Pennsylvania § 4804 - Medical assistance and children's health insurance program coverage.

§ 4804. Medical assistance and children's health insurance program coverage.

(a) MA or CHIP managed care plan payment.--

(1) MA or CHIP managed care plan payments shall be made on behalf of enrollees for medically necessary health care services provided through telemedicine, if all of the following apply:

(i) The health care service would be covered through an in-person encounter.

(ii) The provision of the health care service through telemedicine is consistent with Federal law and regulations, the laws of this Commonwealth, applicable regulations and guidance.

(iii) Federal approval, if necessary for the provision of the health care service through telemedicine, has been received by the Department of Human Services.

(2) The MA or CHIP managed care plan shall pay a participating network provider for covered health care services delivered through telemedicine in accordance with the terms and conditions of both:

(i) the contract negotiated between the MA or CHIP managed care plan and the participating network provider; and

(ii) the agreement with the Department of Human Services.

(b) Applicability.--

(1) Subsection (a) does not apply if the telemedicine-enabling device, technology or service fails to comply with the Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act or other applicable statute, regulation or guidance from the Federal Government or the Department of Human Services.

(2) This section shall apply to MA and CHIP managed care plans beginning on or after January 1, 2026.

(c) Construction.--This section may not be construed to:

(1) Prohibit a MA or CHIP managed care plan from making payments on behalf of enrollees to other health care providers for covered health care services provided through telemedicine.

(2) Require a MA or CHIP managed care plan to pay for a health care service if the delivery of the health care service through telemedicine would be inconsistent with the standard of care.