Reimbursement By Region - North Central: East

Illinois, Indiana, Michigan, Ohio, Wisconsin

 

Telemedicine, often called telehealth, is defined as a two-way, real-time, audio and video connection between a patient and a healthcare provider.

 

Definitions:

Hub and Spoke - A telemedicine connection where the originating site is a health care facility. Typically this is a patient and health care provider in one clinic that connect with an additional provider in another.

Facility to Field - A telemedicine connection where the originating site could be anywhere, but there is some sort of health care provider or telepresenter with the patient.

Direct Connection - A telemedicine connection where the originating site could be anywhere, and there is no health care provider or telepresenter presence required.

 

Private Insurer Parity - Full parity is classified as comparable coverage and reimbursement for telemedicine-provided services to that of in-person services.

Originating Site - Where the patient is located.

Distant Site - The remote location of the provider the patient is communicating with.

Telepresenter - A qualified person who must be present with the patient at the originating site.


Illinois 

MedicareMedicaidPrivate Insurer Parity
Hub and SpokeYesPartialNo
Facility to FieldNoNoNo
Direct ConnectPartialNoNo

The Illinois Medicaid agency imposes restrictions on covered services, patient settings, and distant site providers.

Eligible originating site:

  • Physician office

  • Podiatrist office

  • Local health departments

  • Community mental health centers

  • Outpatient hospitals

  • Rural health clinics

  • Encounter Rate Clinics

  • Federally Qualified Health Centers

Eligible originating site providers include:

  • Physicians

  • Podiatrists

  • Local health departments

  • Community mental health centers

  • Outpatient hospitals

  • Encounter Rate Clinics

  • Federally Qualified Health Centerse (FQHC)

  • Rural Health Clinics (RHC)

Eligible distant site providers include:

  • Physicians

  • Podiatrists

  • Advanced practice nurses

  • Encounter Rate Clinics

  • Federally Qualified Health Centers (FQHC)

  • Rural Health Clinics

Tele-psychiatry eligible originating site providers:

  • Physician

  • Other licensed healthcare professional or other licensed clinician

  • Mental health professional

  • Qualified mental health professional


Indiana

MedicareMedicaidPrivate Insurer Parity
Hub and SpokeYesPartialYes
Facility to FieldNoNoYes
Direct ConnectPartialNoYes

Indiana’s Medicare program only allows hub and spoke connections, and requires the spoke to be more than 20 miles from the hub site, except for four types of spoke sites:

  • Federally Qualified Health Centers

  • Rural Health Clinics

  • Community mental health centers

  • Critical access hospitals.

Eligible services:

  • Consultations

  • Office or other outpatient visit

  • Individual psychotherapy

  • Psychiatric diagnostic interview

  • Pharmacologic management

  • End-stage renal disease (ESRD) services

At least one in-person follow up with a physician is required.


Michigan

MedicareMedicaidPrivate Insurer Parity
Hub and SpokeYesPartialYes
Facility to FieldNoNoYes
Direct ConnectPartialPartialYes

Michigan Medicaid has limits on covered services and patient settings, but does not limit the types of practitioners who are eligible distant site providers. These rules support the hub and spoke model, but rule out facility to field connections. Reimbursable services categories via live video:

  • Inpatient Consults

  • Office or other outpatient consults

  • Office or other outpatient services

  • Psychiatric diagnostic procedures

  • Subsequent hospital care

  • Training services, diabetes

  • End stage renal disease (ESRD) related services. However, there must be at least one in-person visit per month, by a physician, nurse practitioner, or physician’s assistant, to examine the vascular site for ESRD services.

  • Behavior change intervention, individual

  • Behavior health and/or substance abuse treatment services

  • Education service, telehealth

  • Nursing facility subsequent care. The initial visit for nursing facility services must be face-to-face.

Direct connections are allowed only for speech-language and audiology services.


Ohio

MedicareMedicaidPrivate Insurer Parity
Hub and SpokeYesPartialNo
Facility to FieldNoNoNo
Direct ConnectPartialNoNo

Ohio Medicaid limits the originating site to certain types of health care facilities. The originating site must also be more than 5 miles from the distant site. Telemedicine providers are limited to physicians and certain other practitioners.

Eligible Distant Site Providers

  • Physicians (MD, DO)

  • Psychologists

  • Federally Qualified Health Center (medical and mental health)

Provider types eligible as an originating site, either using a Q3014 HCPCS code or a GQ modifier:

  • Primary Care Clinic

  • Outpatient Hospital

  • Rural Health Clinic (Medical)

  • Federally Qualified Health Clinic (Medical)

  • Physician

  • Professional Medical Group

  • Podiatrist

  • Optometrist


Wisconsin

MedicareMedicaidPrivate Insurer Parity
Hub and SpokeYesPartialNo
Facility to FieldNoPartialNo
Direct ConnectPartialPartialNo

Wisconsin Medicaid places no restrictions on the patient setting or originating site. Medicaid places restrictions on covered services and designates eligible distant site providers as a condition of payment.

Eligible services:

  • Office or other outpatient services

  • Office or other outpatient consults

  • Initial inpatient consults

  • Outpatient mental health services

  • Health and behavior assessment/intervention

  • End stage renal disease-related services

  • Outpatient substance abuse services

Eligible providers:

  • Physicians and physician clinics

  • Rural Health Centers

  • Federally Qualified Health Center

  • Physician assistants

  • Nurse practitioners

  • Nurse midwives

  • Psychiatrists

  • Ph.D. psychologists