The Telehealth Explainer Series: A Toolkit for State Legislators

7/15/2021

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Introduction

Telehealth is widely viewed as a cost-effective strategy to increase access to health care services, address workforce shortages and reach patients in rural and underserved areas.

While the state telehealth policy landscape was quickly evolving prior to COVID-19, the pandemic led to a significant increase in telehealth use as well as numerous policy changes. With this rapid reliance on telehealth by both providers and patients, state lawmakers are evaluating telehealth laws and regulations and exploring ways to effectively leverage virtual care moving forward.

This toolkit contains a series of briefs covering key topics, opportunities and challenges related to telehealth policy. When used as a combined series, these briefs provide both an overview and introduction to state telehealth roles and includes a variety of state legislative actions on several key policy areas.

What Is Telehealth?

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By Sydne Enlund

Providers have used telehealth for decades but only in the last few years has its use accelerated. Telehealth uses technology to deliver health care and other health-related services remotely, including care coordination between providers and patients. In many cases it can create efficiencies, extend the reach of the provider and expand the pool of available providers, including specialists, without increasing the size of the provider workforce. Telehealth is not a service itself but rather a different way to deliver health care services.

The Three Types of Telehealth

  1. Real-time communication allows patients to connect synchronously with providers via videoconference.
  2. Store-and-forward refers to the transmission of data, images, sound or video from one care site to another for evaluation.
  3. Remote patient monitoring involves collecting a patient’s vital signs or other health data while the patient is at home or another site and transferring the data to a remote provider for monitoring and response as needed.
Who Benefits From Telehealth?

Telehealth can be a win-win solution for patients living in rural and underserved areas and the providers who treat them.

How Patients Benefit
  • Increases access to primary and specialty care in a timely manner without having to travel long distances.
  • Reduces exposure to COVID-19 and other illnesses, which can be more prevalent in health care settings.
  • Lowers patient costs and the burdens associated with lost work time, transportation and child care.
  • Shortens wait times to see providers, particularly specialists.
How Providers Benefit
  • Builds and supplements workforce capacity in rural areas, where recruiting and retaining health care workers is a challenge.
  • Allows primary care providers to more easily connect patients to specialty care where it is not readily available.
  • Facilitates consultations between providers both local and remote.
  • Allows providers to offer care in various settings, such as home health clinics, hospitals and offices.

Challenges remain as states continue to adopt and refine their telehealth laws and regulations. To support telehealth and health information exchange, access to broadband services and technology is key. Some rural areas do not currently have access to high-speed internet connections, which allow data to be transmitted efficiently. Ensuring that the quality of telehealth care is comparable to that provided during in-person visits is another issue being addressed by policymakers and other stakeholders.

Medicaid Reimbursement for Telehealth

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By Sydne Enlund

States may reimburse for telehealth under Medicaid if the service satisfies federal requirements of efficiency, economy and quality of care. Extensive control is given to states to decide how to structure and administer their Medicaid telehealth policies. Some Medicaid policies are enabled or mandated through state law, but a significant number take place within states’ executive branch through Medicaid rules and regulations.

States have the option to determine whether to allow for telehealth; what types of services to cover; where in the state it can be utilized; how it is implemented; reimbursement rates; and what types of qualified practitioners may deliver services via telehealth.

Medicaid reimbursement for all telehealth modalities—such as live video visits, store-and-forward and remote patient monitoring—has increased significantly over the past the decade.

All state Medicaid programs include policies that provide some type of reimbursement for telehealth, but the scope of these policies varies among states. Ten states stipulate Medicaid coverage and reimbursement for all three common telehealth modalities (live video, store-and-forward and remote patient monitoring). Proponents of expanding Medicaid reimbursement say it improves access to care and allows patients to receive care in their homes and communities. However, opponents suggest that the quality of care is not always equivalent to in-person services and certain technologies may be unreliable for various services and treatments.

Live Video Reimbursement

All 50 states allow for Medicaid reimbursement for some aspect of live video telehealth visits, though variation exists across states. States determine—and may even restrict—the types of services, providers or the patient locations that are eligible for Medicaid reimbursement. A few states, such as Pennsylvania, specify certain types of providers eligible for Medicaid reimbursement for telehealth, while others, including Maine, allow reimbursement to any licensed provider. Some states explicitly list which services provided through telehealth can be reimbursed (e.g., mental health, primary care). Generally, states have been expanding these categories in recent years to allow greater reimbursement for a growing number of providers and services.

Store-and-Forward Reimbursement

Twenty-two states and the District of Columbia allow for reimbursement of store-and-forward—or the electronic transmission of medical images, documents and pre-recorded videos through secure electronic communication. Additionally, four states enacted legislation allowing for store-and-forward reimbursement, but their Medicaid programs have yet to implement the reimbursement policies.

Radiology, dentistry and dermatology are the most common types of services delivered via telehealth to be reimbursed for store-and-forward services. Some states limit the types of settings and services for which store-and-forward services may be reimbursed. For example:

Georgia’s Medicaid program only reimburses for store-and-forward services related to teledentistry in a school-based setting.

Washington state’s Medicaid program only reimburses for teledentistry and teledermatology.

Remote Patient Monitoring Reimbursement

Laws and regulations in at least 27 states allow for Medicaid reimbursement of remote patient monitoring—the use of a specific technology to facilitate interaction between clinicians and patients at home or another remote location. As with store-and-forward, two states have enacted legislation allowing for remote monitoring reimbursement, but each state’s Medicaid program has yet to implement the policies.

In 2020, South Carolina and Washington state removed reimbursement for remote monitoring. Some states also set limits on its use. For example:

Alabama allows reimbursement for providers caring for patients with diabetes, congestive heart failure and hypertension to participate in remote patient monitoring.

Oregon reimburses only dental providers for remote monitoring.

A note about this brief: Although the COVID-19 pandemic ushered in a wave of new Medicaid coverage requirements for telehealth, many of these actions are temporary. State counts listed throughout this brief only include permanent laws and regulations. Please refer to the Telehealth, COVID-19 and Looking Ahead brief for more information.

Telehealth Private Insurance Laws

While many aspects of the telehealth policy landscape have evolved over the last decade, one of the most significant trends has been the proliferation of state laws affecting private insurance coverage for telehealth. Currently, 43 states and the District of Columbia have telehealth private insurance laws—up from 16 states in 2012, according to the Center for Connected Health Policy. These state laws, however, vary greatly in scope—including what exactly private health insurers are required to cover and, in some cases, reimburse for telehealth.

Many providers and policy experts argue guaranteeing coverage and payment for telehealth, especially coverage and payment equal to in-person care, provides a financial incentive for health professionals to use telehealth. Additionally, private insurance coverage increases access to virtual care and reduces out-of-pocket costs for patients receiving care through telehealth. During the COVID-19 pandemic, expanding private insurance coverage for telehealth helped ensure continuity of care, particularly for patients with chronic conditions.

However, some payers and providers maintain telehealth is not always equivalent to in-person care, especially as it relates to establishing a provider-patient relationship. And, while many view telehealth as a cost-effective alternative to in-person services, some policy experts believe requiring equal payment may negate these cost-savings.

Given these considerations, policymakers continue to evaluate the appropriate approach to improve access to virtual care through telehealth private insurance laws. This explainer provides an overview of these state laws, including coverage parity, payment parity and other private insurance requirements affecting telehealth.

Coverage Requirements

Forty-one states and the District of Columbia mandate coverage parity, which requires private insurers to cover telehealth similarly to in-person care. These state laws often specify insurers cover telehealth “in the same manner” or “to the same extent” as in-person services and prohibit insurers from denying coverage solely because a service is delivered through telehealth. Additionally, coverage parity laws typically clarify insurers are not required to cover virtual health services they do not cover in-person, and that they can apply the same level of cost-sharing to telehealth as they would for in-person care. 

Some states set limits on what private insurers are required to cover. For example:

Washington applies telehealth coverage requirements only to services recognized as an essential health benefit under the Affordable Care Act.

South Dakota authorizes private insurers to establish criteria a provider must meet to demonstrate a certain service or treatment can be safely and effectively delivered via telehealth.

Two states with private insurance laws—Florida and Michigan—do not explicitly require coverage parity. Rather, these states give insurers more authority over the extent of coverage they provide for telehealth.

Reimbursement Requirements

While most private insurance laws require coverage parity, fewer state laws stipulate what insurers must pay for telehealth. Twenty-two states mandate payment parity, which requires private insurance reimbursements for telehealth to reflect what the insurer would pay for in-person services. Some state laws require reimbursements for telehealth to be “the same amount” or “at the same rate” as in-person services. Certain policy experts maintain this statutory language provides a stricter standard for private insurers and ensures reimbursement rates are truly equivalent to in-person care.

Other payment parity laws specify private insurers must reimburse “on the same basis” as in-person care, which some argue may better account for potential cost savings achieved through telehealth—such as lower facility and administrative fees.

Some states—including California, Georgia and Washington—require payment parity, but also authorize insurers and providers to voluntarily differentiate reimbursements via contract negotiations.

Several other states have established requirements for private insurance reimbursements, but they do not constitute full payment parity for all services delivered through telehealth. For example:

Some states limit payment parity to certain types of services and specialties. Iowa, Massachusetts and Nebraska mandate payment parity for telemental health or behavioral health services. Massachusetts also temporarily extended payment parity requirements to primary care and chronic disease management services until January 2023. Rhode Island established payment parity for primary care, dietitian and behavioral health services.

At least six states—Florida, Kansas, Nebraska, North Dakota, Tennessee and West Virginia—have statutory language fully deferring to reimbursement rates determined through provider-insurer contract negotiations rather than requiring payment parity.

Louisiana requires private health insurers to reimburse providers at originating sites—or where the patient is located when using telehealth—for at least 75% of the in-person rate.

Other Private Insurance Requirements

Beyond coverage and payment parity, states have enacted legislation enhancing private insurance coverage for telehealth in other ways.

Cost-sharing protections
According to Foley and Lardner LLP, 30 states provide cost-sharing protections for health plan enrollees using telehealth, which often ensures patients do not face higher copayments, coinsurance or deductibles for telehealth visits compared to in-person care.

Coverage for different modalities
Foley also identified 27 states that require private insurance coverage for store-and-forward technologies, and 17 states that mandate coverage for remote patient monitoring.

Limiting coverage exclusions
Some states prohibit insurers from establishing additional criteria as a condition for telehealth coverage. For example, Colorado enacted legislation in 2020 prohibiting health insurers from requiring a previously established provider-patient relationship, or from imposing additional certification, location or training requirements prior to covering telehealth. The legislation also prevents insurers from establishing specific requirements or limitations on telehealth technologies in compliance with the Health Insurance Portability and Accountability Act.

A note about this brief: Although the COVID-19 pandemic ushered in a wave of private insurance coverage requirements, many of these actions are temporary. State counts listed throughout this brief only include permanent laws and regulations. Please refer to the Telehealth, COVID-19 and Looking Ahead brief for more information.

Licensure and Interstate Compacts

States are responsible for several aspects of licensing health professionals, including the determination of provider qualifications and scope of practice, as well as how licensure protects patients within their borders. As such, telehealth care providers typically must be licensed in the state where the patient is receiving care, as well as the state in which the provider is located.

To facilitate telehealth across state lines, states may consider a variety of policy options, including offering reciprocity agreements with neighboring states and joining licensure compacts with other states.

Expanding Licensure Through Reciprocity

Working together, some states have developed reciprocity agreements that fall into two main areas:

Special licenses or certificates allow practitioners to provide care to patients without obtaining new and/or additional licenses. At least nine states have created telehealth-specific licenses that allow out-of-state providers to offer services in the state, if they abide by certain requirements, including not setting up a physical location in the state.

License reciprocity for out-of-state health care providers to practice within their jurisdiction if they meet special license and regulatory requirements. For example, California offers licensure reciprocity for registered nurses who have met a set of educational requirements, passed the National Council Licensure Examination or the State Board Test Pool Examination and currently hold an active license to practice in another state. Arkansas’ Border State Emergency Temporary License allows physicians in Oklahoma, Louisiana, Mississippi, Missouri, Tennessee and Texas to provide telemedicine visits for their established Arkansas patients.

In response to the COVID-19 pandemic, almost all states pursued modifications to their licensure rules, requirements or processes. Changes included expanding the types of health care providers authorized to deliver telehealth services and removing requirements for prior patient-provider relationships.

Definitions

  • Licensure
    The granting of permission, most often from state governments, to practice a profession or occupation.
  • Interstate Compact
    A contract between two or more states creating an agreement on how to address a particular policy issue, adopt a certain standard or cooperate on regional or national matters. Interstate compacts usually require participating states to pass legislation using specific, uniform language.
Creating Interstate Compacts

Licensure compacts have gained traction as a way to allow various types of health professionals to provide services to individuals in other states. Compacts are formed when a certain number of states enact legislation that includes specific uniform language or by a certain date, whichever occurs first. After a state joins a compact, the compact is administered by a nongovernmental organization. However, joining the compact is voluntary for the providers. All compact member states maintain their authority to monitor health care professionals practicing within their borders.

Currently, five active compacts exist across the country and two more are under consideration.

Active Compacts

Interstate Medical Licensure Compact

  • For physicians.
  • Members: 31 states, the District of Columbia and Guam.
  • Administered by the Interstate Medical Licensure Commission.

Nurse Licensure Compact

  • For registered nurses and licensed practical nurses.
  • Members: 37 states and Guam.
  • Administered by the Nurse Licensure Compact Commission.

Physical Therapy Compact

  • For physical therapists.
  • Members: 28 states.
  • Administered by the Physical Therapy Compact Commission.

Psychology Interjurisdictional Compact (PSYPACT)

  • For psychologists.
  • Members: 15 states.
  • Administered by the PSYPACT Commission.

EMS Personnel Licensure Interstate Compact

  • For emergency medical technicians and paramedics.
  • Members: 20 states.
  • Administered by the Interstate Commission for EMS Personnel Practice.

Compacts also exist for other provider types. The Advanced Practice Registered Nurse Compact will become active when seven states have enacted legislation. The Audiologists and Speech-Language Pathologists Compact reached its threshold of 10 states for activation in April 2020.

A note about this brief: Although the COVID-19 pandemic ushered in a wave of changes to provider licensing and reciprocity requirements, many of these actions are temporary. State counts listed throughout this brief only include permanent laws and regulations. Please refer to the Telehealth, COVID-19 and Looking Ahead brief for more information.

Ensuring Patient Safety, Security and Quality of Care

To achieve the potential benefits of expanded access to care for residents, states have implemented regulations to ensure the safety, security and quality of services delivered through telehealth. Similarly, providers are responsible for understanding the standards of care, patient-provider relationship and informed consent requirements within each state when considering telehealth practice across state lines.

Upholding Standards of Care

State statutes define standards of care, as well as malpractice, in very specific terms for health care delivery, both in-person and via telehealth. And because they vary from state to state, providers using telehealth must be aware of the standards of care of each state they practice in. In response to increased telehealth usage, some states, including Idaho, Missouri and Texas, simplified matters and determined that the standard of care for in-person services also applies to telehealth.

Preserving Patient-Provider Relationships

Recognizing that an established patient-provider relationship typically leads to more trust and better health outcomes, all 50 states allow a patient-provider relationship to be established remotely. Some states require patients to receive follow-up care in-person if the initial appointment was conducted via telehealth. Proponents of telehealth are wary of requiring follow-up in-person visits because of the additional burden placed on the patient to seek in-person care, which could potentially recreate some of the barriers telehealth seeks to remove.

Most states require an in-person physical exam before a provider can prescribe medication to a patient, but some states allow a provider to conduct a physical exam through telehealth. For example, Kansas applies the same laws and regulations to both in-person and telehealth prescriptions. In response to the opioid epidemic and changing federal requirements, some states allow the prescription of medication-assisted treatment (or MAT) through telehealth. West Virginia, for instance, allows practitioners to provide MAT within their scope of practice.

Allowing for Informed Consent

In telehealth, informed consent policies require providers to share the benefits and risks associated with telehealth and alternative courses of action with patients. Patients may benefit from knowing the potential limitations of telehealth and that certain conditions may require in-person diagnosis or treatment. Forty-two states and the District of Columbia have an informed consent policy for telehealth. Requirements may vary depending on the origin (statute, administrative code, Medicaid policy) and the intent of the policy. For example, requirements may apply to only certain types of providers, Medicaid, or specific services such as behavioral health. Most states require providers to document verbal consent by patients, but at least seven states and the District of Columbia require written consent generally or for specific services (e.g., transfer of images, recording the session).

A note about this brief: Although the COVID-19 pandemic ushered in a wave of changes to requirements for providers using telehealth, many of these actions are temporary. State counts listed throughout this brief only include permanent laws and regulations. Please refer to the Telehealth, COVID-19 and Looking Ahead brief for more information.

Improving Behavioral Health From Afar

The term “behavioral health” includes both mental health and substance use disorders. More than 1 in 5 U.S. adults—51.5 million— live with a mental illness. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that 9.5 million adults have co-occurring mental health and substance use disorders (SUDs). 

Many experience barriers to accessing treatment. Of these adults with co-occurring disorders, more than 50% did not receive treatment for either disorder and less than 10% received treatment for both. Barriers to treatment—such as proximity to services and behavioral health provider shortages, among others—may lead to increased adverse outcomes, especially for those living in rural and underserved communities.

Telebehavioral health is one strategy state policymakers may use as they explore ways to address gaps and increase access to essential behavioral health services. Such services can take many forms, such as treatment through video conferencing, provider-to-provider consultation and education, medication management and continuity of care.

How It Is Used:

Typically, telebehavioral health services are used primarily in four settings:

  • Hospital care: Hospitals, including those in rural and underserved areas, can utilize behavioral health specialists located elsewhere to provide services to inpatients.
  • Integrated primary care: Behavioral health care services can be offered in primary care settings via telehealth.
  • Mobile health applications or remote monitoring programs: These applications can allow for remote, long-term management of behavioral health conditions and medications.
  • Direct-to-consumer services: Patients, especially those in rural areas, can access behavioral health providers using telehealth applications from anywhere.

 

State Actions

Changes in federal regulations have made it easier for behavioral health providers to offer services through telehealth, including the types of providers and services provided. States can adopt these changes and other policy options, like expanding the kinds of providers that can participate in telehealth or requiring insurance providers and other payers to cover telehealth services, to improve access to telebehavioral health services. For example:

Louisiana expanded the types of health providers who can perform telepsychiatric evaluations to include psychiatric mental health nurses as long as certain requirements, including that an examination take place over videoconferencing, are met.

Oregon requires its Medicaid program to provide coverage for telebehavioral health services to the same extent that those services would be covered if they were provided in-person.

State laws also govern a provider’s authority to prescribe medications electronically, including provider board rules and regulations that set the standard of care for prescribing. Some states require real-time telehealth interactions before a provider can write prescriptions. However, there are many exceptions to these policies, including medication-assisted therapy (MAT) designed to address the opioid epidemic. MAT uses medications (e.g., buprenorphine, methadone, etc.) together with counseling for the treatment of substance use disorders. Many state policies allow remote prescribing of MAT without an initial in-person office visit or without recurring in-person office visits to authorize refills. For example:

Indiana allows electronic prescribing of buprenorphine if it is used to treat or manage opioid dependence.

Vermont allows certain health professionals to renew a patient’s existing buprenorphine prescription without requiring an office visit.

A note about this brief: Although the COVID-19 pandemic ushered in a wave of new policies relating to telebehavioral health, many of these actions are temporary. State counts listed throughout this brief only include permanent laws and regulations. Please refer to the Telehealth, COVID-19 and Looking Ahead brief for more information.

Telehealth, COVID-19 and Looking Ahead

Seeking ways to support health care workers, limit in-person contact and ensure continuity of care, state policymakers pursued numerous actions to leverage telehealth during the coronavirus pandemic. All 50 states, D.C. and Puerto Rico modified their telehealth policies in response to COVID-19. However, many of these changes were tied to state-of-emergency declarations and thus temporary for the duration of the pandemic.

As the pandemic slows, legislators are considering which temporary changes should be made permanent.

At least 37 states enacted over 51 bills to make certain temporary flexibilities permanent after the COVID-19 public health emergency. Beyond permanent changes, some states temporarily extended telehealth flexibilities after the public health emergency ends or established special committees to assess telehealth best practices. Additionally, some states took non-legislative action to keep telehealth changes permanent.

Legislation Permanently Implementing COVID-19 Telehealth Flexibilities
Telehealth Policies Made Permanent Post-COVID

Legislation making COVID-19 flexibilities permanent touched on a multitude of telehealth policy areas. These include Medicaid coverage, private insurance coverage, audio-only telephone consultations, cross-state licensing and several more.

Medicaid Coverage

Twenty-seven states enacted legislation enhancing Medicaid coverage for services delivered via telehealth. For example, Arkansas expanded the list of providers eligible to conduct counseling through telehealth for Medicaid recipients and required coverage for group therapy, crisis intervention services, substance use assessment and other telebehavioral health services.

Private Insurance Coverage

Twenty-seven states enacted bills related to private insurance coverage for telehealth. New Hampshire required insurers to reimburse for telehealth on the same basis as in-person care (i.e., payment parity). Iowa permanently implemented payment parity for mental health services delivered through telehealth.

Audio-Only Telephone Visits

At least 29 states increased access to audio-only telephone visits, which were less common prior to the pandemic. For example, after convening a work group to study permitting telephone consultations after the public health emergency, Vermont required private health plans and Medicaid to cover medically necessary, clinically appropriate audio-only telephone consults to the same extent as in-person care. The legislation also requires the state to study the effects of telephone visits on access to care, utilization, quality of care, patient satisfaction, health care costs and value-based payment arrangements.

Cross-State Licensing

After streamlining the licensure process for out-of-state providers using telehealth during the pandemic, at least five states—Arizona, Kansas, New York, Tennessee and West Virginia—permanently allowed providers licensed in other states to deliver services to in-state residents under certain conditions (separate from provider-specific licensure compacts).

Originating/Distant Site

Many states permanently modified requirements relating to where a patient could receive services via telehealth (i.e., originating site) or where providers could deliver those services (i.e., distant site). For example, New York removed originating site restrictions, allowing patients to use telehealth wherever they are located. Mississippi expanded its definition for both originating and distant site for its Medicaid program to include federally qualified health centers, rural health clinics and community mental health services.

Provider-Patient Relationship

Some states, such as Hawaii, Montana and South Dakota, authorized providers to establish a provider-patient relationship through telehealth under certain circumstances, rather than requiring an initial in-person visit.

Prescribing via Telehealth

A handful of states waived certain restrictions on prescribing medications through telehealth. For example, Virginia authorized providers with an established provider-patient relationship, including one established through telehealth, to issue a prescription for certain controlled substances in accordance with federal law.

The Wait-And-See Approach

While many states have taken legislative action to make changes permanent, some have temporarily extended certain flexibilities beyond the public health emergency or established committees or working groups to further evaluate telehealth policies for the long-term.

Arizona enacted several permanent changes related to telehealth, including payment parity and interstate licensing. The state also established a telehealth advisory committee to develop best practices and guidelines related to telehealth, including the effectiveness of certain telehealth modalities and populations best served by telehealth.

Connecticut enacted legislation to extend certain COVID-related changes for two years until June 2023, including requiring payment parity and expanding the list of providers eligible to use telehealth. State lawmakers also enacted separate legislation to permanently require Medicaid coverage for audio-only telephone visits.

Vermont created the “Facilitation of Interstate Practice Using Telehealth Working Group” and charged the work group to study the effects of streamlining interstate licensing requirements for out-of-state providers using telehealth.

Non-Legislative Action

Some states have taken non-legislative actions—through governor’s offices, Medicaid agencies, licensing boards and other state agencies—to make COVID-related changes permanent.

The California Department of Health Care Services, which operates the state’s Medicaid program, released a list of several COVID-related telehealth modifications it plans to make permanent—including payment parity for services delivered via telehealth in real-time and coverage for audio-only telephone visits.

Idaho’s governor signed an executive order directing state agencies to make more than 150 emergency rules permanent, including several related to telehealth. Changes included streamlining the licensing process for out-of-state providers and allowing providers to use platforms like FaceTime or Zoom.

Ohio Department of Medicaid permanently expanded coverage for different methods of telehealth (e.g., audio-only and remote patient monitoring), authorized different types of providers to deliver services via telehealth, and lifted originating and distant site restrictions. The rules also increased the number and types of services that could be delivered through telehealth, including virtual check-ins by a physician or other provider, physical therapy, additional behavioral health services and more.

This resource is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $853,466 with 100% funded by HRSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.