Telehealth Insurance Coverage: Will Your Virtual Doctor Visit Be Covered?

Telemedicine has made great strides since its pre-pandemic days, with studies showing a 34-fold rise in e-visits. Both health providers and governments at state and federal levels recognize its benefits for improving access and cost of healthcare.

An important cog in health delivery that still concerns patients and providers is the medical insurance industry. At the moment, medical insurance coverage for telemedicine services is too complex. 

Patients aren’t sure if their e-visits will be covered under their Medicare or any private plans they may be under. If they enjoy telemedicine coverage, is it full coverage or do they have to copay?

Healthcare providers are just as unsure. Will they be reimbursed for e-visits? If so what type of e-visits enjoy the coverage? What equipment if any are they required to have to qualify as an approved telemedicine provider? How should the e-visits be conducted for them to qualify for reimbursement?

So many questions! Let’s answer those that we can:

What is the telehealth insurance coverage?

Telehealth insurance cover is a form of insurance that is taken to cover the cost of medical care that is remotely delivered. The hope for patients and medical authorities in most states is to see parity between the cover offered by medical insurers for in-person and virtual visits. At the moment, however, parity has only been achieved in 26 states.

But what is telehealth and how does it differ from telemedicine?

Telemedicine is the delivery of primary healthcare by a medical practitioner to a patient who is in a remote location using interactive video and audio communication technology. It allows a doctor to remotely diagnose and treat a patient.

The terms telemedicine and telehealth are considered to be synonyms in most jurisdictions, including Virginia. But most health providers prefer to limit the telemedicine definition strictly to clinical care. Their definition of telehealth includes the delivery of other health services like disease prevention and medical training.

Is telehealth covered by Medicare?

In short, yes, telehealth is covered by Medicare, the federally funded medical insurance plan. To give a broader perspective, Medicare coverage for telehealth services is limited in its scope, perhaps intentionally. To start with, Medicare only covers seniors aged 65 and over, younger people with disabilities, and patients with end-stage renal disease. So only those population groups have Medicare coverage when registered. 

To add to that, until the emergency Covid-19 regulations that allowed telehealth coverage for Medicare cover holders everywhere else, coverage was only restricted to people in so-called Professional Shortage Areas.

Telehealth coverage is also available under Medicare Plan B and some Medicare Advantage plans. Even then, there is still a limit to the scope of telehealth coverage they get depending on several factors, including:

  • Where do you get your telehealth service,
  • How much does the virtual visit cost,
  • Other medical insurance covers you may have.

Is Medicare telemedicine coverage available in 2022?

The Centres for Medicare and Medicaid Services (CMS) have determined that some telehealth services that had been temporarily added to the standard Medicare telehealth services as a Covid-19 response measure will remain until December 2023. Before the Covid-19 pandemic, Medicare coverage for telehealth services was only available to people in remote and rural areas. People that did not reside in these areas did not qualify for coverage.

This was designed to equalize access to healthcare between people in urban areas where most specialist medical practitioners prefer to work and those in rural areas where facilities and specialists are sparsely distributed.

A condition for Medicare telemedicine coverage is that patients that require remote consultation with a specialist have to be at a health center closest to them. That condition has existed from the start and did not change with the emergency Covid-19 measures.

What about those on Medicaid?

Medicaid coverage rules differ between states but most states have some level of coverage for telemedicine services. In some states, patients have to make their virtual visits from a certified health facility, which is a standard requirement under Medicare.

Does Virginia allow telemedicine?

The state of Virginia has some of the most progressive telemedicine laws in the United States. Telemedicine practitioners in the state have enjoyed full reimbursement for their services since 2011. The Virginia Board of Medicine considers telehealth and telemedicine to mean the same. The VBM does not have separate guidelines for telemedicine. It requires that the same guidelines in use for in-person practice apply to remote care services.

Virginia considers a telemedicine patient’s location to be the actual place of the e-visit. This has implications for those who can practice telemedicine in the state. The practitioner, because of the regulation, must have a license to practice in Virginia. Back to medical insurance coverage for telemedicine services, what is the state of private insurance coverage for telemedicine?

Private insurance coverage for telemedicine

Although slow to act, federal and state governments are making strides in ensuring parity between insurance coverage for telemedicine and in-person doctor appointments. At present, 26 states have parity laws, with 10 considering similar laws. Parity, however, does not mean that coverage is universal. The laws are different between states and the same applies to insurance coverage policies between private insurers.

Generally, private medical insurance providers consider real-time video visits to be the only acceptable form of telemedicine. That said, some do cover remote visits conducted via secure email. Before booking an e-visit with your doctor, you may also want to check if your state or insurer does not require that you have already established a relationship with them via an in-person visit. That’s because some states require it.

It’s worth remembering that some insurers in non-parity states are offering equal coverage for both e-visits and in-person doctor consultations. 

A recent welcome innovation by private health insurers is what they are calling virtual-first policies. Under these, a patient must first meet with a doctor online before they can be referred to an in-person physician for additional care. 

The benefit for patients that have been touted by the insurers offering virtual-first plans is lower premiums. But the bigger beneficiaries of these plans may be the insurers themselves as the plan allows physicians to vet patients and weed out those that do not need to see a doctor, which means the insurers process fewer claims.

Is telemedicine cheaper for patients?

Telemedicine reduces the cost of healthcare for patients. Since you don’t have to travel to a health center to see the doctor, you save on transportation and childcare costs. Some insurers are now also offering lower premiums for people on virtual-first plans.

But perhaps the biggest benefit is improved access for people in regions where getting a consultation or treatment with a specialist is difficult. Telemedicine is a strong fit for sparsely populated states and rural areas where it is not always easy to get specialist medical care, especially for the elderly and those managing chronic conditions.

The hope is that medical insurance guidelines by states and policies by insurers for telemedicine services will improve. At the moment, they are too complex and make access difficult for people who badly need virtual care.

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