Medicaid Telehealth Policies in Response to COVID-19

October 9, 2020
Medicaid Telehealth Policies in Response to COVID-19
Medicaid, authorized in Title XIX of the Social Security
the payment arrangements outlined in the Medicaid state
Act (SSA), is a federal-state program that jointly finances
primary and acute medical services, as well as long-term
services and supports (LTSS), to a diverse low-income
A September 2019 Center for Connected Health Policy’s
population. The 50 states, the District of Columbia (DC),
survey of state and DC telehealth laws and Medicaid
and the five U.S. territories (American Samoa, the
policies found that, as of April 2019, all 50 states and DC
Commonwealth of Northern Mariana Islands, Guam, Puerto
allowed telehealth as a service delivery mechanism but
Rico [PR], and the U.S. Virgin Islands [USVI]) must follow
allowable provider types, modalities, and service categories
broad federal rules to receive federal Medicaid funding, but
varied by state.
they have flexibility to design their own versions of
Medicaid within the federal statute’s basic framework. In
Expanding Telehealth During COVID-19
addition, several waiver authorities allow states to operate
The COVID-19 pandemic accelerated interest in telehealth
their Medicaid programs outside of federal program rules.
as a way to protect health care providers and to maintain or
(For information on waivers, s ee CRS Report R43357,
improve patients’ access to care and safety. This section
Medicaid: An Overview, and CRS Legal Sidebar
identifies the federal authorities states can leverage to
LSB10430, Section 1135 Waivers and COVID-19: An
enhance Medicaid telehealth coverage during the PHE and
Overview). This flexibility results in variability across state
provides an overview of the most commonly added
Medicaid programs in factors such as use of telehealth as a
services, provider types, modalities, and care delivery sites.
service delivery method.
Summary of Certain Emergency-Related
This In Focus provides background on Medicaid telehealth
Authorities under Medicaid
and an overview of telehealth actions in response to the
Coronavirus Disease 2019 (COVID-19) Public Health
Disaster Relief State Plan Amendments: Al ow states to
Emergency (PHE). It discusses how states leveraged
revise Medicaid eligibility, enrol ment, and benefit requirements
existing flexibilities and PHE-specific federal authorities to
in their state plan for the duration of a disaster or emergency.
increase the number of services, provider types, and other
Section 1115 Waivers: Authorize the Secretary of Health and
telehealth coverage options under Medicaid.
Human Services (HHS) to waive a number of Medicaid
requirements to the extent necessary to al ow a state to
Medicaid Telehealth Prior to COVID-19
undertake an “experimental, pilot, or demonstration project.” In
While federal Medicaid statute does not recognize
an emergency, these waivers may be approved without regard to
telehealth as a distinct service, the Centers for Medicare &
normal process-related requirements and do not need to be
Medicaid Services (CMS) defines Medicaid telehealth as
budget neutral to the federal government.
“the use of telecommunications and information technology
Section 1915(c) Appendix K Waivers: Appendix K is a
to provide access to health assessment, diagnosis,
stand-alone appendix that states may use during emergency
intervention, consultation, supervision and information
situations to request amendments to existing1915(c) Home and
across distance.” CMS provides states with broad flexibility
Community Based waivers.
to define which (if any) telehealth services to provide (e.g.,
Section 1135 Waivers: When certain emergency conditions
primary care, behavioral health, LTSS), allowable
are met, al ow the HHS Secretary to temporarily waive Medicaid
modalities (e.g., live video, audio only), where services can
statutory requirements, such as provider licensure, to ensure
be provided, which provider types are authorized to provide
sufficient health care items and services are available to meet the
the service (subject to federal and state law), and the
needs of enrol ees in an emergency area.
populations served, among other criteria. States that limit
telehealth geographically, or to specific providers, must
ensure that enrollees in areas without telehealth coverage
CMS Guidance and Federal Authorities
have face-to-face provider access. In general, states must
CMS released a series of sub-regulatory guidance (e.g.,
reimburse providers for a telehealth service at the same rate
frequently asked questions, fact sheets, tool kits) to
as an in-person service, unless they have CMS approval to
facilitate increased state reliance on telehealth as a
pay a different rate or with a unique reimbursement
Medicaid service delivery tool. These materials identify
methodology. For example, CMS approval is required for
existing state flexibilities available to augment telehealth
payment rates that factor in ancillary costs (e.g., equipment
and provide guidance intended to help states identify and
necessary for the delivery of telehealth services,
address state-level barriers to the adoption of new telehealth
transmission charges) or costs associated with time and
delivery options. For Medicaid changes requiring CMS
resources. Medicaid managed care plans are not limited by
approval, CMS provided templates and checklists to
expedite state requests for time-limited Medicaid

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Medicaid Telehealth Policies in Response to COVID-19
flexibilities through legal authorities such as Disaster Relief
in new service categories. Ten states expanded from a
State Plan Amendments (SPAs) and emergency-related
discrete list of telehealth-eligible services to broadly cover
Sections 1115, 1915(c) Appendix K, and 1135 waivers
services via telehealth within existing categories (“Allowed
(examples of how states used these authorities for telehealth
Prior to COVID-19”).
purposes are available in the “State Activity” section). The
CMS COVID-19 templates and checklists for the Disaster
Figure 1.Number of States, DC, and Territories
Relief SPA and waivers identify an effective date
Allowing Various Services/Specialties via Telehealth
retroactive to March 1, 2020 (or as otherwise approved by
Before and in Response to COVID-19, as of May 2020
CMS); the flexibilities generally sunset in conjunction with
the end of the President’s emergency declaration, but states
have the option to end them earlier. After the PHE, states
may seek CMS approval to continue any otherwise
temporary telehealth policies adopted during the pandemic
via new SPAs and Section(s) 1115 or 1915(c) waivers.
Since the Section 1135 waiver flexibilities are specific to
PHEs, these would not be available to states.
State Activity: Increased Use of Telehealth Service
Delivery Options in Response to COVID-19
According to a Kaiser Family Foundation tracker of
COVID-19-related CMS Medicaid approvals, as of
September 28, 2020, CMS approved Disaster Relief SPAs
in 15 states and DC to allow telehealth “payment variation”

and/or reimbursement for “ancillary telehealth delivery
Source: Created by CRS based on Figure 1 in MACPAC, Changes in
costs.” CMS allowed 47 states and DC to use Section
Medicaid Telehealth Policies Due to COVID-19: Catalog Overview and
1915(c) Appendix K waivers to expand telehealth LTSS
Findings, June 4, 2020.
delivery by adding “an electronic method of service
Note: Table does not reflect states that broadly expanded telehealth
delivery to continue services remotely in home.” The
services within a previously al owed service/specialty category or the
tracker does not specifically identify telehealth changes in
scope of coverage within a service/specialty category.
the 7 states with COVID-19 Section 1115 waivers and the
50 states and DC with COVID-19 Section 1135 waivers .
However, the flexibilities allowed under these CMS
MACPAC also found 32 states expanded the provider types
approvals may impact a state’s telehealth capacity, since
that are permitted to deliver Medicaid services via
any increase in coverable services and available providers
telehealth in response to COVID-19. While the largest
may increase opportunities for care delivery via telehealth.
provider type expansion is categorized as “Other” (19 states
Notably, the COVID-19-related CMS approvals in this
and USVI), dental providers (18 states) were the next most
tracker may not capture other COVID-19-related policies
commonly added provider category, followed by physicians
that states have adopted without CMS sign-off under their
(10 states and USVI), and behavioral health providers (9
existing flexibilities to define Medicaid telehealth, some of
states). The type and number of providers within a category
which are discussed below.
vary by state.
Modalities and Sites
According to a June 2020 Medicaid and CHIP Payment and
Many states also added telehealth coverage for new
Access Commission (MACPAC) report on changes in
modalities and service sites. Specifically, 42 states, PR, and
Medicaid telehealth policies due to COVID-19, most states,
USVI added telephones/audio-only to their covered
DC, and territories expanded the categories of services that
telehealth modalities (previously allowed in 8 states and
are available to be delivered via telehealth. Among its key
DC), and 25 states and DC added the use of the home as an
findings, the report notes that the most commonly added
allowable patient site (previously allowed in 21 states). The
telehealth service categories include physical, occupational,
allowable services that can be delivered via an audio-only
and speech therapies (32 states and USVI), followed by
modality and in the home vary by state.
LTSS (26 states and USVI), and dental services (19 states
and PR) (see Figure 1). The report generally does not
Expiration Dates
distinguish whether a state’s policy change was carried out
For telehealth policies that do not require CMS approval
under the state’s broad flexibility to define telehealth or
(e.g., certain service expansions), states have the flexibility
under a COVID-19 disaster-related federal authority.
to determine the period of time the policy will be in place.
According to MACPAC, 12 states and USVI did not
The report notes that the number of discrete services
specify an end date for their COVID-19 Medicaid telehealth
offered within the service categories referenced in Figure 1
policies, leaving the option to continue the policies beyond
can vary by state. For example, Oklahoma allows telehealth
the PHE. There is also potential for administrative
delivery for a specified list of behavioral health services
rulemaking and/or legislative action to further shape these
(e.g., psychotherapy, crisis intervention), but Wyoming
policies. Since the start of the COVID-19 PHE, the 116th
broadly covers behavioral health services via telehealth.
Congress has introduced several bills to examine access,
Further, not all telehealth service delivery expansions were
increase payment, etc. for Medicaid telehealth services.

Medicaid Telehealth Policies in Response to COVID-19

Evelyne P. Baumrucker, Specialist in Health Care
Julia A. Keyser, Analyst in Health Care Financing

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