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States Leverage Telehealth to Respond to COVID-19

April 08, 2020 | ASTHO Staff

To enhance social distancing and reduce healthcare worker and patient exposure to COVID-19, there have been unprecedented expansions in the use of telehealth in recent weeks. The federal government has expanded telehealth benefits in Medicare and loosened previous restrictions to address COVID-19. States have been quick to follow suit, with many implementing policy changes through emergency declarations, proposing new laws or modifying existing laws, and issuing guidance from relevant state agencies, including Medicaid, departments of insurance, and state medical boards.

Federal Legislation and Guidance

On March 27, Congress approved the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was signed into law by the President. The bill includes several key telehealth provisions

  • Expands Medicare telehealth flexibilities by removing requirements that pre-existing patient/provider relationships be established prior to providing telehealth services and allows expanded authority for the Secretary of the U.S. Department of Health and Human Services (HHS) to waive additional telehealth requirements.
  • Allows federally qualified health centers (FQHCs) and rural health centers to serve as eligible sites of care for telehealth services during the COVID-19 response.
  • Allows telehealth services to be covered pre-deductible for health savings accounts paired with high-deductible health plans.
  • Provides funding for the Health Resources and Services Administration’s (HRSAs) telehealth programs, including for the Telehealth Resource Centers.
  • Provides funding the Federal Communications Commission to aid providers offering telehealth services.

Earlier in March, the Centers for Medicare & Medicaid Services (CMS) issued guidance to expand telehealth in Medicare under 1135 waiver authority and through the Coronavirus Preparedness and Response Supplemental Appropriations Act. This federal action removes geographic restrictions, which previously limited Medicare coverage of telehealth to only rural areas and certain healthcare facilities. The policy change now allows patients to receive telehealth services regardless of location (including the patient’s home). Additional guidance specifies that eligible Medicare providers can deliver services regardless of location (also including in the patient’s home) during a national emergency, which allows for continuity of care while reducing their chances of exposure in a hospital or healthcare setting. Further, on March 30, CMS issued an Interim Final Rule and additional guidance expanding telehealth services and remote patient monitoring capabilities, allowing physicians to virtually supervise billing healthcare providers from offsite settings, and permitting out-of-state practitioners to provide telehealth services in another state.

However, the federal guidance does not expand the types of eligible Medicare providers – which currently includes physicians, nurse practitioners, physician assistants, nurse-midwives, clinical nurse specialists, certified nurse anesthetists, clinical psychologists, clinical social workers, and registered dietitians or nutrition professionals. The Office for Civil Rights (OCR) of HHS announced in guidance that it will “exercise its enforcement discretion” regarding healthcare provider use of telehealth services during the COVID-19 response. The announcement clarifies that popular applications such as FaceTime and Skype are allowed. However, they specify these platforms must be private and not public-facing (meaning platforms such as Facebook Live or TikTok are not allowed.) The guidance also warns that these applications potentially introduce privacy risks and guidance recommends using HIPAA-compliant platforms and offer a business associate agreement (BAA) where feasible such as Zoom for Healthcare, Skype for Business, or Doxy.

Previously developed federal funding changes provide an important opportunity for the healthcare safety net, including FQHCs, to accelerate telehealth efforts in national emergencies. Of note, HRSA’s FY 2020 Capital Assistance for Disaster Response and Recovery Efforts (CADRE) funding includes one-time competitive funding for telehealth equipment for health centers, like laptops, servers, and videoconferencing equipment.

State Action to Expand Telehealth Benefits

  • Waiving Cost Sharing: In recent weeks, states have taken a great deal of action to expand access to telehealth benefits in Medicaid and private insurance. Many states have implemented policies—through emergency declarations and guidance—requiring that Medicaid and private health plans remove or reduce cost-sharing for telehealth services, including Arizona, California, Colorado, Illinois, Iowa, and Missouri. To provide services more efficiently during the crisis, other states, including Tennessee, Vermont, and Virginia, have issued emergency declarations and guidance requiring health plans to remove prior authorization for medically necessary telehealth services.
  • Expanding Coverage and Payment Parity: Massachusetts issued a Medicaid bulletin requiring Medicaid plans to cover telehealth services in the same manner as in-person services, also known as telehealth coverage parity. New Jersey has enacted comparable legislation requiring all health plans implement telehealth coverage parity, while Ohio has introduced similar legislation. Further, Montana issued Medicaid bulletin requiring that telehealth services be reimbursed at the same rate as in-person services, also known as telehealth payment parity. Rhode Island also issued an emergency declaration requiring all health plans to implement telehealth payment parity.

State Action to Remove Restrictions on Telehealth

  • Waiving Requirements for Pre-Existing Patient/Provider Relationships: Following recent changes in Medicare, several states, including New Jersey, have issued guidance requiring all state health plans to waive requirements that pre-existing patient/provider relationships be established prior to providing telehealth services. Missouri issued similar guidance applying to Medicaid plans. In turn, these policies allow patients to receive care from new providers, which may be necessary to ensure continuity of care given the current strains on the healthcare system.
  • Waiving Geographic Restrictions: At least eight states have adopted policies to remove previous geographic requirements for patient location, allowing telehealth services to be provided to patients in their home. The following states have issued Medicaid guidance to this affect: District of Columbia, Iowa, Michigan, Maryland, Virginia, and West Virginia. Further, Ohio and Rhode Island have waived geographic requirements through emergency declarations, applying statewide. Also, Ohio has clarified that healthcare personnel can also deliver telehealth services from their home through an emergency declaration (aligning with CMS guidance). Indiana and Missouri have issued Medicaid guidance to the same affect.
  • Waiving Provider Licensure Requirements: Many state medical boards have waived or modified licensure requirements and renewals in response to COVID-19. For example, Alaska, Missouri, and Tennessee have implemented policies allowing providers licensed out-of-state to practice in the state, as long as they are licensed in the state in which they practice. Other states have acted to expedite licensure approvals. For example, legislation was enacted in New Jersey to expedite out-of-state licensure approval. Additionally, the Medical Board in Texas extended provider licensure renewal deadlines.
  • Waiving Video Requirements: Over a dozen states have adopted policies in line with recent OCR HIPAA guidance, allowing telehealth services to be provided by telephone (audio only) or more commonly used technologies such as FaceTime or Skype. Tennessee and Rhode Island have included this policy through emergency declarations, the Texas Medical Board has issued similar guidance, and at least nine states have issued Medicaid guidance to the same affect (Michigan, Indiana, Iowa, Missouri, Montana, New York, North Carolina, Vermont, and Virginia.)

State Action to Increase Telehealth Awareness and Education
States have also adopted policies to increase provider and consumer awareness of telehealth to increase telehealth uptake during the COVID-19 response. For example, Colorado issued a bulletin directing commercial health plans to conduct outreach and education campaigns to remind enrollees of their telehealth options.

ASTHO will continue to monitor relevant telehealth policy updates related to COVID-19 and share information. If you have any questions or require additional information, please email preparedness@astho.org.

If you’re looking for additional resources on this topic, below are some trusted guides:

The development of this document is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD3OA22890, National Organizations for State and Local Officials. The information, content, and conclusions are those of the presenters and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.