During the first year of the COVID-19 pandemic, many states took measures to encourage greater use of telemedicine. Most took administrative action to respond quickly, but these efforts were temporary. Initial responses were often broad: requiring or allowing coverage of audio-only (i.e., telephone) services, waiving or limiting cost sharing, and requiring reimbursement parity between telemedicine and in-person services.
To understand how states have proceeded with longer-term policy changes to their individual and group health insurance coverage requirements regarding telemedicine, we reviewed legislation and regulation enacted since March 2021. To date, at least 25 states have adopted new legislation or amended their existing telemedicine requirements. Many have taken more nuanced approaches that reflect experiences with telemedicine early in the pandemic.
More States Allowing Telephone Visits Than Before the Pandemic
As was the case with the temporary orders, the biggest area of permanent change is adoption of laws requiring coverage of audio-only telephone visits. At least 20 states took action to allow or require coverage of telephone visits. Telephone visits are essential to reach the 42 million who lack broadband access, individuals who lack devices for video visits, and people unfamiliar with video technology, like many older adults. But while temporary measures generally allowed or required coverage of telephone visits without restriction, permanent legislation often includes limits. For example, Arizona authorizes telephone visits only when video-enabled visits are not available. Nevada requires insurers to cover telemedicine visits as they would in-person visits but allows insurers to limit reimbursement for telephone visits.
Some states also have incorporated new consumer protections for telephone visits. Some consumers had reported that they were surprised to get a bill for a telephone call with their provider during the pandemic. New laws in Arizona and Washington require providers to notify patients if there will be a charge for a telephone call before initiating the visit.
State Action Singled Out Behavioral Health Services
During the pandemic, telemedicine accounted for 40 percent of behavioral health visits and it continues to play a dominant role in the delivery of behavioral health. Some recent state action specifically recognized the essential role of telemedicine in delivering behavioral health services. For example, Nebraska and Arizona exempted behavioral health care from laws that otherwise prohibit or limit the use of telephone visits. California allows patients who are receiving telehealth services for a behavioral health condition to choose to continue to see that telehealth provider rather than use their insurer’s dedicated telemedicine provider.
States Adopted Protections to Preserve Patients’ Access to Their Providers
While virtual visits can be more convenient, some consumers may prefer an in-person visit, including consumers who do not have privacy at home for a telemedicine visit. Illinois and Oregon adopted legislation that prohibits insurers from requiring patients to use telemedicine when the enrollee prefers an in-person visit. A growing number of insurers are promoting visits with dedicated telemedicine networks over virtual visits with traditional network providers, often with lower cost sharing or a requirement that patients use a virtual provider before or instead of an in-person visit. In response, Illinois and Arkansas prohibit insurers from requiring patients to use a dedicated telemedicine provider instead of their regular network provider. Arkansas’s new law also prohibits insurers from charging patients more to see their regular network provider rather than a dedicated telemedicine provider.
States Recognized Equity Considerations
Research has shown that telemedicine use has not been equitable. Patients with limited English proficiency and those with disabilities are more likely to face barriers. Data show lower-income and Black patients were more likely to use telephone visits, and higher-income and white patients were more likely to use video-enabled calls. Oregon’s law requires insurers to provide additional assistance in accessing telemedicine for patients who need an accommodation because of disability, advanced age, or limited English proficiency. Insurers in Oregon also must ensure telemedicine services are culturally and linguistically appropriate. Illinois law requires regulators to report on whether telemedicine improves access, reduces health disparities, and promotes health equity.
States Are Monitoring Telemedicine’s Effects on the Health Care System
During implementation of emergency telemedicine requirements, states had sparse data on utilization. Little was understood about who was using telemedicine and for what services, and the effect it would have on cost and utilization. With recent legislation, states have begun to require data reporting. For example, Oregon law requires a report on the impact of the requirement for reimbursement parity between in-person and telemedicine visits on health insurance premiums. Additionally, Arizona, Illinois, Rhode Island, and Washington directed expert bodies to make recommendations on future policies, including use of telephone visits and reimbursement parity.
Seeing the value of telemedicine for patients and providers, states are adopting permanent changes to their telemedicine coverage requirements. Where pandemic-era policies aimed to bolster coverage with few restrictions, longer-term policies are often narrower in scope while including more consumer protections. State laws also are requiring data to monitor telemedicine’s effects so that future policy changes can further refine telemedicine availability and use.