Background

The COVID-19 PHE created an urgent need for enhanced access to telehealth services, and federal and state policymakers enacted several policies to increase flexibilities for the duration of the PHE. At the federal level, these included making new telehealth services, including audio-only services, payable by Medicare on a temporary basis, lifting geographic and site restrictions, and expanding the types of providers eligible to render certain telehealth services

Similarly, all 50 states took action to make telehealth more widely available, including expanding scope of practice (SOP), improving Medicaid payment, allowing interstate practice, and requiring payment parity for telehealth and in-person services. The end of the PHE could roll back many of these policies, potentially reducing access to telehealth services. While federal legislation is being considered to extend Medicare telehealth flexibilities, additional state action would be needed to preserve the broad access to telehealth services that has been created since 2020.

State Telehealth Policies Vary Substantially

While the PHE temporarily established a more consistent landscape across states for the delivery and payment of telehealth services, greater variation will return as PHE-related flexibilities expire. The three key policy areas where stakeholders are most likely to experience impacts from this variation include state Medicaid policy, commercial market coverage limitations, and state licensure policies.

• Medicaid Coverage Policy: While all 50 state Medicaid programs cover live-video telehealth services to some extent, some have limitations on the types of services that are reimbursable or eligible providers for rendering services. For example, many place limitations on telehealth modalities like audio-only services, remote patient monitoring, or asynchronous services. These limitations can create equity concerns, with patients being unable to access video-enabled services due to lack of Internet access, or access considerations for specific therapeutic areas, such as patients experiencing limitations in access to behavioral health services due to provider type limitations.
• Commercial Market Coverage Limitations: Flexibilities for coverage and payment of telehealth services encouraged providers to offer more telehealth services during the PHE, while ensuring appropriate cost sharing for patients. However, following the PHE, limitations may return. Many states do not require payment parity between in-person and telehealth services among state-regulated commercial plans, or they require parity only for certain services. Most states do not have protections to prohibit plans from creating separate networks for telehealth or from limiting providers within their networks in providing telehealth services. Expiration of PHE policies may not only limit access for patients with commercial coverage, but will also create a more complex policy environment across states.
• State Licensure Policies: Because each state has its own rules for the licensure of healthcare professionals, interstate compacts are necessary to ensure delivery of telehealth services across state lines once PHE-related licensure flexibilities expire. Otherwise, patients may encounter barriers to services previously available during the PHE. To date, 20 states have joined the Interstate Medical Licensure Compact, and 10 have active waivers granting cross-state licensure flexibilities during the PHE. In states that have not joined the compact or when states begin to wind down PHE flexibilities, patients may lose access to telehealth services from providers in other states.  States have also adopted interstate compacts for the practice of nursing, psychology, counseling, and therapy services, but there is broad variation. State SOP laws can also limit patient access to care if a state’s policy limits the number of practitioners authorized to offer telehealth services. For example, there is significant variation across states in terms of the telehealth services nurse practitioners or other specialized nurses may render.

Key Considerations

While the changes outlined above will impact many stakeholders involved in telehealth delivery, plans, providers, and technology vendors in particular will need to monitor how policies across the landscape impact coverage, payment rates, and the eligibility of providers to deliver certain services. It is especially important to monitor how the expiration of PHE-related changes will further create variation in the policy landscape in these key areas. These factors will influence total reimbursement for services, patient access, and how organizations operationalize telehealth service delivery across the country.

• Reimbursement: As PHE-related policies expire, providers may experience greater limitations in payment for telehealth services, potentially reducing the number of providers offering telehealth services.
• Access: Differences across state policies are also likely to drive variation in levels of access to telehealth services across the country. For example, differences in coverage for audio-only services could affect access to telehealth for beneficiaries without broad band. In addition,  as PHE-related licensure flexibilities expire, limitations on access to specialist services may also result, creating further barriers where in-person services may already be limited. For example, telehealth access to rare disease or oncology specialists can help to mitigate travel that may be cost prohibitive for patients, but patients living in states that are not members of interstate licensure compacts would be forced to travel to access the specialist providers needed for treatment, including routine checkups.
• Operational: Payers, providers, and vendors of telehealth platforms will need to navigate differing environments across states based on licensure, SOP policies, and providers eligible for payment. These differences will impact how provider, technology platforms, and payers develop their business model and operations across states.

While most state legislatures are no longer in session, telehealth will likely be a focus of state lawmakers as legislative sessions begin in early 2023. To learn more about how Avalere can support you in understanding the implications of the evolving telehealth policy landscape on your business, connect with us.