CMS Identifies Barriers to Telehealth Use for Medicare Fee-for-Service Beneficiaries

In a recent blog post, CHQI examined the overall findings from a new telehealth report published on November 15, 2018 by the U.S. Centers for Medicare and Medicaid Services (CMS) that included data analysis highlighting current utilization, areas of growth and opportunities for improvement. The CMS report highlights how telemedicine and telehealth services are expanding for Medicare beneficiaries.

As a follow-up, this blog discusses opportunities to expand telehealth services for a significantly wider population of Medicare Fee-for-Service (FFS) beneficiaries if policies and regulations limiting payment were further revised. On October 26, 2018, CMS proposed new rules to modernize how telehealth services are offered by Medicare Advantage plans and allow such plans to offer as a basic benefit additional telehealth services not otherwise available to Medicare FFS beneficiaries. Many of these recommendations, however, were not extended to Medicare FFS arrangements.

Restrictions on reimbursement for telehealth as a separate billable service are broad and still adversely impact many Medicare beneficiaries who could otherwise benefit. For example, 80% of those using telehealth services through Medicare FFS today are white and reside in rural areas. Clearly, opportunities exist to increase the use of telehealth services for minorities who live in urban, among other targeted populations. Fortunately, CMS continues to improve access and eliminate disparities through its recent telehealth rulemaking, but more work needs to be done.

As highlighted in the CMS report, restrictions that have served to stymie greater utilization of telehealth in Medicare FFS relate to what qualifies – and does not – for reimbursement as a separate billable service and relate to where, who, what and how. The “why” of the barriers is largely due to Medicare’s pace in adopting new services and technology, often due to increased cost expectations.


The two most significant barriers are requiring the originating site to be in specific types of rural areas and not permitting one’s home to be an originating site.

 Healthcare Setting (Originating Site)

Reimbursement has only been allowable when the beneficiary is in certain settings when they receive a telemedicine service. Settings under current law are “offices of physicians or practitioners, hospitals, critical access hospitals, rural health clinics, federally qualified health centers, hospital-based critical access hospital-based renal dialysis centers (including satellites), skilled nursing facilities, and community mental health centers.”

 Geographic Area

Reimbursement is also available only when furnished to a beneficiary at an originating site located in certain geographic areas: a rural health professional shortage area (HPSA), a county outside a Metropolitan Statistical Area (MSA), or a site participating in a Federal telemedicine demonstration project approved by (or receiving funding from) the Department of Health and Human Services as of December 31, 2000.

Who: Practitioners

Only certain types of practitioners have been eligible to receive payment for telehealth services: physicians, nurse practitioners, physician assistants, nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, clinical psychologists, clinical social workers, and registered dieticians or nutrition professionals.

 What and How:

 Types of Services

Separate payment for telehealth services under Medicare FFS are limited to those on the list of approved Medicare telehealth services and generally include office visits and consultations plus in-office psychiatry services. These must be provided through a real-time interactive audio and video telecommunications system permitting two-way communication between a Medicare beneficiary and a physician or other specified practitioners.

Additions to the list are made annually through the Medicare Physician Fee Schedule (PFS) public notice and comment process. Effective January 1, 2018, telehealth services eligible for payment also now include: health risk assessment; care planning for chronic care management, and psychotherapy for crisis.


Stakeholders have identified as a barrier that telehealth services must be paid at the same rate as an in-person visit.

No one would ever accuse Medicare of being a “nimble” program but there’s recognition that beneficiaries could clearly benefit from greater access to telehealth services especially the rapidly growing age 85 and older group, persons with disabilities, and those with co-morbidities. Also, access and disparities could be addressed for urban residents.

Next up on the blog, CMS changes designed to overcome barriers.

Leave a Reply

Your email address will not be published. Required fields are marked *