Coverage and Access 

Telehealth has significantly improved access to health care during the COVID-19 pandemic and will continue to be useful in years to come as more Americans receive greater broadband access, decreasing the digital divide. Under federal law, all health plans, including state, federal, and commercial plans, must provide coverage of telehealth services at a rate that is reasonable and does not discourage in-person care. Likewise, State laws should require coverage of and payment for telehealth services. Additionally, plans should not create barriers that limit access to telehealth, such as an annual or dollar maximum for telehealth services, nor implement cost-sharing requirements that favor telehealth over in-person visits. For example, in the recent 2023 NBPP, HHS noted that some insurers have begun to design plans that provide zero copays when a patient receives a virtual service but requires a copay for an in-person visit. This type of preferential copay structuring could result in patients not accessing in-person care when it is deemed medically necessary by a provider or preferred by the patient. Thus, health plans should be required to offer parity for both in-person and virtual health visits.

In-Person Requirement

Some state and federal laws require that patients be seen in person by health care providers before they can initiate treatment with telehealth. Others require or propose periodic in-person visits thereafter. The decision as to whether an in-person visit is necessary should be between the patient and the healthcare provider based on the needs of the patient. Imposing pre-requisites of an in-person visit first before accessing telehealth services may operate as a barrier for some and result in patients not seeking care at all. Similarly, requiring a telehealth visit as a prerequisite or substitute for an in-person visit may not be appropriate once the provider determines that an in-person visit is medically necessary. For example, in some cases, in-person visits may be medically necessary when providers need to physically examine their patients or conduct tests that cannot be done virtually. Therefore, health plans must provide coverage of and access to in-person treatment when deemed medically necessary by a provider or preferred by the patient.

Provider Type

Some state and federal laws limit the types of health care providers who can offer telehealth services. Prior to the COVID-19 public health emergency (PHE), only physicians and certain other practitioners, such as physician assistants, clinical social workers, and clinical psychologists, were eligible to receive Medicare payment for telehealth services. For example, in states like Pennsylvania, only physicians, certified nurse midwives, and select mental health facilities could provide telehealth services. Additionally, federally qualified health centers (FQHCs) and rural health centers (RHCs) were often excluded from providing telehealth services. During the PHE, federal and state regulatory flexibilities expanded the list of providers who could offer and receive payment for telehealth services, including FQHCs and RHCs, significantly increasing patient access. These regulatory flexibilities must be made permanent.

Originating Site  

Health plans have traditionally limited the location of where the patient may be physically present when receiving telehealth services (i.e., originating site). For example, the Centers for Medicare and Medicaid Services (CMS) had previously only authorized physician or practitioner offices, hospitals, critical access hospitals, RHCs, FQHCs, and skilled nursing facilities, among others, as originating sites. Thus, a patient’s home was often excluded from this list thereby limiting the groups of individuals who could benefit from telehealth services.

Many patients find utility in telehealth because they may have difficulties traveling to a provider’s office. Difficulties traveling to the provider’s office may result from a lack transportation, an inability to take time off work, childcare challenges, a compromised immune system, or other mobility challenges. In addition, some patients may experience symptoms of their disease such as light and noise sensitivity or nausea, which would make driving unsafe or inconvenient. For these patients, originating site requirements present the same barrier as in-person visits. As such, originating site locations should be eliminated. Instead, patients should be permitted to select their originating site, whether that be their house, school, community health center, homeless shelter, or other location of their choosing, unless they need a particular service or equipment that they can only receive at a particular location.

Geographic Location 

Some health plans implement certain geographic limitations on telehealth, only allowing full coverage for patients located in rural areas. Many health plans have adopted this approach because, prior to the pandemic, the Medicare program required that telehealth services be provided outside of federally-designated metropolitan areas and within rural areas experiencing a health care professional shortage. However, this policy fails to recognize that many patients need access to telehealth regardless of their geographic location and telehealth may help reduce health disparities in urban areas. Therefore, geographic limitations should be removed.

Interstate Compacts 

Many states require that a provider must adhere to licensing rules and regulations of the state in which the patient is located. However, in rural areas or other areas in which there may be a provider shortage, patients may seek providers in other states. Some states have provider exceptions that allow for cross-state delivery of health care in limited circumstances, whereas others ban it altogether. Laws and regulations must be expanded to allow for interstate compacts – agreements between two or more states – including expediting the licensing process or allowing members to practice under a single multistate license to make it easier for health care providers to practice telehealth in multiple states.

Audio-only 

Prior to the pandemic, many health plans, including Medicare, only paid providers for telehealth services offered via audio/visual technology (and not audio only). During the pandemic, federal and state governments eased restrictions on audio-only technology. While this was an important change to ensure patients without access to broadband or video technology still received the care they needed, some health care providers noted that audio/visual visits allow providers to offer a more complete and thorough examination since they can see the patient and assess visual cues.

As such, audio-only visits should be limited to public health emergencies; reserved for those patients with disabilities where an audio-visual visit would be too difficult to undergo; or reserved for cases in which a patient would not otherwise receive care without an audio-only option. In addition, if health plans choose to allow audio-only visits, then they must be accompanied by in-person visits at regular intervals to ensure a complete and through examination of the individual. 

Congress must also continue to expand broadband infrastructure so that it is available to those in areas that currently lack access to broadband and video technology. In 2021, Congress passed the Infrastructure Investment and Jobs Act, which includes a $65 billion investment in broadband infrastructure that will help provide access to telehealth for those who currently lack access to broadband and video technology. We support the expansion of the broadband infrastructure to help close the digital divide that impairs health equity.

Health Disparities  

Telehealth services can improve access to care and reduce health disparities. For instance, Black, Indigenous, and Hispanic patients are more likely to experience transportation barriers in accessing care. In addition, patients with mobility disabilities may also experience barriers in accessing care that can be improved by the availability of remote visits. Improving access to telehealth services could not only mitigate transportation barriers, but also address the impact of lost wages and childcare costs on low-income communities, thereby increasing their ability to access and afford health care.

Telehealth also requires patients to have access to internet, technology, and digital literacy skills. Those without access to these services and skills risk an increase in health disparities. The technological divide disproportionately impacts Black and Hispanic patients, elderly patients, rural populations, patients with disabilities, and patients with limited English proficiency. Thus, increasing access to telehealth must be simultaneously implemented with increased efforts to bridge the digital divide and ensure diverse and minority communities have equal access to technology, digital literacy, and telehealth services.