How Does Medicare Cover Telemedicine?

By Danielle K. Roberts, a Medicare insurance expert and co-founder, Boomer Benefits.

Danielle Kunkle Roberts

The telehealth revolution gives health providers the opportunity to assist patients in remote or rural areas; the same kind of care that they give to patients in person. It saves money on travel and improves efficiency in healthcare as well.

While telehealth options in healthcare are helpful to individuals at any stage in life, they can be particularly helpful in treating older adults with chronic illnesses. The Centers for Medicare and Medicaid Services have recognized this and have put together guidelines for primary care physicians who treat patients in geographical areas where it may be difficult for those beneficiaries to otherwise gain access to certain specialists and medical experts.

Telehealth services are made available to these Medicare beneficiaries who have signed up for Medicare Part B. Here’s how Medicare covers telemedicine for these people.

Medicare outpatient coverage for telemedicine

Medicare has two original parts: Part A hospital coverage and Part B outpatient coverage. Telehealth services fall under Part B. Medicare Part B will cover a telehealth consultation whenever a consultation is medically necessary, and your Medicare doctor follows the guidelines in arranging the consultation.

The specialist must conduct your teleconsultation using two-way interactive communication that must include both live audio and video feeds. Fortunately, with the prevalence of digital technologies and telehealth platforms, this has become common practice for most healthcare organizations.

The Medicare beneficiary needs to live within designated rural areas, and the video conferencing call must be held at a designated originating site. Approved originating sites include your physician’s office or rural health clinic. Calls can also be conducted from within a federally qualified health center, a skilled nursing facility, inpatient hospital, critical access hospital or community mental health facility.

The process and re-imbursement to providers

If you as the provider, feel your Medicare patient would benefit from a telehealth appointment with a specialist or any remote physician, you can coordinate the call. If the patient is already in a healthcare facility designed as an originating site (as noted above),the doctor will help them initiate a call to the specialist or expert, which is called the Distant Site.

Medicare will pay for the telehealth consultation. It will also pay a facility fee or provider fee to the facility or doctor that is acting as the originating site. Medicare has made a list of the types of providers that are approved to provide consultations via a video chat. This list includes:

There is a set list of providers eligible to be paid by Medicare for telemedicine services. Medicare has an online tool that can confirm what providers are truly eligible for reimbursement.

Patient co-pays and co-insurance under Part B

While Medicare covers the bulk of a beneficiaries’ medical expenses, it doesn’t cover everything. Just like any other insurance, there are deductibles, co-pays and co-insurance that they are responsible to pay as they use medical services.

Part B has an annual deductible of $183 in 2018. Upon a patient’s first outpatient visit of the year,  they will satisfy this deductible first, and then Part B pays 80 percent of their covered expenses. This includes ordinary doctor’s visits and telehealth visits, as well as many other outpatient services.

If a patient enrolled in a Medigap plan, their supplement will pay some or all of the other 20 percent depending on which plan they signed up for.  A doctor sends his bills to Medicare. Medicare will process the claim, and if the claim is approved, Medicare will pay its share and forward the rest of the invoice to their Medigap insurance company, which will then pay its share.

While many people with original Medicare enroll in Medigap plans to help them with expenses, there is also another option. Some individuals opt out of original Medicare and get their services through a Part C Medicare Advantage plan instead.

Medicare Advantage plans pay copays for services as they go along. If a patient is enrolled in a Part C plan and they need a telehealth consultation, their network doctor can help them arrange an appointment with eligible providers who are also in the plan’s network. The plan’s Evidence of Coverage will outline what they  can expect to pay for such a consultation.

On the horizon

Every year Medicare releases a new proposal for doctor’s fees in the upcoming year. In this year’s proposal, CMS said it plans to increase the options for using virtual care. If the proposal’s suggestions are approved, we may find that telehealth becomes an even more routine part of care for older adults in rural areas.

Another area where telemedicine is particularly promising is in relation to re-admissions to inpatient hospital and skilled nursing facilities. It’s not uncommon for patients released from a facility to be readmitted to the hospital or facility within the 30 days following the discharge date.

Medicare’s coverage of telemedicine can help to reduce the number of patients returning to the hospital.  By allowing remote medical consultations with hospital or facility,  using video and other telehealth technologies,  this avoids unnecessary re-admissions and all the costs that come along with them.

Likewise, individuals who are living with chronic conditions in a long-term care facility can still see specialists or physicians for follow up appointments, from within the facility with the use of various telehealth technologies. Access to telehealth consultations increases the patient’s access to care that they might not otherwise have the opportunity to receive.

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