Medicare and Medicaid Coverage for Telemedicine

CMS expands telehealth options for medicare beneficiaries

A woman having a telemedicine consult with her doctor via computer

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Not everyone can make it to the doctor's office for a visit. There may not always be an appointment available on any given day. There could be transportation issues or it could be physically difficult for someone to make the trip if they have an underlying illness. Thank goodness telemedicine, also known as telehealth, is available to offer services from the comfort of your own home. The Centers for Medicare and Medicaid Services (CMS) are increasing coverage for these services.

What is Telehealth?

Telehealth comes in three varieties.

  • Live conferencing: This is the most common type of telemedicine used today. It is defined as a real-time audio and video consultation between a medical provider and a patient.
  • Remote patient monitoring: This type of telemedicine involves the evaluation of pre-recorded patient information. Examples include evaluation of physiologic measurements like weight, blood pressure, pulse oximetry, and respiratory rate.
  • Stand and forward: In stand and forward cases, sessions are recorded and reviewed at a later time by a medical provider. Stand and forward can be used for patient-doctor visits but is often used for consultations between medicals providers, e.g., a specialist speaking with a primary care physician. Teleradiology is another example, where an imaging study is performed and subsequently analyzed by a licensed radiologist.

Medicare only covers live conferencing. Medicaid, depending on the state, may cover any of the three types of telemedicine.

Medicare Coverage for Telehealth

Medicare has traditionally limited access to telehealth. For people on Original Medicare (Part A and Part B), the service was only available to people if they lived in a qualifying rural area and were requiring medical care via live audio-visual conferencing from one of eight designated locations. Notably, care from home was not covered.

The designated covered locations are:

  • A community health center
  • A critical access hospital (CAH)
  • A doctor's office
  • A federally qualified health center
  • A hospital
  • A hospital-based or critical access hospital-based dialysis facility
  • A rural health clinic
  • A skilled nursing facility

Your Part B benefits cover approved telehealth visits. Medicare pays for 80% of the cost, leaving you with a 20% coinsurance.

The Bipartisan Budget Act of 2018 allowed for the expansion of Medicare's covered telehealth services. In 2019, CMS finalized telemedicine policies for Medicare Advantage plans. For one, telestroke services have been expanded to cover both rural and urban locations for evaluation of suspected stroke.

Medicare will also now cover telehealth services performed at independently run dialysis facilities. For people who receive dialysis at home, Medicare will now allow telehealth services in the home as long as other criteria are met. These new telehealth visits will be covered only if the person using them also has an in-person visit with their medical provider at least once a month during the first three months of their home dialysis treatment and then at least once every three months.

Remember that you can choose to be covered by Original Medicare or Medicare Advantage but not both.

This legislation has also expanded telehealth services for people on Medicare Advantage (Part C). Up to that time, telemedicine had been limited to a supplemental benefit and was not included in all Medicare Advantage plans included.

These changes will allow these Medicare plans to add the service as part of their basic benefits package. Considering that 19 million people were enrolled in Medicare Advantage in 2018, far more people will now be able to access telehealth when they need it.

Medicaid Coverage for Telehealth

Medicaid has traditionally been more generous when it comes to covering telehealth and telemedicine services.

While each state varies in how it defines the term and what it specifically covers, forty-nine states and the District of Columbia provide Medicaid reimbursement for some form of the service.

Massachusetts does not have a policy for telehealth reimbursement at this time.

With the exception of Massachusetts, all Medicaid programs cover live conferencing, albeit according to their own rules. For example, New Jersey only covers telepsychiatry. Teledentistry is only offered in Arizona, California, Georgia, Minnesota, North Carolina, New York, and Washington.

Some states have additional requirements based on the type of service received (e.g., an office visit, an in-hospital consultation), the type of provider who performs the service (e.g., a physician, a nurse practitioner, a physician assistant), in what state the medical professional is licensed, what type, if any, prescriptions are allowable, and where the service is provided (e.g., at home or at a medical facility).

Not all states consider teleradiology to be of the stand and forward type. Excluding teleradiology, only 11 states currently reimburse stand and forward through their Medicaid programs.

The states that reimburse stand and forward include:

  • Alaska
  • Arizona
  • California
  • Connecticut
  • Georgia
  • Maryland
  • Minnesota
  • New Mexico
  • Nevada
  • Virginia
  • Washington

California limits the service to teledermatology, teleophthalmology, and teledentistry. Connecticut only covers eConsults, which the state defines as email consultations between medical providers regarding a specific patient.

Remote patient monitoring is covered by Medicaid programs in twenty states:

  • Alabama
  • Alaska
  • Arizona
  • Colorado
  • Illinois
  • Indiana
  • Kansas
  • Louisiana
  • Maine
  • Maryland
  • Minnesota
  • Mississippi
  • Missouri
  • Nebraska
  • South Carolina
  • Texas
  • Utah
  • Vermont
  • Virginia
  • Washington

Only seven states cover all three services—live conference, remote patient monitoring, and stand and forward. These include:

  • Alaska
  • Arizona
  • Maryland
  • Minnesota
  • Nevada
  • Virginia
  • Washington

A Word From Verywell

Telehealth is becoming more popular in the United States, and CMS is taking notice. In fact, they are expanding services for Medicare in 2019.

Original Medicare has increased coverage for stroke evaluations and for people on dialysis. Medicare Advantage plans will soon offer telehealth services as part of their basic benefits package, instead of limiting it to supplemental benefits.

Keep in mind that people on Medicaid may have more telehealth options than those on Medicare depending on where they live.

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Article Sources

  1. Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List. Centers for Medicare and Medicaid Services. Updated March 4, 2019.

  2. State Telehealth Laws and Reimbursement Policies Report. Center for Connected Health Policy. Published October 2018.

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