Insurance and Telehealth

Telehealth coverage by US insurance is a moving target. Parity laws vary by state, Medicare rules have changed substantially since 2020, Medicaid varies more, and employer plans run on their own terms. This page describes the landscape and the practical steps for understanding what your plan covers.

The short version

State telehealth parity laws determine whether commercial plans must cover services delivered remotely on the same terms as in-person.
Medicare telehealth flexibilities, expanded during the COVID-19 public health emergency, have been partially extended; the precise rules continue to evolve. Check current CMS guidance.
Medicaid telehealth coverage varies significantly by state.
The No Surprises Act protects against many surprise bills from out-of-network providers in specific situations.
Always read the explanation of benefits (EOB) — it is not a bill, but it tells you what the insurer paid and what you may owe.
Most denials are appealable through internal then external review.

Parity laws (state level)

"Parity" in the telehealth context means an insurer covers a service delivered by telehealth on the same terms as the same service delivered in person. Most states have some form of telehealth parity law for commercial plans, but the laws vary in important ways:

Coverage parity — must cover telehealth services that would be covered in person.
Payment parity — must pay the same rate for telehealth as for in-person.
Some states require both; some only one; some require neither.
Modality matters: audio-only ("phone") may or may not be covered on parity terms.
Self-funded employer plans (governed by ERISA) are not subject to state insurance laws and follow their own terms.

The state's department of insurance is the regulator for fully insured commercial plans. If a fully insured plan is denying telehealth coverage in a state with parity, the department of insurance is where complaints go.

Medicare

The Centers for Medicare and Medicaid Services (CMS) administers Medicare. Pre-pandemic, Medicare telehealth coverage was tightly limited — restricted to certain rural settings and specific originating sites. The COVID-19 public health emergency triggered substantial expansions: more services covered, audio-only allowed for many services, broader patient locations including the home, and waivers of geographic restrictions.

After the public health emergency, Congress and CMS extended many of these flexibilities through specific dates, and some have been made permanent for specific services (notably mental health). Other flexibilities have or will sunset. The exact status of Medicare telehealth coverage has shifted multiple times since 2023, and is the most likely part of this page to change quickly. For current coverage, the best sources are CMS guidance, the practice's billing office, and 1-800-MEDICARE. See telehealth with elderly parents for caregiver context.

Medicare Advantage plans can offer telehealth benefits beyond traditional Medicare, and may have their own networks and rules. Coverage details are plan-specific.

Medicaid

Medicaid is jointly funded by the federal government and the states, with significant state discretion in coverage rules. Telehealth coverage in Medicaid varies substantially state to state. Most states cover at least some telehealth services for at least some categories of patients; the breadth, modality (live video vs. audio-only vs. asynchronous), and provider types covered all vary. State Medicaid agencies publish telehealth policy. For Medicaid managed care plans, the plan's policies apply within state rules.

Employer plans

Many people in the US are insured through self-funded employer plans, which are governed by ERISA at the federal level rather than state insurance law. State telehealth parity laws do not apply to these plans. Employer plans set their own rules and may be more or less generous than state-regulated plans. The plan documents (summary plan description, summary of benefits and coverage) are the controlling reference. HR or the plan administrator can answer specific coverage questions.

Many employers also offer separate telehealth services (often through contracted vendors like a national virtual care company) as an employee benefit. These are sometimes free or low-cost to the employee for visits.

The No Surprises Act

The federal No Surprises Act, in effect since 2022, protects insured patients from many surprise medical bills:

Out-of-network emergency services are billed at in-network cost-sharing rates.
Out-of-network providers at in-network facilities (the classic "out-of-network anesthesiologist at an in-network hospital" scenario) cannot balance-bill in most cases.
Self-pay patients have a right to a "good faith estimate" from providers.
An independent dispute resolution process resolves disagreements between providers and insurers when balance billing is prohibited.

The protections are strongest in emergency settings and at in-network facilities. They have less direct application to most telehealth visits, which are scheduled and where the patient knows in advance who they are seeing. For surprise telehealth bills, see disputing a telehealth bill.

How to read an EOB

An explanation of benefits is the document the insurer sends after processing a claim. It is not a bill — that comes from the provider — but it tells you what the insurer thinks it paid and what you may owe. The line items typically include:

Date of service.
Provider and a service code (CPT code).
Billed amount (what the provider charged).
Allowed amount (what the insurer agreed to pay or apply to deductible).
Amount paid by insurance.
Patient responsibility (deductible, coinsurance, copay).
Reason codes if anything was denied or reduced.

Compare the EOB to the bill from the provider. They should match. If the provider's bill exceeds the EOB's "patient responsibility" amount, that may be balance billing — sometimes legal, sometimes not depending on the situation. Save EOBs at least until the matching bill is settled.

Pre-visit checks

Before a telehealth visit, the simple steps that prevent most surprises:

Confirm the practice and clinician are in your network — the insurer's directory or a call to member services.
Ask the practice whether telehealth is billed differently from in-person.
Check whether your plan covers audio-only visits if that is what you are scheduled for.
Note your deductible status — early in the year or after a deductible reset, you may pay more out of pocket.
Save the visit confirmation and any cost estimates.

When a claim is denied

Most insurance denials are appealable. The process generally has two stages:

Internal appeal

The insurer reviews the denial. You request the internal appeal in writing, with any supporting documentation (medical records, a letter from the clinician describing medical necessity). Internal appeals have specific timelines under federal and state rules.

External review

If the internal appeal fails, an external review by an independent reviewer is generally available. For state-regulated plans, the state insurance department oversees this. For self-funded ERISA plans, federal external review processes apply. The external reviewer's decision is generally binding on the insurer.

The clinician's note matters for both stages. A note that documents medical necessity in detail is worth more than a generic appeal letter. See advocating for yourself in a remote visit for how to ask the clinician to document specifically.

Cash-pay and out-of-network

Many telehealth services operate on cash-pay terms, especially specialty services (menopause, GLP-1, ADHD, etc.). Cash pricing should be transparent before the visit. The No Surprises Act good-faith estimate requirement applies to self-pay patients in many cases. If you have insurance and are seeing an out-of-network provider, you may be able to submit the bill yourself for partial out-of-network reimbursement; the practice can usually provide a "superbill" with the relevant codes. Whether reimbursement comes through depends on your plan's out-of-network benefits.

What to ask insurance and the practice

Is this practice/clinician in my network?
Is a telehealth visit covered the same as in-person?
Are audio-only visits covered?
What is my expected out-of-pocket cost?
Is prior authorization required for any tests or treatments that may be ordered?
If I receive a denial, what is the appeal process?

When this is not enough

If a claim is wrongly denied, internal and external appeals are the path. If a state-regulated plan is violating telehealth parity, the state department of insurance is the regulator. For surprise bills, see disputing a telehealth bill. For cross-state issues that complicate insurance — for example, an out-of-state visit for a vacation — see cross-state licensing.

Insurance and telehealth