State Policy Options to Encourage Greater Use of Telehealth in State-Regulated Health Plans
JoAnn Volk and Sabrina Corlette, Georgetown University Center on Health Insurance Reforms
Telemedicine has long been understood as a critical tool for reaching patients in underserved communities, including rural areas, and to improve access to services such as primary care and behavioral health. The COVID-19 pandemic has brought renewed and urgent interest in using telehealth to enable remote access to care across service areas and provider types. In response to the pandemic, federal and state policymakers are encouraging broader use of telehealth services, in order to decrease the need for in-person visits. At the federal level, legislation responding to the COVID-19 crisis includes provisions intended to facilitate the use of telehealth services. Recent guidance from the Centers on Medicare & Medicaid Services (CMS) makes it easier for plans to expand the use of telehealth. States can go further to eliminate barriers to broader use of telehealth in state-regulated health insurance. This expert perspective summarizes the federal legislation and guidance and discusses actions state departments of insurance can take to encourage greater access to telehealth services.
On March 24, CMS issued a set of Frequently Asked Questions regarding ways issuers and health plans can promote the use of telehealth. That guidance says:
- The HHS Office for Civil Rights is waiving certain regulatory requirements under HIPAA to encourage providers to offer telehealth, although CMS encourages providers to continue protecting patient privacy “to the maximum extent possible.”
- CMS will not take enforcement action against issuers that amend catastrophic plans to provide pre-deductible coverage for telehealth, even if the services are not related to COVID-19.
- CMS will waive the prohibition on issuers and group health plans making mid-year changes to their plans to provide for greater coverage, or to lower or eliminate cost-sharing for telehealth services, regardless of whether those services are COVID-19 related or not. CMS notes, however, that it will continue to enforce against any issuer that attempts to limit or eliminate other benefits to offset the costs of increasing coverage of telehealth services. States are encouraged to take a similar approach.
The Families First Coronavirus Responsibility Act, enacted March 18, requires issuers and group health plans to cover COVID-19 tests, including services required to determine the need for a test, without cost-sharing, regardless of whether the services are provided in-person or by telehealth (a full summary of the coverage provisions in the bill is available here). The Coronavirus Aid, Relief, and Economic Security (CARES) Act, enacted March 27, creates a safe harbor for HSA-eligible high-deductible health plans to cover telehealth services pre-deductible without jeopardizing the tax status of contributions to the HSA. The safe harbor applies to plans beginning on or before 12/31/21 (a full summary of the coverage provisions of the CARES Act is available here).
State Policy Options
States have options to encourage broader use of telehealth services by reducing barriers for plan enrollees to use those services and for providers to offer care through telehealth. These include:
Limit or Eliminate Cost-Sharing for Enrollees. States can require issuers to cover telemedicine visits with cost-sharing that is no greater than cost-sharing that applies to in-person visits, as the District of Columbia has done. States could go further to require issuers to cover telemedicine visits with cost-sharing that is lower than services provided in-person, as Arizona has, or to cover telehealth visits without any cost-sharing (Massachusetts, New Mexico and New York take this approach; California regulators encourage, though don’t require, health plans to waive cost-sharing).
Expedite or Eliminate Prior Authorization. States can encourage or require issuers to expedite their review or relax requirements regarding prior authorization (California). States can also prohibit issuers from requiring prior authorization prior to obtaining services via telemedicine (Massachusetts).
Eliminate Requirements That Would Limit the Use of Telehealth. States can encourage or require issuers to eliminate any requirements that would limit to the use of telehealth. That may be a general requirement to treat telehealth and in-person visits equally, with no limitations on telehealth services that do not also apply to in-person care (New Mexico and New York). States can also enumerate specific conditions that should be waived, such as limiting the device or platform used to deliver telehealth care; requiring that the provider or patient have a prior relationship, or that the telehealth visit be provider-to-provider; requiring greater documentation for claims submissions; or limiting coverage to in-network providers (See e.g., Massachusetts, Louisiana, and Texas).
Provider Reimbursement Cannot be Lower. States can also require issuers to reimburse providers for telehealth visits at a level no lower than the rate that applies for in-person services (see Massachusetts, New Mexico and Texas).
States may want to take additional steps to encourage the broader use of telehealth, such as:
Addressing Provider Licensing, Credentialing, and Malpractice Issues: Federal guidance encourages states to consider whether state licensing laws could be relaxed to enable more in-state and out-of-state providers to offer telehealth services during the public health emergency. For example, Mississippi is allowing out-of-state providers to deliver telehealth services without a state license, so long as they have a prior relationship with the patient. Departments of Insurance can complement such directives by requiring or asking issuers to relax credentialing requirements (see, e.g., Vermont). Malpractice concerns may also warrant guidance. For example, Wisconsin regulators have asked medical malpractice insurers to provide coverage for telemedicine under the same terms for providers as if they were providing services in-person.
Coding Complaints to Capture Telehealth Issues: In order to monitor compliance with guidance encouraging greater use of telehealth services, regulators should code complaints to capture problems with obtaining coverage of telehealth services, whether for enrollees or providers. New Mexico regulators have issued guidance urging issuers to take proactive measures to encourage use of telehealth. However, after receiving calls from providers and consumers reporting problems with coverage of telehealth, regulators issued additional guidance reminding issuers of their obligations under the state’s telehealth parity law and the Mental Health Parity and Addiction Equity Act.
Collect Data to Inform and Support Post-Pandemic Use: States that have issued guidance that applies only during the public health emergency may want to extend those policies to improve access to underserved areas and underrepresented providers after the crisis has passed. To help inform broader use post-pandemic, states should collect data to identify gaps in access. For example, communities without reliable broadband service or families without wireless connections cannot take advantage of telehealth services. Understanding these barriers and their impact on access to care is critical to building support for a more equitable telemedicine infrastructure. This will be important not only to improve health outcomes in underserved communities but also to support the social distancing necessary to combat COVID-19 and any future pandemics.
Next Steps for States
Federal and state public health authorities are strongly recommending the use of telemedicine in order to reduce exposure to COVID-19. To make that possible on a widespread basis, state officials have a critical role to play in reducing potential regulatory and financial barriers to this method of health care delivery. Several state departments of insurance have already issued guidance or instructions to insurers regarding coverage of and reimbursement for telehealth services and more are likely to follow. In doing so, state DOIs will also need to closely track issuer and consumer experiences with services delivered via telehealth and the payment of associated claims.