Medicare is a federal health insurance program in the United States that facilitates medical care by providing health insurance to people over 65 years of age, people with disabilities, and people with end-stage renal disease or amyotrophic lateral sclerosis (ALS).

Medicare and Telehealth — Medicare’s Outlook on Remote Healthcare Services

The Medicare program was signed into law in 1965. Today, the program is run and governed by the Centers for Medicare & Medicaid Services (CMS). In 2021, there were almost 63.8 million Americans receiving health coverage through Medicare.

The Medicare program has four parts, each covering specific services:

  1. Medicare Part A (hospital insurance)

The first part pertains to inpatient hospital care, which includes critical access hospitals, hospices, and skilled nursing facilities. 

  1. Medicare Part B (medical insurance)

Part B of the Medicare program covers outpatient care and doctor services, as well as some services provided by physical and occupational therapists and various forms of home healthcare.

  1. Medicare Part C (Medicare Advantage plans)

Medicare Advantage plans provide coverage for the same services covered by standard Medicare, with a few additions, such as prescription drugs, dental care, vision care, and hearing care.

  1. Medicare Part D (prescription drug coverage)

Part D covers prescription drugs and is generally available to all Medicare participants.

Why is Medicare crucial? 

The insurance coverage Medicare provides is invaluable for millions of Americans who would otherwise often face astronomical medical bills. Most people over 65 years old and people with disabilities typically have treatments that involve various prescription drugs and are more likely to experience various medical conditions. That is why the help Medicare offers, in the form of insurance coverage, is indispensable.

Apart from payment for medical services, there’s also the question of access to medical care. For the older population and people with disabilities, regular visits to a doctor’s office or a medical facility are a taxing endeavor. 

Add to that the fact that there’s a shortage of healthcare professionals — mainly specialists — in the United States, and that patients in rural and geographically isolated areas have limited access to healthcare, and it becomes evident that something more needs doing.

That’s why CMS embraced telemedicine and telehealth as legitimate ways of delivering medical care to Medicare program members. Any healthcare provider that accepts Medicare needs to know how Medicare views remote healthcare services, what limitations it may impose, what providers are eligible to provide telemedicine and telehealth to Medicare members, and how to bill Medicare for those services.

On March 13, 2020, former United States President Donald Trump made an emergency declaration under the Stafford Act and the National Emergencies Act, empowering CMS to issue waivers to Medicare program requirements to support health care providers and patients during the pandemic. In 2020, over half of all plans are offering these additional telehealth benefits, reaching approximately up to13.7 million Medicare Advantage enrollees. 

In 2020, the CMS added 135 allowable services, more than doubling the number of services that beneficiaries could receive via telehealth. Examples include emergency department visits, initial nursing facility and discharge visits, home visits, and physical, occupational and speech therapy services. Medicare also ensured that health care providers like physicians were paid for these telehealth services at the same payment rate as they would receive for in-person services. over 9 million beneficiaries have received a telehealth service during the public health emergency, mid-March through mid-June.

How does Medicare view telemedicine and telehealth?

With technological advancements, specifically telecommunications, more and more states have accepted telemedicine and telehealth as a viable alternative to in-person medical care. Remote healthcare services have also proven to be an effective way to combat the shortage of medical workers and improve access to healthcare across the country.

In recent years, most states have enacted telemedicine parity laws, providing an incentive for patients and healthcare providers to embrace remote healthcare services. Although the laws vary from state to state, most large commercial payers in the United States cover telemedicine and telehealth services.

The Medicare program also has a favorable outlook on telemedicine and telehealth and provides coverage for a wide range of remotely delivered medical services to program members. 

Medicare does enforce certain limitations regarding eligible healthcare providers and the sites at which participants can receive remote healthcare services. Some restrictions and limitations may apply, though, which is why knowing how Medicare defines telemedicine and telehealth, and what other terms the program uses to refer to remote healthcare services, is important to fully understand the covered services. 

Medicare Telemedicine and Telehealth Definitions 

Although some state laws recognize the difference between telemedicine and telehealth, Medicare uses the two terms interchangeably. 

As far as Medicare is concerned, telemedicine and telehealth both refer to healthcare services that are delivered remotely through the use of electronic information and telecommunications technology. 

Telemedicine often refers to a traditional clinical examination, diagnosis, and treatment, while telehealth is considered to be a more encompassing term that also includes patient and provider health-related education, public health, and health administration.

When it comes to Medicare, the main goal of telemedicine and telehealth is to improve access to healthcare and facilitate the delivery of healthcare services to program members. To that end, Medicare allows healthcare professionals to utilize software and equipment that allows for two-way, real-time interactive communication between them and a patient.

The key thing to note here is that, while Medicare provides coverage for telemedicine, it only does so when the services are delivered via live, two-way audio-video communication. In other words, Medicare does not provide coverage for telephone-only doctor-patient consultations or facsimile transmissions.

Medicare provides coverage for a variety of telemedicine and telehealth services. The program’s members can take advantage of modern technology to get:

  • General healthcare
  • Medication prescriptions
  • Dermatology services
  • Eye exams 
  • Nutritional counseling 
  • Mental health counseling 
  • Urgent care for a variety of medical conditions (back pain, urinary tract infections, rashes, etc.)

Medicare program has become more prominent — thanks to providers who offer free annual wellness visits and other services through telemedicine. During the COVID-19 pandemic, many telemedicine services offer free check-ups to support many patients’ needs during the difficult times. 

Other Medicare  Remote Healthcare Key Terms

Apart from telemedicine and telehealth, there are a few other key terms that Medicare uses in regard to remote healthcare services. As a healthcare professional, you should familiarize yourself with these terms if you plan on providing remote healthcare services to Medicare beneficiaries. 

These key terms are:

  • Originating (spoke) site 
  • Distant (hub) site
  • Remote patient monitoring
  • Store-and-forward 

An originating site refers to the Medicare patient’s location at the time of receiving remote healthcare services. Given that Medicare members are people older than 65 or people with disabilities, they often need a telepresenter at the originating site to facilitate the delivery of remote healthcare services.

A distant site is the location of a healthcare provider who provides the telemedicine and telehealth services. 

Remote patient monitoring refers to leveraging modern equipment to collect and transmit patient medical data from an originating site to a healthcare provider at a distant site.

Store-and-forward technology refers to the transmission of medical data from one site to another using telecommunications technology. 

What’s interesting to note is that CMS medical codes give providers an opportunity to get reimbursed for store-and-forward when using the technology to analyze and diagnose images sent to them by established patients if they are in Alaska or Hawaii, provided that the patient is at an eligible originating site. 

What is a Medicare telehealth eligible site, and what providers can see Medicare patients?

The crucial thing to understand about Medicare and remote healthcare services is that not every medical professional is eligible for reimbursement

Medicare provides an exclusive list of healthcare providers who are eligible for reimbursement for services delivered to Medicare beneficiaries through telehealth and telemedicine. Under Medicare, eligible healthcare providers are:

  • Physicians
  • Physician assistants
  • Nurse practitioners
  • Nurse-midwives
  • Certified registered nurse anesthetists
  • Clinical nurse specialists
  • Clinical psychologists and clinical social workers
  • Registered dietitians and nutrition professionals

Aside from listing which healthcare professionals can offer remote healthcare services to Medicare beneficiaries, CMS also has a detailed list of eligible originating sites. When most people think of telemedicine, they immediately picture a patient sitting at home and talking to a doctor on their laptop or phone. 

In 2020, Medicare established some changes that providers can set up their telehealth services in their private offices as long as they have internet connection. Additionally, Medicare now recognizes patients’ homes as eligible originating sites where they can receive telemedicine services at the comfort of their home. 

Eligible distant sites under Medicare are:

  1. Healthcare providers’ offices
  2. Hospitals 
  3. Rural health clinics
  4. Federally qualified health centers
  5. Critical access hospitals
  6. Skilled nursing facilities
  7. Community mental health centers 
  8. Hospital-based or critical access hospital-based renal dialysis centers

There are exceptions to location limitations, though, through Medicare.

Medicare Exceptions From Location Limitations

The geographic limitations that we mentioned above proved to be a bit limiting in practice. 

That’s why CMS allows for a few exceptions from geographic and facility restrictions for a handful of conditions:

  1. End-stage renal disease (ESRD)
  2. Acute stroke treatment
  3. Substance use disorder (SUD) treatment

End-Stage Renal Disease

Given the severity of this medical condition, ESRD services are an exception to the usual rule in that both renal dialysis facilities and the patient’s home are considered eligible originating sites. In the event that ESRD services are delivered remotely to a patient in their home, a monthly in-person visit from a medical professional is required for the first three months. After that, an in-person visit is necessary every three months. 

Acute Stroke Treatment

When it comes to acute stroke treatment, a mobile stroke unit is eligible for reimbursement, and standard geographic limitations do not apply. One thing to note is that a site that otherwise doesn’t meet Medicare’s eligibility criteria is not eligible for an originating site facility fee. 

Substance Use Disorder Treatment

The standard geographic restrictions do not apply for telehealth services rendered in regards to the treatment of substance use disorder or a co-occurring mental health disorder. In these two instances, the patient’s home is also considered an eligible originating site, but it does not qualify for the facility fee.

How do healthcare providers get Medicare telemedicine reimbursement?

Apart from eligible originating and distant sites, there are a couple of other things healthcare providers need to be aware of when billing for delivering telemedicine services to Medicare participants.

Providers are reimbursed at the same rate as if the services were delivered in-person for  Medicare telemedicine services. That means services have to mimic in-person visits — the technology used needs to enable healthcare providers to examine, diagnose, and treat the patient in accordance with the standards of practice applicable to an in-person setting.

Keep in mind that the patient needs to be at an eligible originating site. If you’re unsure whether a site meets the geographic restrictions, you can quickly check it using the Health Resources and Services Administration’s (HRSA) handy Medicare eligibility analyzer tool.

When billing Medicare for telemedicine and telehealth services, you also have to make sure to use the appropriate HCPCS/CPT code. The code must correspond to the services provided, and you also need to use the GT modifier when billing to indicate that the services were delivered remotely.

Medicare allowing telehealth is of great significance for patients and medical practices.

Many people believe that access to quality healthcare is a fundamental right and a characteristic of civilized society, while others feel that it’s their responsibility to take care of themselves. Medicare and telehealth play a crucial role in the financial security of older Americans, as well as their health security. Through telemedicine, delivering care becomes easier and safer, as older patients don’t have to travel and get exposed to various diseases. Medicare and telehealth are lifelines that place care in reach of millions of people with disabilities and older people. 

Medicare helps Americans over 65 years old stay healthy and independent by providing a full range of services and guarantees affordable health insurance. Healthcare providers must remember that the program is a critical part of any medical practice,