Editor’s Note: As the demand for telemedicine services continues to grow, states are implementing new policies related to the payment for, and provision of, care via telemedicine modalities for all patients. State Medicaid programs, other payers and health systems across the country are increasingly relying on telemedicine technologies to address healthcare challenges, such as provider shortages, system capacity and access to care. In a new article for Inside Medical Liability, summarized below, Manatt Health reviews the changing landscape of state telemedicine laws and policies.
Information in the article is based on Manatt Health’s survey across 50 states and Washington, DC, of state laws and Medicaid policies related to practice standards and licensure; Medicaid coverage and reimbursement; Medicaid-eligible patient settings; Medicaid-eligible provider settings; Medicaid-eligible technologies; Medicaid service limitations; and corporate practice of medicine.1
Manatt’s survey reveals that nearly all state Medicaid fee-for-service (FFS) programs provide reimbursement for some telemedicine services, generally expanding access to telemedicine for their Medicaid FFS beneficiaries. The survey also highlights that Medicaid FFS programs provide significantly more expansive coverage than what is available to Medicare beneficiaries. At this time,2 Medicare FFS provides telehealth coverage only for a very limited set of services that meet strict requirements related to the technology utilized, the originating site and the provider type.
In contrast, state Medicaid FFS programs offer comprehensive coverage of telemedicine, allowing a broad range of services, providers, locations and technologies that are eligible for reimbursement. Most states allow various types of providers to administer care via telemedicine, and few impose impactful restrictions on the types of services that can be provided through these modalities.
Key Barriers and Implications
Despite this notable progress, major barriers still exist in some states to the provision of telemedicine services for Medicaid FFS beneficiaries: (See Table 1 for definitions of key terms used in this section.)
- Patient’s home as a site of care. Twenty-six states’ Medicaid programs provide reimbursement for telemedicine services initiated from a patient’s home. This helps patients who are in rural areas or who have mobility limitations connect with their providers without undue burden, and also helps health systems increase clinic capacity by conducting routine visits via live video conferencing.
- Established patient relationship. Nine states require a provider to have an established relationship with a patient before she or he can receive care via telemedicine, as a condition of reimbursement. Established patient relationship requirements limit a patient’s ability to seek care via telemedicine for emergent issues.
- Telepresenter. As a condition for reimbursement, ten states’ Medicaid programs require a medical assistant or provider, often referred to as a telepresenter, to be physically present with a patient while she or he receives care from a distant-site provider. This requirement imposes a major obstacle for patients, as their telemedicine visit is subject to a telepresenter’s availability and location. It also creates staffing inefficiencies for providers and health systems, since, to meet the telepresenter requirement, a medical assistant or provider must oversee a telemedicine visit rather than directly provide care to another patient who is on-site.
- Beyond live video conferencing. Nearly all state Medicaid programs provide coverage and reimbursement for live video conferencing, but fewer states reimburse for other telemedicine technologies, such as store and forward, remote patient monitoring, or e-mail/fax/phone. Twenty-nine states are reimbursing for at least one method in addition to live video, and 16 states are reimbursing for three of the four different telemedicine technologies.
- Frequency limits. Nine states place limits on the frequency with which Medicaid patients can receive care via telemedicine within a given time frame. Frequency limits can place unnecessary barriers to care for patients with chronic conditions who may be located remotely from their providers or are frail.
- Geographic limits. Nine states’ Medicaid programs place geographic restrictions on telemedicine encounters. In these states, reimbursement within the Medicaid program is dependent upon the distance between the patient or originating site provider (spoke site) and the remote provider (hub site). For example, in Indiana, the state reimburses for telemedicine services only when the hub and spoke sites are greater than 20 miles apart.
States may implement restrictive policies for a variety of reasons—fear of overutilization leading to skyrocketing costs, new technology and risk. There is little evidence to date that validates those concerns. Conversely, health systems have indicated that telemedicine programs are delivering positive benefits, including increased clinic and in-patient capacity, reduced hospital readmissions, and improved patient satisfaction and quality of care.
Telemedicine will be central to the role of healthcare delivery in the future. Manatt predicts that over time, all payers will re-evaluate their telemedicine reimbursement policies and take proactive steps to reduce barriers to care and expand access to digitally enabled care.
Key Terms and Definitions
|Live Video Conferencing
||Two-way, interactive audio-video conferencing between a patient at an originating site and a provider at a distant site.
|Store and Forward
||The electronic transmission of medical images, records or prerecorded videos through secure email transmission.
|Remote Patient Monitoring
||The ongoing collection and transmission of health data, from a patient in one location to a provider in a different location.
|Hub Site/Remote Provider Site
||Where the provider who is delivering care via a telemedicine modality is located.
|Spoke Site/Originating Site
||Where the patient or provider requesting telemedicine services from a remote provider is located.
1Unless otherwise noted, the scope of this survey and the findings included in this article are limited to Medicaid fee-for-service. This is a known limitation given that many states are transitioning large portions of their Medicaid populations into managed care plans.
2The Proposed Rule Medicare Program: Revisions to Payment Policies Under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B, released on July 12, 2018, if adopted, substantially expands the reimbursement for certain technology-based services that fall outside of the statutory definition of telehealth.