Whether your practice, hospital, or health system was forced to adopt telehealth, or ran toward it as a natural next step in virtual care, the ending of the COVID-19 public health emergency (PHE) on May 11, 2023 has created a pivot point for all providers.
Will you continue using telehealth modalities to deliver care? Would you consider increasing the use of telehealth if it enhanced patient care and supported your business objectives?
Your decision probably depends on many factors, but reimbursement, coverage, and licensing policies are the most important. This overview highlights current public and private insurance policies as of May 2023. Some coverage has been made permanent, and others were temporarily extended.
The latest CMS coverage policies can be found here.
What types of telehealth are you using or considering?
Telehealth, aka telemedicine, uses a variety of modalities to facilitate real-time or asynchronous communication, extending care beyond the clinic or hospital. Telehealth modalities may include videoconferencing, store-and-forward imaging, streaming media, and landline or mobile phone communications.
Payment arrangements depend primarily on the type of payer and each state’s rules around physician license use, as well as state professional board rules.
Telehealth has become embedded in care delivery
Telehealth use grew exponentially during the pandemic. According to the US Department of Health and Human Services (HHS), pre-pandemic telehealth visits for Medicare beneficiaries went from hundreds of thousands to tens of millions, with many utilizing telehealth for the first time. Telehealth use increased 63-fold from 2019 to 2020.
The federal government supported telehealth access by implementing more than 200 regulatory waivers due to the PHE. These policy changes enabled providers to deliver care across state lines, waiving specific HIPAA privacy and security requirements and allowing a host of flexibilities in telehealth use and reimbursement.
What was a way to deliver healthcare during the lockdown and social distancing initially has become a tool for more efficient, convenient, and less burdensome care. One US study revealed that an in-person urgent care visit took an average of 10 times longer than the average total time for a virtual urgent care visit. Survey respondents were highly satisfied with a virtual visit (90%), with 40% stating that they would have alternatively presented at an emergency room or delayed care.
Other studies indicate that telehealth increases access to care without increasing cost.
The typical virtual care patient sees a 61% decrease in their health care expenses compared to in-person care. Clinicians and specialists have voiced that telehealth improves access for underserved and rural communities, historically marginalized populations, and senior and disabled adults.
One study found that oncology patients saved $200 each virtual visit, experiencing less driving distance and time, lost income, and time waiting. A fall 2022 report revealed that 70% of consumers believe telehealth is better or comparable to in-person visits.
With the global telehealth market projected to grow from $87.8 billion in 2022 to $285.7 billion by 2027, and research showing telehealth’s valuable impact on access, cost, and convenience, the current state of telehealth opportunities continues to expand.
Making sense of post-PHE telehealth rules and deadlines
While some telehealth policies are now permanent, other waivers and exceptions expired on May 11. However, at the end of 2022, the president signed the Consolidated Appropriations Act (CAA) for Fiscal Year 2023, enacting extensions for many telehealth waivers and the Acute Hospital Care at Home (AHCaH) individual waiver that would have ceased with the end of the PHE.
The following highlights some of the permanent as well as temporary extensions (dates as noted) that are most relevant to physicians and provider organizations.
HHS offers an up-to-date collection of Medicare and Medicaid policies, including telehealth flexibilities.
Medicare
Permanent: Medicare beneficiaries are now permanently eligible to receive telehealth services for behavioral health care from their homes, including audio-only visits, with no geographic restrictions for originating sites.
CMS permanently added certain services to the Medicare telehealth list, including the newly-established E/M visit complexity code.
Temporary: CMS created new categories of services, including codes added to the Medicare telehealth list under the Medicare Physician Fee Schedule that will remain until December 31, 2023. However, CMS may extend these items on the telehealth list in alignment with the two-year extension of other telehealth waivers.
The following extensions remain until December 31, 2024, or until further congressional action is taken:
- Medicare patients can continue receiving telehealth services in their homes
- There are no geographic restrictions for originating site for non-behavioral/mental telehealth services
- Some non-behavioral/mental telehealth services can be delivered using audio-only communication platforms
- An in-person visit within six months of an initial behavioral/mental telehealth service and annually thereafter is not required
- All eligible Medicare providers can provide telehealth services
The Drug Enforcement Agency (DEA) extended telehealth flexibilities that enable clinicians to continue prescribing controlled medications virtually for another six months.
Hospitals Without Walls
Temporary: Since the implementation of the Acute Hospital Care at Home (AHCaH) individual waiver in 2020, 144 health systems, including 260 hospitals across 37 states, have instituted the waiver.
The Consolidated Appropriations Act of 2023 permits eligible distant site physicians and practitioners to continue to bill for a Medicare telehealth service under the Medicare physician fee schedule for professional services furnished via telehealth to patients in their homes through December 31, 2024.
The flexibilities currently in place under the Hospital Without Walls Initiative considered the patient’s home as a provider-based department of the hospital. That designation will end in 2024 without regulatory changes at the federal level.
Medicaid, Children’s Health Insurance Program (CHIP), and State Policies
Permanent: Medicaid and CHIP telehealth flexibilities are not connected to PHE’s end. Many state Medicaid programs have covered telehealth long before the pandemic, and those policies vary by state. However, states have also expanded their permanent telehealth policies during the pandemic.
States have also expanded the telehealth modalities they reimburse beyond live video, including audio-only and authorizing coverage for additional providers and services. No two states’ telehealth coverage approaches are alike. However, all 50 states and Washington DC cover some form of live video in Medicaid fee-for-service, and other modalities are covered to varying degrees, including
- 28 states reimburse for store-and-forward
- 34 states reimburse remote patient monitoring, and some have added new eligible services and conditions to existing reimbursement policies
- 36 states and DC reimburse for audio-only telephone, some with limitations
- 22 states reimburse for all four modalities, including live video, store-and-forward, remote patient monitoring and audio-only
- 24 states have explicit payment parity laws
Temporary: The Center for Connected Health Policy (CCHP) provides a comprehensive online database to determine which states offer permanent or temporary extensions to their telehealth policies. State-specific policies by modality can be referenced in this cross-walk document from the CCHP.
State professional boards & licensing
Permanent and temporary: During the COVID-19 PHE, all 50 states and Washington, DC, used emergency authority to issue license waivers for some aspects of state licensing requirements. Since the PHE ended, some states have discontinued cross-state licensing waivers, and other states have enacted legislation to make the waivers permanent or extend them for a specified period.
States have leveraged licensure portability – the ability for a clinician to practice in another state with minimal barriers or restrictions – and licensure compacts – agreements between states to streamline the application process for licensure in other states. These practices were critical to telehealth use during the PHE and continue today.
The Federation of State Medical Boards (FSMB) provides the latest updates on changes to state-based telehealth-related licensing rules. CCHP also provides profiles of each state with the latest policies, including professional requirements, cross-state licensing, and licensure compacts.
Payment parity
Temporary: CMS has reimbursed telehealth visits at the same rate as in-person services. The 2023 Physician Fee Schedule Final Rule includes extensions to this coverage until December 31, 2023. Barring additional rulemaking by CMS, distant-site practitioners would only be reimbursed based on facility rates.
CMS’s changes to direct supervision rules, permitting supervising clinicians to be remote and use real-time, interactive audio-video technology, will also end on December 31, 2023.
HIPAA
Temporary: Since the end of the PHE, HHS has extended compliance discretion related to Health Insurance Portability and Accountability Act (HIPAA) protections during telehealth and non-public-facing remote communication technologies for 90 days until August 9, 2023.
Rural Coverage
Permanent: Rural Emergency Hospitals (REHs) are now permanently eligible as originating sites for telehealth. Medicare will also pay for mental health visits delivered through Rural Health Clinics and Federally Qualified Health Centers (FQHCs) using interactive video-based telehealth, including audio-only telephone calls.
Medicare Advantage
Temporary: During the PHE, Medicare Advantage (MA) plans were able to cover all telehealth services covered under Medicare fee-for-service. In 2021, 98% of MA plans offered a telehealth benefit. MA plans were not required to cover telehealth, and some may tailor their offerings before the flexibilities expire at the end of 2024.
Accountable Care Organizations
Temporary: After December 31, 2024, Accountable Care Organizations (ACOs) may offer telehealth services that allow doctors and other practitioners participating in the ACO to care for patients without an in-person visit, no matter where they live.
Private Commercial Health Insurance
Permanent and temporary: After the PHE ended, coverage for telehealth and other remote care services continued as before, varying by each private insurance plan. Many insurers, including employer-sponsored plans, have made telehealth benefits permanent.
A policy allowing employers to offer telehealth as a stand-alone benefit to employees not eligible for other employer-sponsored coverage will also end. In response, a group of lawmakers in the House has reintroduced the Telehealth Benefit Expansion for Workers Act of 2023, which would establish telehealth as a permanent benefit exempt from ACA requirements.
Private health insurance plans have taken various routes to include telehealth services in their benefits. While some plans added network providers that solely offer services via telehealth, other payers include providers that deliver care in person and via telehealth.
A 2022 survey revealed the percentage of employers covering telehealth benefits:
- 87% of employers with 50-199 employees
- 96% of employers with 200 or more employees
High deductible health plans (HDHPs) will continue to cover telehealth services before beneficiaries meet their deductible until December 31, 2024.
Federal and state regulators are covering and using telehealth post-PHE. CMS permanent coverage for Medicare is an essential step for the future of telehealth. Additionally, state Medicaid agency use of telehealth establishes telehealth as a standard of care. Private telehealth insurance coverage, particularly for behavioral health, also contributes to adoption and acceptance. The following year will demonstrate further value to clinicians, politicians, and patients, providing evidence that may encourage lawmakers to make more PHE extensions permanent.
Now is the time to maximize and prove the value of telehealth
In the meantime, there are many opportunities to leverage telehealth as part of care delivery, particularly for patients with barriers to in-person care.
Beyond cost savings and efficiency, telehealth offers flexibility that makes care more accessible and convenient, providing a backbone to offering additional services like care coordination, chronic care management, remote patient monitoring, and behavioral health integration.
ThoroughCare’s comprehensive software platform supports such services through interactive, patient-centric care planning. Our solution coordinates care with the use of data analytics and interoperability to inform clinical decisions. Providers can easily implement and scale our platform based on its intuitive design that’s considerate of workflow and service requirements.
