For executives of provider organizations, deciding whether delivering services via telehealth is a good investment can be tricky. Whether you can use telehealth – and where and how – is increasingly dependent on where a consumer lives and their health plan. Taking a look at Medicare and Medicaid reimbursement rules illustrates the challenges.
In Medicare there are three different sets of rules for providing telehealth services depending on whether a person is enrolled in Medicare FFS in the 48 continental states, enrolled in Medicare FFS in Hawaii or Alaska, attributed to a Next Generation ACO, or participating in the Medicare Bundled Payment Initiative for lower extremities.
- Medicare FFS in the 48 continental states: Provider organizations are limited to providing telehealth services via two-way real time audio-visual communication to individuals at health care facilities in rural areas. Only a handful of services are reimbursed under this model.
- Medicare FFS in Hawaii or Alaska: Telehealth reimbursement is expanded to include asynchronous store-and-forward technology. Telehealth services are still restricted to rural areas and limited to a handful of services.
- Next Generation ACOs and Bundled Payment Initiatives: Both these demonstration programs waiver some of the Medicare FFS telehealth requirements. Individuals may reside in any area of the country, not just rural areas and telehealth services can be delivered to individuals in their homes instead of at health care facilities (see The Latest Telehealth Example: Pay-For-Value and Medicare ‘Next Generation’ Accountable Care Organization Model Features Greater Savings Sharing, But Greater Risk).
Medicaid, on the other hand, has 51 different Medicaid programs and 51 different telehealth reimbursement policies. State Medicaid programs are not required to cover telehealth services, but may choose to do so. Each state sets their own definition of telehealth that determines what services are covered via telehealth, what types of technology can be used, and where services can be delivered.
Currently, there are 47 states that have legislation or administrative codes that reimburse at least some Medicaid services delivered via two-way real time audio-visual communication. The last three hold-out states are Rhode Island, Massachusetts, and Connecticut. Presumably the high density and small size of these states makes the provision of telehealth less important.
Although nearly all states require the coverage of two-way real time audio and visual reimbursement, fewer states allow for the use of store-and-forward technology or remote patient monitoring. There are currently 13 states that allow store-and-forward and 17 states that allow remote patient monitoring. In general, the use of telehealth is gradually expanding – see The Telehealth Market – The Future Has Arrived, The Uneven Adoption Of Telehealth – The Idaho Example, Preparing For The Telehealth Tipping Point, 2016 Medicare Physician Fee Schedule Rules Include Telehealth Codes For New Originating Sites, and Alabama Medical Board Suspends In-Person Visit Rule As Prerequisite For Telehealth.
The key to sustainability is keeping on top of the rules. Our new briefing helps you do just that – with the details on the rules for all the variations in Medicare and every state Medicaid plan. For more, see our report: How Do Medicare and Medicaid Reimburse Telehealth Service?: An OPEN MINDS Market Intelligence Report. The report provides details on the Medicare rules for reimbursement and a state-by-state chart of Medicaid reimbursement policies for telehealth. The three sections of the report are:
- How Is Telehealth Defined?
- How Does Medicare Reimburse Telehealth?
- How Does Medicaid Reimburse Telehealth?
The report is free to all OPEN MINDS Circle premium members, and can be purchased in the OPEN MINDS e-Store for $495. For even more, join us this November at The 2016 OPEN MINDS Technology & Informatics Institute in Washington, D.C., where OPEN MINDS Senior Associate Alsten Tauro will discuss the evolution of telehealth and its place in the future health and human service market in his session, “Next Generation Service Delivery: The Future Of Telehealth Technology.”