Is Medicare still reimbursing physicians for telehealth (telehealth) appointments?

Medicare Telehealth Reimbursement Status

Yes, Medicare continues to reimburse physicians for telehealth appointments, but with significant restrictions that vary based on geographic location, service type, and whether temporary pandemic-era flexibilities remain in effect.

Current Medicare Reimbursement Framework

Traditional Medicare Coverage (Pre-Pandemic Baseline)

Medicare has provided reimbursement for telehealth services since 1999, but with substantial limitations 1:

• Geographic restrictions: Services must originate from sites outside metropolitan statistical areas or in rural census tracts designated as health professional shortage areas 1
• Technology requirements: Only interactive audio-video telecommunications systems qualify; store-and-forward technology is reimbursed only in Alaska, Hawaii, and federal demonstration programs 1
• Covered services: Reimbursement is narrowly confined to certain Part B services 1
• Both providers reimbursed: Medicare reimburses both the consulting and referring practitioners 1

Recent Expansions and Current Uncertainty

The Centers for Medicare & Medicaid Services (CMS) has incrementally expanded coverage 1:

• The fiscal year 2014 Medicare Physician Fee Schedule expanded eligible geographic locations to include rural areas within metropolitan statistical areas 1
• Next-generation accountable care organizations can receive reimbursement for services at 8 originating sites, including the patient's home 1
• Historical reimbursement has remained low, with approximately $12 million paid in 2013 1

Critical caveat: Temporary pandemic waivers dramatically expanded Medicare telehealth coverage starting March 2020, removing location restrictions, allowing patients and providers to engage from home, providing full reimbursement parity, and covering additional specialties 2. These waivers were expected to end with the public health emergency in 2023, potentially creating a "telehealth cliff" affecting nearly 64 million Medicare patients 2.

Key Restrictions to Navigate

Geographic Limitations

The most significant barrier: Traditional Medicare reimbursement excludes most urban and metropolitan areas 1:

• Services must originate outside metropolitan statistical areas or in designated health professional shortage areas 1
• This restriction was adopted in 2000 to control costs (initially estimated at $150 million over 5 years, but actual expenditures were only $2 million annually) 1
• Underserved urban patients face the same access barriers as rural patients but lack reimbursement eligibility 1

Technology and Service Type Requirements

Only specific modalities qualify for reimbursement 1:

• Interactive video-conferencing or two-way communication systems are required 1
• Store-and-forward technology (asynchronous transmission of medical information) is excluded except in Alaska and Hawaii 1
• Remote monitoring coverage varies 1

Comparison with Other Payers

Medicaid Coverage

State Medicaid programs show more flexibility than Medicare 1:

• 46 states and the District of Columbia reimburse for interactive/live video 1
• 10 states reimburse for store-and-forward technology 1
• 13 states reimburse for remote monitoring 1
• Reimbursement policies vary widely by state, creating uncertainty for practitioners 1

Private Insurance

Private payers have been more progressive 1:

• 21 states and the District of Columbia mandate private insurance coverage for telehealth services 1
• Many private insurers voluntarily cover telehealth services even without mandates 3
• Private payers increasingly recognize cost benefits and have expanded coverage beyond public health plans 1
• Survey data from 2012 showed telehealth services were being reimbursed by private payers, though progress was slower than expected 3

Clinical Practice Implications

Common Pitfalls to Avoid

Verify eligibility before providing services 1:

• Physicians may provide telemedicine only to discover they are not eligible for reimbursement 1
• The technology used may not qualify for reimbursement 1
• Geographic location may disqualify the service 1
• Reimbursement rates may be lower than expected 1

Specialty-Specific Considerations

Mental health services show the strongest telehealth adoption 4:

• Roughly half of the 369 providers with 10+ Medicare telehealth consultations in 2009 were mental health professionals 4
• The verbal (rather than physical contact) nature of mental health care provides a comparative advantage 4

Telestroke programs have specific reimbursement pathways for acute consultations using interactive audio-video systems 1.

Policy Advocacy Position

The American College of Physicians supports 1:

• Lifting geographic site restrictions that limit reimbursement to rural areas 1
• Reimbursement for appropriately structured telemedicine communications (synchronous or asynchronous, text-based or supplemented with voice/video/device feeds) 1
• Recognition that limited access to care affects urban underserved populations equally 1