What to Ask Your Insurance: Telehealth Benefits

This is Part 3 of a 3 Part Series

Coverage for mental health services via telehealth has changed, mostly for the better, with the COVID-19 public health emergency declaration and the federal government’s move to expand telemedicine services through waivers, increasing flexibility of location from where services can be offered, and payment parity for telehealth and in-person visits. With increased usage, we’ve been able to see that telehealth is necessary, beneficial, and can be just as effective as in-person therapy. I do hope these changes are here for good.

What to Ask Your Insurance and Why

Telehealth Benefits

As with all of your calls to insurance, get a reference number or representative identifier (first name and last initial, for example) and jot down the date of your call.

Most plans do cover telehealth now, including video, phone, and app-based services, but this wasn’t the case prior to the pandemic. It was highly dependent on your specific plan. From my experience prior to the pandemic, I would see maybe 1 out of 10 clients that had a plan that covered telehealth. So even though your plan should cover telehealth now, I recommend playing it safe and getting it confirmed (and recorded over the phone).

You can do your therapist a favor and confirm how claims need to be billed for them to be processed correctly. Likely the representative won’t (be able to) give you the place of service (POS) and modifier codes. Point of service indicates where the therapist is providing the service from (02 indicates telehealth, 11 indicates office). Each insurer does its own thing. Some plans can’t process the claim correctly with the telehealth place of service so even though the service was provided via telehealth, clinicians still need to put 11 for office. The modifier code indicates synchronous video-conferencing and, at this point, GT and 95 mean the same thing. Some plans don’t care and some require one over the other.

Some insurers require that members meet with therapists via a specific video-conferencing platform, like Teladoc. On one hand, I can support this if the insurance company is requiring that therapists use HIPAA-secure platforms because that’s just good practice. However, most of the time, they are partnered with a platform that requires that the clinician also be contracted with them and it generally means an absurdly low reimbursement rate.

Many clients also generally seek out video-conferencing for their therapy. However, I often get requests for one-off sessions via audio or there are times where clients’ connections were so poor that it would have disrupted the quality of the session. This leads to a last minute scramble to confirm whether or not insurance will cover phone-only sessions. If you are considering telehealth in general, I strongly recommend you confirm if audio/phone is covered, even as a backup.

Back before the pandemic, insurers generally reimbursed for telehealth sessions less than in-office sessions. For you as a client, this could mean having a different co-insurance amount, since it is a percentage of the contracted rate. Additionally, some plans waived cost-sharing (for telehealth sessions) at the beginning of the pandemic; some plans, though few, still continue to waive cost-sharing.

The takeaway here is that things change constantly. It is always best to ask and confirm your benefits as well as find out how they plan to inform you of any changes so you are not caught unawares.

Questions to Ask

Telehealth Benefits

Does my plan include telehealth coverage (secure video-conferencing)?

Is a specific video-conferencing platform required? If yes, what is it?

Does my plan include telehealth coverage for phone calls/audio-only?

Which point of service (POS) code does my therapist need to use for claims to be processed accurately for video and for audio only?

• 02 telehealth
• 11 office

Which modifier code does my therapist need to use for claims to be processed accurately?

• GT
• 95

Do I have a different co-insurance (%) or co-pay (fixed $ amount) for telehealth sessions?

Does my plan cover telehealth at the same rates as in-person sessions?

Covid-19 Pandemic Specific Questions to Ask

Is cost-sharing currently waived during the Covid-19 pandemic? I.e., is my plan currently waiving my co-insurance/co-pay and/or deductible?

Are any of my current telehealth benefits subject to change before the end of my plan year? If yes, how will I be informed of these changes?