This document provides information about telehealth laws and regulations in California and New Jersey. It discusses what services are covered by Medicaid/Medi-Cal in each state, technology requirements, reimbursement policies, documentation standards, and other guidelines for delivering telehealth services in accordance with each state's laws and rules. Requirements addressed include informed consent, privacy/security, licensing, and establishing the provider-patient relationship for telehealth.

1. Telepractice:
Telehealth Law &
Ethics Implementation
Workshop
Lesson 2

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Orientation to
Your Training
Materials
2
Lessons:
Next
Steps:
Resource
s:
• Lesson One
• Lesson Two
• Lesson Three
• Assignments
• Post-Test
• Course Evaluation
• Course Certificate
• Course Documents
• Bibliography
• Tools

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Assignment #1
3
• Lesson 1 Assignment: Check the Standards, Guidelines and/or
Competencies in Your Discipline
• Please look for the "Course Documents" link to the immediate left of this
instructional box. Click the link and look in the Telehealth list of documents
to find the published ethical standards (code of conduct), guidelines
and/competencies for your discipline. If it is absent, please go to your
national professional association and ask for them. (Then please forward to
us and we will add it to our list of it is publically available. Our address is
contact@telehealth.org. Thank you.)

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Assignment #1
4
• This training's first assignment involves your reading all relevant documents
for your discipline and listing all the documentation requirements or other
suggestions made. With a pad in hand (electronic or paper), read all
relevant documents, create a bullet-point list of such requirements or
suggestions and paste them as a response to this question below. This
exercise is designed to motivate you to take the hour(s) needed to
accomplish list. The resulting list will be developed for your purposes only. It
can then be used in your work setting to document your compliance with
ethical standards (code of conduct), guidelines and/competencies in your
discipline(s).

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Assignment #2
5
• Lesson II Assignment: Check the Regulatory Code for Each of Your States
of Licensure
• Please go to your state board website(s). Look for their documents related
to the practice of your discipline(s) in each relevant state. Click the link and
look in the Telehealth list of documents to see if we have any helpful
documents for your discipline(s). If it is absent, please send us what you
find. If you are a telesupervisor, please look for any relevant specialty
documents as well. As with assignment for Lesson I, the current assignment
involves your reading all relevant regulatory documents for your discipline
and listing all the documentation requirements or other suggestions. Please
make a bullet-point list of such requirements or suggestions and paste them
as a response to this question below.

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Although most
psychologists
(80%) considered
it ethical for
licensed mental
health
professionals to
deliver TBH, only
58% were aware of
state and federal
laws or regulations
governing such
activities
6

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Addiction Professionals shall maintain electronic records in accordance with
relevant state and federal laws and statutes. Providers shall inform clients on
how records will be maintained electronically and/or physically. This includes,
but is not limited to, the type of encryption and security used to store the
records and the length of time storage of records is maintained.
VI-17 Records
7

8. California Law

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Go to your
board(s) and look
up all relevant
terms.
Remember that 25
terms have been
documented
across states in
the behavioral
disciplines.
If in doubt call your
board to ask which
term they use.
9

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12

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The informed consent procedure shall
ensure that at least all of the following
information is given to the patient or the
patient's legal representative verbally and in
writing:
1. The patient or the patient's legal
representative retains the option to
withhold or withdraw consent at any time
without affecting the right to future care
or treatment nor risking the loss or
withdrawal of any program benefits to
which the patient or the patient's legal
representative would otherwise be
entitled.
Notice to
California
Consumers
Regarding the
Electronic
Delivery of
Psychological
Services
13

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2. A description of the potential risks,
consequences, and benefits of
telemedicine.
3. All existing confidentiality protections
apply.
4. All existing laws regarding patient access
to medical information and copies of
medical records apply.
5. Dissemination of any patient identifiable
images or information from the
telemedicine interaction to researchers or
other entities shall not occur without the
consent of the patient.
Notice to
California
Consumers
Regarding the
Electronic
Delivery of
Psychological
Services
14

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• This law requires that the patient or the
patient representative signs a written
statement prior to the delivery of health
care via telemedicine, indicating that the
patient or the patient's legal representative
understands the written information
provided in 1 through 5 above and that this
information has been discussed with the
health care practitioner or his/her
designee.
Notice to
California
Consumers
Regarding the
Electronic
Delivery of
Psychological
Services
15

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California Standards of Practice for Telehealth: Psychology
3) The licensee determines that delivery of psychological services via
telehealth is appropriate after considering at least the following factors:
a) The patient or client's diagnosis, symptoms, and medical/psychological
history;
b) The patient or client's preference for receiving services via telehealth:
c) The nature of the services to be provided, including anticipated benefits,
risks, and constraints resulting from their delivery via telehealth;
d) Any benefits, risks, or constraints posed by the patient or client's physical
location. These include the availability of appropriate physical space for the
receipt of psychological services via telehealth, accessibility of local
emergency psychological services, and other considerations related to the
patient or client's diagnosis, symptoms, or condition.
18

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California Standards of Practice for Telehealth: Psychology
4) The licensee is competent to deliver such services based upon whether he
or she possesses the appropriate knowledge, skills, and abilities relating to
delivery of psychological services via telehealth, the information technology
chosen for the delivery of telehealth services, and how such services might
differ from those delivered in person.
19

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California Standards of Practice for Telehealth: Psychology
5) The licensee takes reasonable steps to ensure that electronic data is
transmitted securely, and informs the patient or client immediately of any
known data breach or unauthorized dissemination of data.
6) The licensee complies with all other provisions of the Psychology Licensing
Law and its attendant regulations, and all other applicable provisions of law
and standards of care in this and the other relevant jurisdiction.
c) Failure to comply with these regulations may constitute unprofessional
conduct.
20

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CA.GOV Telehealth Frequently Asked Questions
What types of telehealth services does Medi-Cal cover?
Existing Medi-Cal benefits when appropriately provided via telehealth can be
reimbursable subject to the standard authorization review process. See
specifics below:
• Selected Evaluation and Management (E&M) services for patient visit and
consultation.
• Selected psychiatric diagnostic interview examination and selected
psychiatric therapeutic services.
• Store and forward teledermatology.
22

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CA.GOV Telehealth Frequently Asked Questions
What types of telehealth services does Medi-Cal cover?
• Store and forward teleophthalmology.
• Teledentistry.
• Transmission costs (up to 90 minutes per patient, per day).
• Originating site facility fee.
• Interpretation and report of X-rays and electrocardiograms performed after
telehealth transmission.
For more information, please see the Medi-Cal Provider Manual: Telehealth.
23

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CA.GOV Telehealth Frequently Asked Questions
Who can I call if I have questions about submitting claims?
Questions about claims and billing may be directed to Telephone Service
Center (TSC) at 1-800-541-5555 or via email to Medi-
CalOutreach@Xerox.com.
24

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26

27. New Jersey Law

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CMS and Telehealth
29
• The Centers for Medicare & Medicaid Services (CMS) recognizes that
telehealth is a cost-effective alternative to the traditional face-to-face
interaction between the provider and the Medicaid beneficiary and allows for
the provision of telehealth services
• However, Medicaid regulations do not recognize telehealth as a distinct
service.
• CMS relies on the standards established for Medicare under 42 CFR S
410.78 which established Medicare guidelines for telehealth services.

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Technology Choices
30
• The telehealth law requires that telehealth be provided using interactive,
real-time, two-way communication technologies.
• The law specifically prohibits, by themselves, the use of audio-only
telephone calls, electronic mail, instant messaging, phone texts or images
transmitted via facsimile machines.
• A healthcare provider engaging in telehealth services may use
asynchronous store and forward technology for the transmission of medical
information.

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Store-and-Forward
31
• "Asynchronous store and forward technology" is defined as the acquisition
and transmission of a patient's medical information either to, or from, an
originating site to the provider at the distant site, where the provider can
review the information without the patient being present.
• Information includes transmission of images, diagnostics, data and
other information necessary to the medical process.

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Types of Equipment
32
• A provider may use interactive, real-time, two-way audio in combination with
asynchronous store-and-forward technology, without video communication,
if the provider has determined that the provider is able to meet the accepted
standard of care provided if the visit was face-to-face.

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Types of Equipment
33
• The interactive audiovisual equipment must provide for two-way
communication at a minimum bandwidth of 384 kbps (kilobits per second).
• Telephones, facsimile machines, and electronic mail systems do not meet
the definition of an interactive telecommunications system.
• Sessions may not be recorded.

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Types of Technology
34
• Please note that several commonly used software programs for audio visual
communication were not designed for the purposes of transmitting
confidential healthcare information and have received criticism for their
security measures.
• While these programs meet the 128-bit level of encryption, the use of these
types of programs could lead to a breach in confidential information and
open the provider to charges and financial penalties.
• Providers are encouraged to utilize software that meets HIPAA standards to
ensure protection of personal health information.

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Reimbursement
35
• For the provision of services, providers are expected to follow the same
rules they would follow if the patient visit was face-to-face.
• This includes instances when a license is for an entity such as an
independent clinic.

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Reimbursement
36
• For the purposes of NJFC reimbursement for telehealth services, an
"Interactive, realtime, two-way telecommunications system" means
multimedia communications equipment that includes, at a minimum, audio
and video equipment permitting two-way, real-time interactive
communication between the patient and distant site physician or
practitioner.

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Reimbursement
37
• This license is for a specific address and is not tied to specific personnel.
• In this instance, the service may only be billed when provided at the address
listed on the license.

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Billing
38
• When billed by the clinic, the service provider (for example a physician) may
provide services from a remote location but the patient must receive those
services while physically present at the independent clinic (licensed
location).
• Independent practitioners have a person specific license that is not tied to a
specific address.
• Services billed by independent practitioners do not have location
restrictions.

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Geographic Location
39
• The patient and/or the provider may be at any location as long as the
provider is licensed to practice in New Jersey.
• The offsite provider is responsible for determining that the billable service
meets all required standards of care.
• If the provider cannot meet that standard of care via telehealth, the provider
shall notify the patient to seek a face-to-face appointment.
• When a physical evaluation is required, the telehealth provider may utilize
an individual licensed to provide physical evaluations (e.g. RN) who is
onsite.

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No Face-to-face Required
40
• If the service being provided is an initial interaction, an initial face-to-face
visit is not required to establish a provider-patient relationship.
• However, the provider must review and be familiar with the patient's history
and medical, records, when applicable, prior to the provision of any
telehealth services.

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Documentation
41
• All services that are provided shall be documented to show the service was
provided by telehealth.
• The onsite provider/program is responsible for maintaining all
documentation of services for which they are the primary, billing provider.
• Off-site clinicians must have access to the patient's chart with the ability to
document the therapeutic services provided.

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Standard of Care
42
• Prior to seeing the patient, providers are required to establish that telehealth
services can be provided under the same standards of care as a traditional
face-to face visit.
• The provider must then establish a proper provider-patient relationship by
ensuring authentication and identification of the NJFC patient participating in
a telehealth session.
• This may be done, at a minimum, utilizing the patient's name, date of birth
and address.

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Disclosures and Patient Proficiency
43
• The provider must then identify themselves and disclose their specialty,
license and title.
• The provider shall review the patient's history and available medical records.
• The provider shall ensure that the patient has sufficient knowledge on how
to operate any equipment before the session begins.
• They shall also ensure that staff is readily available to answer any technical
questions or concerns the participant may have before, during or after the
session.

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Continuity of Care
44
• The provider is responsible to refer the patient to any appropriate follow up
or complimentary care as needed.
• The provider's contact information must be made available to the patient
after the provision of services and the provider must be available for at least
72 hours following the provision of services to answer any patient questions
or concerns.

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Prescribing Medication
45
• Unless the provider has established a proper provider-patient relationship
with the patient, a provider shall not issue a prescription to a patient based
solely on the responses provided in an online questionnaire."

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Prescribing Medication
46
• For the prescribing of medication, N.J.S.45:162.d(2) specifically states
"diagnosis, treatment, and consultation recommendations, including
discussions regarding the risk and benefits of the patient's treatment
options, which are made through the use of telemedicine or telehealth,
including the issuance of a prescription based on a telemedicine or
telehealth encounter, shall be held to the same standard of care or practice
standards as are applicable to in-person settings.

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Prescribing of Controlled Substances
47
• N.J.S.45:1-62.e further states: "The prescription of Schedule Il controlled
dangerous substances through the use of telemedicine or telehealth shall be
authorized only after an initial in-person examination of the patient, as
provided by regulation, and a subsequent in-person visit with the patient
shall be required every three months for the duration of time that the patient
is being prescribed the Schedule 'll controlled dangerous substance.

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Prescribing of Controlled Substances
to a Minor
48
• N.J.S.45:1-62.e further states: However, the provisions of this subsection
shall not apply, and the in-person examination or review of a patient shall
not be required, when a health care provider is prescribing a stimulant which
is a Schedule Il controlled dangerous substance for use by a minor patient
under the age of 18, provided that the health care provider is using
interactive, real-time, two-way audio and video technologies when treating
the patient and the health care provider has first obtained written consent for
the waiver of these in-person examination requirements from the minor
patient's parent or guardian."

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Screening Services
49
• A mental health screener, screening service, or screening psychiatrist
subject to the provisions of P.L. 1987, c. 116 (C.30:4-27.1 et seq.) shall not
be required to obtain a separate authorization in order to engage in
telemedicine or telehealth for mental health screening purposes, and shall
not be required to request and obtain a waiver from existing regulations,
prior to engaging in telemedicine or telehealth.

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Screening (cont.)
50
• Screening service providers should ensure compliance with any applicable
regulations issued by the Division of Mental Health and Addiction services at
N.J.A.C. 10:31-1.1 et seq., particularly N.J.A.C. 10:31-2.3(f)2i and -2.3(i).

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Reimbursement
51
• For Fee-For-Service (FFS) claims submitted to State's fiscal agent, any
claim submitted for a telehealth service should include an existing revenue
code and/or a HIPAA compliant HCPCS code with a GT modifier.
• This modifier is for informational purposes only and will not affect payment.
• FFS payments for telehealth services shall be reimbursed at the same rate
as an in-person visit.

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More Reimbursement & Contact
Information
52
• All costs associated with the provision of telehealth services, including but
not limited to the contracting of professional services and the
telecommunication equipment, are the responsibility of the provider and are
not directly reimbursable by NJFC.
• Managed care plans may have different requirements and providers are
encouraged to request guidance from those plans with which they have
contracts.

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More Reimbursement & Contact
Information
53
• If you have any questions concerning this Newsletter, please contact the
Division of Medical Assistance and Health Services, Office of Customer
Service at (609) 631-4641.

54. Other Documentation &
Administration Issues to
Consider

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• To successfully obtain reimbursement for
telehealth from 3rd party carriers, the
clinician must provide the following
documentation:
• Valid professional license
• Approved credentialing by the insurer
as a telehealth provider
• The proper CPT and ICD-10 coding
• Use of proper equipment that meets all
laws
• HIPAA & HITECH
• Any additional state laws that apply
Documentation
Related to
Reimbursement
55

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• Since the adoption of ICD-10 codes for
billing, all practitioners including
telepractitioners carry the ultimate
responsibility to:
• Choose the appropriate CPT codes
• Document why those particular codes
were used
CPT Codes
and ICD-10
56

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HIPAA
Compliance
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Client/Patient
Training
58

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• Represents a "meeting of the minds"
• Information is influenced by many factors,
including:
• Client/Patient's capacity for absorbing
information
• Time Limits
• Clinician's schedule
Informed
Consent
Discussion
vs.
Document
59

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• Preferences (Email/Texting/Telephone/Video)
• Skills
• Concerns / resistance
• File exchanges via email, text or websites
• What will happen if someone else sends clinician
information
• How someone else can easily intercept
information
• Social networking-social media policy
Client/Patient
Training
60

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Use variety of education methods such as:
• Discussion
• In-office demo
• Hands-on training
• Home or video visit by an assistant
• Demo via remote control of patient's desktop or
laptop
• Video instruction
• Handouts
• Instructions on your clinical practice website
• Online training program
• Frequently Asked Question resources
How to
Educate?
61

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• Subject matter is often too complex and
technical
• Clinician thinks she is speaking English but
some words are not understood
• Client/Patient may be under stress (or may
assert so later)
• Mental illness
Informed Consent Discussion vs.
Just Signing a Document
62

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IC Represents a "meeting of the minds”
• Information transfer is influenced by many
factors, including:
• Client/Patient’s capacity for absorbing
information
• Time Limits
• Clinician's schedule
Informed Consent Discussion vs.
Just Signing a Document
63

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• Document only serves as important evidence
of discussion
• Document is usually only an addendum
added to your regular informed consent
document
All standard informed consent elements
apply
Just add telemental health elements
Informed Consent
Discussion VS Document
64

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• Specific statuses govern informed consent in
telehealth
• Who's state law controls?
• Solution: assume that the law of the
client/patient's location will most likely be
applied
• More conservative approach is to
determine the law in both your and your
client/patient's state and follow mandates
of the more stringent law
Informed Consent
Discussion VS Document
65

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AB 415 - Telehealth Advancement Act
AB 415 changes telehealth's additional written
patient consent requirement to verbal consent.
• Providers found that the written consent form
stigmatized the use of telehealth, and created an
unnecessary barrier to care.
• AB 415 replaces the written consent with a verbal
consent. This establishes parity between services
provided in person and those provided via
telehealth. (Must be documented.)
http://cchpca.org/telehealth-advancement-act
Relevant
California
State Law
66

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Depending on your existing documents, these
topics may be considered for inclusion into your
Informed Consent process or document:
1. Date
2. Diagnosis
3. Outline of intervention
Informed
Consent
Documen-
tation Library
67

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• Explain your compliance with state/provincial
law
• Your license/discipline?
• Where? (Name the states,
provinces/countries)
• Outline consequences if they change
locations
68

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6. Identify and record client/patient preferences
regarding technology, treatment, arrangements
Informed Consent
Documentation Library
69

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Telehealth
Checklist?
Lessons:
Next
Steps:
Resource
s:
• Lesson One
• Lesson Two
• Lesson Three
• Assignment - 1
• Post-Test
• Course Evaluation
• Course Certificate
• Course Documents
• Bibliography
• Tools
71

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• Document, document, document
• Opening protocol verification of identity,
location, and privacy (at a minimum)
• Clinical protocols followed (evidence-
based research articles in your
specialty niche or population served)
• Time in, time out
Progress
Note
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Intake form - compare your existing form to
your state statutes to make sure you have
covered all the required bases
• Mental status exam
• Preferences for technology
• Risks/benefits (See ATA/APA
comparison checklist)
• Diversity needs
• Gait analysis
• Hygiene check
• Alcohol?
Intake
Form
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reserved.
• Dropped connections
• Intrusions / interruptions
• Lighting
• Adaptive Equipment
• Progress toward established goals
• How technology helped/hindered
• Peer consultation using telehealth systems
(e-consults)
Progress
Note
74

75. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
• Use your general form, but comment on:
• Success/pros/cons of telehealth
• Problems encountered and resolutions
if any
• If telehealth is suggested for future
Termination
Note
75

76. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
• Use wording from informed consent
agreements about "no-shows/termination"
if termination letter is needed
• Social media policy about "friending" (e.g.
Facebook) or giving ratings (e.g. Yelp) and
alternative ways to comment after
meetings come to a close
Termination
Note
76

77. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
• Identify yourself and your geographic
location
• Ask your client/patient to do the same (as
needed)
• Audio/video check (e.g. Do you hear & see
me clearly?)
• Is there anyone in your room or within ear-
shot today? (Agree on safety code words,
signals or phrases)
• Is there anything else I might notice and
find of interest if I were in the same room
with you today?
Opening
Protocol
77

78. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
Telehealth
Sample of
Initial
Evaluation
(Intake) Form
78

79. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
Telehealth
Sample of
Telehealth
Informed
Consent
Addendum
79

80. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
Telehealth
Sample of
Progress
Note
80

81. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
Telehealth
Sample of
Risk
Assessment
Form
81

82. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
• What are typical emergencies experienced by the
population(s) that you serve?
• Suicide or Homicide
• What is suicide plan?
• Are firearms accessible?
• Abuse
• What are the imminent dangers?
• Are children or elderly people in
environment?
• lf substance abuse is an issue, is
substance in the home?
• ls abduction a flight risk if child abuse
reporting is discussed?
Emergency
Planning
Introduction
82

83. ©
1994-2022
Telehealth.org,
LLC.
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rights
reserved.
• What are typical emergencies experienced by the
population(s) that you serve?
• Medication reactions
• Physical emergencies
• ls client/patient alone?
• Is social support available?
• What repercussions might ensue if you pull
in a friend or family?
• Other?
Emergency
Planning
Introduction
83

84. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
• Include the emergency plan in your informed
consent (IC) document, where your client/patient
will sign that they agree to it
• Review the specifics of your telehealth informed
consent verbally, then ask for signed IC document
Emergency
Planning
Introduction
84

85. ©
1994-2022
Telehealth.org,
LLC.
All
rights
reserved.
Collect & Document Local Emergency Resources
• These can be dependent on your client/patient
population (e.g., autistic children and their
families, depressed adults, unwed teen mothers,
elderly men with anger management issues and
subtance abuse)
• Document telephone numbers, hospital
admissions, local clinical resources, local
champion or proctor, friend/family member(s)
Emergency
Planning
Introduction
85

86. Telehealth.org
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