Some states that expanded telehealth access and coverage during the COVID-19 pandemic are moving to make those changes permanent.
Colorado Gov. Jared Polis signed a bill on Monday that expands telehealth access by barring insurers from requiring that patients have a pre-established relationship with a virtual care provider or imposing additional location, certification or licensure requirements on providers as a condition for telehealth reimbursement.
The new law, which applies to state-regulated health plans and Medicaid, adds remote patient monitoring as a covered service and does away with restrictions on the technology used for telehealth visits. As long as the audio or video technology is compliant with HIPAA, it is covered. The law was modeled off of Colorado's emergency order expanding telehealth on April 1, said state Rep. Susan Lontine, a Democrat who sponsored the legislation first introduced in June.
"Providers began to really like that flexibility that they were given under the executive orders, and so we began to look at how we could extend (the flexibility) after the executive orders ended," Lontine said in an interview. "In the current atmosphere we are still faced with the risk of exposure to COVID, so whatever we can do to encourage people to continue with their visits but limit their risk of exposure is helpful."
Meanwhile, Idaho Gov. Brad Little issued an executive order in late June that asks state agencies to take steps to make permanent the waivers of telehealth rules and other regulations that he issued during the COVID crisis. The waivers had broadened the technology that could be used for telehealth, allowed telehealth providers to prescribe more medications, including medication-assisted treatment for substance use disorder, and allowed out-of-state providers to treat Idaho patients.
"Our loosening of healthcare rules since March helped to increase the use of telehealth services, made licensing easier, and strengthened the capacity of our healthcare workforce — all necessary to help our citizens during the global pandemic. We proved we could do it without compromising safety. Now it's time to make those healthcare advances permanent moving forward," Little said in a news release.
The states' actions show they see value in virtual care beyond the pandemic, when access to in-person care was limited because of stay-at-home orders, fear of exposure to the novel coronavirus and providers' need to conserve resources.
"We are thrilled to see Colorado and Idaho embracing telehealth by permanently breaking down state regulatory barriers. The reality is that many of the barriers in place needlessly restrict patient access to healthcare providers through technology. The flexibilities allowed during this pandemic have clearly illustrated the necessity of re-examining the rules that were so quickly changed for an emergency," said Krista Drobac, executive director of the Alliance for Connected Care, a Washington-based group that advocates for greater access to telehealth.
When the pandemic began to affect patient volumes in March, health systems and physician offices quickly pivoted to telehealth as a way to maintain income and keep track of chronically ill patients. Payers made it easier for them to do so.
The CMS temporarily expanded coverage of telehealth for Medicare members during the public health emergency, loosening restrictions that previously required patients to be located at specific sites in rural areas. The agency also increased the number of services it would pay for when delivered via telehealth, allowed providers to conduct telehealth by phone, and enabled out-of-state clinicians to provide virtual care.
All states expanded access to telehealth for Medicaid beneficiaries through emergency waivers. Private health insurers also committed to covering telehealth services for COVID-19 and other conditions often at no cost to the patient, either voluntarily or in conjunction with state orders.
As a result, telemedicine visits skyrocketed overnight. Visits grew 14% between February and early April compared with pre-pandemic levels, according to an analysis by Harvard University researchers and healthcare technology company Phreesia. Other data released Tuesday by not-for-profit FAIR Health showed that the number of telehealth claim lines—or procedures listed on an insurance claim—for the privately insured rose to 13% of all medical claim lines in April 2020, compared with 0.15% a year ago.
While some telehealth advocates have insisted the surge in telehealth will be part of the "new normal" after the COVID crisis subsides, others are skeptical. Many of the state and federal coverage changes are set to expire when the public health emergency ends, though CMS officials have suggested that they support making some telehealth flexibilities permanent. Senate health committee Chair Lamar Alexander (R-Tenn.) has called for changes to Medicare reimbursement of telehealth.
The Harvard analysis of Phreesia data showed that already, the use of telemedicine is beginning to taper off. At mid-June, telehealth visits were up 8% compared to pre-pandemic levels—down from the peak of 14% in early April.
In an op-ed in STAT, Harvard and Phreesia researchers surmised that physicians are abandoning telehealth and switching back to in-person care because they don't know if they will continue to be reimbursed for virtual visits after the pandemic. Telehealth adoption will lose momentum if payers don't clarify their long-term plans, they wrote.
Nathaniel Lacktman, chair of the telemedicine and digital health industry team at law firm Foley & Lardner, said Colorado's telehealth statute is already further along in terms of coverage and reimbursement than many states, but the new law would "codify certain coverage protections that benefit patients, and it would also further cement the use of telehealth, broadly, as a covered medical benefit for insured patients."
The law effectively bars insurers from requiring providers to use a specific telehealth software for the service to be covered, he said. It also keeps them from creating a narrow network by requiring clinicians to have a special accreditation or training or be in a specific location. Notably, he said the law requires insurers to cover telehealth delivered by phone—an option that Medicare granted to providers on a temporary basis in March.
It does not make significant strides towards reimbursement parity between telehealth and in-person services, however, requiring only that that the state pay certain providers for telemedicine services provided to Medicaid recipients at the same rate as it pays for those services when delivered in person.
Just 10 states require commercial insurers to pay providers for a telehealth service at the same reimbursement rate for in-person care, according to Foley & Lardner's December 2019 report on commercial coverage of telehealth. Colorado does not require payment parity, according to the law firm.
