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New Medicare Law Requires In-Person Visit for Telehealth Coverage
In December 2020, the Consolidated Appropriations Act of 2020, section 123 includes language that requires behavioral health providers to have seen their client in person during the prior six months before a telehealth visit will be covered by Medicare. Further, providers must have in-person visits on a “regular interval” to be determined by the Health and Human Services Department for telehealth visits to be covered by Medicare.
As discussed in the blog by Nate Lacktman, a partner at Foley & Lardner who chairs the Telemedicine and Digital Health Industry team “the in-person exam requirement is at odds with a direction that telehealth policy has moved over the last decade. It disrupts Medicare’s historical approach which is to defer to state laws on professional practice requirements and clinical standards of care.” (Click here for more information on state telehealth medicare laws.)
Going Backward with Telehealth?
While requiring in-person visits to establish the doctor-patient relationship was a part of many states’ telehealth medicare laws in years past, the trend has been moving towards allowing providers to see new clients via telehealth for the first visit. Enter COVID-19 and the emergency measures put in place to allow for greater coverage and access to healthcare. Many mental health providers closed their brick-and-mortar offices and have guided their new and existing clients to telehealth use to reduce the spread of the virus. (See Virtual Waiting Room.)
What Happened to Parity?
More confounding is the fact that Section 123 of the bill applies only to mental health treatment and not to patients seeking other medical services. Provider reimbursement for mental health services is being predicated on this requirement, in spite of the Mental Health Parity and Addiction Equity Act and years of work to establish mental health parity.
A Hindrance to Accurate, Safe Assessment
This requirement in section 123 is at odds with providing a safe environment in which to establish a positive client-clinician relationship. Especially now during the pandemic, clients are presenting with anxiety related to contracting the virus. Sitting in a small office, provider and client sitting at least six feet apart for 50 minutes with masks on, makes little sense. An integral part of the initial assessment, clinicians depend on visual cues from client facial expressions that are largely hidden by a mask. Moreover, providers wearing masks will have a more difficult time conveying warmth and empathy; so critical to establishing a connection in the first session. Many times clients are in emotional pain, crying and blowing their noses, adding to the potential for viral spread. Many providers’ offices are outfitted with comfortable fabric chairs that don’t allow for thorough cleaning between clients, making the environment potentially riskier.
Medicare Law: Does Section 123 Actually Block Access to Care?
Clients qualifying for Medicare may be seniors with pre-existing medical conditions. They may want therapy to help cope with the very same physical disabilities that prohibit them from being able to go to a provider’s office. (Click here for more information on helping disabled clients via telehealth). Other clients may also have pre-existing conditions that make them more vulnerable to contracting the virus if they must leave their homes to attend an in-person appointment.
Counselors Still Restricted
Under the current Medicare law, counselors continue to be excluded from being reimbursed by Medicare for providing counseling services. Only psychiatrists, psychologists, clinical social workers, and psychiatric nurses are allowed to bill Medicare for counseling services provided to Medicare beneficiaries. Although many attempts to pass Medicare laws to include counselors as Medicare providers have been attempted over the years, none has been successful. On January 21, 2021, however, Rep. Mike Thompson (CA- 05) and Rep. John Kato (NY-24) reintroduced the Mental Health Access Improvement Act, a bipartisan bill that would allow counselors and marriage and family therapists to become Medicare providers. See
Why Restrict Access to Care During a Behavioral Healthcare Provider Shortage?
While nearly all of the changes that have been made by the federal and state governments to expand telehealth as a result of the pandemic have been helpful in making telehealth more widely available to deliver medical care, section 123 appears to be illogical and care blocking action to behavioral healthcare. Further, with the shortage of mental health providers, especially at this critical juncture with the pandemic creating increasing levels of depression, anxiety, grief, and suicide, counselors are needed more than ever to assist those of the 62 million Medicare beneficiaries in need of mental health care.
An article in the New York Times, February 17th titled “Nobody Has Openings:” Mental Health Providers Struggle to Meet Demand describes how overloaded behavioral health providers have become since the pandemic began. Many are not able to take on new clients and waiting lists stretch out months for many providers. Read the full story here. By passing the Mental Health Access Improvement Act, and allowing the well over 100,000 licensed counselors and marriage and family therapists to render services to Medicare beneficiaries, legislators have an opportunity to create significant gains in access to mental health care for millions of Americans.
What to Do if You Support Counselors Getting Medicare Reimbursement??
Write a letter to your elected officials about this issue today. Here’s how:
- Write to the legislators for whom you can vote. You will find them by searching the Internet by your state or territory of official residence, followed by “.gov” such as California representatives.gov. Alternatively, you can search for Representatives or Senators HERE.
- Keep it brief: Letters should never be longer than one page
- State who you are and what you want upfront: In the first paragraph, tell your legislators that you are a constituent and identify the issue about which you are writing.
- Address your letter correctly. Be sure you use the correct address and salutation. All Presidential appointees and Federal- and State-elected officials are addressed as The Honorable. (b) All Mayors are addressed as The Honorable. However, as a general rule, county and city officials are not addressed as The Honorable. For example, “The Honorable (Full Name), Governor of (State).”
- Be polite and avoid ultimatums and rudeness.
- Do not enclose additional material.
- Do not exaggerate or lie.
- Make sure your message is timely.
- Address only one issue per letter. …
- Ask for something specific. …
- Make it personal. …
- Restate your request at the end of the letter, for example urging them to support or oppose the bill.
- Thank the legislator for his or her support and offer to address any questions that he or she might have.
- Be sure to include your contact information, and sign the letter.z
See Telehealth.org’s Medicare Telehealth Reimbursement: Act Introduced to Allow Counselors to be Reimbursed by Medicare for a legislative update on the issue of counselors becoming eligible for Medicare reimbursement.
Basic Telehealth Clinical Best Practices
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I agree that it is ridiculous to expect anyone to insist on an in-person session every 6 months. At age 68 I had a total hip-replacement. Months before that I had started Teletherapy with a disabled client because I could no longer get her electric wheelchair out of her van and assist her into my office. She is a Champus paid client, so I have never been denied payment for services. I see a largely aging population several of whom are disabled and Teletherapy has been a huge benefit to them and has helped protect me as well during the pandemic. The only issue I have had are usually technical, poor reception on my encrypted Video/Teletherapy service (SIGNAL). If I stop getting paid for Teletherapy I will have to retire sooner than I expected which only adds to the therapist shortage.
Katherine, Thank you for taking a moment to comment. Many other therapists are in the same boat. Telehealth allows greater access to care for clients and patients, AND allows therapists greater and longer-term access to their caseloads.
I am confused. Has this law already been passed or is it still being considered?
So how will this work with the new PsyPac rules? I have been able to work with my clients across state lines to provide care. There is no way we can meet every six months. I guess I could justify a trip to Arizona and meet with clients there once every six months….But if they really want to address dealing with rural areas, even a state like Colorado…it is a long way for many of my clients to see me…Government…where the heck are their brains??? They make one thing work, and then they undo it…..
What does this mean for initiating services for new clients? During the pandemic, I am assuming this law remains not in effect.
Does this also apply to Medicare Advantage members? Do we need to scramble to see these clients in person ASAP? I haven’t been vaccinated yet and my medicare clients are just starting to get them.
I am not sure what professionals across the country are doing about this, because I think most people don’t know about it. We at TBHI pride ourselves on being the #1 news source for professionals with regard to telehealth, and behavioral telehealth in particular. Our news is often waay ahead of actual enforcement.
I am sure that if Medicare wants this to stick, much more information will be forthcoming about it in the months to come. I for one would certainly not scramble to meet anyone in person at this point, with or without the vaccine.
I encourage you to seek more information and in the meantime, write to your legislators, and come back to report any other news if you learn anything helpful. This blog is moderated to keep our irrelevant comments and is open to everyone for free to exchange information.
Does this law only apply to Medicare patients? It is a shame when patients are fearful during the pandemic to come face to face to office.
How can we as a group address this?
Kenneth Corbin, BCCC,BCPC,LCSW-R
Hello Kenneth, Yes, this law only applies to Medicare patients. The thing to note is that other carriers have their own rules, and they not only differ from one to another but also differ within the same company from state to state. We have many other posts here at TBHI about insurance companies and COVID. You can search for them using the search bar on our page. Best regards to you!
Since mid-March 2020 the clinic where I practice has been completely virtual secondary to Covid-19 precautions. As I understand it, the US is still under a health emergency condition. it has been almost one year since I’ve seen patients in person. What are the dates of the 6-month period during which I must see Medicare patients face-to-face?
Once every six months in person right in the middle of a pandemic or are they willing to wait for this to end before implementing in person visits?
I agree and am giving approval for my comment to be sent to my legislators. An in-person visit every six months for Medicare beneficiaries makes no sense, and I believe is dangerous. Especially with the new COVID variants that are emerging now, we should not be requiring people to enter enclosed spaces, even with masks and hepa filters. CDC guidelines discourage this kind of exposure, and so do I. It’s a civil rights issue, in my opinion, to require endangerment of our senior citizens and disabled folks in order for them to secure their entitlement to teleheatlh mental health benefits that other groups can receive without that endangerment.
Sherry, Thank you for posting. We at TBHI do not have the funding to arrange a campaign to contact legislators for our readers, so I hope you are not thinking that we will do that for you? And BTW, I agree with you 100% that it doesn’t make sense to ask professionals in the behavioral world to meet with people every six months. When we learned of this ruling we thought it essential that we let everyone know and ask that everyone contact their legislators through this blog.
Does this apply to places that are considered rural areas with lack of providers where access to a Medicare provider is an issue?
Sarah, While we offer a variety of services at TBHI, including the publication of this telehealth-focused blog, weekly and monthly newsletters, and consulting to research issues that our readers cannot research on their own, but first, we encourage you to: speak with your billing service if you have one, or contact Medicare directly for details of how this new law applied to you. As mentioned in the article, contacting your legislators is very important if you have objections to how this current law reads. We also will make your question visible in the blog to encourage other professionals to respond to you here if they have relevant information that can help you.
Question: So, if I have been working with a client for many years who happens to be on Medicare, and until this past year, we have always been face to face, am I to understand that in order for me to continue to be reimbursed, we must meet face to face every 6 months?
This makes absolutely no sense to me at all.
Tanya Lentz, LISW
Yes, you are right. As the law reads now, to continue being reimbursed, you must meet face to face every 6 months with all your Medicare patients. The absurdity of this law needs to be addressed by our community ASAP, which the reality is sinking in and legislators are focused on advancing telehealth.
This why we at TBHI have gone to great lengths to disseminate this information. We need to advocate for ourselves in writing by sending a letter to our legislators, state and national associations.