Attachment I_NYS OMH Telehealth Guidance_04.2023.pdf

April 2023 Telehealth Services Guidance for OMH Providers

New York State Office of Mental Health

SECTION 1: Introduction

SECTION 2: Definitions

SECTION 3: General Implementation Guidance

Considerations for the use of Telehealth Services General Standards for Telehealth Services

Considerations for Use of Telehealth – General Services

Considerations for the Use of Telehealth - Specific Services

Informed Consent Confidentiality and Privacy of Health Information Staff Qualifications, Supervision, and Training Documentation and the Electronic Health Record Prescriptions, Labs, and Orders

SECTION 4: Program-Specific Implementation Guidance

Outpatient Programs Article 31 Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) Programs for Adults and Children

Article 31 Satellite, School-based Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) Programs

Assertive Community Treatment (ACT)

Behavioral Health Home and Community Based Services (BH HCBS) and Community Oriented Recovery and Empowerment (CORE) Services (Adult)

Children’s Day Treatment

Children and Family Treatment and Support Services (CFTSS)

Continuing Day Treatment

Partial Hospitalization Programs (PHP)

Personalized Recovery Oriented Services (PROS)

Crisis Services Crisis Intervention – Crisis Residential Programs (Adult Residential Crisis Support, Adult Intensive Crisis Residence, and Children’s Crisis Residence Services)

Crisis Intervention – Mobile Crisis

Crisis Stabilization Centers

Residential Programs

Adult Residential Programs (OMH Licensed)

Children’s Community Residences (CCRs)

Residential Treatment Facilities (RTFs)

Hospital-Based Programs Comprehensive Psychiatric Emergency Programs (CPEP)

OMH Licensed Inpatient Psychiatric Services

SECTION 5: Guidance for Contracting with Telehealth Companies

SECTION 6: Billing Guidelines

Medicaid Billing Guidelines Medicare Billing Guidelines

SECTION 7: Applying to Use Telehealth Services

APPENDIX A: Attestation of Compliance for Approval for Telehealth Services

APPENDIX B: Technical Guidelines Checklist for Providers

SECTION 1: Introduction The purpose of this document is to provide implementation guidance to providers licensed pursuant to Article 31 of New York State (NYS) Mental Hygiene Law, as well as providers designated or otherwise authorized by the NYS Office of Mental Health (OMH) to provide services that are approved to utilize telehealth pursuant to Part 596.

The use of telehealth provides increased access to mental health services and enhances service engagement for adults, children and families. OMH has updated Part 596 of Title 14 NYCRR to allow for greater flexibility and capacity for the utilization of Telehealth Services in NYS. Providers should review Part 596 in addition to this guidance to inform necessary policy changes, as applicable. Regulatory changes include: changing the title from “Telemental Health” to “Telehealth”; allowing for the use of Audio-only; expanding the definition of Telehealth Practitioner; allowing all Telehealth Practitioners the option to deliver services from locations located outside of NYS, but within the United States or its territories; and allowing for the use of Audio-visual technologies for Article 9 examination, evaluation, or assessment.

The regulations prescribe that, when approved by OMH, Telehealth Services may be utilized for licensed, designated, and authorized services provided from a site distant from the location of an individual receiving services, where the individual is physically located at a provider site licensed by the Office, or the individual’s place of residence located in NYS, other identified NYS location, or temporary location out of State. Generally speaking, Telehealth Services are considered to be provided where the individual is located. Therefore, practitioners must ensure any services provided to individuals out of state also comply with local law. OMH’s regulations do not govern the provision of Telehealth Services to individuals who have permanently relocated outside of

NYS.

OMH supports the implementation of telehealth in order to:

• Increase access to care and reduce barriers to participation

• Expand individualized service delivery options to prioritize person-centered care and recognize voice and choice

• Increase capacity and flexibility for family and network-oriented treatment approaches

• Facilitate continuity of care in response to a clinical need or circumstance that would otherwise result in an interruption in program or service participation

• Promote opportunity for planned interventions in settings, situations or activities that are particularly challenging

• Increase real time responsiveness to help decrease the utilization of crisis and emergency interventions

This document offers broad guidance that applies to all OMH providers approved to deliver telehealth as well as specific programmatic guidance that will support the implementation of telehealth in different program types, while maintaining fidelity to program-specific regulations and standards. This guidance affirms OMH’s position that in-person and Audio-visual telehealth are the preferred methods for service delivery, while recognizing that Audio-only service delivery, where appropriate, has an important role to play in increasing access to care. OMH expects providers to use their judgment and respect individual and, as applicable, family preference in deciding which services and in which circumstances to utilize the appropriate telehealth modality to best meet the individual’s needs.

SECTION 2: Definitions A. Audio-only means the use of telephone and other Audio-only technologies to deliver services synchronously.

B. Audio-visual means the use of both audio and video technologies to deliver services synchronously, through programs, platforms, or technologies that enable synchronous transmission of audio and video data.

C. Distant or “hub” site means the distant secure location at which the Telehealth Practitioner rendering the service using Telehealth Services is located.

D. In-person means being present physically in the same location when a service is delivered.

E. Originating or “spoke” site means a site where the individual receiving services is physically located at the time mental health services are delivered to them by means of Telehealth Services, which may include the individual’s place of residence, other identified location in state, or other temporary location out-of-state.

F. Provider refers to a provider agency that may operate one (1) or multiple OMH licensed, designated, or authorized programs or services.

G. Telehealth Practitioner means:

1. A prescribing professional eligible to prescribe medications pursuant to federal regulations; or

2. Any other staff authorized to provide in-person services within a program or services licensed, designated, or authorized by OMH who are authorized to provide such services utilizing telehealth, consistent with their scope of practice and in accordance with guidelines established by the Office.

H. Telehealth Services means the use of Telehealth Technologies by Telehealth Practitioners to provide mental health services at a distance. Such services do not currently include an electronic mail message, text message, or facsimile transmission between a practitioner and an individual receiving services, services provided where the originating and distant sites are the same location, or a consultation between two (2) physicians or nurse practitioners, or other staff, although these activities may support Telehealth Services.

Telehealth Services must be synchronous. Where program regulations or guidance define an individual’s service provider as a collateral, a discussion or consultation between the Telehealth Practitioner and the individual’s other provider is considered a collateral contact, therefore is considered a Telehealth Service.

I. Telehealth Technologies means a dedicated, secure, and interactive Audio-only or Audio-visual linkage system approved by the Office to transmit data between an originating/spoke site and distant/hub site for purposes of providing Telehealth Services.

SECTION 3: General Implementation Guidance

Considerations for the use of Telehealth Services General Standards for Telehealth Services The following standards apply to all programs approved to provide Telehealth Services. Programs approved to provide Telehealth Services must ensure that services are provided consistent with both the following general and program-specific standards (see Section four (4)), as applicable for each program.

1. Maintain compliance with regulatory requirements. All regulatory requirements applicable to mental health services (e.g., development and periodic review of treatment plans, entry of progress notes, timeliness of documentation, etc.), apply to Telehealth Services to the same extent as they apply to in-person services.

2. Maintain capacity for in-person services. A program may not refuse to provide services to an individual who expresses a preference for in-person service delivery. No program can offer only Telehealth Services. Providers must maintain capacity to deliver in-person services in accordance with applicable OMH regulations. In-person operations must be readily available to individuals and families without significant disruption in care, including through continuity with the treating clinician when possible. Provider must have a process to provide emergency in-person evaluations as required.

3. Be person-centered. Telehealth Services are delivered at an intensity and quality that meet the needs of the individuals and families being served, consistent with their treatment, service, or recovery plan goals and the intended outcomes of the program.

Telehealth Services are utilized to meet individual and family needs and preferences, as applicable, rather than to address primarily administrative or cost saving purposes.

Providers should continually assess the individual’s and family’s appropriateness for telehealth and adjust service delivery accordingly.

4. Be culturally and linguistically competent. Telehealth Services must be culturally responsive, respecting the individual’s and, as applicable, their family’s cultural norms, acceptability around service provision and impact on participation. It is the expectation of OMH and required by the Americans with Disabilities Act that Deaf or hard of hearing individuals seeking Telehealth Services are accommodated with appropriate interpreter or communication access services. Programs must also ensure language needs are met for individuals with Limited English Proficiency when delivering Telehealth Services.

5. Ensure that all components of services can be effectively delivered using Telehealth Technologies. Telehealth Services must include all elements of the billable procedure code or rate codes and all required documentation, and the provider must decide that services can be effective using Telehealth Technologies and without an in-person component. Additionally, for Audio-only Telehealth Services, pursuant to Department of Health (DOH) regulation 18 NYCRR § 538.2, providers must decide that services can be effectively delivered without a visual or in-person component.

Considerations for Use of Telehealth – General Services The use of telehealth is part of a broader approach to care based on assessment of the unique, individualized needs and preferences of the individuals and families being served, as well as the design and intent of services within a program (see Section four (4) for additional Program-

Specific Considerations). Since the needs, preferences, appropriateness for, and clinical effectiveness of telehealth service delivery may change during treatment, Telehealth Practitioners are expected to continuously assess effectiveness and appropriateness and to adjust the mode of service delivery accordingly.

The following are key factors Telehealth Practitioners need to consider when making determinations concerning telehealth appropriateness with individuals receiving services.

1. Individual and, as applicable, family preference. Access to in-person services for individuals receiving Telehealth Services should be provided in as seamless a manner as possible to minimize disruption in care as their preferences or needs change. Provider protocols must describe this requirement and process.

2. Ability of the distant site Telehealth Practitioner to communicate and work with program staff as a collective treatment team, regardless of service modality.

3. Ability of individual and, as applicable, family, to participate in and benefit from the critical components of the service or program model via telehealth, considering the following:

a. Need for in-person services, including but not limited to laboratory testing, physical examination, or long-acting injectable medications.

b. Need to engage in the physical structure or immersive nature of a program

c. Ability to maintain continuous engagement in services.

d. Need for engagement in home or community setting to address specific goals.

e. Need for physical co-location to address specific goals.

f. Consultation from other programs or services in which the individual is participating in-person regarding the individual’s ability to participate in and benefit from Telehealth Services.

g. Other individual-specific factors.

4. Clinical factors, including but not limited to the below, should be considered in balancing the need for in-person and Telehealth Services:

a. The individual’s capacity to safely engage in Telehealth Services, including the ability to implement an individualized safety plan or respond to urgent/emergent situations. Telehealth Services should be avoided when there is concern for safety that cannot be addressed through the modality, or when an individual or family, as applicable, does not consent to developing or adhering to a needed safety plan.

Telehealth Services are contraindicated when severity of the risk increases, or telehealth does not allow for an adequate assessment of risk. In such high-risk situations, risk related to providing Telehealth Services instead of in-person services must be balanced, with a strong preference for in-person services where possible.

b. Type or complexity of the individual’s presentation, symptoms or conditions that may impede their ability to tolerate or adequately respond to Telehealth Services, including:

i. Risk factors, such as risk for suicide or self-injurious behavior, substance use disorder relapse, housing stability, violence, use of emergency services or hospital admissions, etc.

ii. Whether current symptoms or behaviors, including co-occurring conditions or medication side effects, warrant visual assessment (e.g., disordered eating, self-injurious behaviors, non-verbal cues) that cannot be reasonably assessed via telehealth.

iii. Use of medications that could result in extrapyramidal symptoms or tardive dyskinesia (i.e., the need to conduct an abnormal involuntary movement scale (AIMS) assessment).

iv. Symptoms or comorbidities that could preclude the use of telehealth (e.g., impairment of vision or hearing, delusions related to technology, etc.).

v. Cognitive and developmental functioning including motor and communication skills.

c. Response to treatment, including whether presenting or co-occurring conditions are worsening.

i. Appropriateness for telehealth should be reassessed after a clinically significant event, including but not limited to hospitalization or ED/CPEP visit.

d. Engagement with treatment and strength of therapeutic relationship, including previous engagement through Telehealth Services delivery.

e. Continuity of care, specifically the consideration for in-person engagement or warm hand-off at critical transitions, including but not limited to recent hospital or CPEP/ER discharge and recent re-entry from incarceration.

f. For individuals who may require additional assistance, the individual’s capacity to engage in telehealth alone or jointly with staff or parent/guardian, and their ability to engage with the Telehealth Technology.

5. Factors related to the appropriateness of Audio-only Telehealth Services:

a. For individuals without the developmental capacity to participate meaningfully telephonically, the Audio-only modality is not recommended.

i. Children 0-5 do not have the developmental capacity to participate meaningfully telephonically. Audio-only telehealth is not permissible for individual sessions with children 0-5 or dyadic sessions with a child 0-5 and parent. Audio-only telehealth is permissible for collateral sessions with parent/guardian of a child 0-5.

b. For all Telehealth Services including children/youth, Audio-visual is strongly encouraged.

i. All services for children/youth (up to age 18 or 21, based on regulation and program guidance) must include visualization of the individual (using Audio-visual Telehealth Services or in-person) in the initial assessment period and every 12 months thereafter at minimum. When this does not occur, reasons should be documented.

ii. Audio-visual options should be fully explored with parents/guardians prior to considering Audio-only services.

6. Presence of a new or worsening declared public health emergency or other significant occurrence, such as a natural disaster, which impacts all or a specific segment of the population’s ability to receive services in person, including the Telehealth Practitioner’s ability to mitigate the specific health risks, such as through the use of personal protective equipment or other environmental accommodations at the site of care.

7. Factors related to accessibility of the Telehealth Technologies, including:

a. The individual’s and, as applicable, family’s familiarity and comfort with the available technology.

b. Technological capability within the home or community setting and its accessibility to the individual or family, as applicable.

c. For interventions in which multiple individuals are required, the ability of the technology platform to support concurrent communication and each individual’s ability to access technology, e.g., if family members or other identified supports residing in different locations are needed to jointly participate in sessions.

d. Issues related to access (device ownership, privacy, data plan, minutes, broadband access, etc.).

e. Issues related to incorporating additional assistive technologies (i.e., captioning) or individuals (i.e., language interpreters).

f. For information about how to support individuals and families with limited or lack of access to devices and services, please see Section VIII of the NYS DOH’s Medicaid Update Special Edition: Comprehensive Guidance Regarding Use of Telehealth & Telephonic Services After the Coronavirus Disease 2019 Public Health Emergency (health.ny.gov).

8. Factors related to the setting in which the individual is located at the time of service:

a. The availability of an adequate, safe, and private space for the individual to receive Telehealth Services, including adequacy to maintain confidentiality.

b. When delivering in community-based settings (e.g., community residence, shelter), Telehealth Practitioners should collaborate with staff within those settings (with consent, where required) to ensure access and that appropriate accommodations are made.

c. The degree to which consistency of location may impact treatment.

9. Cultural and linguistic factors, including, but not limited to:

a. Individual and, as applicable, family’s cultural norms and acceptability around service provision, including Telehealth Services, and impact on participation.

b. The individual’s comfort receiving Telehealth Services using required accommodations to meet the language needs of individuals with Limited English Proficiency and individuals with hearing loss or who are deaf.

Considerations for the Use of Telehealth - Specific Services The use of telehealth for certain specific services requires additional considerations.

1. Considerations for prescribing controlled medications using Telehealth Services.

Note that the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which amended the Controlled Substances Act, requires at least one (1) in-person medical evaluation prior to issuing a prescription for controlled substances that is facilitated by the internet, unless an exception applies. For the most updated information about this requirement, including NYS requirements, please review OMH’s guidance available at https://omh.ny.gov/omhweb/guidance/.

https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.health.ny.gov%2Fhealth_care%2Fmedicaid%2Fprogram%2Fupdate%2F2023%2Fdocs%2Fmu_no3_feb23_speced_pr.pdf&data=05%7C01%7CChristopher.Smith2%40omh.ny.gov%7C34518ef8259b42e4c9b808db24c7ea05%7Cf46cb8ea79004d108ceb80e8c1c81ee7%7C0%7C0%7C638144213263423133%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=eq8Cakl5HnvyzWybZM%2BdLFErGBEIu9AbZYBoLF3%2FKyA%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.health.ny.gov%2Fhealth_care%2Fmedicaid%2Fprogram%2Fupdate%2F2023%2Fdocs%2Fmu_no3_feb23_speced_pr.pdf&data=05%7C01%7CChristopher.Smith2%40omh.ny.gov%7C34518ef8259b42e4c9b808db24c7ea05%7Cf46cb8ea79004d108ceb80e8c1c81ee7%7C0%7C0%7C638144213263423133%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=eq8Cakl5HnvyzWybZM%2BdLFErGBEIu9AbZYBoLF3%2FKyA%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.health.ny.gov%2Fhealth_care%2Fmedicaid%2Fprogram%2Fupdate%2F2023%2Fdocs%2Fmu_no3_feb23_speced_pr.pdf&data=05%7C01%7CChristopher.Smith2%40omh.ny.gov%7C34518ef8259b42e4c9b808db24c7ea05%7Cf46cb8ea79004d108ceb80e8c1c81ee7%7C0%7C0%7C638144213263423133%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=eq8Cakl5HnvyzWybZM%2BdLFErGBEIu9AbZYBoLF3%2FKyA%3D&reserved=0 https://omh.ny.gov/omhweb/guidance/

2. Considerations for Health Monitoring related to Medication Management.

In programs where practitioners prescribe medications, the standard of care requires that individuals receive a thorough mental status exam and appropriate laboratory testing.

a. Audio-visual Telehealth Services can be used to examine appearance, behavior, affect, involuntary movements, gait, or conduct an AIMS using an adequate video connection. If practitioners determine that a thorough exam is not feasible by Telehealth Services (e.g., the individual is unable to cooperate or the video connection is not sufficient to allow an exam), an in-person evaluation should be conducted.

b. To ensure safety and quality, laboratory testing should be conducted in-person.

c. When Medication Management can be safely conducted without the need for Health Monitoring, program-specific guidance should be followed regarding the use of Audio-only Telehealth Services.

3. Considerations for Hybrid Groups or Classes.

In programs that include group-based services, groups or classes may be provided using telehealth.

a. Groups may also be offered as a hybrid, wherein some individuals attend in-person and others using Telehealth Technologies. If any individual is participating in-person, a member of the program staff must also be present in-person to facilitate or co-facilitate the session or class.

b. It is recommended that at the start of each group session, the facilitator should review etiquette and group rules. This may include, but is not limited to:

i. Verifying participant location at the beginning of each telehealth service to ensure safety and wellbeing.

ii. Reminding participants of what to do if any participant, or the entire group, gets disconnected.

iii. Discussion around privacy expectations and use of private space.

iv. Review of phone or web-conferencing features, including the mute button and raise hand buttons.

v. Identifying the speaker when any participant is using Audio-only Telehealth

Services.

4. Considerations for Developmental and Psychological Testing.

a. Testing administration is restricted to Audio-visual, except for tests that are expected to be completed independently without monitoring.

b. Use of telehealth for individual tests should be informed by guidelines from test developers.

c. As clinically indicated, a staff member should be present in-person with the individual during the testing in order to present stimuli or perform other testing functions that cannot be accomplished using telehealth. The staff member should be familiar with the testing materials and have experience with individuals with similar developmental and clinical presentations to the individual being tested.

d. For children/youth: as children/youth are more likely to leave the prescribed testing area, either due to developmental considerations or due to the design of the assessment, Audio-visual technology must be capable of capturing a wide field.

Informed Consent

1. Informed consent means that Telehealth Practitioners provide individuals with sufficient information and education about telehealth to assist them in making an informed choice to receive Telehealth Services. This must include the following:

a. The Telehealth Practitioner must confirm that the individual is aware of the potential advantages and disadvantages of telehealth, be given the option of not participating in Telehealth Services and information regarding their right to request a change in service delivery mode at any time.

b. The Telehealth Practitioner must inform individuals that they will not be denied services if they do not consent to Telehealth Services or request to receive services in-person.

c. Where the individual is a minor, consent shall be provided by the parent/guardian or other person who has legal authority to consent to health care on behalf of the minor.

2. Informed consent shall be obtained through a process of communication between the Telehealth Practitioner and individual receiving services. Although some Providers may choose to document informed consent to receive Telehealth Services using a form, it is not necessary to use a specific form. Informed consent processes should be specified in Providers’ policies and procedures.

3. Informed consent must be obtained before or during the first visit in which Telehealth Services are provided and documented in the case record.

4. Individuals, or a minor individual’s parent or guardian, should be informed how to verify a Telehealth Practitioner’s professional license.

Confidentiality and Privacy of Health Information

1. Providers must have policies and procedures regarding compliance with all relevant state and federal confidentiality laws, regulations, and guidance, including, but not limited to NYS Mental Hygiene Law Section 33.13 and HIPAA Privacy and Security regulations codified at 45 C.F.R. Parts 160 and 164, including Health Information Technology for Economic and Clinical Health (HITECH) breach notification procedures.

2. Provider must ensure the privacy and security of all records containing identifiable health information is maintained at all times, including when practitioners transmit documents to individuals receiving services at an originating site or remove records from the program site or create records off-site while providing Telehealth Services.

3. The Telehealth Practitioner must have access to HIPAA-compliant Audio-visual and telephonic Telehealth Technology at all times while providing Telehealth Services.

4. The Telehealth Practitioner’s and individual’s location should be assessed for privacy and confidentiality during each encounter. Where there are concerns about the individual’s location, the Telehealth Practitioner should discuss with the individual options for relocating, rescheduling, or continuing despite the concerns with appropriate mitigation.

Staff Qualifications, Supervision, and Training

1. Staff qualif ications remain the same whether a service is delivered in-person or using telehealth. Telehealth Practitioners are subject to all applicable pre-employment checks prior to the provision of service.

2. Supervisory requirements remain the same whether a service is delivered in-person or using telehealth.

3. Providers must ensure that staff providing Telehealth Services, whether employed directly by the provider or contracted, are trained in best practices, applicable OMH guidance, other available guidance related to specific payer policies (e.g., Medicaid, Medicare), how to use the Telehealth Technologies, and other provider policies and procedures for communication, emergency response, incident reporting, and other operations.

Documentation and the Electronic Health Record

1. All care provided by distant/hub site Telehealth Practitioners must conform to the

Provider’s policies and procedures related to the provision of care, including but not limited to documentation of initial evaluation, diagnoses, treatment planning, ongoing encounters, and discharge summaries.

2. Providers must ensure program specific documentation reflects that a Telehealth Service was delivered.

a. The use of telehealth must be documented in each progress note, including the time the service was started and the time it ended.

b. The individual’s location should be confirmed at the start of each encounter and documented in the record.

c. Treatment plan/service plan/individual recovery plan reviews shall document appropriateness of Telehealth Services, including through a person-centered discussion on the use of telehealth as a service modality.

3. For Audio-only Telehealth Services, DOH Medicaid guidance requires that providers document why Audio-only services were used for each encounter, i.e., Audio-only Telehealth Services are the individual’s preference or Audio-visual Telehealth Services are not available due to lack of equipment or connectivity.

4. The Telehealth Practitioner must have real-time access to the full electronic health record.

5. Centers for Medicare & Medicaid Services (CMS) has provided additional guidance regarding documentation standards for Telehealth Services, available at https://www.cms.gov/files/document/telehealth-toolkit-providers.pdf.

Prescriptions, Labs, and Orders

1. Lab results must be delivered to the ordering or treating practitioner in a timely manner

(e.g., lab results that arrive to a clinic via fax must be uploaded to the electronic health record and flagged for the ordering or treating practitioners.).

https://www.cms.gov/files/document/telehealth-toolkit-providers.pdf

2. Prescribers and other Telehealth Practitioners who work remotely must proactively communicate to other program staff completion of new or renewed prescriptions, prior authorizations, ordering labs, reviewing labs, and other critical information.

3. All Providers must adhere to Federal and State laws and regulations that govern prescription of medications using telehealth (e.g., the Ryan Haight Act).

SECTION 4: Program-Specific Implementation Guidance

All Program-Specific Implementation Guidance is supplemental to Section three (3): General Implementation Guidance. As such, programs should ensure that policies and procedures are aligned with both Section three (3) and the applicable sections in Section four (4).

Outpatient Programs Article 31 Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS)

Programs for Adults and Children Note: For the purpose of telehealth allowances, all references to “face-to-face” in 14 NYCRR 599 includes allowable Telehealth Services, both Audio-visual and Audio-only, in accordance with Part 596 and this guidance.

Considerations for Use of Telehealth MHOTRS programs are designed to serve individuals with a range of needs. The modality of service delivery should be determined by the individual’s and, as applicable, family’s needs and preferences. In-person service delivery must be available when there is a need or preference.

Program Guidelines Admission to and services provided by MHOTRS programs should not be denied based on lack of in-person assessment or availability.

1. Assessment/Screening:

a. Any session requiring a full mental status exam must include visualization of the individual, either in-person or using Audio-visual telehealth. MHOTRS programs can conduct in-person assessments in the home or community.

2. Initial Assessment:

a. At least one (1) initial assessment should be conducted in-person or using Audio-visual telehealth. If the assessing clinician determines that the Audio-visual or Audio-only platform is insufficient to assess the individual, at least one (1) in-person assessment session should be conducted. However, ongoing engagement and initiations of services as clinically appropriate should not be denied based on lack of in-person assessment.

b. Audio-only telehealth may be used for conducting initial assessments when an individual does not have access to or is uncomfortable using Audio-visual technology or is unable to attend an in-person service. When this occurs, reasons for conducting the intake assessment using Audio-only should be documented.

i. Audio-only telehealth shall not be utilized to provide initial assessment for children aged 0-5.

ii. Audio-only telehealth is permissible for collateral contact with parent/guardian of a child 0-5.

iii. For children/youth, if Audio-only telehealth was used for all initial assessment sessions, an in-person or Audio-visual telehealth should be conducted as soon as possible after admission. Clinics can conduct in-person assessments in the home or community.

3. Psychiatric Assessments:

a. Psychiatric Assessment services should be performed in-person or using Audio-visual telehealth where, in order to provide services, the clinician must observe physical, nonverbal aspects of an individual’s presentation, including appearance, hygiene, facial expression, eye contact, movement in the environment, etc., as well as interactions between the individual and any others participating in the assessment (e.g., parent, if applicable).

b. Any initiation or continuation of a medication that requires a full mental status exam must include visualization of the individual, either in-person or using Audio-visual telehealth.

4. Medication Treatment:

a. Medication treatment services performed subsequent to admission to the clinic should be performed in-person or using Audio-visual telehealth where the clinician, in order to provide services, must observe physical, nonverbal aspects of an individual’s presentation, including appearance, hygiene, facial expression, eye contact, movement in the environment, etc., as well as interactions between the individual and any others participating in the assessment (e.g., parent, if applicable).

b. However, the provision of medication treatment should not be delayed or prevented by the inability to provide timely in-person or Audio-visual services. When clinically appropriate, prescribers may provide medication treatment services using Audio-only telehealth. Clinics can also conduct in-person medication treatment in the home or community.

Billing Standards MHOTRS programs cannot use the off-site billing codes when providing Telehealth Services.

Licensed programs may use Telehealth Technologies, including Audio-visual or Audio-only modalities for the provision of all Clinic CPT procedure codes, except:

• Injectable Medication Administration with Monitoring and Education (H2010) and Injection Only (96372) is restricted to in-person only.

• Health Physical (99382-99387) (New Patient) and 99392-99397 (Established Patient) – is restricted to in-person or Audio-visual only.

• Developmental (96110, 96111) and Psychological Testing (96101, 96116, 96118) is restricted to in-person or Audio-visual for testing administration.

Article 31 Satellite, School-based Mental Health Outpatient Treatment and Rehabilitative Services (MHOTRS) Programs The above guidelines for Article 31 MHOTRS programs also apply to satellite, school-based MHOTRS programs. Additional considerations and guidelines are below.

Considerations for Use of Telehealth School-based satellite MHOTRS programs are designed to be site-based programs with in-person service delivery. Benefits of school-based satellites include increased access to care for children/youth and families within a natural environment, increased opportunity for early identif ication of mental health concerns, and well-coordinated treatment through partnership among staff and families to address clinical needs. Services must be delivered in-person and on-site, with exceptions as noted below, unless there is a clinical rationale for delivering services via telehealth for a limited term basis (e.g., a crisis prevention session in response to an acute increase in stress or symptoms, an infection risk). This clinical rationale must be documented in a progress note.

Where limited-term services are provided using telehealth, Audio-visual telehealth modalities are strongly encouraged. It is always preferable to employ Audio-visual telehealth to allow practitioners to see the individual and their environment. If an individual does not have access to Audio-visual technology, then Audio-only may be used temporarily while assisting the individual to obtain Audio-visual technology, or training or otherwise helping them become comfortable using Audio-visual technology. If despite this assistance, the individual is unable to use Audio-visual technology, then the appropriateness of telehealth as a modality should be reconsidered.

In such situations, depending on clinical determinations and the individual’s or family’s preference, the provider should work to transition the individual and the family to in-person services or transition to alternate outpatient services, which can be effectively delivered through Audio-only telehealth.

Telehealth may also be used as an adjunct to in-person operations to engage others in the individual’s care, such as for family therapy sessions, collateral contacts, etc.

Program Guidelines Telehealth Services may be provided by a school-based satellite to augment service delivery by expanding capacity for parent or family participation, or to enable continuity of care for enrolled children/youth when in-person services cannot be provided. For example, Telehealth Services may be used from the school site or from another location operated by the Provider (distant/hub site):

• To provide a treatment service for a child/youth or family outside the hours of operation or school day, when the child/youth is no longer at school (e.g., “by appointment” for family therapy, collateral session, medication treatment, etc.).

• To provide a treatment service for a child/youth who is not at school during hours of operation, including during school breaks.

• To provide specialized assessment, treatment including medication treatment by a prescriber, or support not otherwise accessed directly via school-based satellite.

Telehealth Services may also be provided to a youth located at school in circumstances where if care is not delivered remotely, the youth may experience an increase in symptoms or risk, e.g., a session to prevent crisis. Providers should establish protocols with host schools for these circumstances. Policies and procedures should include:

• Method for immediate communication between the Telehealth Practitioner and the host school should an emergent need arise.

• Identif ication of appropriate school staff to accompany the youth or have a nearby presence during telehealth delivery.

• Standards and processes for determining the youth’s capacity to participate in Telehealth Services without the on-site presence of the school-based satellite Telehealth Practitioner.

• Ensuring confidentiality and safety within the identified space (e.g., no access to confidential material; removal of objects that may present a danger).

Assertive Community Treatment (ACT) Considerations for Use of Telehealth ACT (Adult, Young Adult, and Youth ACT) teams are specifically designed to serve vulnerable, high-risk individuals who have not been able to engage in traditional outpatient services.

Individuals receiving ACT services are at high risk of disengaging from care absent assertive in-person interventions. Therefore, providers should prioritize in-person service delivery. Telehealth must not replace in-person program requirements. Telehealth may be used to supplement in-person services to optimize engagement (e.g., for screening so that the individual can learn about choices in services), to temporarily provide care in circumstances where in-person engagement is not possible (e.g., risk of infection), or to engage others in the individual’s care (e.g., family therapy sessions, collateral contacts, etc.).

Where limited-term services are provided using telehealth, Audio-visual telehealth modalities are strongly encouraged. It is always preferable to employ Audio-visual telehealth to allow practitioners to see the individual and their environment. If an individual does not have access to Audio-visual technology, then Audio-only may be used temporarily while assisting the individual to obtain Audio-visual technology, or training or otherwise helping them become comfortable using Audio-visual technology. If despite this assistance, the individual is unable to use Audio-visual technology, then the appropriateness of telehealth as a modality should be reconsidered.

In such situations, depending on clinical determinations and the individual’s or family’s preference, the provider should work to transition the individual and the family to in-person services or transition to alternate outpatient services for which services can be effectively delivered through Audio-only telehealth.

Clinical factors such as critical points of transition should be heavily weighed when determining the use of telehealth. For example:

• For individuals returning to the community from incarceration, it is recommended that in-person warm hand-offs be facilitated on the day of release to ensure safe transition to housing and access to psychiatric medication, food, clothing, and a telephone for Telehealth Services, as applicable. Community re-entry is a critical juncture, and many individuals will require in-person assistance to reconnect to services as they readjust to the community environment.

• For individuals who are recently discharged from hospital or CPEP/ER or have a recent increase in hospital/ER admissions, in-person services should be provided to support a warm hand-off during this critical time.

• For youth who are discharged from residential care, in-person services should be provided to support a warm hand-off.

Program Guidelines ACT Providers must have a plan for in-person availability and accessibility 24/7, as required by ACT Program Guidelines. If an individual is experiencing a possible emergency or crisis episode and cannot be engaged through Telehealth Technologies, ACT teams must determine need for in-person contact, and if appropriate, engage in-person or work with local emergency personnel to address the crisis in a timely manner.

When providing Telehealth Services, ACT teams should always ascertain the location of the individual to ensure appropriate mobilization of services or available resources in an emergency or crisis episode.

For individuals receiving ACT services pursuant to Assisted Outpatient Treatment (AOT) orders, requirements for in-person service delivery may be more intensive based on individual case considerations. ACT teams must collaborate with the Local Governmental Unit(s) responsible for AOT monitoring to ascertain whether Telehealth Services may be used on a case-by-case basis.

Staffing Requirements ACT teams shall continue to comply with all ACT Program Guidelines regarding team staffing, treatment, and team communication.

ACT team staff must be in sufficient proximity to be able to provide in-person services, as indicated, with the exception of prescribers as noted below. All staff, regardless of location, must maintain active involvement in ACT team operations, including participation in the daily meeting, in-person or virtually.

In exceptional circumstances, in areas with low access to prescribers, psychiatrists or psychiatric nurse practitioners may provide Telehealth Services. In these circumstances, the Telehealth Practitioners must be located within the United States. When providing Telehealth Services, the psychiatrist or psychiatric nurse practitioner must alert the nurse within 24 hours of making any medication changes.

Billing Requirements ACT teams may not use Telehealth Services to provide all of the minimum contacts required for ACT billing. A contact is defined as a minimum of a 15-minute interaction for both in-person and Telehealth Services, with the individual or collateral. The following standards will continue to apply for ACT billing:

For full billing (rate code 4508), which requires at least six (6) contacts per month, three (3) of which may be with the collateral:

• At least three (3) contacts must be provided in-person with the individual;

• A maximum of three (3) contacts may be provided using Telehealth Services; and

• Where collateral contacts are provided, a maximum of two (2) collateral contacts may be provided using Telehealth Services.

For partial billing (rate code 4509), which requires a minimum of two (2) contacts per month, which must be with the individual:

• At least two (2) contacts must be provided in-person with the individual; and

• Any additional contacts with the individual may be provided using Telehealth

Services.

For inpatient billing (rate code 4511), which requires a minimum of two (2) contacts per month, which must be with the individual:

• At least one (1) contact must be provided in-person and the other contact may be provided using Telehealth Services;

• In the month of admission or discharge, the full payment rate reimbursement is permitted for any month in which at least six (6) contacts are provided, including four (4) or more community-based contacts, consistent with the standards stated above for full billing, combined with a minimum of two (2) inpatient contacts, consistent with the standards in this paragraph; and

• In the month of admission or discharge, the partial payment rate reimbursement is permitted when a minimum of one (1) in-person community contact, combined with a minimum of one (1) in-person inpatient contact, is provided.

Behavioral Health Home and Community Based Services (BH HCBS) and Community Oriented Recovery and Empowerment (CORE) Services (Adult)

This guidance is intended to outline the program-specific rules, restrictions, and recommendations for use of telehealth by OMH-Hosted Adult BH HCBS and CORE Services Providers under OMH’s Part 596 regulations. OASAS-hosted Providers must also follow any applicable OASAS telehealth guidance.

Considerations for Use of Telehealth Adult BH HCBS and CORE Services are designed to provide rehabilitative and supportive services in home and community-based settings where people live, work, learn, and socialize.

As rehabilitative services, BH HCBS and CORE Services include skill building components and interventions, such as role playing, modeling and demonstrations, coaching, and opportunities for practice. Telehealth Practitioners must make person-centered determinations regarding the extent to which rehabilitative services can be effectively provided using telehealth based on each individual’s needs, each staff person’s skills and training, and the specific skill being addressed.

In making these determinations, Telehealth Practitioners must consider their ability to maintain fidelity to the service design.

Telehealth may be used to supplement in-person services, to optimize engagement (e.g., for screening so that the individual can learn about choices in services), to provide care in circumstances where in-person engagement is not possible (e.g., risk of infection), in-person access is challenging due to distance, e.g., in rural areas, or routine in-person care is not the individual’s preference. Telehealth can be helpful to engage others in the individual’s care, such as for family therapy sessions, collateral contacts, etc.

Where services are provided using telehealth, Audio-visual telehealth modalities are strongly encouraged. Due to the rehabilitative nature of these services, there are significant limitations to the type and quality of interventions that can be delivered via Audio-only telehealth. It is always preferable to employ Audio-visual telehealth to allow practitioners to see the individual and their environment. If an individual does not have access to Audio-visual technology, then Audio-only may be used temporarily while assisting the individual to obtain Audio-visual technology, or training or otherwise helping them become comfortable using Audio-visual technology. If despite assistance, the individual is unable to use Audio-visual technology, then the appropriateness of telehealth as a modality should be reconsidered. In such situations, depending on clinical determinations and the individual’s or family’s preference, the provider should work to transition the individual and the family to in-person services or transition to alternate outpatient services which can be effectively delivered through Audio-only telehealth.

Program Guidelines BH HCBS and CORE Services are intended to promote and facilitate community participation and independence. Providers must have capacity to deliver services with respect to each individual’s preferences regarding modalities and locations that are convenient for them and best suited for their desired outcomes. This also includes the capacity to provide in-person services in the community in all counties the provider is designated in.

BH HCBS and CORE Services are often provided by unlicensed behavioral health staff, and professional/clinical supervision is critical to the success and quality of these services.