admissions;
- a documented history of poor adherence to ordered medication regimens;
- a documented risk of falls; and
- a documented history of care access challenges
- Ensure that clinical information gathered by the following providers while providing home telemonitoring services is shared with the recipient ’s physician:
- a home and community support services agency;
- a federally qualified health center;
- a rural health clinic; or
- a hospital
- Ensure that the home telemonitoring provided under this section do not duplicate disease management program services provided under 32.057, Human Resources Code; and require providers to:
- establish a plan of care that includes outcome measures for each recipient who receives home telemonitoring services under this section; and
- share the plan and outcome measures with the recipient ’s physician.
Not withstanding any other provision of this section, the commission shall ensure that home telemonitoring services are available to pediatric persons who:
- are diagnosed with end-stage solid organ disease;
- have received an organ transplant; or
- require mechanical ventilation.
In addition to determining whether to provide home telemonitoring services to Medicaid recipients with the conditions described under Subsection (c)(2), the commission shall determine whether high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective. If the commission determines that high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective:
- the commission shall, to the extent permitted by state and federal law, provide recipients experiencing a high-risk pregnancy with clinically appropriate home telemonitoring services equipment for temporary use in the recipient ’s home; and
- the executive commissioner by rule shall:
- establish criteria to identify recipients experiencing a high-risk pregnancy who would benefit from access to home telemonitoring services equipment;
- ensure that, if cost-effective, feasible, and clinically appropriate, the home telemonitoring services equipment provided includes uterine remote monitoring services equipment and pregnancy-induced hypertension remote monitoring services equipment;
- subject to Subsection (c-3), require that a provider obtain:
- prior authorization from the commission before providing home telemonitoring services equipment to a recipient during the first month the equipment is provided to the recipient; and
- an extension of the authorization under Subparagraph (i) from the commission before providing the equipment in a subsequent month based on the ongoing medical need of the recipient; and
- prohibit payment or reimbursement for home telemonitoring services equipment during any period that the equipment was not in use because the recipient was hospitalized or away from the recipient ’s home regardless of whether the equipment remained in the recipient ’s home while the recipient was hospitalized or away.
For purposes of Subsection (c-2), the commission shall require that:
- a request for prior authorization under Subsection (c-2)(2)(C)(i) be based on an in-person assessment of the recipient; and
- documentation of the recipient ’s ongoing medical need for the equipment is provided to the commission before the commission grants an extension under Subsection (c-2)(2)(C)(ii).
If, after implementation, the commission determines that a condition for which the commission has authorized the provision and reimbursement of home telemonitoring services under Medicaid under this section is not cost-effective and clinically effective, the commission may discontinue the availability of home telemonitoring services for that condition and stop providing reimbursement under Medicaid for home telemonitoring services for that condition, notwithstanding Section 531.0216 or any other law.
To comply with state and federal requirements to provide access to medically necessary services under Medicaid, including the Medicaid managed care program, and if the commission determines it is cost-effective and clinically effective, the commission or a Medicaid managed care organization, as applicable, may reimburse providers for home telemonitoring services provided to persons who have conditions and exhibit risk factors other than those expressly authorized by this section.
SOURCE: TX Government Code Sec. 531.02164 as amended by HB 2727 (2023 Session), (Accessed Aug. 2023).
CSHCN Program
Home telemonitoring services are a benefit only for clients who are diagnosed with one or more of the following conditions:
- Diabetes
- Hypertension
- Congestive heart failure
- End-stage solid organ disease
- Organ transplant recipient
- Requiring mechanical ventilation
Clients with diabetes or hypertension must exhibit two or more of the following risk factors for approval of telemonitoring services:
- Two or more hospitalizations in the previous 12-month period
- Frequent or recurrent emergency department visits
- A documented history of poor adherence to ordered medication regimens
- Documented history of falls in the previous six-month period
- Limited or absent informal support systems
- Living alone or being home alone for extended periods of time
- A documented history of care access challenges
SOURCE: TX Medicaid CSHCN Services Program Provider Manual Telecommunications Services (Aug. 2023), p. 11. (Accessed Aug. 2023).
PROVIDER LIMITATIONS
Data must be reviewed by a registered nurse (RN), NP, CNS, or PA, who is responsible for reporting data to the prescribing physician in the event of a measurement outside the established parameters.
Scheduled periodic reporting of the client data to the physician is required at least once every 30 days, even when there have been no readings outside the parameters established in the physician’s orders. The RN, NP, CNS, or PA in a licensed home health agency or a hospital is responsible for reporting data to the prescribing physician. Telemonitoring providers must be available 24 hours a day, 7 days a week. Although transmissions are generally at scheduled times, they can occur any time of the day or any day of the week, according to the client’s plan of care.
Collection and interpretation of a client’s data for home telemonitoring services (procedure code 99091) is a benefit in the office or outpatient hospital setting when services are provided by a physician or other qualified health care professional. Procedure code 99091 is limited to once in a 30-day period.
The physician who orders home telemonitoring services has a responsibility to ensure the following:
- The client has a choice of home telemonitoring providers.
- The client has the right to discontinue home telemonitoring services at any time.
Although Texas Medicaid supports the use of home telemonitoring, clients are not required to use this service.
SOURCE: TX Medicaid Telecommunication Services Handbook, p. 13-14 (Aug. 2023). (Accessed Aug. 2023).
Home telemonitoring service providers must:
- Comply with all applicable federal, state and local laws and regulations;
- Be enrolled and approved as home telemonitoring services providers;
- Bill for the services covered under the Texas Medicaid Program in the manner and format prescribed by HHSC;
- Share clinical information gathered while providing home telemonitoring services with the patient’s physician; and
- not duplicate disease management program services provided under Human Resources Code §32.057 and further described in Division 32 of this subchapter (relating to Texas Medicaid Wellness Program).
See specific documentation requirements for telemonitoring providers in manual.
SOURCE: TX Admin Code. Title 1, Sec. 354.1434(c). (Accessed Aug. 2023).
OTHER RESTRICTIONS
Home health agency and hospital providers who wish to provide telemonitoring services must notify the Texas Medicaid & Healthcare Partnership (TMHP) as follows:
- Current providers must use the Provider Enrollment and Management System (PEMS) to indicate that they provide telemonitoring services.
- Newly enrolling or re-enrolling home health agency or outpatient hospital providers must indicate whether they provide telemonitoring services during the enrollment process.
The provision and maintenance of home telemonitoring equipment is the responsibility of the home health agency or the hospital. The one-time initial setup and installation (procedure code S9110 with modifier U1) of the equipment in the client’s home is a benefit when services are provided by a home health agency or an outpatient hospital. Monthly home monitoring services (procedure code S9110 with the appropriate modifier) are a benefit when services are provided by a home health agency or an outpatient hospital. Hospital providers must submit revenue code 780 with procedure code S9110 and one of the appropriate modifiers listed in the table within this section.
Documentation supporting medical necessity for telemonitoring services must be maintained in the client’s medical record by the entity providing the service (home health agency or hospital) and is subject to retrospective review. All paid telemonitoring services not supported by documentation of medical necessity are subject to recoupment.
Requests for additional home telemonitoring services that are received after the current prior authorization expires will be denied for dates of service that occurred before the date the submitted request was received.
SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 3 & 14-15 (Aug. 2023). (Accessed Aug. 2023).
A cardiac rehabilitation program in which the cardiac monitoring is done using telephonically transmitted electrocardiograms to a remote site is not covered by Texas Medicaid.
Cardiac rehabilitation must be provided in a facility that has the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment (i.e. oxygen, cardiopulmonary resuscitation equipment, or defibrillator) available for immediate use. If no clinically significant arrhythmia is documented during the first three weeks of the program, the provider may have the client complete the remaining portion without telemetry monitoring by the physician’s order.
SOURCE: TX Medicaid Inpatient and Outpatient Hospital Services Handbook, p. 54 (Aug. 2023). (Accessed Aug. 2023)
CSHCN Program
The CSHCN Program has certain requirements around equipment, prior authorization, and billing instructions. Please refer to manual for specifics.
SOURCE: TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Aug. 2023), p. 9-13 (Accessed Aug. 2023).
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