Medicaid Telehealth Policies States Can Make Permanent to Ensure Access for Children/Families

Manatt on Health: Medicaid Edition

October 20, 2020

In response to the COVID-19 pandemic, state Medicaid agencies have temporarily expanded their telehealth coverage and reimbursement policies in varying degrees. States, providers, advocates and families recognize the important role that telehealth has played in maintaining access to care during the pandemic and are now turning to the difficult work of evaluating which components of a state’s temporary telehealth policies can be made permanent beyond the public health emergency. The following table provides background on key Medicaid telehealth policy domains that impact access to care and describes which state Medicaid telehealth policies can be made permanent in order to best support children and their families on an ongoing basis.

Priority Pediatric Telehealth Policy Domains and Post-COVID-19 Public Health Emergency Policy Opportunities
Policy Domain	Background	Post-COVID-19 Policy Opportunity
Coverage and Reimbursement by Telehealth Modality
Video Visits	Before the pandemic, 50 states + D.C. reimbursed for some services delivered via video visit. In response to the pandemic and social distancing measures, almost all states broadened their coverage of video visits, with many covering any “medically necessary and clinically appropriate services” delivered via video visits, and reimbursing for these visits at parity with in-person visits.	Make permanent a policy that covers all medically necessary and clinically appropriate services covered via video visit and reimburses for such services at parity with in-person care.
Audio-Only (Telephone) Visits	Few state Medicaid programs provided coverage and reimbursement for audio-only visits prior to the COVID-19 pandemic; however, the pandemic highlighted the importance of enabling providers to connect with patients over the phone, particularly with low-income or rural patients who may not have access to broadband internet or video-enabled devices required to participate in a video visit. In response to the pandemic, 50 states + D.C. issued Medicaid guidance to cover some form of audio-only services, such as: Audio-only visits in lieu of video or in-person visits, where providers were able to bill their typical procedure codes for services delivered over the phone. Note: Some states have broadly enabled this type of audio-only visit during the pandemic, but outside of a public health emergency, it may be necessary to narrow the scope of audio-only enabled services to only those that can be conducted in a clinically appropriate manner over the telephone. Telephonic evaluation and management codes, which provide reimbursement for brief check-in calls between a provider and patient. Both types of audio-only visits will be important to maintain after the public health emergency ends, in order to ensure equal access to care for all patients, regardless of their location or income level.	Make permanent a policy that enables coverage and reimbursement for: Audio-only visits in lieu of video or in-person visits at parity with in-person visits for select services that can be delivered via a telephone call in a clinically appropriate manner (e.g., psychotherapy counseling, low-complexity primary care visits, etc.); and Telephonic evaluation and management codes for brief check-ins with patients over the phone (Note: No in-person or video visit equivalent; therefore, not reimbursed at parity with in-person visits).
Sites of Care
Originating Site (i.e., where the patient is located during a telehealth visit)	Many states enabled patients to receive care from their homes via telehealth prior to the pandemic; however, there were still several states that required patients to physically travel to a clinic or facility in order to receive remote care. As a result of the pandemic, it was necessary for all states to ensure that patients’ homes (or wherever they may be located) were included as an eligible originating site. In addition, many states issued policies that explicitly stated that there were “no restrictions on originating sites.” Post-COVID-19, it will be critical to maintain access to remote care for patients who are located outside of a clinical setting.	Make permanent a policy that allows patients to receive care via telehealth from their homes or wherever they may be located.
Distant Site (i.e., where the provider is located during a telehealth visit)	Many state Medicaid telehealth policies previously precluded providers from delivering telehealth care from outside of their typical clinical settings. In response to the pandemic, state Medicaid programs have temporarily expanded their distant site rules to allow providers to deliver care from their homes (or wherever they may be located). As telehealth becomes a more commonly utilized form of care delivery, it will be important to give providers the flexibility to deliver care from locations outside of their clinic or facility.	Make permanent a policy that allows providers to deliver care from their homes or wherever they may be located.
Services of Particular Interest for Children
Well-Child Services	Prior to the pandemic, it was atypical for well-child visit services to be offered via telehealth because well-child visits are often a pediatrician’s annual in-person touchpoint with patients and their families. As a result of COVID-19, many state Medicaid programs made some well-child visit services (those that do not require physical touch) available via video visit. However, it is important to note that these states often prioritized the continuation of in-person well-child care for children up to 24 months of age. Going forward, pediatricians may continue to encourage in-person well-child visits for children of all ages, while advocating for telehealth policies that include coverage for well-child services via video visit for children 24 months or older only during future public health emergencies or states of emergency; this can ensure continued coverage of these important services for an age-appropriate population during future emergencies.	For children up to 24 months of age: Encourage in-person visits for in-person newborn care, well-child visits and immunizations. For children 24 months of age and older: Enable telehealth as an option for annual well-child, preventive visits only during the duration of a public health or other state of emergency, and for two quarters thereafter, to provide a buffer period for families that may not yet be able to travel for in-person visits.¹
Specialized Therapies	Few state Medicaid programs covered specialized therapy services (e.g., physical, occupational, speech therapies) via video visit prior to COVID-19. The pandemic, however, underscored the importance of having a video visit option for select specialized therapy services that can be conducted over video when it is not possible for providers to deliver care in person. As a result, many states enabled the delivery of some physical, occupational and speech therapy services via video visits, which has proven to be a critical tool in continuing the delivery of specialized therapies for many children with special healthcare needs during the pandemic.	Make permanent a policy that covers and reimburses for the delivery of specialized therapy services via video visit, as clinically appropriate, to Medicaid enrollees of all ages (in coordination with telehealth-enabled early intervention therapy services).
Early Intervention Services	Similar to the delivery of specialized therapies via video visit, early intervention services were rarely offered via video visit prior to the pandemic. However, after the onset of COVID-19, some states have enabled a limited set of services that can be conducted in a clinically appropriate manner to be delivered via video visits in light of social distancing measures. Most states enabled the delivery of a limited set of services that can be conducted in a clinically appropriate manner via video visits. Looking ahead, enabling some early intervention services via video visit can help ensure continuity of care in the future when in-person visits may not be possible.	Make permanent a policy that covers and reimburses for only select early intervention services that can be delivered via telehealth in a clinically appropriate manner (e.g., case management, patient/family training and counseling).
Children’s Behavioral Health	Prior to COVID-19, it was common for state Medicaid programs to cover and reimburse for the delivery of behavioral health services via video visit, and in some cases audio-only visit. In response to the pandemic, almost all states have enabled a broad set of common behavioral health services, including applied behavioral analysis and research-based autism spectrum disorder services, that can be delivered via video or audio-only visit in a clinically appropriate manner. COVID-19 has highlighted the critical role that telehealth can play in making behavioral health services more accessible for patients. Going forward, it is likely that states will continue offering these services via telehealth modalities such as video and audio-only visits.	Make permanent a policy that covers and reimburses for a broad range of behavioral health services, including research-based autism spectrum disorder services, that can be delivered via telehealth (including video or audio-only visit) in a clinically appropriate manner.

Notes:

The emergency-only use of telehealth is specific to annual well-child visits and services; the delivery of sick child visits and services via telehealth should not be subject to the same emergency limitations.

This analysis was funded through the generous support of the Robert Wood Johnson Foundation and the Lucile Packard Foundation for Children’s Health.