Telehealth Payer Policy in Response to COVID-19

Payers should cover all forms of telehealth (live video, storeand-forward, remote patient monitoring, telephone care and electronic consults). This should include live audio/visual or audio (telephone) only. Payers should also explicitly pay for virtual check-ins and e-visits.

There should be no restrictions on originating sites where the patient can be located—in particular during this time of social distancing, states and payers should ensure payment for services that take place at the patient’s home. Clinicians should also be free to provide telehealth care to patients from locations other than their normal clinical settings (office, hospital, etc.), to ensure maximum clinician flexibility (ie, pediatricians thus can treat patients during a time of proactive self-quarantine or other social distancing).

A small number of states and payers may maintain geographic restriction requirements that could limit payment for telehealth care to a rural or underserved area. Such requirements should be lifted to ensure payment for all patients, no matter their physical location in the state.

There should be no restrictions for either established or new patients to receive services via telehealth. To the extent feasible and in order to create and maintain direct linkages to the medical home, providers can attempt to see new patients via video whenever possible.

No. Particularly during this time of crisis and social distancing, all patients with all conditions and concerns should be able to be seen via telehealth care when clinically appropriate.

During this time of crisis, states and payers should not limit the types of licensed clinicians available to treat via telehealth as long as the services provided are clinically appropriate. Children must have access to all services they need during this crisis.

Medicaid and other payers must ensure coverage of payment to the pediatric medical home and pediatric medical subspecialists and surgical specialists, and not default to such vendors. This will ensure appropriate and continued linkages between pediatricians and the children in their care.

During this crisis, states and payers should follow the HHS OCR March 17 guidance and subsequent HHS OCR FAQ and allow for the use of apps and platforms for good faith telehealth care use. Of note, these could include end user-to-end user apps such as FaceTime, Skype, Facebook Messenger, Google Hangouts Video, and others. These notably do not include public facing apps/platforms such as Facebook Live or TikToc. As always, providers should take every effort to protect patient information, and use HIPAA-compliant platforms whenever possible.

There should be no restrictions for when a patient may be treated via telehealth care in relation to when they had their last or will have their next face-to-face visit.

As several carriers have adopted new modifications in response to COVID-19 for a 90-day period, pediatricians are advised to monitor whether timeframes will be extended. Several states have indicated that Medicaid telehealth care policy changes will remain in effect as long as there is a state emergency, but pediatricians and chapters should again monitor notifications for changes.

The Academy has created a useful reference for coding and billing with respect to COVID-19. Please see “Coding for COVID-19 and Non-Direct Care” or contact the Academy at COVID-19@aap.org for targeted consultation.

To the extent possible, states and payers should work together to ensure the same coding/billing requirements so that practices do not have to change administrative procedures for different payers. Please keep in mind that if a payer requires the reporting of a code outside of its intended use, practices should be sure to obtain this requirement in writing from the payer as this will provide documentation in the event of an audit.

The Academy strongly recommends payment for telehealth care visits be set at parity with payment for in-person visits. In response to the COVID-19 crisis, some states are beginning to adopt such a parity requirement, and many payers may already do so. Telehealth care in pediatrics requires medical judgment and is associated with practice expense and medical liability risk. Particularly during this time of crisis, payers should not be disincentivizing telehealth care by providing less than appropriate payment. To ensure pediatricians can provide telehealth visits to the same extent as in-person visits, payment for telehealth care visits should be set at parity with that of in-person visits AAP chapters, pediatric councils, and members should advocate to achieve such payment parity. Of particular note, Medicaid programs that move to pay for telehealth care at parity can avoid filing a state plan amendment (SPA) to do so.

Payers should recognize that pediatricians have in many cases already begun providing telehealth care during the COVID-19 crisis and should make payment and payment parity retroactive (ie, to an established start date such as the date of your state’s emergency declaration, January 31 National Public Health Emergency, or March 13 national emergency).

Yes. Payers should pay the originating or distant site a transmission or facility fee, or for other associated costs. Medicaid should pay for such services via an additional payment or separate administrative expense.

Yes, during this time of crisis, telehealth care should be delivered without the added burden of cost sharing. Medicaid, CHIP, and private insurance payment amounts for telehealth care visits should be inclusive of what might otherwise be cost sharing amounts, so that waived cost sharing does not become a financial penalty for providers.

For useful reference, the above guidance can also be found in the AAP Guidance Checklist on the first page. As always, the AAP is here to help as chapters and members advocate for changes in telehealth policy. Please continue to contact COVID-19@aap.org with all related questions.