must be priced out for the governor and the general assembly. However, Virginia has embraced telemedicine not as new service, but instead as a method in the delivery of services. Therefore, telemedicine is seen as a new mechanism to provide access for Medicaid clients. In October 2009, the program expanded the list of originating sites. Recently, even more services have been added to the Medicaid telemedicine program based on services available in the commercial market.

Over time, as Virginia has moved farther away from fee-for-service payment systems toward managed care (Virginia Medicaid is about 70 percent managed care), the use of telemedicine has evolved from needing a specific modifier on claims to being included as part of the global payment for what is done to serve the individual. Providers of telemedicine are expected to fully comply with service documentation and other coverage and billing requirements, and they may be audited for their compliance. Telemedicine coverage is similar to Medicare coverage, but it is not tied to rural area definitions. Even though telemedicine tends to be used in rural areas, telemedicine is also very useful method in urban areas.

Use of telemedicine in fee-for-service Medicaid looks low if you just look at claims. However, this may be because some providers are not using the billing modifiers on claims forms, some providers are using telemedicine as part of a larger bundle of services, and hospitals and clinics often do not break out telemedicine on their claims. Medicaid managed care plans have gone even further in their use of telemedicine. Surveys of these plans show that one plan has focused on adolescents and psychiatric services while another focused on aged, blind, and disabled individuals. One plan covers telemedicine without preauthorization.

Virginia Medicaid is discussing the use of telemedicine for home health services, postoperative care, high-risk pregnancies, and infections. They are also considering S&F coverage (e.g., for ophthalmology). In addition, Virginia Medicaid is working on a memo to help inform out-of-state physicians about how to receive reimbursement in caring for Virginia residents.

THE MARYLAND PERSPECTIVE

Laura Herrera, M.D., M.P.H.
Maryland Department of Health and Mental Hygiene

Maryland is like Virginia in terms of the numbers of individuals it serves in the Medicaid program, but unlike Virginia, it is not as far along in using telehealth. In 2010, the Maryland Health Quality and Cost Council (chaired by the lieutenant governor and the secretary of health) was tasked with identifying challenges and solutions to advancing telehealth. After the council issued a report, a task force (led by the Maryland Health Care



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