Reimbursement for virtual care is an ever-evolving matter that has been largely dependent on state and federal regulations. The combination of technological advancements, consumer convenience expectations, and provider shortages have forced federal and state regulators into proactive modes; however, laws in vary each state, resulting in significant differences in telemedicine reimbursement regulations between each state.
Understanding the variations in telemedicine law first requires knowledge of the various terms utilized by legislators, along with various forms of telemedicine. There are three main types of telemedicine reimbursement: Live Video, Store-and-Forward, and Remote Patient Monitoring. Live synchronous video is the most broadly accepted form of telemedicine or telehealth, but reimbursement laws continue to advance, expanding reimbursement opportunities for other variants of telehealth.
A form of virtual care delivery in which patient data is collected outside of traditional care settings and transmitted to a provider at a remote location. It can be used most simply to monitor blood sugar levels or blood pressure.
The means of providing healthcare services via live video conferencing, facilitating two-way audio and video communication either between a patient and provider, or two providers.
The process of collecting and sharing clinical information electronically to another clinician for evaluation. Information typically includes medical history, documents such as laboratory reports, images, and video and/or sound files.
There are a number of additional terms that are utilized in state and federal legislation and within the telehealth policies of individual insurers. It is necessary to understand these terms in order to uncover the reimbursement opportunities that exist for providers and facilities.
Distant Site references the location of the physician that is providing care through telehealth. It is also referenced as a Referral Site, Specialty Site or Hub Site in some legislation.
Originating Site is the location of the patient during a telemedicine session, and it is also commonly referred to as the Remote Site or Spoke Site. Examples of originating sites include but are not limited to the following:
Many state and federal laws reference Eligible Providers that are qualified to be reimbursed for telemedicine. In many cases, laws will reference specific licensure types. Examples include Registered Nurse, Nurse Practitioner, Medical Doctor, Physician Assistant, Psychologist, and Licensed Mental Health Professional.
State Licensure refers to the state medical boards and examiners that control licensing for medical providers. In order to provide virtual care services to residents of a specific state, providers must be licensed by that state’s medical board.
HIPAA stands for the Health Information Portability and Accountability Act. It is a law that sets a minimum threshold for patient privacy, security of medical records, and guarantee patients the right to their medical records. Virtually all telemedicine laws either require compliance with the minimum standards of HIPAA or require that all sessions and information related to a telemedicine visit be encrypted and secure. If not, the virtual care services are not eligible for reimbursement.
Electronic Health Records or Electronic Medical Records are stored in enterprise medical platforms utilized by health systems, provider groups, and individual provider offices. In many cases, the law requires that telemedicine events/appointments and related information be stored in an EHR/EMR platform.
Telehealth Parity is utilized to describe laws that mandate that telehealth services be reimbursed at a rate that is the same or equivalent to in-person care.
Federal telemedicine laws tend to be very focused on either specific government health programs or a desire to impact a designated health crisis. As such, the majority of federal laws do not make broad changes to the entire US population. Recent legislation has been focused on:
Despite the limited scope of federal legislation, over 41 bills were introduced over the past 2 years. If passed, new legislation would expand Medicare reimbursement for the treatment of numerous health conditions via telehealth.
States are leading the way for telemedicine by drafting and passing “Telehealth Parity Laws”. These laws explicitly state that services provided through telemedicine are to be reimbursed at a rate that is equivalent to in-person care, provided the quality of care is equal. These laws are responsible for initiating reimbursement policies for virtual care within private insurers and Medicaid.
As of 2019, 34 states and Washington, DC have parity laws in place; however, the presence of a parity law does not mandate that all services are deemed equivalent to in-person care, nor are these laws equally applied to Medicaid and Private Insurers. For example, Connecticut has a parity law in place for private insurers; however, the law is significantly limiting for Medicaid, stating:
Connecticut Medicaid is required to cover telemedicine services for categories of health care that the commissioner determines are appropriate, cost-effective and likely to expand access.
Of those states that do not have parity laws, 4 have proposed parity bills within the House or Senate:
11 other states do not have parity laws and are not pursuing them:
Every insurance payer is different, with variances on what qualifies as a reimbursable telemedicine service. The following key factors can impact reimbursement eligibility and should be researched with credentialed insurance payers:
Delivering Care Across State Lines:
The #1 question pertaining to telemedicine is centered on delivery of care across state lines. We typically see this question for providers that want to continue serving under 3 scenarios:
The rule-of-thumb is to maintain licensing in the state where your patient resides; however, continuity of care will be the deciding factor for temporary travel or seasonal location changes. If the patient maintains a residence in the state where the medical provider is licensed, continuity of care will justify the continuation of care via telemedicine.
The Interstate Medical Licensure Compact does offer a pathway for qualified physicians to obtain licensure across multiple states. Various physician and practice restrictions may apply.
Over the last few years, state Medicaid programs have advanced coverage for telemedicine with 28 states providing reimbursement for medically necessary services at the same rate as in-person care:
20 States have limited coverage for telemedicine:
All state Medicaid programs reimburse for some form of telemedicine, but there are many states that still restrict the majority of telehealth services. To learn more about Medicaid telehealth reimbursement, visit our State Telemedicine Reimbursement Page.
Medicare telehealth reimbursement is greatly dependent upon federal legislation and the Center for Medicaid and Medicare (CMS) policies. In some cases, federal legislation will open reimbursement opportunities and, in other cases, CMS will proactively modify policies in their process of creating annual Physician Fee Schedules. The annual Physician Fee Schedule will be preceded by a proposed rule change that includes a comment period.
Medicare reimbursement has been traditionally utilized to solve for access challenges related to patients that receive care at a facility that is in:
The Health Resources and Services Administration (HRSA) determines HPSAs, and the Census Bureau determines MSAs. You can access HRSA’s Medicare Telehealth Payment Eligibility Analyzer to determine a potential originating site’s eligibility for Medicare telehealth payment.
Medicare requires the use of synchronous or interactive video conferencing in order for services to qualify for reimbursement, provided that the patient is at an eligible originating site. Asynchronous or Store & Forward technology is not permitted unless the provider is part of a telemedicine demonstration program in Hawaii or Alaska.
Originating Sites Authorized By Law:
The patient must be located in one of the following sites to meet Medicare’s requirement for reimbursement:
Medicare-Eligible Telemedicine Providers
The following practitioners are eligible to furnish telehealth services and receive payment from Medicare:
To access a full list of applicable Telehealth CPT & HCPCS codes, see CMS’s MLN Booklet on Telehealth Services.
Medicare continues to respond to the changes in federal law and population needs by creating individual initiatives that are not part of the core telemedicine program. Some examples include efforts to fight opioid addiction, a focus on improving outcomes in chronic care, and behavioral health.
Medicare launched Behavioral Health Integration initiatives in 2018 focusing on Primary Care settings, including FQHCs, Rural Health Centers. This program is designed to address mental health access by incentivizing Primary Care groups to incorporate behavioral health into their practices. Under General BHI and the Psychiatric Collaborative Care Model, Medicare removed geographic and originating site restrictions and is one of the most innovative behavioral health initiatives initiated by a payor. The VisuWell team created a detailed guide for this initiative that can be downloaded here.
Medicare additionally launched programs for Chronic Care Management. These initiatives are also directed towards Primary Care and remove geographic and originating site restrictions, opening up broad usage of telehealth along with reimbursement opportunities. Information related to Chronic Care Management can also be found in the VisuWell Guides to Medicare Reimbursement for Primary Care & FQHCs
For services furnished after July 1, 2019, Medicare will remove geographic limitations and allow the home to be an originating site. (See CMS Manual Pub 100-04 Page 4)
For Prolonged Preventative Service Codes HCPCS G0513 & GO514, effective January 1, 2019 patients in end-stage renal disease can use the home and renal dialysis facilities as originating sites. (See CMS Manual Pub 100-04 Page 5)
Telestroke | Effective January 1, 2019, any hospital, critical access hospital, or mobile stroke unit is eligible to serve as an originating site for acute stroke care; however, these sites are not eligible for originating site fee reimbursement unless they meet the pre-existing requirements for an originating site. G0 (G Zero), to be appended on claims for telehealth services related to acute stroke care.
Effective January 1, 2019, the home can serve as an originating site for a 5-10 minute brief technology-based check-ins for evaluation and management of established patients. (HCPS code G2012)
State telehealth laws, referenced at the top of this article, are the primary driver for telehealth reimbursement among private insurers. To garner specific information about private payer telemedicine reimbursement in your state, visit our State Telemedicine Reimbursement Page.