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Telemedicine Reimbursement: A Guide to Payment Parity and Covered Services

Telemedicine Reimbursement: A Guide to Payment Parity and Covered Services

Every day, as new developments around COVID-19’s impact continue to be discovered, policymakers have rolled back once strict telemedicine regulations in an effort to expand access to healthcare services, while promoting social and medical distancing.

With the new changes, understanding the intricacies of telemedicine reimbursement has become even more complicated, though they are considered more favorable to providers. Below, we’ve outlined federal and state reimbursement policies for telemedicine services, provider updates from health insurance companies, and guides to billing for telemedicine visits, including those that are Medicare-specific.

We’ll continue to update this telemedicine reimbursement resource as new information is released. 

Will I get reimbursed for telemedicine?

Amidst the COVID-19 outbreak, legislation has helped remove barriers to telemedicine, supporting unprecedented adoption and reimbursement. The lift on restrictions brings new federal and state telemedicine reimbursement regulations, and to help navigate the inherent complexities, we’ve compiled the best resources on eligible services as well as billing and coding.

Does health insurance cover telemedicine?

Health insurers were quick to adapt telemedicine policies for COVID-19 coverage and cost-share eligibility, and policies and deadlines are continuing to evolve still. Your contract and insurance partners are always the best resources for telemedicine billing guidelines, but as a start, we’ve outlined notable policy changes for four of the largest insurers:

Does Medicare or Medicaid cover telemedicine?

The COVID-19 pandemic has disrupted strict guidelines on virtual access to care, expanding telemedicine coverage under Medicare and Medicaid — from eligibility to reimbursement amount. Below, you’ll find access to coverage overviews, coding guidelines, telehealth toolkits, and more.

Federal Telemedicine Laws & Reimbursement

Which telemedicine services are eligible for reimbursement?

With the passage of the Coronavirus Preparedness and Response Supplemental Appropriations Act and the CARES Act, Medicare has expanded the list of eligible services that can be provided via telehealth. Some of the lifted restrictions include patient location, provider type, provider location, modality used to conduct telemedicine visit, services eligible for reimbursement, and, most notably, the amount of reimbursement. These and many other policies that once proved insurmountable barriers have been revised, allowing for widespread telemedicine adoption.

The list of expanded codes is available on the CMS website.

Medicare telehealth FAQs

Naturally, providers have questions around telemedicine regulations and, specifically, reimbursements. Answers to the most frequently asked questions, as outlined by CMS, can be found on their website.

Medicare telemedicine coverage guidance

Due to the COVID-19 pandemic, CMS has encouraged states to consider offering telemedicine services as a way of increasing access to care, while reducing the risk of spreading COVID-19. Medicaid providers using telemedicine to treat patients have different policy options regarding reimbursement for these services. The CMS has provided guidelines for understanding these options.

Medicare telemedicine coding

CMS has outlined medicare telehealth coding guidelines in a fact sheet on their website. For quick reference, the table below summarizes the coding guidelines for telemedicine reimbursement.

Medicaid & CHIP Telehealth Toolkit

CMS developed a toolkit to help states more quickly adopt telemedicine coverage policies in the Medicaid and Children’s Health Insurance Programs (CHIP) during COVID-19.

This toolkit includes descriptions of each of these areas and the challenges they present:

  • Patient populations eligible for telehealth
  • Coverage and reimbursement policies
  • Providers and practitioners eligible to provider telehealth
  • Technology requirements
  • Pediatric considerations
  • This toolkit also includes a compilation of frequently asked questions (FAQs) and other resources available to states.

Access the Medicaid & CHIP Telehealth Toolkit Checklist for states

Medicaid fee-for-service telehealth overview

  • States are encouraged to facilitate clinically appropriate care within the Medicaid program using telehealth technology to deliver services covered under the State plan.
  • States have a great deal of flexibility with respect to covering Medicaid services provided via telehealth.
  • States are not required to submit a State plan amendment (SPA) to pay for telehealth services if payments for services furnished via telehealth are made in the same manner as when the service is furnished in a face-to-face setting.
  • A state would need an approved State plan payment methodology (and thus, might need to submit a SPA) to establish rates or payment methodologies for telehealth services that differ from those applicable for the same services furnished in a face-to-face setting.
  • States may pay a qualified physician or other licensed practitioner at the distant site (the billing provider) and the state’s payment methodology may include costs associated with the time and resources spent facilitating care at the originating site. The billing provider may distribute the payment to the distant and originating sites.
  • Medicaid guidelines require all providers to practice within the scope of their State Practice Act. States should follow their state plan regarding payment to qualified Medicaid providers for telehealth services.
  • States may also pay for appropriate ancillary costs, such as technical support, transmission charges, and equipment necessary for the delivery of telehealth services.
  • A state would need an approved State plan payment methodology that specifies the ancillary costs and circumstances when those costs are payable.
  • Ancillary costs associated with the originating site for telehealth may be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state when a Medicaid service is delivered. The ancillary costs must be directly related to a covered Medicaid service provided via telehealth and properly allocated to the Medicaid program.
  • States are encouraged to reach out to their state lead as soon as possible if they are interested in submitting a state plan amendment.

CMS physician and practitioner guidance

As a response to the COVID-19 public health emergency, many regulations around telemedicine were granted temporary waivers and providers were given new rules to allow for more flexible healthcare delivery. These regulatory waivers, as set forth by the Trump Administration, have several goals, including to:

  1. Expand the healthcare system workforce by removing barriers for physicians, nurses, and other clinicians to be readily hired from the community or from other states.
  2. Ensure that local hospitals and health systems have the capacity to handle a potential surge of COVID-19 patients through temporary expansion sites (also known as CMS Hospital Without Walls).
  3. Increase access to telehealth in Medicare to ensure patients have access to physicians and other clinicians while keeping patients safe at home.
  4. Expand in-place testing to allow for more testing at home or in community based settings.
  5. Put Patients Over Paperwork to give temporary relief from many paperwork, reporting and audit requirements so providers, health care facilities, Medicare Advantage and Part D plans, and States can focus on providing needed care to Medicare and Medicaid beneficiaries affected by COVID-19.

Some of the changes made to accelerate telemedicine adoption to address COVID-19 include https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf. See a full list of regulatory changes on CMS.gov.

State Telemedicine Laws & Reimbursement

Nearly every state has passed laws to remove barriers to telemedicine utilization during the COVID-19 pandemic. While some states, such as California and Maryland, have introduced many newly flexible regulations to offering and being reimbursed for telemedicine visits, other states have kept their initiatives light in comparison. The Center for Connected Health Policy is the best resource for state-by-state billing and coding, as well as state-by-state actions related to COVID-19.

Health Insurance Updates for COVID-19 & Telemedicine

Health insurers responded quickly to the initial COVID-19 outbreak, and their policies of what will and will not be covered (or what will be cost-shared) continue to rapidly evolve. America’s Health Insurance Providers (AHIP) has detailed changes insurers have made regarding coverage for COVID-19 related expenses—a useful tool. Below, we’ve included details on several large insurers’ responses to COVID-19, but it’s always best to refer back to your contract to determine what language exists around how telemedicine should be billed. From there, you can reach out to your insurance partners to learn their policy for telemedicine billing and best practices.

Aetna

Aetna’s response to COVID-19 has been focused on ensuring coverage for all members, as well as reimbursement parity for providers. They have updated their telemedicine policies around both patient and provider usage and payment. In addition to providing several options for mental health and well-being services to front-line healthcare workers, CVS Health employees, seniors, and others affected by COVID-19, Aetna sends care packages to members and employees diagnosed with COVID-19.

Some notable changes to Aetna’s telemedicine policies include:

  • Waiving co-pays for all diagnostic testing. That includes all member costs associated with diagnostic testing for Commercial, Medicare, and Medicaid lines of business. Self-insured plan sponsors will be able to opt-out of the program at their discretion.
  • Offering zero co-pay telemedicine visits for any reason.
  • Extending its Medicare Advantage virtual evaluation and monitoring visit benefit to all fully insured members.
  • Waiving member cost-sharing for inpatient admissions at all in-network facilities for treatment of COVID-19 or health complications associated with COVID-19. This policy applies to all Aetna-insured commercial plan sponsors and is effective immediately for any such admission through September 30, 2020.
  • Extension of no-cost benefit to behavioral health services provided via telemedicine.
  • Instituting rate parity for face-to-face and telemedicine visits. In- or out-of-network benefit levels will apply, depending on the provider’s network participation status.

Aetna providers can find additional resources here.

Blue Cross Blue Shield

With a network of 36 independent and locally operated Blue Cross Blue Shield (BCBS) companies, Blue Cross Blue Shield Association has continued to build on its commitment to safe, quick, and easy access to care amidst the COVID-19 outbreak. Applicable to fully-insured, individual, and Medicare members, BCBS companies expanded coverage for services to include:

  • Waiving prior authorizations for diagnostic tests and covered services for members diagnosed with COVID-19.
  • Covering diagnostic tests at no cost share to members.
  • Waiving prescription refill limits on maintenance medications.
  • Expanding access to telehealth and nurse/provider hotlines.
  • Waiving cost-sharing for telehealth services for fully-insured members, applicable to in-network telehealth providers, through June 19, 2020.

Blue Cross Blue Shield Association is also continuing to work with state Medicaid and CHIP agencies to ensure access to necessary care. Coverage may vary, so be sure to check with your local BCBS company for complete information on services.

Cigna

Cigna has expressed its commitment to protecting both providers and communities through high-quality, accessible patient care, now more than ever. Effective March 17, 2020 through at least July 31, 2020, Cigna expanded telehealth requirements to better support care continuity. Cigna’s response to COVID-19 includes covering the cost of coronavirus testing, waiving all copays or cost-shares for fully insured plans, and waiving customers’ out-of-pocket costs for COVID-19 testing-related visits with in-network providers, as well as the following:

  • Covering the cost of coronavirus testing.
  • Waiving all co-pays or cost-shares for fully insured plans, including employer-provided coverage, Medicare Advantage, Medicaid, and individual market plans available through the Affordable Care Act. Organizations that offer Administrative Services Only (ASO) plans will also have the option to include coronavirus testing as a preventive benefit.
  • Recognizing that health outbreaks can increase feelings of stress, anxiety and sleeplessness, and sometimes loss, Cigna is staffing a 24-hour toll-free telephone help line to connect customers and caregivers directly with qualified clinicians who can provide support and guidance on coping and resilience.
  • Waiving customers’ out-of-pocket costs for COVID-19 testing-related visits with in-network providers, whether at a doctor’s office, urgent care clinic, emergency room or via telehealth. This includes customers in the United States who are covered under Cigna employer/union sponsored group insurance plans, globally mobile plans, Medicare Advantage, Medicaid, and the Individual and Family plans. Employers and other entities that sponsor self-insured plans administered by Cigna will be given the opportunity to adopt a similar coverage policy.
  • Making it easier for customers with immunosuppression, chronic conditions or who are experiencing transportation challenges to be treated virtually by in-network physicians with those capabilities.
  • Cigna’s Express Scripts Pharmacy offers free home delivery of up to 90-day supplies of prescription maintenance medications. Cigna has opened a 24-hour toll-free help line (1-866-912-1687) to connect people directly with qualified clinicians who can provide support and guidance.
  • Offering a webinar to the general public raising awareness about tools and techniques for stress management and building resilience, along with the ability to join telephonic mindfulness sessions.
  • Waiving prior authorizations for the transfer of its non-COVID-19 customers from acute inpatient hospitals to in-network long-term acute care hospitals to help manage the demands of increasingly high volumes of COVID-19 patients.
  • Waiving customer cost-sharing and co-payments for COVID-19 treatment through. The policy applies to customers in the U.S. who are covered under Cigna’s employer/union sponsored insured group health plans, insured plans for U.S. based globally mobile individuals, Medicare Advantage, and Individual and Family Plans. Cigna will also administer the waiver to self-insured group health plans.
  • For individual providers and outpatient clinics: Telehealth may be used for outpatient therapy, applied behavior analysis (ABA), medication management, and Employee Assistance Program (EAP) services.
  • For facilities: Some or all services may be provided via virtual video or telephone sessions.

Specific billing guidance for individual providers and outpatients clinics as well as facilities are outlined and continue to be updated here.

UnitedHealthcare

UnitedHealthcare has laid out its new policies surrounding telemedicine coverage and reimbursement. The UnitedHealthcare website recommends that providers keep up to date with which temporary telemedicine measures are expiring and which are being extended through their COVID-19 Date Provision Guide. One important action taken by UnitedHealthcare was opening a special enrollment period for some of its existing commercial customers, beginning March 23 through April 13 due to the COVID-19 pandemic. There have been no new updates since the April 13 extension date passed.

Some other measures encouraging telemedicine adoption that have been announced by UnitedHealthcare include:

  • Waiving costs for COVID-19 testing provided at approved locations in accordance with the CDC guidelines.
  • Waiving copays, coinsurance and deductibles for visits associated with COVID-19 testing, whether the care is received in a physician’s office, an urgent care center or an emergency department. This coverage applies to Medicare Advantage and Medicaid members as well as commercial members.
  • Expanding provider telehealth access and waiving member cost sharing for COVID-19 testing-related visits.
  • UnitedHealthcare also suspended prior authorization requirements to a post-acute care setting and when a member transfers to a new provider, both of which May 31, 2020.
  • Waiving member cost sharing for the treatment of COVID-19 through September 30, 2020 for its fully insured commercial, Medicare Advantage, and Medicaid plans.
  • Starting March 31, 2020 until June 18, 2020, UnitedHealthcare will also waive cost sharing for in-network, non-COVID-19 telehealth visits for its Medicare Advantage and Medicaid fully insured members.

How to bill for telemedicine visits?

The American Medical Association (AMA) is maintaining an up-to-date coding guide advising COVID-19 billing best practices. Outlining advice for 26 different scenarios, the AMA’s guide accounts for whether or not the patient needs to be tested, where the patient is directed for COVID-19 testing, as well as telehealth billing for non-COVID-19 related virtual visits and more.

How to bill for Medicare telemedicine visits

With broadened access to Medicare telehealth services following President Trump’s emergency declaration, three types of virtual services are now eligible for Medicare patients:

  1. Telehealth visits: Leveraging real-time audio and video communications and limiting patient travel as much as possible, patients can receive virtual care for office, hospital visits, and other services that typically occur in-person.
  2. Virtual check-ins: Defined as “brief communication technology-based service,” established Medicare patients are able to exchange information with providers from their homes via telephone, video, or image to avoid unnecessary in-person visits.
  3. E-visits: For patient-initiated communication with providers, established Medicare patients can have non-face-to-face interaction with their doctors through online portals from their home or anywhere.

To help healthcare providers with reimbursement processes for these Medicare telemedicine services, the CMS has put together a quick guide summarizing relevant billing codes:

Service Description HCPCS/CPT Code Patient Relationship
Medicare Telehealth visits A visit with a provider that uses telecommunication systems between a provider and a patient. Commong Telehealth services include:
  • 99201-99215 (Office or other outpatient visits)
  • G0425-G0427 (Telehealth consultation, emergency department or initial inpatient)
  • G0406-G0408 (Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs)
Complete list here
For new patients or established patients
Virtual check-ins A brief (5-10 min) check-in with your practitioner via telephone or other telecommunications device to describe whether an office visit or other service is needed. A remote evaluation of recorded video and/or images submitted by an established patient.
  • HCPCS code: G2012
  • HCPCS code: G2010
For established patients
eVisits A communication between a patient and their provider through an online patient portal.
  • 99421
  • 99422
  • 99423
  • G2061
  • G2062
  • G2063
For established patients

Policy changes and deadline extensions surrounding telemedicine reimbursement and services are constantly changing as healthcare professionals and communities continue grappling with COVID-19. As new information becomes available, we will update this resource guide to help keep you easily informed and focused on what you do best: caring for your patients.

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