HB 234-INSURANCE COVERAGE FOR TELEMEDICINE  3:53:59 PM CHAIR OLSON announced that the next order of business would be HOUSE BILL NO. 234, "An Act relating to insurance coverage for mental health benefits provided through telemedicine." 3:54:42 PM REPRESENTATIVE LIZ VAZQUEZ, Alaska State Legislature, introduced HB 234, to be presented by Anita Halterman. 3:55:10 PM ANITA HALTERMAN, staff to Representative Liz Vazquez, Alaska State Legislature, speaking on behalf of Representative Vazquez, advised that HB 234 is a mental health parity bill. The bill requires that the health insurance industry provide reimbursement for mental health coverage through the delivery mode of telemedicine. Alaska Medicaid has paid for mental health and substance abuse telemedicine for many years; however, only one insurer in Alaska has been providing reimbursement. The bill requires that insurers reimburse for telemedicine care without requiring a face-to-face visit, which could improve access to mental health services for 15 percent of the population in Alaska. This bill does not provide new coverage, but it provides a new means of reimbursement for a coverage option currently available through the health insurance industry. 3:56:21 PM MS. HALTERMAN said one concern related to HB 234 is the prohibition of face-to-face visits. She directed attention to a document entitled, "The American Telemedicine Association, 50 State Telemedicine Gaps Analysis" from the National Conference of State Legislators, which described the national status regarding telemedicine. The analysis indicated that 22 states have laws giving them the highest possible "grade" and Alaska received an A+ for telemedicine Medicaid reimbursement. However, Alaska received an F grade as to the private sector, and this bill is an effort to correct that issue. Most private insurers cover reimbursement for telemedicine without a face-to- face visit; the states of Texas and Arkansas appear to be the only states with a face-to-face requirement, and the state of Arizona is the only state requiring a face-to-face encounter before mental health services can be delivered. She pointed out that HB 234 does not prohibit a health care professional from requiring a face-to-face visit, but leaves the decision up to the medical professional, not the insurer. Further, she stressed that this is an insurance bill, not a medical bill. 3:59:02 PM MS. HALTERMAN advised that the second concern raised pertained to licensing within Alaska, and she clarified that the bill requires a provider be licensed in Alaska in order to practice within the state. The third concern was a request to add substance abuse to the bill; however, the Alaska Statutes that originally required that substance abuse be provided were repealed in 1997. She said she has received input from stakeholders within the industry about what definitions might be useable, but Alaska has no clear definition of substance abuse in statute, so the issue of including substance abuse has been tabled. Ms. Halterman reiterated that this is a parity bill requiring the health insurance industry to do what Medicaid has been doing for many years. CHAIR OLSON cautioned that the substance abuse issue would complicate the bill. MS. HALTERMAN agreed. Returning attention to the first concern, she referred to a code of ethics and other guidance documents with regard to face-to-face requirements, and other issues that may affect this particular industry. REPRESENTATIVE VAZQUEZ pointed out that she does not want to attempt to micromanage the medical profession and that it is up to them to require face-to-face visits. REPRESENTATIVE COLVER asked for clarification that substance abuse telemedicine is not included in the bill. MS. HALTERMAN advised that the sponsor had been asked to consider introducing a definition for substance abuse, but after consulting with Legislative Legal and Research Services, and individuals within the insurance industry, discovered there is no clean definition available currently in Alaska that has been vetted by stakeholders in this industry. 4:03:05 PM REPRESENTATIVE COLVER expressed concern that this legislation not "opt out" smoking cessation, which is generally handled over the telephone. He also expressed concern regarding someone who just needs counseling as to where to go for treatment services for substance abuse. Representative Colver restated smoking cessation can be provided over the telephone, and urged that the proposed legislation not opt out smoking cessation services. MS. HALTERMAN expressed her understanding that ICD-10 medical codes are uniformly used primarily for substance abuse and mental health. She explained that many individuals require services that are mental health in nature, may directly be substance abuse related, and which may be covered by this bill. Insurers such as AETNA have indicated that much of what would be included in a definition of substance abuse may already be covered because of the uniform use of ICD-10 codes for behavioral health. She advised stakeholder input is needed to determine what is necessary to ensure that whatever additional coverage might not be provided by this bill is considered next session. REPRESENTATIVE HUGHES observed that a mental health care provider must be licensed in Alaska, and asked whether a telemedicine, mental health care provider could be located out- of-state. She asked whether this legislation would broaden the scope of access for Alaskans. MS. HALTERMAN deferred the question to an invited witness. REPRESENTATIVE HUGHES spoke in support of consistency in providers and questioned whether it is advisable to provide a person's mental health services totally by telemedicine, or whether there should be face-to-face contact. If so, out-of- state providers could not provide that service. She stressed the importance of knowing if the bill allows for out-of-state providers. 4:07:27 PM REPRESENTATIVE COLVER read from the end of the second paragraph of an email from John DeRuytern, Hope Counseling Center, addressed to Representative Vazquez, 1/16/16, available in the committee packet, which read as follows [original punctuation provided]: However, I am very concerned that the bill's language specifically prohibits a requirement that face-to-face evaluation occur prior to telehealth services being reimbursed. This prohibition is a SIGNIFICANT end run around Best Practices and the safe delivery of mental health services using telehealth technologies. REPRESENTATIVE COLVER asked Ms. Halterman to address the foregoing issue. MS. HALTERMAN reminded the committee that the bill is an insurance bill and does not influence medical professionals. Therefore, the mandate of a face-to-face requirement is a mandate on the insurance industry and not on the medical professionals. There is no intent to change the best practices of the medical professionals, and they retain the right to require a face-to-face visit. This bill directs that insurers not impose a face-to-face requirement and that the decision is left to medical professionals. 4:09:19 PM REPRESENTATIVE JOSEPHSON assumed that some face-to-face contact improves the efficacy of counseling. He asked whether a Juneau citizen could hire someone in Anchorage rather than hiring a Juneau practitioner. MS. HALTERMAN confirmed that the bill allows some flexibility for the medical professional, and it will be up to that professional to determine whether or not it is appropriate to deliver mental health services without a face-to-face requirement. The risk assumed for not requiring a face-to-face visit would rest with the medical professional, who retains the right to establish practice rules allowing them to have a face- to-face requirement. In fact, it would be their liability if they didn't require a face-to-face visit. She said: ... this bill is not to influence the medical practice, but rather is trying to influence restrictions on the insurance industry that they not impose additional obligations. This bill is strictly restricting them from imposing a face-to-face requirement. It in no way restricts the medical professional from making a decision based on risk with their patients to require a face-to-face ... 4:11:37 PM CHAIR OLSON asked whether using Skype would be considered face- to-face contact. MS. HALTERMAN referred to the previous analysis document and opined Skype may be an option. She noted that Texas has a face- to-face requirement, but does not clearly define whether it is a physical face-to-face meeting. Neither Texas nor Arizona describe "what that face-to-face obligation actually is." CHAIR OLSON noted that a telemedicine program has been operational in Kotzebue and around the North Slope using Skype or something similar. MS. HALTERMAN reiterated that Medicaid has been reimbursing for telemedicine in Alaska since 1999-2005, when Alaska introduced the first telemedicine regulations in the nation. She noted Medicaid has not had any concerns with regard to mental health or substance abuse services delivered via telemedicine in Alaska. For instance, [Alaska Native health services] and the [U.S. Department of Veterans Affairs] have a lot of exceptions, and Medicaid has been openly reimbursing. Previous testimony from Director Margaret Brodie, Health Care Services, Department of Health and Social Services, related that the bill will benefit Alaska Medicaid because currently, Medicaid is reimbursing for mental health services through telemedicine, but is unable to process a third party recovery for those reimbursements since the private sector may not. This bill, she said, would allow Medicaid to possibly recoup some monies from the private sector. CHAIR OLSON opined that Medicaid pays air travel expenses. MS. HALTERMAN agreed that transportation from a remote area in order for a patient to receive a face-to-face visit can be costly in Alaska, and noted that mental health services have been delivered and reimbursed by Medicaid in at least 36 Medicaid states, with few problems. CHAIR OLSON opened public testimony. 4:15:40 PM AROM EVANS M.D., Medical Director, Orion Behavioral Health Network, advised that Orion Behavioral Health delivers telemedicine throughout the state. Dr. Evans explained that in the past private insurance primarily paid for services, but the funding has been cut in the last three years, which has reduced care to many Alaskans who subsequently lost their insurance benefits when coverage changed to a third-party administrator. The population served by Orion Behavioral Health Network would not receive care without telemedicine; for example, patients who are homebound or who live in small communities that cannot provide direct psychiatric care. He said the bill allows services to reach individuals, even those who do not qualify for Medicaid, such as adolescents and developmentally delayed adults, and may prevent an emergency situation from developing. Dr. Evans clarified that the bill affects insurance and does not seek to change licensing board practices and current rules regarding face-to-face contact, which are fairly strict. At this time the [State Medical Board, Department of Commerce, Community & Economic Development] does not allow out-of-state providers to practice telemedicine, except under certain, limited circumstances. DR. EVANS cautioned that, in some cases, if a person is unable to receive services without a face-to-face visit, the result will be that the patient doesn't receive services due to the aging of Alaska's population and the limited care in rural communities. REPRESENTATIVE HUGHES understood that the bill would increase access to care and asked what the best practices are for the standard of care for treatment without ever having a face-to- face visit. She referred to related proposed legislation. DR. EVANS advised that proposed SB 74 requires the medical board to adopt standards regarding out-of-state providers. Currently, practice by out-of-state providers is allowed only in certain circumstances. As for the standard of care, he said that most states allow for care via telehealth without an in-person examination, as do the ethical guidelines for the American Telemedicine Association. In his practice, Dr. Evans said, every effort is made to do a face-to-face visit. Face-to-face visits are provided whenever possible, although there are certainly times when it is just not possible, and best care practices dictate administering service via telemedicine. 4:22:16 PM CHAIR OLSON announced that public testimony would remain open. [HB 234 was held over.]