Based on current COVID-19 recovery trends, the Department of Health and Human Services announced that the US federal Public Health Emergency (PHE) waivers will end on May 11, 2023. Emergency declarations, Congressional legislative actions, and state regulations implemented unprecedented changes to many healthcare delivery aspects. Private payers, Medicaid, and Medicare initiated widespread telehealth reimbursement approvals. Some of these changes will expire in the next few weeks, but many will continue while further legislative action develops. The article below clarifies and summarizes the end-of-pandemic reimbursement decisions made by private payers, Medicare, and Medicaid. Resources for other end-of-pandemic decisions are also provided.
Access to Telehealth Services
Private Health Insurance
Coverage for telehealth and other remote care services will vary by state and private insurance plans. Some states have mandated the continued reimbursement of all healthcare services through telehealth, while others have not.
Also known as commercial insurers, these payers also have rules within their state-based plans that differ from one state to another. More specifically, company “A” in one state can have different benefit offerings from company “A” in a neighboring state. These issues are particularly important for providers to realize and correct as the end of the pandemic draws near, lest they be vulnerable to charges of insurance fraud for practicing over state lines without a license and billing insurance for those services.
The client’s location at the time of the contact can be a serious point of contention by private carriers if providers have been lax with their billing practices when delivering telehealth services to a client who relocated to a different state. Using the example above, if a client moves from state “A” to state “B,” and the provider continues to bill the insurer from state “A” without approval from that insurer, the provider may technically be committing insurance fraud. Different payers have different policies and rules from one state to another. Malpractice coverage is also at risk. Many providers also fail to understand that practicing illegally over state lines can nullify one’s malpractice insurance in most cases, particularly when illegal billing has occurred.
Another issue of importance when dealing with private insurers is that their coverage for telehealth may require cost-sharing, prior authorization, or other management forms for telehealth and technology-based remote care services. Such technology-based remote care services might include e-visits, remote patient monitoring, and digital therapeutics, including wearables and virtual reality, to name a few. For additional telehealth-related information on any private insurer’s approach to telehealth, contact the insurer’s customer service number, usually found on the back of a client or patient’s insurance card.
Medicare and Telehealth
Reimbursement for many audio and video behavioral telehealth services has been permanently approved and will extend beyond the PHE without interruption for Medicare beneficiaries. To be more specific, behavioral telehealth visits can be delivered by telephone or another audio-only channel if someone cannot use audio and video, such as with a smartphone or computer. The Consolidated Appropriations Act of 2023 extended many other telehealth flexibilities through December 31, 2024, including the following:
- Rather than only in rural areas, Medicare beneficiaries can receive telehealth services in any geographic location in the United States.
- They can receive care from their homes rather than traveling to a health care facility.
- Medicare Advantage plans may offer additional telehealth benefits.
- After December 31, 2024, when these flexibilities expire, some Accountable Care Organizations (ACOs) may offer telehealth services that allow primary care doctors to care for patients without an in-person visit, no matter where they live.
- Other changes are expected but have not yet been announced.
Medicaid, CHIP, and Telehealth
For Medicaid and the Children’s Health Insurance Program (CHIP), telehealth flexibilities are not tied to the end of the PHE. In fact, these programs have been available in many states long before COVID. Coverage varies by state, but a recent Kaiser Family Foundation survey of state Medicaid officials across 44 states showed an increased interest in permanently adopting pandemic-era telehealth policy expansions.
States seeking assistance with continuing, adopting, or expanding telehealth coverage may benefit from the CMS State Medicaid & CHIP Telehealth Toolkit and an associated supplement. They help identifies the policy topics that should be addressed to facilitate the widespread adoption of telehealth for states.
COVID-19 Waivers and Administrative Flexibilities: How Health Care Providers and Suppliers are Affected
During the PHE, CMS temporarily changed the definition of “direct supervision” to allow supervising healthcare professionals to use real-time audio/video technology. CMS clarified that the temporary exception to allow immediate availability for direct supervision through virtual presence also facilitates the provision of telehealth services by clinical staff “incident to” the professional services of physicians and other practitioners.
This flexibility will expire on December 31, 2023, for most medical providers, but for addiction professionals, counselors, and marriage and family therapists, January 1, 2024, will mark the start of when they can receive Medicare reimbursement. Their roles were described in the Physician’s Fee Schedule as needing to work “incident to” supervisors in many situations.
More End-Of-Pandemic Emergency Information
These added resources may be helpful to providers planning for their end-of-pandemic strategic planning.
- A complete list of end-of-pandemic declarations, legislative actions by Congress, and regulatory actions across the government can be seen in the CMS Newsroom announcement.
- For more information about these waivers in the downloadable that was created and made publically available by the National Policy Center – Center for Connected Health Policy: Medicare Telehealth/Connected Health Waivers Post-PHE
- The Administration, States, and private insurance plans will continue to provide guidance in the coming months. It may be helpful to consider that the Administration’s continued response is not entirely dependent on the COVID-19 PHE. Some significant flexibilities and actions will not be affected by the end-of-pandemic. For a comprehensive overview, visit the Public Health Emergency Roadmap fact sheet.
Telehealth.org will inform you of official telehealth-related reimbursement announcements as they are released in the future.
Optimizing Telehealth Billing: Current Telehealth CPT Codes & Telehealth Reimbursement Strategies
Today’s telehealth CPT codes and other telehealth billing issues are in rapid flux. Information gathered from online searches or colleagues can be outdated and incorrect — and lead to frustrating claim denials.