Navigating the Insurance Maze

The Therapist's Complete Guide to Working with Insurance - And Whether You Should

by Barbara Griswold, LMFT

The Public Health Emergency Ends May 11th: What Does it Mean for Us?

By Barbara Griswold, LMFT (April 3, 2023, updated April 24, updates in red)

You may be aware that the Biden Administration has announced that the federal COVID Public Health Emergency (PHE) will end on May 11, 2023.  What will this mean for you and your clients?

TELEHEALTH PLATFORMS: During the PHE, the government looked the other way when we used telehealth platforms like Facetime and the free versions of Skype and Zoom that are not compatible with the Health Insurance Portability and Accountability Act (HIPAA). Enforcement of penalties on providers for HIPAA-noncompliance was scheduled to resume on May 11th.  However, on April 11th, the federal government announced they would allow a 90-day transition period for providers to come into compliance with the HIPAA telehealth platform rules. This gives you until August 9, 2023 to get in compliance.  During that time, the government with “continue to exercise its enforcement discretion and will not impose penalties on covered health care providers for noncompliance with the HIPAA Rules that occurs in connection with the good faith provision of telehealth.”  By August 9th, we should all be using a telehealth platform that claims HIPAA-compliance and offers a Business Associate Agreement (BAA).  Just to be clear, this extra three months only applies to telehealth platform compliance, not to other aspects of HIPAA, where compliance will be enforced.

Here is a partial list of some that claim HIPAA-compliance, but you must have a BAA in place with them:

CONSENT: As of November 2022, 45 states, DC, and Puerto Rico include some sort of telehealth consent requirement in their state laws or Medicaid policies. If you aren’t having each telehealth client sign a written telehealth consent, I STRONGLY recommend it, and you may need it to follow the law (I have a sample telehealth consent in my Practice Forms Packet).

PRIVATE HEALTH PLANS:

  • For your clients with private health insurance, the federal PHE may not matter much, as the federal PHE only directly governs federal plans like Medicare.  Private plans may look more to the status of state emergency orders (most of which have already expired), state laws, and their own policies.
  • As of November 2022, 7 states have no law requiring private health plans to cover telehealth.  Those states are Alabama, Idaho, North Carolina, Pennsylvania, South Carolina, Wisconsin, Wyoming.
  • In some states like California, in-network telehealth services are mandatory for state-regulated commercial plans, but reimbursement for out-of-network telehealth will no longer be mandated.  Out-of-network telehealth may continue to be covered, depending on each plan’s policies (check with each plan directly).
  • Plans may require a physical office address for in-network provider directory listings. This requirement was suspended in many states during the PHE to protect the privacy of providers working from home. Some insurers may not accept a home address as your office address (check with each plan directly).
  • Health plans may require credentialing/approval for providing telehealth services in addition to the regular network credentialing process. Telehealth credentialing was suspended by many plans during the PHE.
  • Payment Parity requires that telehealth sessions are reimbursed at the same rate as in-person visits.  During the pandemic, many states temporarily required payment parity. While some states have now made it permanent, as of March 2023, only 21 states require payment parity from private payers, 6 states have payment parity in place with caveats, and 23 states have no payment parity (click here for more info).This means clinicians in many states may now find that telehealth is reimbursed at a lower rate than in-person sessions.

MEDICARE:  As I reported in January, President Biden signed the omnibus spending bill into law (HR-2617) in December 2022, which extended Medicare telehealth provisions put in place during the COVID-19 PHE for another two years. Advocates hope this extra two years will give them time to convince Congress to make telehealth coverage permanent.

Key Medicare provisions include:

    • All eligible Medicare providers may continue to provide telehealth at least until December 31, 2024.
    • The in-person screening requirement for Medicare clients will not be required until at least December 31, 2024.  Bills have been introduced in Congress (S-4965 and HR-8497) that seek to permanently remove this requirement for mental health services.
    • Other telehealth flexibilities in Medicare that have been extended to December 31, 2024, include temporary suspension of the geographic site requirement, and continuing to allow the home as an eligible client site.
    • The use of the phone (audio-only) to provide mental health services has been approved permanently.
    • During the pandemic, Medicare telehealth visits have been paid at the same rate as in-person. These higher rates are scheduled to end at the end of 2023. Telehealth rates may then be reduced unless lawmakers extend the policy.
    • For more info on the spending bill, read the article from the Center for Connected Health Policy

MEDICAID:   

  • All 50 states and Washington DC provide reimbursement for some form of live video in their Medicaid fee for service programs.
  • As of October 2022, 34 state Medicaid programs and DC reimbursed for audio-only telephone in some capacity, though often with limitations.
  • LOSS OF COVERAGE ALERT!!!  During the pandemic, Medicaid enrollment grew 28%, in part due to worsened economic conditions, Medicaid expansion in several states, increased federal Medicaid funding, and legislation that did not allow states to disenroll Medicaid recipients. However, March 31, 2023, was the end of this legislation. Now, the Center for Medicare and Medicaid Service (CMS) estimates that more than 15 million recipients will suddenly lose Medicaid coverage as they are booted off the Medicaid rolls. And many clients won’t realize they have lost their Medicaid coverage until they use a service. “The client may not have received notification from the state, for instance, if they moved and didn’t update their information,” says Susan Frager, certified biller and owner of YourBillingBuddy.com. “Verify your client’s Medicaid eligibility every session – at least for the next few months,” advises Frager.  “If you verify prior to service and find that their eligibility is lapsed, you will have time to make financial arrangements with your client, and will not be blindsided by denials.”
  • A new federal government determination allows Medicaid and CHIP programs to cover interprofessional consultations, such as those between primary care doctors and behavioral health clinicians. Both providers could potentially be reimbursed for a consultation.  Note that it will be up to each state to decide if and how they implement this allowance — there is no requirement to cover consultations.

STAY UP TO DATE with the ever-changing rules of telehealth!  Subscribe to my e-newsletter here and to The Center for Connected Health Policy’s Updates — click here

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