Telehealth: Does Coverage Survive the End of the Pandemic?
There may not have been many benefits from the pandemic, but there were a few. One was the work-from-home trend which gave many employees newfound time flexibility and taught parents a lot – firsthand – about their children's education.
For Medicare beneficiaries, a significant benefit has been the expansion of Medicare-paid telehealth – initially the only way people could engage continuously with their doctors without risking COVID-19 infection. Today it remains a more convenient means of consulting on non-emergency issues.
The history of telehealth coverage
The Centers for Medicare & Medicaid Services (CMS) defines "telehealth" as: "… services provided through telecommunications systems (for example, computers and phones) and allows health care providers to give care to patients remotely in place of an in-person office visit."
Before the COVID-19 pandemic, the primary beneficiaries of telehealth services were those who lived in rural areas (where doctors were scarce) and who had to travel long distances to clinics and hospitals. Those beneficiaries could also receive telehealth services at a designated health care facility, but audio-only services (by telephone) were not allowed.
Certain treatments, such as substance abuse disorders and related mental health issues, were also not allowed.
How the Covid pandemic changed telehealth coverage
In 2020 and 2021, legislation was passed to broaden telehealth services for those on Medicare. The goal was to keep access to health care providers as freely available as before the pandemic. Through different pieces of legislation, all Medicare beneficiaries were granted access to telehealth services from their homes.
Also, all health care providers who accepted Medicare could provide such services and bill Medicare the same as for in-person care. Physical, occupational and speech therapists were added to the pre-pandemic list of covered providers.
Mental telehealth services became available for substance abuse disorders and related mental health concerns. However, some restrictions were proposed for these services, such as previous in-person interaction. The beneficiary would have an in-person visit with the provider within six months before the telehealth session.
Popular online platforms like Zoom, Google Meet and Facetime were authorized, even though they didn't comply with the protective rules covering technology under HIPAA, the Health Insurance Portability and Accountability Act. Now audio-only services (using a telephone) were allowed, and patients could have first-time dialogues with a non-mental health care provider; a prior relationship was not required.
As proof of the popularity of telehealth, telehealth services accounted for 1% of Medicare services before the pandemic. In April 2020, when COVID-19 was new and most confusing, usage peaked at 32% of Medicare claims, then settled to 13-17% by mid-2021.
What telehealth services are covered today?
So what is the current status of access to telehealth services? The key is understanding that legislators originally tied the more flexible telehealth access to the federal COVID-19 Public Health Emergency (PHE). Such access was scheduled to expire 151 days after the PHE did. Recently, COVID-19 trends have led the Department of Health and Human Services (HHS) to target May 11, 2023, as the date the PHE will expire, so expanded telehealth access would expire about five months later.
However, legislation continued to change COVID-19 regulations, making them a moving target. Most recently, the Consolidated Appropriations Act of 2023 – also known as the $1.7 trillion omnibus bill – extended several of telehealth's flexibilities through the end of 2024. What that means for you depends on what form of Medicare coverage you have.
Original Medicare – For Original Medicare beneficiaries, the Consolidated Appropriations Act extends the following benefits through December 31, 2024:
Offering telehealth access to Medicare beneficiaries throughout the United States and not only in rural areas.
Allowing telehealth services to be provided even across state lines, subject to both states' requirements.
Allowing Medicare beneficiaries to receive telehealth services at home, including behavioral health services, such as counseling, psychotherapy and psychiatric evaluations.
Delaying the requirement of an in-person visit before behavioral telehealth services are allowed.
Honoring the expanded list of providers (including physical, occupational and speech therapists).
Allowing audio-only (telephone) access where someone can't use a smartphone or computer.
Conducting hospice recertification.
Allowing hospitals to use telehealth services to facilitate acute care from home.
After that date, you will have to be in a doctor's office or medical facility in a U.S. rural area to benefit from telehealth. If you have Original Medicare coverage and want to use telehealth services, call Medicare at 1-800-MEDICARE (1-800-633-4227) or contact your local State Health Insurance Assistance Program (SHIP)if you have any doubts about Medicare coverage.
Medicare Advantage – By law, Medicare Advantage (Medicare Part C) insurers must offer beneficiaries a minimum of what Original Medicare offers as Part A (Hospital Insurance) and Part B (Medical Insurance). As a result, the telehealth services listed above under Original Medicare must also be available under Medicare Advantage plans.
Medicare Advantage frequently offers benefits beyond Original Medicare, such as prescription drug, vision, dental, hearing and fitness coverage. So, if you have a Medicare Advantage plan, it may well provide telehealth benefits beyond what Original Medicare provides. Check with your Medicare Advantage plan provider to see what's available until 2024 – and beyond.
Takeaway action step: Your Medicare Advantage plan provider is your best resource if you are concerned about whether specific telehealth services will be covered. Call and check before risking an unexpected invoice.
Accountable Care Organizations – The Consolidated Appropriations Act makes one more differentiation. It identifies what telehealth services are available for Accountable Care Organizations (ACOs).
What are ACOs? They are groups of doctors, hospitals and other health care professionals who decide to band together to provide more coordinated service to higher-need patients. ACOs are most effective if you have a chronic disease like heart disease or diabetes, as the various specialists in the group can coordinate your treatment – which avoids duplicate testing and conflicting treatments.
ACO is not a separate form of health insurance. It reflects a different way that Medicare compensates providers – sharing in any cost savings resulting from their care. You can't proactively "enroll" in an ACO. Instead, if one of your doctors happens to belong to an ACO, they might bring your care into their ACO group.
In the case of telehealth services, some ACOs may continue to use telehealth services for primary care doctors even beyond the Consolidated Appropriations Act's extended deadline of December 31, 2024.
Takeaway action step: Your relationship within an ACO is privileged, typically with particularly close communications. Your ACO provider can explain how your benefits might differ from other Medicare beneficiaries.
What telehealth services will remain available after December 31, 2024?
After the Consolidated Appropriations Act's extension expires, certain telehealth services will remain available without the "rural setting" condition. These include:
Monthly visits for home dialysis for End-Stage Renal Disease (ESRD).
Diagnosis, evaluation or treatment of acute stroke symptoms wherever you are.
In-home treatment of a substance use disorder or related mental health issue.
In-home diagnosis, evaluation or treatment of a mental health disorder.
What do telehealth services cost?
Most telehealth services are covered by Medicare Part B (Medical Insurance). With Original Medicare, after you meet the deductible, you will pay 20% of the Medicare-approved amount for the service. You will typically pay the same amount for a telehealth visit as you would for an in-person visit. If you have an optional Medicare Supplement Insurance (Medigap) plan, that should pay the 20%. With Medicare Advantage plans, typical coinsurance and deductibles will apply.