The Landscape of Telemental Health Coverage After the PHE
With the end of the COVID-19 public health emergency (PHE) nearing on May 11, 2023, clinicians are wondering how telehealth services will continue to be covered. Predicting coverage can be challenging because, in many instances, payers can set their own policies. Below, we outline information across payer types to help APA members anticipate telehealth coverage for your patients. However, coverage policies and determinations are ultimately up to your patient’s payer and may vary across payers, plans, and markets.
What is the current state of Original Medicare coverage of telehealth?
On January 1, 2023, the Centers for Medicare & Medicaid Services (CMS) CY 2023 Physician Fee Schedule (.pdf) extended some flexibilities for telehealth services that were established under the COVID-19 PHE. These flexibilities in the Medicare program include the permanent allowance of audio-only telehealth for mental health and substance use disorder (MH/SUD) care when requested by the patient, deferral of in-person care requirements for mental health services through the end of 2024, the patient’s home being added as an originating site for telemedicine care, and permanent removal of geographic originating site restrictions (i.e., rural residence) on telehealth eligibility. At the end of 2023, CMS also plans to revert to paying the facility fee rather than the non-facility fee for Medicare telehealth services, constituting a reduction in reimbursement relative to in-person, in-office visits for the same codes.
For further information about Medicare coverage of telemental health, please refer to APA’s FAQ: What Happens when the Public Health Emergency Ends? Telepsychiatry and Hybrid Practice Post-PHE and blog: “Medicare Telemental Health Care Beyond the Public Health Emergency: Changes APA Advocated for in the Physician Fee Schedule.”
What is the current state of Medicare Advantage coverage of telehealth?
Medicare Advantage (MA) plans are required to cover all Part A and Part B benefits covered under Original Medicare. In 2022, 98% of Medicare Advantage plans offered a telehealth benefit.
2023 MA coverage largely extends to the telehealth modalities and services that are currently covered by traditional Medicare. An examination of MA plans from 2023 with greater than 2% market share indicates that these plans adhere to the same modalities and services covered by the CY 2023 Physician Fee Schedule, including coverage of audio-only services, delay in in-person mental health care requirements, the patients home being added as an originating site for telemedicine care, and removal of geographic originating site restrictions.
What is the current state of Medicaid coverage of telehealth?
All states and the District of Columbia provide reimbursement for some form of live video in Medicaid fee-for-service. During the COVID-19 pandemic, many states expanded Medicaid coverage for telehealth. However, Medicaid coverage of telehealth varies widely from state to state.
Per Kaiser Family Foundation (KFF), as of July 2022, 44 states provided Medicaid audio-only coverage of MH/SUD services. Texas, Connecticut and Rhode Island reported only coverage of audio-only mental health (but not SUD) services, while Wyoming and Mississippi reported not providing audio-only Medicaid coverage of any behavioral health services.
Twenty-five states provide reimbursement for Medicaid store-and-forward telehealth, or collecting clinical information and sending it electronically to another site for evaluation. Twenty-four states reimburse for remote patient monitoring, which involves digital technology usage to record the medical and personal health data of a patient. Seventeen states reimburse for store-and-forward, remote patient monitoring, and audio-only services. For details about specific states, you can visit the Federation of State Medical Boards’ Telemedicine Policies (.pdf) resource.
The 2022 Bipartisan Safer Communities Act will require CMS to issue guidance on Medicaid and telehealth by the end of 2023, so more will be known about the landscape of Medicaid coverage of telehealth when this guidance is issued later in the year. In addition, during the PHE, states have been required to maintain enrollment for almost all Medicaid beneficiaries. In the CAA 2023, Congress decoupled Medicaid continuous eligibility from the PHE, allowing states to begin Medicaid disenrollment processes (also called “unwinding”) on April 1, 2023. Every state will approach this differently, and some states have put in motion policy to extend Medicaid continuous enrollment. Each state has different policies on Medicaid eligibility, enrollment, and disenrollment. You can take a look at each state’s disenrollment timelines here (.pdf).
What is the current state of private insurance coverage of telemental health?
Most private insurance carriers don’t make their plans publicly available, and there is significant variation within and between carriers, so it can be challenging to assess the full landscape of coverage. Here is what we do know.
The majority of private insurers covered telemedicine before the pandemic began. This is not expected to change when the PHE expires in May. Forty-three states and the District of Columbia govern private payer telehealth reimbursement policies, and 24 states require private payers to reimburse telehealth visits at the same rate as in person visits. For details about specific states, you can visit the Federation of State Medical Boards’ Telemedicine Policies (.pdf) resource.
According to KFF, in 2019, 82% of large employers offering health benefits covered telemedicine. As of late 2022, among firms with 50 or more workers offering health benefits, 87% of small firms (50-199 workers) and 96% of large firms reported covering the provision of some health care services through telehealth in their largest health plan.
The top carriers of private insurance in the country – Blue Cross Blue Shield, UnitedHealthcare, Centene, Cigna, Aetna, Humana, and Kaiser Permanente – all offer some form of coverage for telehealth services. Telehealth options may vary based on specific plan selections, so clinicians should make sure to verify each payer’s policy and ask patients to verify their coverage ahead of appointments. Private plans vary widely, so please let us know if you are getting rejections for standard telehealth services so that we can advocate for changes that enable appropriate telemental health.
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