Use of telehealth, which permits sufferers to see well being care suppliers with out being in the identical location, has grown quickly in recent times, amongst each privately-insured sufferers and Medicare beneficiaries. Previous to the COVID-19 pandemic, telehealth utilization in conventional Medicare was very low, however it rose dramatically in 2020 following momentary measures put in place at first of the COVID-19 public well being emergency that enormously expanded the scope of Medicare protection of telehealth. Since early 2021 telehealth use has declined steadily, however it stays larger than pre-pandemic ranges, with appreciable variation by earnings stage, race and ethnicity, and concrete versus rural location, amongst different components.
Congress has prolonged a lot of pandemic-era flexibilities round Medicare protection of telehealth past the COVID-19 public well being emergency, which ended on Might 11, 2023, however most of those flexibilities are because of expire in December 2024. There’s bipartisan assist for proposed laws to increase these provisions for one more two years, and Congress is weighing the potential advantages, dangers, and prices of completely increasing Medicare protection of telehealth companies. Medicare beneficiaries are usually happy with their telehealth visits, and plenty of well being care suppliers are supportive of maintaining these companies accessible, however questions stay in regards to the longer-term affect on affected person care, Medicare spending, and program integrity.
These FAQs present solutions to key questions in regards to the present scope of Medicare telehealth protection, together with each momentary and everlasting modifications adopted via laws and regulation, and coverage concerns that lie forward.
What’s the present scope of Medicare telehealth protection and the way did it change at first of the COVID-19 pandemic?
Previous to the declaration of the COVID-19 public well being emergency, Medicare protection of telehealth was largely restricted to beneficiaries in rural areas and to sure forms of suppliers, amenities, and companies. On the time, beneficiaries have been usually required to journey from their houses to accepted scientific websites the place they may obtain care from suppliers at different places. To make it simpler and safer for beneficiaries to hunt medical care through the pandemic, the Secretary of the Division of Well being and Human Providers (HHS) waived many of those restrictions in March 2020, enabling broader use of telehealth companies for all Medicare beneficiaries. Whereas the pandemic-related enlargement of telehealth protection underneath Medicare was initially because of expire on the finish of the COVID-19 public well being emergency, subsequent laws prolonged many of those flexibilities via December 2024 and included others into this system on a everlasting foundation (Determine 1).
The next checklist summarizes key provisions of present regulation associated to protection of telehealth in conventional Medicare, each momentary and everlasting. (See part under for a dialogue of telehealth protection by Medicare Benefit plans.)
Short-term telehealth provisions (at the moment because of expire after December 31, 2024)
Waiver of geographic and “originating website” necessities: Telehealth is at the moment out there to Medicare beneficiaries in each city and rural areas, and sufferers can obtain telehealth companies from any location, together with their house because the “originating website.” Previous to the enlargement, telehealth protection in conventional Medicare was restricted to rural areas (with sure exceptions), and sufferers have been required to journey to an accepted originating website, reminiscent of a clinic or physician’s workplace, when receiving telehealth companies. (Suppliers collaborating in choose accountable care organizations (ACOs) are permitted to waive these necessities underneath the Bipartisan Funds Act of 2018, and will proceed to supply telehealth companies with out geographic restrictions, and to beneficiaries of their houses, ought to the present flexibilities expire.)
Enlargement of coated telehealth companies: Medicare at the moment gives protection for an expanded set of telehealth companies, together with bodily and occupational remedy, emergency division visits, and nursing facility care. Previous to the enlargement, Medicare provided protection for a extra restricted set of telehealth companies, reminiscent of preventive well being screenings, workplace visits, and psychotherapy. The Facilities for Medicare & Medicaid Providers (CMS) has the authority to broaden the checklist of allowable telehealth companies when there’s a demonstrable scientific profit and continues to judge choose companies for everlasting inclusion on this checklist.
Protection of audio-only companies: Medicare at the moment permits a restricted set of telehealth companies to be supplied to sufferers by way of audio-only platforms, reminiscent of a phone or a smartphone with out video. Previous to the enlargement, Medicare required all telehealth companies to be supplied by way of a two-way audio/video connection, reminiscent of an interactive audio-video system or a smartphone with video enabled.
Enlargement of eligible “distant website” telehealth suppliers: At the moment, any well being care supplier who’s eligible to invoice for Medicare-covered companies can present and invoice for telehealth as a “distant website” telehealth supplier and will conduct an preliminary telehealth go to whether or not or not they’ve handled the beneficiary beforehand. Moreover, federally certified well being facilities (FQHCs) and rural well being clinics (RHCs) at the moment are licensed to supply and invoice for telehealth. Previous to the enlargement, solely physicians and sure different suppliers (e.g., doctor assistants, scientific social staff, and scientific psychologists) have been permitted to invoice for telehealth companies because the distant website supplier and should have handled the beneficiary receiving these companies inside the final three years. FQHCs and RHCs weren’t licensed to function distant website suppliers however may function originating websites if positioned in a qualifying space.
Waiver of in-person go to requirement for behavioral well being: At the moment, Medicare beneficiaries receiving behavioral well being companies might choose to obtain these companies by way of telehealth with no in-person go to necessities. The Consolidated Appropriations Act of 2021 made quite a few modifications to Medicare protection of behavioral telehealth (see under), together with a provision that beneficiaries should have an in-person go to with their behavioral well being supplier not more than six months earlier than their preliminary telehealth appointment and yearly thereafter. Subsequent laws delayed this requirement till January 2025.
Use of telehealth for hospice recertification: Affected person recertification for the Medicare hospice profit can at the moment be performed by way of telehealth, supplied there’s a two-way audio/video connection that permits for real-time interplay between the affected person and hospice supplier. Previous to the enlargement, solely in-person encounters may very well be used for the needs of hospice recertification.
Everlasting telehealth provisions
Behavioral well being: The Consolidated Appropriations Act of 2021 completely eliminated geographic and originating website restrictions for any telehealth service used to diagnose, consider, or deal with a psychological well being dysfunction. (These restrictions had already been lifted for remedy of substance use problems and co-occurring psychological well being problems in 2018). Whereas many different provisions associated to telehealth protection expire on the finish of 2024, Medicare beneficiaries might proceed to obtain behavioral well being companies from their houses, in each city and rural areas, and will achieve this by way of audio-only platforms if they’re unable to entry a video connection or don’t consent to video use. Moreover, FQHCs and RHCs are completely allowed to function telehealth suppliers for behavioral well being companies.
What tendencies have emerged in Medicare beneficiaries’ use of telehealth companies?
Telehealth use in conventional Medicare elevated dramatically at first of the COVID-19 public well being emergency, with almost half (46.7%) of all eligible beneficiaries receiving at the least one telehealth service within the second quarter of 2020, in comparison with simply 6.9% within the first quarter (Determine 2). Whereas use has declined since that point, it stays almost two occasions larger than pre-pandemic ranges, with a couple of in ten (12.7%) eligible beneficiaries receiving a telehealth service within the ultimate quarter of 2023.
Use of telehealth companies varies by geography, race and ethnicity, motive for Medicare eligibility, and twin enrollment in Medicare and Medicaid (Determine 3).
Geography: Charges of telehealth use in 2023 have been larger amongst beneficiaries dwelling in city areas than these in rural areas (27% vs. 19%), which can be due partly to disparities in entry to broadband and different communication applied sciences. Beneficiaries in rural or underserved areas might lack the infrastructure to assist dependable video telehealth visits or the means to afford web entry, which can additional impede entry to telehealth if protection of audio-only companies is lowered or eradicated.
Race and ethnicity: Charges of telehealth use in 2023 have been highest amongst Asian and Pacific Islander (31%) and Hispanic (30%) beneficiaries, and considerably decrease amongst Black (26%), American Indian or Alaska Native (25%), and non-Hispanic White beneficiaries (24%). On condition that beneficiaries of shade are extra seemingly than non-Hispanic White beneficiaries to report issue accessing wanted well being companies, telehealth use might assist to enhance entry to look after sure teams.
Purpose for Medicare eligibility: Charges of telehealth use in 2023 have been larger amongst beneficiaries who qualify for Medicare based mostly on having end-stage renal illness (ESRD) (37%) or a long-term incapacity (37%), relative to those that qualify based mostly on age (23%). This can be due partly to larger total charges of service use amongst folks with ESRD and disabilities (whether or not in-person or by way of telehealth) however may additionally replicate a desire for telehealth companies amongst these populations, or a higher ease of accessing care by way of telehealth relative to in-person care. Beneficiaries underneath age 65 who qualify for Medicare based mostly on having long-term disabilities are extra seemingly than older beneficiaries to report having three or extra limitations in actions of each day dwelling, and could also be extra more likely to profit from the elevated flexibility of receiving well being care companies from their house by way of telehealth.
Twin-eligible people: Charges of telehealth use in 2023 have been larger amongst beneficiaries dually eligible for each Medicare and Medicaid in comparison with Medicare beneficiaries who weren’t Medicaid-eligible (34% vs. 23%). Twin-eligible people are 4 occasions extra seemingly than different Medicare beneficiaries to reside on incomes of lower than $20,000. Prior research have discovered that having decrease earnings or dwelling in a socioeconomically disadvantaged neighborhood is related to larger charges of telehealth use, suggesting that telehealth might have the potential to enhance well being care entry for beneficiaries with restricted entry to in-person companies.
How does Medicare pay suppliers for telehealth companies?
Medicare at the moment pays suppliers for telehealth companies, each video and audio-only, on the identical fee that will be paid if the service have been delivered in individual. As with most companies paid underneath the Medicare doctor payment schedule, fee charges for telehealth companies at the moment fluctuate based mostly on the placement of the supplier, with companies furnished by suppliers based mostly in a non-facility setting, reminiscent of a health care provider’s workplace, reimbursed at the next fee than companies furnished by suppliers based mostly in a facility setting, reminiscent of a hospital outpatient division.
Previous to the COVID-related momentary enlargement, Medicare paid for all coated telehealth companies on the decrease facility fee, no matter supplier location. Which means that suppliers in non-facility settings at the moment obtain larger fee for telehealth companies than they did earlier than the momentary enlargement. Nonetheless, assuming no change to present regulation, Medicare will resume paying for many telehealth companies (except for behavioral well being companies) on the decrease facility fee starting in January 2025. The Consolidated Appropriations Act of 2021 completely established fee parity between in-person and telehealth companies within the context of behavioral well being. Ought to the present flexibilities expire, Medicare will proceed to pay suppliers for behavioral telehealth companies on the identical fee they might obtain if the service have been delivered in individual.
CMS completely licensed FQHCs and RHCs to supply and invoice for behavioral telehealth companies in 2022. As with different forms of suppliers, clinicians in these settings are paid the identical fee for behavioral telehealth companies as they might obtain if the service have been delivered in individual on a everlasting foundation. Nonetheless, for all different forms of telehealth companies, FQHCs and RHCs are solely eligible for reimbursement via December 2024. Medicare at the moment pays FQHCs and RHCs at charges corresponding to these set underneath the doctor payment schedule, that are decrease than what they might obtain for comparable in-person care, since Medicare usually pays extra for clinician companies supplied by FQHCs and RHCs than these supplied in different forms of settings.
How do Medicare Benefit plans cowl telehealth?
Medicare Benefit plans are required to cowl all Half A and Half B advantages coated underneath conventional Medicare, and have some flexibility to supply extra advantages as nicely, together with telehealth advantages not routinely coated by conventional Medicare (outdoors of the present telehealth enlargement), reminiscent of telehealth companies supplied to enrollees in their very own houses, companies supplied outdoors of rural areas, and companies supplied via audio-only platforms.
Since 2020, Medicare Benefit plans have been permitted to incorporate the prices related to choose telehealth companies of their fundamental Medicare Half A and B profit bundle, and will proceed to take action after December 2024 whatever the standing of the momentary telehealth expansions in conventional Medicare. Telehealth companies could also be included in a plan’s fundamental advantages bundle in the event that they meet sure necessities, reminiscent of protection underneath Medicare Half B when the identical service is supplied in individual. When these necessities are usually not met, plans might proceed to supply supplemental telehealth advantages by way of distant entry applied sciences and/or telemonitoring companies, however should cowl the price of these advantages utilizing rebates or supplemental premiums.
What extra steps have been proposed to broaden Medicare protection of telehealth?
Choices to increase or make everlasting lots of the present flexibilities round Medicare protection of telehealth have been the topic of a lot of hearings in each the U.S. Senate and the Home of Representatives. Bipartisan payments such because the Preserving Telehealth, Hospital, and Ambulances Act and the Telehealth Modernization Act of 2024 embrace provisions that will briefly lengthen the present flexibilities via December 2026. Nonetheless, outdoors of choose modifications, reminiscent of completely permitting FQHCs and RHCs to supply non-behavioral telehealth companies, neither invoice gives for a everlasting enlargement of Medicare telehealth protection.
The Biden-Harris Administration has introduced extra measures to protect telehealth entry for Medicare beneficiaries, reminiscent of a grant program to assist the event of an interstate licensure compact that will make it simpler for licensed social staff to observe throughout state strains, and provisions in a latest CMS proposed rule that will completely lengthen sure telehealth flexibilities, reminiscent of protection of audio-only companies that meet all different circumstances for Medicare telehealth protection. Nonetheless, within the absence of Congressional motion, implementation of those provisions will probably be restricted to the forms of suppliers, companies, and settings the place telehealth was permitted earlier than the present flexibilities have been put in place (except for behavioral well being flexibilities, which have been made everlasting).
Associated to licensure, Medicare suppliers are usually required to be licensed in any state the place they’re working towards, and this requirement extends to telehealth. Normally, a distant website telehealth supplier should be licensed within the state the place the beneficiary receiving companies is positioned when the telehealth go to takes place. Nonetheless, sure states have taken motion to develop multi-state licensure compacts, which has allowed for added flexibility associated to licensure in collaborating states. These compacts are shaped when states agree upon a uniform normal of care and enact state legal guidelines which permit certified suppliers to observe throughout state strains whereas sustaining a single license or to keep up a number of licenses or which expedite the method of gaining extra licensure throughout member states. These compacts could also be continued past December 2024, although different restrictions might restrict their use if the present flexibilities are allowed to run out.
What are the implications of telehealth for Medicare program integrity?
As policymakers weigh whether or not to increase or make everlasting present flexibilities round Medicare protection of telehealth, a number of questions have been raised in regards to the affect of telehealth companies on affected person care high quality and program spending, in addition to the potential for fraud and overuse.
Because the present flexibilities have been launched, state and federal businesses have filed a number of lawsuits concerning the submission of fraudulent claims by telehealth firms to Medicare and different insurers. Nonetheless, investigations by the HHS Workplace of the Inspector Common (OIG) into supplier billing patterns through the first yr of the COVID-19 pandemic discovered that simply 0.2% of suppliers who billed for a telehealth service through the interval engaged in extreme billing patterns that posed a excessive threat to the Medicare program, and clinicians usually complied with Medicare necessities when offering Analysis and Administration companies via telehealth, suggesting little proof of widespread misuse thus far. MedPAC has really useful that CMS take sure precautions if the present telehealth flexibilities are prolonged, reminiscent of making use of extra scrutiny to “outlier” clinicians who ship extra telehealth companies than others and requiring in-person visits earlier than high-cost assessments and medical gear are paid for.
What’s the anticipated affect of telehealth use on Medicare spending and the estimated value of increasing protection?
Increasing telehealth protection is anticipated to result in a rise in Medicare spending, however the total magnitude in the long run is unsure. Some telehealth companies might substitute in-person care, as within the case of behavioral well being visits, however simpler entry to telehealth may additionally result in an total enhance in use of companies and better prices. Prior analysis has discovered modest will increase in scientific encounters and spending per individual amongst Medicare beneficiaries in geographic areas and well being methods with larger charges of telehealth use. On the identical time, there may be proof to recommend that beneficiaries with higher entry to telehealth companies might have fewer emergency division visits and improved adherence to sure medicines. Further analysis would assist policymakers and different events decide whether or not any will increase in Medicare spending because of expanded telehealth protection are offset by enhancements in high quality of care or decreases in different prices, reminiscent of spending on preventable hospital admissions and different forms of acute care companies.
The Congressional Funds Workplace (CBO) scored the extension of telehealth flexibilities via December 2024 underneath the Consolidated Appropriations Act of 2023 as costing $2.4 billion, on high of the $663 million estimated for a previous extension underneath the Consolidated Appropriations Act of 2022. CBO has not but scored the price of the newest payments into consideration by the Home of Representatives (see above), which embrace provisions to increase these flexibilities via December 2026.
As policymakers weigh the implications of laws to keep up or broaden Medicare protection of telehealth, a key consideration is find out how to set fee charges for telehealth companies throughout completely different care settings and supplier sorts. Fee parity between in-person and telehealth companies might encourage suppliers to take a position extra time and assets into telehealth, however some have raised questions on how to make sure that this funding doesn’t come on the expense of affected person care high quality or entry to in-person companies for beneficiaries preferring them. MedPAC has really useful that CMS return to paying the decrease facility fee for many telehealth companies, together with these furnished by FQHCs and RHCs, and gather knowledge on observe prices to be able to modify telehealth fee charges sooner or later. The place policymakers find yourself on these points would seemingly have an effect on the general value of extending or making everlasting Medicare protection of telehealth past 2024.
