North Carolina has drastically expanded its telehealth services during the COVID-19 pandemic in order to give individuals increased access to remote care. The following article outlines many of the important changes implemented.

Licensure

On March 10, 2020, Governor Roy Cooper issued Executive Order No. 116 (available here) waiving the requirement that healthcare and behavioral healthcare personnel be licensed in North Carolina in order to provide healthcare services to individuals within the state. The Order broadly references "healthcare services," presumably including the provision of telehealth services. Out-of-state healthcare professionals must submit information to the applicable licensing board (e.g., physicians must submit an Emergency Disaster License Application to the North Carolina Medical Board to obtain authorization to practice within North Carolina; (available here) out-of-state licensed advanced practice registered nurses (APRNs) must hold an unrestricted license in any Nurse Licensure Compact State, perform medical acts under the supervision of a licensed North Carolina physician, and notify the North Carolina Nursing Board in writing of the name, location, and phone number of the primary supervising physician).

Additionally, the North Carolina Medical Board adopted and implemented several emergency procedures and orders including the following:

• Emergency procedures (21 NCAC 32B.1707) allowing physicians and physician assistants (PAs) who inactivated their North Carolina licenses within the past 24 months to return to practice for a period of 90 days or 30 days after the emergency declaration is withdrawn or ends. PAs must practice under the direct supervision of an onsite physician who is either licensed in North Carolina or otherwise approved to practice in North Carolina during the state of emergency. An inactive physician or PA seeking to obtain an emergency license may do so by submitting an online application. (Available here).
• Waiver of the notice requirement to the Board when a PA is temporarily reassigned to a new practice area to meet a critical need by a hospital, health system, or multispecialty group practice, provided certain requirements are met (g., PA only performs medical tasks within his/her expertise; reasonable and immediate access to a physician (either in-person or electronically) if a medical issue arises; compliance with all applicable rules and conference with a physician on at least a monthly basis to ensure meaningful supervision).
• Approval of fellows with resident training licenses to apply for a Limited Emergency license to obtain a temporary full and unrestricted medical license.

Similarly, the North Carolina Nursing Board (Nursing Board) announced on March 24, 2020, the following relaxations to existing licensure requirements and intends to issue internal processes and an emergency rule with further guidance:

• Temporary permits will be issued for retired or inactive nurses to allow them to re-enter the workforce; and
• Registered nurse (RN) and license practical nurse (LPN) students who are eligible for graduation are eligible to apply for a "graduate" temporary license and temporarily practice under the supervision of a licensed North Carolina registered nurse.

Telemedicine and Telenursing Practice Requirements

The Medical Board has not relaxed any existing requirements regarding the provision of telemedicine or teleprescribing services. However, unlike many other states that have recently expanded the definition of "telemedicine" or "telehealth" to include audio-only communications, the NC Medical Board's current broad definitions of "telemedicine" and "telenursing" (as defined below) likely already include audio-only communications.

On March 17, 2020, the Medical Board reminded licensees of their obligations to provide telehealth services with the same standard of care as in-person services and in accordance with the Board's existing Telemedicine Position Statement. (Available here). The existing Board Telemedicine Position Statement broadly defines "telemedicine" to include the practice of medicine using electronic communication, information technology, or other means between a licensee in one location and a patient in another, which presumably includes the use of audio-only (i.e., telephone) communications. Under the existing telemedicine guidance, licensees must, among other things, ensure staff members are trained on the use of technology to deliver care; provide an appropriate evaluation prior to diagnosing or treating a patient, which may be performed using technology sufficient to adequately diagnose and treat the patient; identify the proper licensee and his/her credentials and the patient's identity; and maintain the privacy and security of patient medical records.

APRNs, RNs, and LPNs are authorized to practice nursing using telehealth/telenursing (i.e., use of electronic communication, information technology, or other means between a licensee in one location and a patient in another) modalities within their scope of practice. These nursing professionals must comply with the Nursing Board’s existing Telehealth/Telenursing Position Statement. (Available here).

Teleprescribing Requirements

Similarly, the Medical Board has not needed to relax its teleprescribing requirements because prescriptions may be issued without an in-person exam under existing Medical Board guidance. The existing Medical Board's Position Statement on prescriptions (available here) permits a licensee to issue a prescription to a patient whom the licensee has not personally examined under certain circumstances including in a telemedicine encounter where the threshold information to make an accurate diagnosis has been obtained. For guidance on the prescription of controlled substances via telemedicine, the Medical Board refers licensees to review the federal Drug Enforcement Administration's guidance regarding the prescribing of controlled substances via telemedicine during the COVID-19 pandemic. (Available here).

Medicaid Updates

On March 30, 2020, NC Medicaid (Division of Health Benefits) issued temporary changes to its Telemedicine and Telepsychiatry Coverage Policy to expand the availability of telemedicine services during the pandemic. (Available here). The changes are retroactive to March 10, 2020 and will continue until North Carolina cancels its declaration of a state of emergency or until this policy is rescinded. The existing Medicaid practice and reimbursement policy (available here) continues to apply, which provides for the reimbursement for telehealth or telepsychiatry services at the same rate as in-person services.

For Medicaid purposes, the following modifications regarding telehealth services apply:

• Waiver of Prior Authorization and In-Person Examination Requirement: A prior authorization and initial in-person examination are no longer required prior to a patient receiving telehealth or telepsychiatry services.
• Eligible Devices: Telehealth (including telepsychiatry) services may be provided through video cell phone interactions using HIPAA-compliant, secure technology with audio and video capabilities, including, for example, smart phones, tablets, and computers consistent with the federal guidance issued by the Office of Civil Rights. Of note, NC Medicaid continues to exclude telephone audio-only communications from its permitted telehealth interaction methods.
• Originating & Distant Sites: The originating site may include any location where the patient is located. Previously, patients had to be located at a Medicaid enrolled provider location such as a provider’s office, hospital, or health clinic. Similarly, the distant site provider may be located in any location; however, providers need to ensure that patient privacy continues to be protected.
• Eligible Providers: The types of providers who may provide telehealth services is now expanded to include the following: clinical pharmacists, licensed clinical social workers, licensed clinical mental health counselors, licensed marriage and family therapists, licensed clinical addiction specialists, and licensed psychological associates. Previously, only the following providers could provide telehealth services: physicians, nurse practitioners, nurse midwives, physician assistants, advanced practice psychiatric nurse practitioners, advanced practice psychiatric clinical nurse specialists, licensed psychologists (doctorate level), licensed clinical social workers, and community diagnostic assessment agencies.
• Mental Health Treatment
  • For Federally Qualified and Rural Health Centers, telephone assessment and management codes may be billed for telehealth services provided by certain licensed mental health professionals (g., clinical addiction specialists, clinical mental health counselors, psychologists).
  • Only licensed prescribing providers such as physicians, physician assistants, and nurse practitioners may bill Medicaid using the psychiatric diagnostic evaluation and psychotherapy codes.

Expanded Coverage by Private Third Party Payors

The North Carolina's Insurance Commissioner issued guidance to private third party insurers to review existing telehealth policies to meet increased demand but has not issued any orders or rules related to coverage for telehealth services.

However, many private third party payors including, but no limited to, Blue Cross Blue Shield, Aetna, and Cigna are waiving cost sharing amounts for certain telemedicine visits. Providers should review specific coverage and reimbursement policies of the various private third party payors as the expansion and waivers related to telehealth may vary (e.g., limited in duration or to COVID-19 related telehealth services).

Please review our previously issued articles on federal and other state telehealth updates issued in response to the COVID-19 crisis. For questions or more information for these new and developing telehealth requirements and implications in North Carolina, please contact any member of the Akerman Healthcare team.