Written by Michelle Ries

North Carolina Actions to Improve Telehealth Services During COVID-19

In response to the COVID-19 pandemic, Session Law 2020-4 (House Bill 1043) and Session Law 2020-3 (Senate Bill 704) were passed by the North Carolina House and Senate on May 2, and signed into law by Governor Cooper on May 4. These bills appropriate almost $1.6 billion in federal funds from the CARES Act to provide financial relief related to public health and safety, educational needs, small business assistance, and continuity of state government operations.

NCIOM has written previously about COVID-19 and the “digital divide,” and the ways in which lack of access to adequate internet coverage or other technological resources has disparate impacts for low-income and rural Americans. In last week’s bills, $9 million was allocated to improve broadband service in rural areas of North Carolina.

An immediate impact of the digital divide during this pandemic is a lack of access to telehealth services. In last week’s bills, the following provisions were included to address additional need for telehealth services during the COVID-19 pandemic:

• $50 million to NC Department of Health and Human Services will fund services for rural and underserved communities impacted by the pandemic. This amount includes the provision of enhanced telehealth services and other health-related needs to these communities.
• $20 million to NC Department of Health and Human Services will fund local health departments, rural health providers, the State Laboratory of Public Health, and behavioral health and crisis services. Expansion of telehealth services is included in this funding.
• $65 million to establish the COVID-19 Rural Hospitals Relief Fund. This fund will offset expenses incurred for providing patient care in response to COVID-19, for hospitals designated as critical access hospitals and hospitals located in a Tier 1 county or a Tier 2 county with a population under 150,000. This funding can be used for planning, training, and implementing expanded telehealth capabilities and services.
• $15 million to establish the COVID-19 Teaching Hospitals Relief Fund, which will provide grants in the amount of $3 million to each eligible teaching hospital (Wake Forest Baptist Medical Center, Duke University Hospital, University of North Carolina at Chapel Hill Medical Center, Vidant Medical Center, and Central Harnett Hospital). This funding can be used for planning, training, and implementing expanded telehealth capabilities and services.
• $15 million to establish the COVID-19 General Hospitals Relief Fund. This funding can be used for planning, training, and implementing expanded telehealth capabilities and services.
• Expanded use of telehealth technology to make involuntary commitment determinations (due to mental illness or substance use disorder)
• Also related to telehealth, the legislation includes emergency video notarization, video witnessing, and waiver of 2-witness signature requirements for advance directive documents

There have also been federal, state, and private payment reforms related to improving access to telehealth services. In March, the Trump administration announced expanded Medicare coverage for telehealth clinical visits so older Americans could access health care services from home and reduce the risk of exposure to COVID-19 for both patients and health care providers. Prior to this announcement, Medicare coverage for telehealth was narrower and only paid clinicians for routine visits for patients living in rural areas. Telehealth services will now be reimbursed at the same amount as in-person services. The NC General Assembly is also requesting that the federal Centers for Medicare and Medicaid Services pay for services provided through audio-only means (such as telephone) under Medicare, in order to increase access for older adults. Private payers are also increasing their coverage of telehealth services; in North Carolina, the largest private insurer, Blue Cross and Blue Shield of North Carolina, is covering telehealth services at the same payment rate as in-person visits. Blue Cross and Blue Shield is also eliminating cost-sharing for telehealth services and including audio visits in these policies.

In addition, North Carolina Medicaid requested a temporary waiver from the federal Centers for Medicare and Medicaid Services to increase flexibility around enhanced telehealth services during the COVID-19 pandemic. Policy changes include removal of restrictions on technologies that can be used to deliver services; services can now be delivered via any HIPAA-compliant, secure technology with audio and video capabilities, including (but not limited to) smart phones, tablets and computers. Providers may also use popular video chat applications, including FaceTime, Facebook Messenger chat, Google Hangouts, or Skype, to provide telehealth services. In addition, restrictions on sites where telehealth services can be provided have been removed, and the list of eligible telehealth providers has been expanded to include clinical pharmacists, licensed clinical social workers (LCSWs), licensed clinical mental health counselors (LCMHCs), licensed marriage and family therapists (LMFTs), licensed clinical addiction specialists (LCASs), and licensed psychological associates (LPAs). No prior authorizations or approvals are required for receipt of telemedicine services through NC Medicaid. A comprehensive listing of NC Medicaid COVID-19 telehealth policies is available here.

Several North Carolina Institute of Medicine task forces and stakeholder groups have identified improved broadband access and reduction of the digital divide as a crucial step toward improving access to health care and increasing health equity. Most recently, the Task Force on Serious Illness Care recommended continued robust investment in broadband access throughout the state in order to improve access to telehealth services and communication between health care providers. The movement by the North Carolina General Assembly and the Governor to address broadband access and improve telehealth access will allow more North Carolinians to access needed health services, while ensuring the safety of patients and providers during the COVID-19 crisis.