The Telehealth Transformation: How US States are Leveraging Virtual Care in Response to COVID-19

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By Alana Lerer, MPH, CAHIMS, Manager, Government Relations, HIMSS

Governments across the globe are leveraging information and technology tools to help flatten the curve of COVID-19. Telehealth is one such tool that has transformed care delivery at the U.S. federal and state level as new policies have significantly eased restrictions to ensure access to care while social distancing measures are in place.

On April 23, the U.S. Centers for Medicare & Medicaid Services (CMS) announced a COVID-19 telehealth toolkit to accelerate state use of telehealth in Medicaid and Children’s Health Insurance Program (CHIP). Medicaid provides states with a great deal of flexibility to use telehealth services in their programs. Now, in response to COVID-19, CMS is offering states additional flexibilities, which includes temporarily reducing delays on enrolling new and out-of-state providers, which has implications for telehealth. CMS also issued a FAQ on March 24 on how states and health insurance carriers can leverage telehealth.

In March, the Office for Civil Rights at the U.S. Department of Health and Human Services (HHS) issued a Notification of Enforcement Discretion for Telehealth Remote Communications during COVID-19. This authorized providers to use technology for telehealth that may or may not comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) during the declared national emergency, with the exception of public-facing technology (such as Facebook Live, Twitch or TikTok). This allows greater accessibility to patients and providers who may not have the infrastructure developed for HIPAA-compliant telehealth.

State Actions

All 50 states and Washington, D.C., have taken actions to improve access to telehealth in response to COVID-19. The majority of actions states have taken fall into the following three categories:

Licensure requirements and renewal waivers
Expansion of coverage of telehealth under the state Medicaid program
Expansion of coverage of telehealth under commercial health insurers

Licensure Requirements and Renewal Waivers

Before the emergency declaration, medical boards of 49 states and D.C. required that providers delivering care via telehealth must be licensed in the state where patient is located, with some exceptions. To expand the healthcare workforce and improve access to care while social distancing measures are in place, all 50 states and D.C.* are temporarily waiving licensing requirements, allowing providers to deliver care via telehealth and practice across state lines and/or temporarily expediting the process to get licensed to deliver telehealth. The Federation of State Medical Boards issued recommendations for federal, state, and local governments on licensure requirements during a pandemic to ensure that these temporary changes include patient protection safeguards.

For example, in Florida, with approval, out-of-state providers may temporarily deliver telehealth services to Floridians without attaining a Florida license. Some states, such as Alabama, have adopted emergency licensing procedures and expedited the process to offer temporary licenses to qualified medical personnel during the declared emergency.

In addition, the U.S. Drug Enforcement Administration (DEA) announced that DEA-registered providers may temporarily prescribe controlled substances via telehealth to patients in states where the provider is not registered to practice telehealth with DEA.

Expansion of Medicaid Telehealth Coverage

Before the declared emergency, all 50 states and D.C. provided reimbursement for some form of telehealth (i.e., live voice and video) in Medicaid fee-for-service.

Now, in response to COVID-19, all 50 states and D.C.** have temporarily expanded access to telehealth for Medicaid recipients. These policies include one or more of the following rules:

Patient can be at home during a telehealth visit;
Provider reimbursement for telehealth is equal to that of a traditional in-person visit;
Additional telehealth services are covered;
Multiple modes of technology are covered, such as using a phone without video; and
A first-time appointment with a patient does not need to be in-person.

Washington State has a unique program. The Washington Health Care Authority has purchased a limited number of licenses of a popular video conferencing platform for providers who do not have access to such technology and are prioritizing providers who mainly serve Medicaid beneficiaries or are in smaller practices with less infrastructure, among other considerations.

For remote patient monitoring and store-and-forward, some states include that in their policy (Arizona), but most do not include such a step. Maryland refined its original executive order by adding asynchronous (one-way) telehealth to be reimbursed by Medicaid and commercial insurers. This means that patients and providers can use other modalities, such as email, and beyond audio, to deliver telehealth and providers will be reimbursed accordingly.

Expansion of Commercial/Private Insurance Coverage

In 33 states***, commercial insurance carriers are temporarily relaxing requirements around telehealth, either through state mandates or on their own. This may include waiving all copays, coinsurance, and deductibles for patients relating to COVID-19 diagnostic testing and requiring provider reimbursement for telehealth be the same as reimbursement for a traditional in-person visit.

Before the pandemic and currently, 40 states and D.C. govern commercial/private insurer telehealth coverage in their state, while other states can urge health insurance carriers to increase coverage for telehealth services. Before the pandemic, only six states allowed telehealth reimbursement to be equal to that of an in-person visit.

HHS provided guidance for HIPAA-compliance during the emergency, but some states, such as Utah, require providers to still use HIPAA-compliant platforms to the greatest extent possible. Other states are following federal guidelines. California has authorized the following:

Suspension of verbal or written consent rule before telehealth service delivery;
Suspension of penalties from unauthorized, inadvertent access or disclosure of health information during the good faith provision of telehealth services; and
Delivery of telehealth should be consistent with the U.S. HHS Office for Civil Rights’ Notification of Enforcement Discretion.

The “Genie is out of the Bottle”

To respond to the spread of COVID-19, HIMSS recommends that states and localities follow a set of immediate strategies, which includes utilization of telehealth and other virtual care tools. Learn more about these strategies.

Questions remain on what all of these changes mean for the future of telehealth. As Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS), expressed, “I think the genie’s out of the bottle on this one, I think it’s fair to say that the advent of telehealth has been just completely accelerated, that it’s taken this crisis to push us to a new frontier, but there’s absolutely no going back.” Tennessee is one state where telehealth coverage changes have already been made permanent.

As we look ahead, HIMSS and its members are seeking to find solutions that leverage the accelerated telehealth changes while protecting patient care and privacy.

*Licensure requirements and renewal waivers: Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawai’i, Idaho, Illinois, Iowa, Indiana, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Maryland, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Washington, D.C., West Virginia, Wisconsin, and Wyoming