The majority of Medicare recipients receive their health insurance coverage directly from the federal government, through the Center for Medicare and Medicaid Services. However, the number of recipients opting to receive coverage through Medicare Advantage, a private insurance alternative, is rapidly growing.

CMS expects nearly 23 million people to enroll in Medicare Advantage (MA) plans in 2019. Although these plans are administered through private insurers, CMS rules place restrictions on what benefits the insurers may provide. These rules place limitations on MA telehealth benefits as well, restricting which telehealth services that are eligible for reimbursement.

What is The System Like Now?

In recent years, CMS has been reluctant, or sluggish at the least, to expand telehealth services to Medicare recipients. In 2018 and years prior, CMS severely limited the telehealth services for which they offered reimbursement, and for which they allowed MA plans to offer reimbursement. For basic Medicare plans, telehealth services are extremely limited. Individuals receiving telehealth must communicate directly with a doctor or another healthcare provider that is not at their location.

At first, that seems rather broad. But the restrictions begin to pile up upon closer inspection of the rules. Patients must live in designated “rural health professional shortage” areas and receive their telehealth services at preapproved sites – never can they receive treatment from their own home. Not only has this been inconvenient for patients, as they cannot receive care in their own homes, but it relieves very few burdens from the physicians since they must still make time to receive patients in their rural clinics and cannot receive reimbursement for other remote patient monitoring.

Medicare Advantage plans, until recently, haven’t had it much better. CMS has placed restrictions on what services MA plans can offer, so if they wanted to offer more telehealth services, the extra cost is paid for by the recipient. However, the new CMS rules that will take effect in 2020 are set to expand telehealth reimbursement and thus telehealth services.

What is The New Rule?


CMS issued their proposed rules over the summer and their finalized rules on November 1st, as open enrollment began. The proposed changes would drastically change eligibility for telehealth services for Medicare Advantage recipients. MA will now be able to offer telehealth services for a broad array of services and to patients who live in urban and rural areas (as opposed to only rural enrollees as it was before). As well, patients will be able to receive telehealth services from more locations, namely from their home, instead of having to drive to a CMS-qualified telehealth service center.

Through the new rule, Medicare recipients who receive coverage from a private insurer via Medicare Advantage will have greater access to telehealth services from the comfort of their own homes. Additionally, these benefits can now be offered on their MA plan as basic benefits instead of “additional telehealth benefits” – meaning MA enrollees could very well get these added services at a reduced cost to them.

How will Healthcare Providers Benefit?

As coverage of patients via telehealth expands, providers are certainly set to benefit. In 2019, CMS will roll out new billing codes (CPT codes) that will expand remote patient monitoring. Although CMS does not consider these services to be telehealth, they fall under the umbrella of many telehealth companies and telehealth programs run by hospitals. These codes expand which health professionals are qualified to analyze patient metrics and provide reimbursement for in-home setup of services. In 2020, these reimbursements to providers will likely expand further as MA patients will be eligible for more telehealth services.

All in all, healthcare providers will begin receiving reimbursement for many of the telehealth services they already offer, and providers not yet offering services can look to expand.