When does Medicare pay for telehealth services? Answer in under 100 words. Cite only eCFR (www.ecfr.gov) sources.

Details / How it works

Under 42 CFR § 410.78(b), Medicare Part B pays for covered telehealth services when:

• The service is on the Medicare telehealth list and furnished via an interactive telecommunications system.
• The distant-site physician or practitioner is licensed under State law to furnish the service.
• The distant-site practitioner is one of the enumerated provider types (e.g., physician, PA, NP, CNS, nurse-midwife, clinical psychologist, clinical social worker, registered dietitian, CRNA, marriage and family therapist, mental health counselor).
• The beneficiary is located at an eligible originating site, which generally must be in a Health Professional Shortage Area or non-MSA county (geographic requirements waived for certain services).
• The medical examination remains under the control of the distant-site physician or practitioner.

For the duration of the COVID-19 PHE (as defined in § 400.200), Part B also pays for office and other outpatient visits, professional consultation, psychiatric diagnostic interview examination, individual psychotherapy, pharmacologic management, and ESRD-related monthly capitation services via interactive telecommunications when the same conditions are met.

Numbers & thresholds

Exceptions & edge cases

Per 42 CFR § 410.78(b)(3)(xiv), when the beneficiary's home is used as an originating site for diagnosis, evaluation, or treatment of a mental health disorder between the day after the end of the PHE and December 31, 2024, Medicare pays only if the distant-site practitioner furnished an in-person service (without telehealth) within 6 months prior to the initial telehealth service and at least once within 12 months of each subsequent telehealth service. The in-person requirement may be met by another physician or practitioner of the same specialty/subspecialty in the same group if the telehealth practitioner is unavailable. Geographic requirements are waived for home dialysis ESRD clinical assessments, acute stroke services (on/after Jan 1, 2019), SUD services (on/after Jul 1, 2019), and mental-health services (on/after Jan 1, 2025). A telepresenter is not required unless medically necessary per the distant-site practitioner.