Telehealth, and how it is covered

Remote consultation moved from a marginal service to a routine one within a very short period, and the coverage rules have been catching up unevenly since.

The current landscape

Most commercial plans cover telehealth, and the terms vary considerably.

Some cover it at the same cost sharing as an in-person visit. Some at lower cost sharing, to encourage use. A few at higher, or with limits.

Many plans contract with a dedicated telehealth vendor, offering visits at a low flat fee, separate from the general network.

Coverage frequently differs by service type: general medical consultation, mental health, specialist consultation, and remote monitoring are treated differently.

Mental health specifically

The area where telehealth has had the largest effect, both in access and in coverage.

Remote therapy and psychiatric consultation are now widely covered, and for many people they are the only realistic route to care given provider shortages.

Mental health parity requirements generally require that limits on mental health benefits be no more restrictive than those on medical benefits, which extends to telehealth in most analyses.

If a plan covers medical telehealth and restricts mental health telehealth more tightly, that is worth questioning.

The licensing constraint

An issue people encounter unexpectedly.

Clinicians are generally licensed by state and must be licensed in the state where the patient is located at the time of the consultation.

Which means a therapist in one state generally cannot treat a patient who has travelled to another, even temporarily.

Interstate compacts exist for several professions, easing this in participating states, and coverage is not universal.

Practical implications: tell your clinician if you will be elsewhere; students at university in another state may need a local provider; and people who move states may need to transfer care.

What works well remotely

Follow-up consultations for stable chronic conditions.

Medication management and prescription renewals.

Mental health therapy, where evidence generally supports comparable outcomes to in-person for many conditions.

Triage and advice about whether in-person care is needed.

Dermatology consultation with good images.

Review of test results.

Specialist consultation where physical examination is not central, which reduces travel for people in rural areas.

What does not

Anything requiring physical examination, palpation or procedures.

Emergency presentations, which require in-person assessment.

Situations where vital signs, imaging or laboratory work are needed immediately.

First consultations for undifferentiated symptoms, frequently, though this varies.

A good telehealth clinician will tell you when you need to be seen in person, and that referral is a sign of quality rather than a failure of the service.

Cost considerations

Check whether telehealth applies to the deductible or is covered by copay.

Check whether the plan's dedicated telehealth vendor is cheaper than a virtual visit with your own physician, which it frequently is.

Note a specific interaction for people with health savings accounts: rules permitting high deductible plans to cover telehealth before the deductible without disqualifying HSA eligibility have been subject to temporary provisions with expiry dates.

Check the current position if you have an HSA, since a plan covering telehealth pre-deductible could affect eligibility if the relief has lapsed.

Direct-to-consumer services

A growing category of services sold directly rather than through insurance — subscription primary care, mental health platforms, and services focused on specific conditions.

Points worth considering.

Payment is generally out of pocket and may not count toward your deductible.

Continuity with your regular care may be poor, and records may not flow to your usual physician.

Prescribing practices vary, and services with a commercial interest in prescribing a particular product warrant scrutiny.

For straightforward needs and for access where none exists, they are useful. As a substitute for a continuing relationship with a physician who knows your history, less so.

Making a remote consultation useful

Prepare. Write down your symptoms, their timeline, your questions and your current medications.

Have your own measurements if relevant — blood pressure, temperature, weight, glucose readings.

Use good lighting and a stable connection, and be somewhere private.

Take photographs in advance if the issue is visible, since live video quality is often poor for skin conditions.

Ask what the plan is if the problem does not resolve, and how to escalate.

Request that the notes be shared with your regular physician.

The equity issue

Worth acknowledging.

Telehealth requires a device, a connection, some digital literacy and a private space.

The people with the greatest difficulty accessing in-person care are frequently the same people with the least access to reliable connectivity, which limits how much of a solution it is.

Audio-only consultation, where covered, addresses part of this, and coverage for audio-only varies by plan and payer.

General information about insurance coverage, not insurance or medical advice. Telehealth coverage rules, licensing requirements and tax provisions vary and change. Consult your plan documents and your clinician.