Expanding Telemental Health in Response to the COVID-19 Pandemic

The use of social distancing to “flatten the curve” and prevent the spread of COVID-19 has catapulted the use of telehealth.¹ It has become critical to conduct patient encounters by telephone or video conference during the current pandemic, especially as many patients are currently experiencing increased levels of stress and anxiety. Their psychotherapy and psychiatric management must continue to prevent further decompensation and avoid potential consequences like suicide attempts, emergency department visits, and psychiatric hospitalizations in the face of a pandemic that strains health care resources. Because face-to-face appointments both risk the transmission of COVID-19 and use personal protective equipment that is in dire shortage, telehealth has emerged as an important alternative.

Telehealth innovation is thought to offer many opportunities, including improvement of the patient’s experience, increased health care access, and reduction of health care costs.² Research demonstrates that telehealth interventions produce positive outcomes when used for remote patient monitoring for chronic conditions, communication, counseling, and psychotherapy.³ Psychotherapy provided via telemental health has demonstrated efficacy in reducing pain, disability, depression, and anxiety comparable to traditional face-to-face encounters and without significant risks or adverse effects.⁴

Prior to the pandemic, telemental health expanded significantly from 2017 to 2019.⁵ All 50 states and the District of Columbia provided some coverage for telehealth services for their Medicaid members. Furthermore, 42 states and Washington, DC had telehealth commercial payer laws but there was enormous variability across states.⁶ Uncertainty regarding state-to-state differences and lack of reimbursement parity dissuaded many providers from entering telemental health.

Federal and state legislation and regulation has rapidly changed in response to the current pandemic in order to increase availability of telemental health services.^7,8 As these actions have occurred through multiple avenues across various levels of government, it is challenging for many providers to keep up with the swift changes while caring for their own, potentially distressed, patients.

There has been broad bipartisan support to increase access to telehealth at the federal level. The House of Representatives voted to allow the easing of telehealth restrictions for Medicare patients on March 5, and the Senate passed a similar bill 96-1. On March 6, HB 6074, Coronavirus Preparedness and Response Supplemental Appropriations Act 2020 was signed by the president.⁹

With implementation of the bill on March 17, The Center for Medicare and Medicaid Services (CMS) revised regulations that previously limited the patient location during telehealth encounters for Medicare patients, and then challenged state Medicaid agencies to adopt the same rules.^10,11 Whereas previously, telehealth services could only take place in certain designated locations with the use of synchronous video technology, the bill allowed patients to receive services at home, using their telephone with some limitations on the type of phone. In addition, this bill included $500 million for an emergency waiver that will expand coverage for telehealth services in Medicare. Requirements around qualified providers and eligible services remain the same.

The Department of Health and Human Services Office for Civil Rights (HHS OCR) announced that it would waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.¹⁰ The Department of Health and Human Services and Vice President Mike Pence announced an easing of regulations to allow providers to practice across state lines “to meet the needs of hospitals that arise in adjoining areas.”¹² While the details of this are unclear, many suspect that this may allow telehealth to be practiced across state lines.

The Drug Enforcement Agency (DEA) announced suspension of the federal Ryan Haight Act upon the declaration of a public health emergency in order to facilitate the use of telehealth in providing medication-assisted treatment.^13,14 The Ryan Haight Act previously required that physicians must conduct a face-to-face examination before prescribing controlled substances via telehealth to ameliorate concerns about online trafficking of controlled substances. The current exception allows prescribers practicing via telehealth to prescribe controlled substances to patients without a prior face-to-face exam while the designation of a public health emergency remains in effect.

Substance Abuse and Mental Health Services Administration (SAMHSA) released

to ensure that substance use disorder treatment services are uninterrupted.¹⁵ Their guidance includes increasing flexibility in providing pharmacotherapy for opioid use disorder, allowing patients up to 1-month supply of doses of take-home medication, and waiving requirements for written patient consent forms.

Forty-two states, along with Washington, DC, have telehealth payer laws pertinent to commercial payers. The statutes and regulations dictate coverage and reimbursement that vary from state-to-state.

Before the COVID-19 pandemic, 21 states mandated Medicaid coverage of telehealth but a range of state regulations affected telemental health utilization. Some state policies restricted the patient’s setting or location, requiring that the patient be located in a health care facility or within a certain distance of the provider during the encounter. Others restricted the specific technology used for the encounter, such as requiring the use of a synchronous technology, which may be an obstacle for patients who are living in rural areas with limited broadband connectivity, although this population has been a target of telehealth efforts.

Since the pandemic, many states have made both legislative or regulatory changes to loosen these restrictions and increase telemental health access as well as reimbursement.^16,17 As of April 7, at least 46 states have applied and have been approved for Section 1135 waivers that allow for greater flexibility with certain Medicaid and Children’s Health Insurance Program requirements.¹⁸ Most of the states with the waivers now allow out-of-state providers to temporarily provide care for their Medicaid patients.¹⁹ Most of the states and Washington, DC have now expanded telehealth access to Medicaid patients in other ways such as removing restrictions on location and allowing telehealth to be delivered by telephone as well as video.

Regulation of private payers has also varied by state. A few states have required private insurers to waive copayments (copays) for telehealth.²⁰ Some insurers, such as Aetna and Blue Cross Blue Shield, had already waived copays on telehealth visits. Beyond the efforts mentioned, some states are taking more aggressive actions.

New York Governor Andrew Cuomo authorized the New York Licensed Office of Mental Health Programs to waive sections of regulatory requirements pertaining to telehealth to reduce barriers and increase access to mental health treatment across the state (Ann Marie Sullivan, personal communication, March 11, 2020). This aims to streamline the approval process governing telehealth in order to increase the number of providers who can utilize telehealth to treat patients.

The New York State Department of Financial Services (DFS) adopted a new emergency regulation under New York Insurance Law requiring New York State insurers to waive cost-sharing, including, deductibles, copays, or coinsurance for in-network telehealth.²⁰ Moreover, New York created a new platform for mental health services during the pandemic that is available free of charge and unrelated to insurance status called the COVID-19 Emotional Support Hotline.²¹ More than 6000 mental health professionals volunteered to provide free online mental health treatment during the pandemic, and residents of New York can call the state's hotline to schedule a free appointment.²²

The Ohio Department of Mental Health and Addiction Services announced expansion of telehealth for the treatment of mental health and substance use during the COVID-19 pandemic.²³ This measure will permit telephone encounters, eliminate the requirement that new patients must be seen face-to-face for their initial encounter, and increase flexibility of monitoring medication-assisted treatment of opioid use disorders. This will allow patients to both establish and continue mental health and substance use treatments via telemental health during the pandemic.

Massachusetts Governor Charles Baker mandated that health insurers cover telehealth services for all in-network providers, reimburse these services at the same rates as face-to-face encounters, and they cannot require prior authorizations for these services.²⁴ Furthermore, all carriers were instructed to cover all telehealth copays to promote its use.²⁵ An additional executive order authorized licensed Massachusetts providers to extend telemedicine services across state lines to their already established patients, who were enrolled during the 2019-2020 in a college or university located in Massachusetts.²⁶ Massachusetts’ Board of Registration in Medicine processes were modified to expand the number of providers who may be able to respond to medical needs, including providers abroad, for the duration of the state of emergency.²⁷

Many advocates and lobbyists continue to ask Congress to mandate that all insurers expand coverage for telemental health, require reimbursement parity, allow providers to practice across state lines, eliminate geographic restrictions and cover multiple modalities including telephone. While many states moved quickly to reduce barriers, others have not. Most legislation and regulations have targeted Medicare or Medicaid, but fewer have addressed private payers.

Disclosures:

Dr Conrad is a Clinical Fellow in Psychiatry, Harvard Medical School; Ms Rayala is an MD candidate, University of Michigan Medical School; Dr Diamond is a Fellow, Harvard Medical School Center for Bioethics and Director, Policy and Business Relations, Department of Accountable Care and Integration, Boston Children’s Hospital; Dr Busch is a Clinical Fellow in Psychiatry, Harvard Medical School; and Ms Kramer is a Fellow in Clinical Psychology, Boston Children’s Hospital. They report no conflicts of interest concerning the subject matter of this article.

Acknowledgement-The authors thank Michelle Riba, MD, MS, University of Michihttps://www.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/gan Medical School, David DeMaso, MD, Boston Children’s Hospital, and Mildred Solomon, EdD, Harvard Medical School.

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