Reimbursement

Medicare

Congress remains pivotal in addressing telehealth limitations by considering legislation to remove geographic restrictions and expand eligible originating sites. While the Centers for Medicare & Medicaid Services (CMS) operates within existing laws, it continues to refine reimbursement policies through updates to the Medicare Physician Fee Schedule (PFS).

As of the 2025 PFS, CMS has implemented several notable changes:

  1. Expanded Telehealth Services List: New services like caregiver training and PrEP counseling have been permanently added to the Medicare Telehealth Services List. Safety planning interventions are now also included to support comprehensive care approaches.

  2. Extended Flexibilities: Temporary suspension of visit frequency limits for inpatient and nursing facilities has been extended, offering more consistent access to critical care consultations.

  3. Audio-Only Telehealth Options: Recognizing barriers to video-based telehealth, CMS will continue reimbursing for real-time, audio-only services under specific circumstances starting in 2025.

  4. Virtual Supervision: Permanent policies allow physicians to provide certain services via virtual “direct supervision” using interactive video technologies, a critical step in modernizing remote care for Medicare beneficiaries​.

Technological Innovations and Coding Updates

CMS continues to expand codes for telehealth and related services:

  • CPT Code Additions: CMS annually evaluates new codes, including public submissions with supporting evidence on equivalency to in-person care. For example, remote patient monitoring codes have been refined to clarify usage for chronic disease management, but they remain categorized separately from telehealth​.

  • Brief Communication Services: Codes for virtual check-ins, asynchronous evaluations, and interprofessional consultations have been maintained to encourage flexible care delivery methods.

Post-Pandemic Trends and 2025 Projections

The expiration of COVID-19-era waivers has necessitated adjustments to maintain telehealth’s accessibility:

  • Projected Growth: Telehealth utilization is expected to stabilize at higher levels than pre-pandemic rates. This reflects the expanded acceptance of virtual care in specialties like behavioral health and chronic care management​.

  • Equity and Access Goals: CMS policies aim to reduce disparities in telehealth usage by addressing technological barriers and supporting underserved populations​.

Advocacy and Projected Outlook

Stakeholders, including healthcare providers and telehealth advocates, are lobbying for further permanency in telehealth flexibilities. Proposals in Congress may address broader access and reimbursement parity issues in the coming years, making 2025 a pivotal year for shaping telehealth's role in U.S. healthcare​

For detailed guidance on specific codes or legislative developments, consulting organizations like the Center for Connected Health Policy or the National Telehealth Resource Centers can provide additional resources.

Download the current list of Medicare Telehealth Services List.

Medicaid

Medicaid is a medical assistance program for low-income patients funded jointly at the federal and state level. The vast majority of Medicaid policy is developed by states, though within federal guidelines—telehealth services must meet the federal Medicaid standards of efficiency, economy, and quality of care.

Because of this state-level freedom, each state has a different Medicaid program and a different way of reimbursing telehealth.

States can determine:

  • Whether or not to cover telemedicine

  • What types of telemedicine to cover

  • Where in the state it can be covered

  • How it is provided/covered

  • What types of telemedicine practitioners/providers may be covered/reimbursed, as long as such practitioners/providers are “recognized” and qualified according to Medicaid statute/regulation

  • How much to reimburse for telemedicine services, as long as such payments do not exceed Federal Upper Limits. (medicaid.gov)

To learn more about Medicaid reimbursement of digital health, contact our staff at info@ctel.org to learn more about our 50-state Medicaid reimbursement report. As with the federal government, state governments enacted temporary changes affecting telehealth to ensure access to care amid the coronavirus pandemic. Some states have taken steps to make those changes permanent after the Public Health Emergency has passed.

Evaluation of Telehealth Services that are Clinically Appropriate for Reimbursement in the US Medicaid Population: Mixed Methods Study

Private-Payer

There are no federal laws governing private insurance coverage of telehealth services, but at least 39 states and the District of Columbia have laws about reimbursement and payment parity. While not all states have laws requiring private insurers to reimburse for telehealth services, some states require that insurance reimburse telehealth services at the same rate as in-person services. Most states only require that the services be offered.

Coverage Parity

Requires payors to cover a service via telehealth if it is also covered in-person and can be delivered remotely while meeting the standard of care.

Coding and Payment

Payment Parity

Requires payors to reimburse for telehealth at the same rate as the equivalent in-person service.

Coding and reimbursement for telehealth services can be complex and challenging to navigate. With ever changing legislative parameters, it can be confusing to know which codes to use when and for which service. Below is a highlight of common CPT codes used in telehealth reimbursement:

Telehealth Visit

Telephone Evaluation and Management Service

Remote Monitoring

UnitedHealthcare Virtual Visits: Describes general coverage for telehealth visits for UnitedHealthcare plans. 

Aetna Virtual Care: Describes general coverage for telehealth visits for Aetna plans. 

Humana: Describes general coverage for telehealth visits for Humana plans. 

Online Digital Visits

Additional information telehealth and remote monitoring specific CPT and HCPCS codes are available on the AMA website, or simply reach out to CTeL for specific information related to CPT and HCPCS codes.

Our reimbursement and claims denial working group is also a trusted resource to our members, providing valuable insight and real-life application of each of these scenarios as well as process of advocating for additional CPT codes.

New Codes Added in 2025

  • 17 new telemedicine codes (98000-98016) in the Evaluation and Management (E/M) section:

    • New Patients (98000 – 98003)

    • Established Patients (98004 – 98007)

    • Audio-only for New Patients (98008 – 98011)

    • Audio-only for Established Patients (98012 – 98015)

    • Brief communication technology-based service (98016)

  • 7 new Category III codes for AI-augmented services:

    • Medical Chest Imaging (0877T – 0880T)

    • Electrocardiogram Measurements (0902T, 0932T)

    • Image Guided Prostate Biopsies (0898T)

  • New codes for skin grafts and wound care (15011–15018)

  • New codes for surgical techniques for elimination of abdominal tumors (49186–49190)

  • 96041 - New genetic counselor code (replacing 96040)

  • 9X091 - Virtual check-in encounters (replacing G2012-G2252)

  • GIDXX - New add-on code for infectious disease care

  • New codes for digital mental health treatment

    • GMBT1: Supply of digital mental health treatment device and initial education and onboarding per course of treatment that augments a behavioral therapy plan.

    • GMBT2: First 20 minutes of monthly treatment management services directly related to the patient's therapeutic use of the DMHT device, requiring at least one interactive communication with the patient/caregiver during the calendar month.

    • GMBT3: Each additional 20 minutes of monthly treatment management services directly related to the patient's therapeutic use of the DMHT device, requiring at least one interactive communication with the patient/caregiver during the calendar month.

    • These are new HCPCS codes proposed by the Centers for Medicare & Medicaid Services (CMS) specifically for digital mental health treatment devices and services. They are modeled in part on the existing CPT codes for Remote Therapeutic Monitoring (RTM) services and are intended to create a reimbursement pathway for FDA-cleared digital mental health treatment devices used in conjunction with ongoing behavioral healthcare treatment.

  • New codes for caregiver training and home INR monitoring

    • 96202: Initial 60 minutes of multiple-family group behavior management/modification training for caregivers of patients with a mental or physical health diagnosis, administered by a qualified healthcare professional, without the patient present.

    • 96203: Each additional 15 minutes of multiple-family group behavior management/modification training.

    • 97550: Initial 30 minutes of caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community.

    • 97551: Each additional 15 minutes of caregiver training.

    • 97552: Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community, with multiple sets of caregivers.

It's important to note that while these codes are being added, some existing codes are being replaced or deleted. For example, the old telephone-only codes (99441-99443) and HCPCS code G2012 are being replaced by the new audio-only and brief communication codes.

*Not an exhaustive list, for more information visit www.ama.org.

High Deductible Health Plans

The expiration of High-Deductible Health Plan (HDHP) telehealth waivers on December 31, 2024, marks a significant turning point in healthcare access and affordability. These waivers, introduced through the CARES Act in 2020 and extended via the Consolidated Appropriations Acts (CAA) of 2022 and 2023, allowed HDHPs to cover telehealth services pre-deductible without disqualifying participants from contributing to Health Savings Accounts (HSAs).

With the waivers now expired, patients and providers are grappling with the realities of increased costs, reduced access to care, and operational disruptions. Below, we analyze the current impacts and explore potential pathways forward.

Now what?

The expiration of the HDHP telehealth waivers has introduced significant challenges for patients, providers, and the healthcare system. Increased costs threaten to diminish telehealth’s role as a cornerstone of accessible care, while operational and financial disruptions strain healthcare providers.

To safeguard the progress telehealth has made in transforming healthcare delivery, stakeholders across the spectrum—policymakers, employers, and providers—must collaborate on solutions that prioritize affordability and access. Restoring a safe harbor for telehealth is not just a policy imperative but a necessary step toward ensuring equitable and sustainable healthcare for all.