To encourage patients with nonurgent health issues to stay home to slow the spread of COVID-19, private insurance companies as well as the Centers for Medicare & Medicaid Services (CMS) have temporarily relaxed their rules for telehealth coverage. Right now, more patients have access to video visits than ever before, and in many cases, this virtual care is free.
But the specific rules depend on which insurance plan you have, so it can be tricky to figure out which tele-services are covered and how much you’ll end up paying to see a doctor on your laptop screen. It’s also still unclear exactly how the current coverage rules will change once we’re past the worst of the pandemic.
Either way, video visits are becoming the norm for many patients, so it’s important to stay on top of how they’re being covered. “We crossed a threshold,” says Shawn Martin, senior vice president and CEO designee at the American Academy of Family Physicians. “Acceptance of telehealth as a service is going to be richer.”
Martin says most new rules surrounding telehealth are likely a short-term strategy, with regulations remaining loosened through the end of the 2020 calendar year. “It depends on how we ebb and flow through outbreaks into 2021,” he says. “I don’t think the rules stay where they are today, but I do think we see telemedicine more broadly used.”
Currently there’s no set standard for private health insurance when it comes to covering telehealth services during the pandemic. But many if not most insurance companies are urging patients to use telehealth whenever possible — and they’ve improved coverage for telehealth services in order to make virtual care widely accessible.
Government support has played a role in expanding telehealth coverage, even for privately insured patients. At the federal level, the Department of Health and Human Services waived certain rules regarding telehealth visits, such as the requirement that healthcare providers use HIPAA-compliant video-conferencing platforms. As a result, providers are allowed to use FaceTime, Zoom, Skype and other consumer platforms to conduct video visits. Some states created their own pro-telehealth policies. New York, for example, mandated that all state-regulated health plans cover telehealth.
So how does this expanded telehealth coverage affect cost? When a doctor’s visit is “covered,” that means you aren’t responsible for the full cost of care. But it doesn’t mean the visit is entirely free. You may still owe something — a copay, for instance. For the time being, some insurers are covering telehealth visits just like regular in-person office visits — you’d pay whatever your normal office co-pay is. Other health insurance companies have gone a step further, temporarily waiving all fees for any type of telehealth visit.
Aetna, for example, is currently offering zero co-pay video visits for any reason and reimbursing all providers for telemedicine at the same rate as in-person visits. I.e., video visits are free for patients.
All 36 independent and locally operated Blue Cross and Blue Shield companies are also waiving cost sharing for telehealth services through early summer for members who are fully insured. Blue Cross Blue Shield of Massachusetts says it’s processed 180,000 telehealth claims since changing its policy, with March telehealth claims 3,600 percent higher than February’s and 5,100 percent higher than the monthly average for 2019.
Anthem is also waiving cost-sharing for telehealth visits through June 14, including visits for mental healthcare and for select physical, occupational and speech therapies. That applies to members of Anthem’s employer-sponsored, individual and Medicare Advantage plans, and where permissible, Medicaid plans. Visits are covered whether a patient uses Anthem’s telemedicine platform or a different one. Anthem is also covering phone-only visits with in-network providers.
With Anthem, as with other private insurance companies, members’ employers can choose to opt out of the decision to waive cost sharing. In that case, even if your health insurance company has announced zero co-pays for telemedicine appointments right now, you would still be responsible for a co-pay.
In any case, if you’re billed by insurance for a telehealth visit, it’s worth calling your insurance company to ask about the charge. Your employer may have chosen not to waive costs, or your insurance company could have accidentally billed you by mistake.
If you have a private health plan, visit AHIP’s extensive database of policy responses to COVID-19 for more details from your health insurance provider.
Medicare and Medicaid
Before COVID-19, most Medicare patients who had telehealth visits were in rural settings. Patients could have a telemedicine appointment with a doctor they had a prior relationship with, and the virtual visit had to take place inside a healthcare facility. It was a way for isolated patients to connect with specialists.
“Medicare viewed telemedicine as a geographically limiting product,” Martin says. “It was never viewed as part of a comprehensive care plan.”
But in March, to help keep healthy patients from being exposed to COVID-19, CMS temporarily broadened access to Medicare telehealth services. Now and at least through the end of the pandemic, patients with Medicare can have a telemedicine appointment covered with any provider, even a doctor they’re seeing for the first time and out-of-state doctors, and they can do it from their home using a variety of platforms.
“COVID-19 has dragged Medicare kicking and screaming into the 21st century,” says Danielle Roberts, a Medicare expert and cofounder of Boomer Benefits.
In 2019, Medicare tweaked its rules to cover virtual check-ins, or e-visits, which entailed short, five-minute talks that addressed topics like medications refills. But patients couldn’t get a diagnosis during the check-in. “Now people can FaceTime from home,” Roberts says.
If you have Medicare, your telehealth visit will be covered just like an in-person office visit. You’ll pay a co-pay equal to that of what you’d pay if you were seeing your doctor in person. Some Medicare patients might not have a fee at all. That would be the case if your doctor decides to waive the co-pay she’s allowed to collect.
Doctors can choose to do that, says Roberts. “But I think a lot of doctors are considering their business down the road right now,” she adds, “and they may be very happy to be able to bill telehealth appointments just like an in-person visit.”
If you have Medicare and you’re asked for a co-pay, it can’t hurt to ask your doctor to waive the fee since so many private insurance companies are currently doing so.
One nuance with Medicare is that it isn’t currently covering telemedicine appointments for therapy services, including physical, speech and occupational therapy. A patient who needs speech therapy after a stroke, for example, can’t have a virtual visit covered.
“That’s a type of appointment you could have via telehealth,” Roberts says. “The patient is risking going out and potentially exposing themself to the coronavirus just to get that therapy.”
Recently, lawmakers have urged CMS to change this rule, expanding coverage of telehealth services to therapy services as well.
Medicaid is more complicated because it’s administered by states. Most states are waiving Medicaid requirements in light of the pandemic and allowing telehealth, according to the California-based Center for Connected Health Policy. Some have also eased rules to let patients access telemental health services from home.
In Massachusetts, for example, the Department of Public Health ordered all commercial insurers, self-insured plans and state health plans to cover clinically appropriate telehealth services at the same rate as in-person care.
“There’s a great deal of leniency toward the use of telehealth and Medicaid, but not anywhere as near as universal as with Medicare or private insurance,” Martin says. “With Medicaid, you have a very different population.”
If you’re a Medicaid recipient, here’s an interactive overview of state-by-state telehealth coverage.
As the pandemic eases, zero co-pays for telehealth visits will almost certainly go away. What’s yet to be seen is whether private insurance and the government will keep some of the flexibility they’ve extended for virtual visits.
“I would love it if Medicare would take some time to review how this went during the pandemic, and then maybe say, ‘Let’s go ahead and leave it,’” Roberts says. “Or maybe it won’t go well, and they won’t want to extend it.”
Insurers and the government don’t necessarily lose money by making telehealth more prevalent. Virtual visits are less expensive than those at brick-and-mortar care settings, Martin points out. Although, telehealth may not always lead to lower overall healthcare costs. One 2017 study from the RAND corporation suggested that, in some cases, patients who seek out virtual care are more likely to get follow-up care for the same issue than patients who initially see doctors in person.
Regardless, Martin anticipates a “pretty significant loosening on the Medicare service side” with telehealth as the coronavirus pandemic eases, though it’s still unclear exactly how it plays out. “We’ll definitely see a greater utilization of telemedicine with physicians of all types,” he says. “But right now, it’s an open book on how telehealth is best utilized.”