• The service is determined to be safely and effectively provided through telemedicine or store and forward technology according to generally accepted health care practices and standards; • The technology used to provide the service meets the standards required by state and federal laws governing the privacy and security of protected health information; and • The service is recognized as an essential health benefit under section 1302(b) of the federal Patient Protection and Affordable Care Act (PPACA) in effect on January 1, 2015. If services are provided through store and forward technology, there must be an associated office visit between the covered person and the referring health care provider. The associated office visit may be in person or via telemedicine. For audio-only telemedicine, the member must have an established relationship with the provider. The originating site (the member’s physical location) for telemedicine services must be one of the following sites: • Community mental health center • Federally qualified health center • Home or any location determined by the individual receiving the service • Hospital • Physician's or other health care provider's office • Renal dialysis center (except independent renal dialysis center) • Rural health clinic • Skilled nursing facility Any originating site, except home, may charge a facility fee for infrastructure and preparation of the member. Telemedicine and store and forward technology are subject to all terms and conditions of the plan, including utilization review, preauthorization requirements, deductibles, and copay requirements. Services obtained from out-of-network providers will be reimbursed at the out-of-network rate. The following are not covered by the plan: • Email or fax transmissions between provider and member • Home health monitoring • Installation or maintenance of any telecommunication devices or systems • Originating sites’ professional fees • Services that are not medically necessary • Services that would not be covered if delivered in person • Store and forward technology without an associated office visit between the covered member and the referring health care provider • Telemedicine or store and forward services for services that are not recognized as essential health benefits under section 1302(b) of the PPACA in effect on January 1, 2015 • Telemedicine or store and forward services that cannot be safely and effectively provided through telemedicine or store and forward technology • Telemedicine or store and forward services that use technology that does not meet state and federal requirements for privacy and security of protected health information 78 2024 UMP Classic (PEBB) Certificate of Coverage