Telehealth Reimbursement: Medicare, Medicaid & Private Insurance

Telehealth reimbursement sounds like it should be simple.

A doctor provides a medical service. The patient attends through video instead of sitting in an exam room. The insurance company pays the claim.

Sometimes it works exactly that way.

Sometimes it does not.

The United States does not have one telehealth reimbursement system. Medicare follows federal rules. Medicaid programs operate state by state. Private insurers follow a combination of state law, individual health-plan rules and contracts with healthcare providers.

Even two patients carrying insurance cards from the same company may have different telehealth benefits.

That makes one question particularly important for healthcare providers:

Do not just ask whether telehealth is covered. Ask whether this specific service, delivered by this provider, through this type of telehealth, is covered by this patient's plan.

That is where telehealth reimbursement begins.

Telehealth Reimbursement at a Glance

Payer	Who Sets the Rules?	Telehealth Coverage	Major Variable
Medicare	Congress and CMS	Many services are covered	Federal rules and eligible services
Medicaid	Individual states	Widely available	State Medicaid policy
Commercial insurance	State law and individual plans	Common	Plan terms and provider contracts
Self-funded employer plans	Employer/federal framework	Varies	Individual plan design

Telehealth is generally a way of delivering healthcare, not a separate category of healthcare.

That distinction matters.

The underlying medical service still has to qualify for coverage. The healthcare professional must be eligible to provide it. Coding and documentation still matter. State licensure rules still apply.

A video connection does not turn an otherwise non-covered service into a covered one.

How Medicare Telehealth Reimbursement Works

Medicare has been one of the biggest forces shaping telehealth in the United States.

Before 2020, traditional Medicare generally placed significant restrictions on where telehealth could be used. Geographic requirements, originating-site rules and limitations on eligible services kept Medicare telehealth relatively narrow.

The COVID-19 public health emergency changed that.

Congress and federal regulators dramatically expanded access to virtual care. Millions of Medicare beneficiaries became able to receive healthcare remotely, including from home.

Some of those changes became permanent.

Others were temporary.

Still others have been extended several times — most recently by the Consolidated Appropriations Act, 2026, which extended the major Medicare telehealth flexibilities through December 31, 2027. Behavioral and mental health telehealth from home was made permanent under earlier legislation.

That history creates one of the most important rules in telehealth reimbursement:

Never assume last year's Medicare telehealth rules are still the rules today.

CMS maintains guidance governing Medicare telehealth and updates eligible services and payment policies through federal rulemaking, including the Medicare Physician Fee Schedule.

Before billing Medicare for telehealth, a provider should confirm:

• whether the service is currently eligible;
• whether the provider type is eligible;
• whether the patient's location qualifies;
• whether audio-only care is allowed;
• which modifier is required;
• which place-of-service code applies; and
• whether the service carries an in-person requirement.

These are not small administrative details. They can determine whether a claim gets paid.

TeleMed Today Note: Medicare telehealth policy has changed repeatedly since 2020. When a rule depends on a temporary federal extension, verify the current CMS guidance rather than relying on an old article, billing sheet or expiration date.

Behavioral Health Has Different Telehealth Rules

Mental healthcare is one of the areas where telehealth has become particularly important.

Federal policy has permanently removed certain geographic restrictions for Medicare tele-mental-health services, allowing patients to receive qualifying behavioral healthcare from home.

That has made services such as telepsychiatry much more accessible.

But permanent access does not mean every behavioral health rule is simple or permanent.

Federal requirements involving in-person visits, provider eligibility and specific billing circumstances have changed or been delayed over time.

Providers offering virtual:

• psychiatry;
• psychotherapy;
• psychiatric medication management;
• substance use disorder treatment; or
• other behavioral healthcare

should verify the current Medicare requirements before building billing procedures around them.

The direction of federal policy has clearly moved toward greater use of virtual behavioral healthcare.

The billing details still matter.

Does Medicare Pay for Audio-Only Telehealth?

Sometimes.

Telehealth does not always require video.

Audio-only care became particularly important as telehealth expanded because not every patient has reliable broadband, a modern smartphone or the technical ability to complete a video appointment.

For some patients, a telephone is the most realistic way to reach a healthcare professional.

But providers should not assume that telephone and video visits are reimbursed the same way.

Coverage depends on the service and current payer policy.

When audio-only care is permitted, the medical record should accurately document the modality used.

Modifier 93 is generally associated with synchronous audio-only telemedicine services.

The key principle is simple:

Bill the encounter that actually occurred.

A telephone visit should not be represented as an audio-video encounter simply because the reimbursement rules are more favorable.

Medicaid Telehealth Reimbursement

If Medicare telehealth reimbursement can be complicated, Medicaid adds another layer.

There is no single national Medicaid telehealth reimbursement policy that answers every billing question.

Medicaid is jointly funded by the federal government and the states, but states have substantial flexibility over how telehealth is structured within their Medicaid programs.

A state may determine:

• which Medicaid services can be delivered through telehealth;
• which healthcare professionals may provide them;
• whether audio-only services qualify;
• whether asynchronous care is covered;
• whether remote patient monitoring is covered;
• where patients may receive telehealth;
• whether certain facilities can collect fees; and
• how providers are reimbursed.

This means there is no useful national answer to:

"How much does Medicaid pay for telehealth?"

You need to know the state.

And sometimes even knowing the state is not enough.

A patient enrolled in a Medicaid managed-care plan may be subject to billing requirements that differ from the state's traditional fee-for-service Medicaid program.

Providers operating across multiple states should therefore maintain state-specific reimbursement procedures rather than assuming one Medicaid billing workflow will work everywhere.

For the broader legal differences between states, see our guide to telemedicine laws by state.

Private Insurance and Telehealth Reimbursement

Private insurance creates a different challenge.

Most major health insurers now have significant experience covering virtual healthcare.

That does not mean they all pay for it the same way.

Commercial telehealth reimbursement can depend on:

• state insurance law;
• the patient's specific plan;
• whether the plan is fully insured or self-funded;
• the provider's contract;
• the medical service;
• the type of telehealth used; and
• network participation.

This is where the word parity becomes important.

It is also where parity is frequently misunderstood.

Coverage Parity Is Not the Same as Payment Parity

There are two different concepts providers should understand.

Coverage Parity

Coverage parity generally means that when a qualifying healthcare service is covered in person, an insurer must also cover that service when it is appropriately delivered through telehealth.

Payment Parity

Payment parity deals with how much the healthcare professional gets paid.

Those are different questions.

A state can require an insurance company to cover telehealth without requiring the insurer to pay exactly the same amount it would have paid for an in-person visit.

That means a telehealth claim can be:

covered but reimbursed differently.

The distinction matters for providers evaluating the economics of a virtual-care program.

A practice can have excellent telehealth coverage and still discover that its payer contracts create a meaningful difference between virtual and office-based reimbursement.

Why Self-Funded Employer Health Plans Matter

There is another wrinkle that patients and providers frequently miss.

Many Americans receive health insurance through employers that operate self-funded health plans.

These plans are generally governed by the federal Employee Retirement Income Security Act, better known as ERISA, rather than ordinary state insurance regulation.

That can affect whether a state telehealth insurance mandate applies.

Here is why that matters in the real world.

Two patients can walk into the same medical practice carrying cards with the same major insurance-company logo.

One patient's employer purchased a fully insured plan.

The other patient's employer operates a self-funded plan administered by that same insurance company.

Their telehealth benefits may not be identical.

The logo on the insurance card does not always tell you the whole story.

Verify the plan.

Telehealth CPT Codes, Modifiers and Place of Service

Telehealth usually does not replace the code for the underlying medical service.

Instead, the provider bills the healthcare service performed and uses additional billing information to communicate that the encounter occurred remotely.

That may include modifiers and place-of-service codes.

Here are several common examples:

Code	General Purpose
99202–99205	New patient office/outpatient evaluation and management
99211–99215	Established patient office/outpatient evaluation and management
Modifier 95	Synchronous audio-video telemedicine
Modifier 93	Synchronous audio-only telemedicine
POS 02	Telehealth provided somewhere other than the patient's home
POS 10	Telehealth provided in the patient's home
99453	Remote physiologic monitoring setup and patient education
99454	Remote monitoring device/data supply
99457	Initial qualifying RPM treatment-management time
99458	Additional qualifying RPM treatment-management time

These are common examples, not universal billing instructions.

Payers can establish their own billing requirements, and federal rules can change.

Providers should verify the current requirements of the payer before submitting claims.

Modifier 95 vs. Modifier 93

This distinction is easier than it sometimes sounds.

Modifier 95

Modifier 95 generally identifies a synchronous telemedicine encounter conducted using real-time audio and video.

Think of a traditional video appointment where the patient and healthcare professional can see and hear each other live.

Modifier 93

Modifier 93 generally identifies a synchronous telemedicine encounter conducted through audio-only communication.

Think telephone.

The modifier should describe what actually happened during the encounter.

Accurate coding is not simply a reimbursement issue.

It is a compliance issue.

POS 02 vs. POS 10

Place-of-service coding tells the payer something different: where the patient received the telehealth service.

POS 02

POS 02 generally indicates telehealth was provided while the patient was located somewhere other than the patient's home.

POS 10

POS 10 generally indicates telehealth was provided while the patient was located in the patient's home.

That distinction can affect reimbursement.

It also highlights why healthcare professionals should know where a patient physically is during a telehealth appointment.

Patient location can matter for billing.

It can also matter for professional licensure.

Our guide to telehealth laws explains the broader legal issues surrounding virtual practice.

Remote Patient Monitoring Is Different From a Video Visit

Remote patient monitoring is often grouped together with telehealth.

Operationally, it is different.

A video appointment is still an encounter between a patient and healthcare professional.

Remote patient monitoring allows healthcare professionals to collect and review physiologic information while the patient goes about daily life outside a medical facility.

Depending on the patient's condition and the monitoring program, that can include information such as:

• blood pressure;
• weight;
• blood glucose;
• oxygen saturation; or
• other qualifying physiologic measurements.

RPM therefore has its own coding and reimbursement framework.

Common Medicare RPM codes include 99453, 99454, 99457 and 99458.

A good RPM program is not simply a device being mailed to a patient.

The reimbursement model can involve device setup, data collection and clinical treatment-management requirements.

Providers considering RPM should understand those requirements before purchasing technology or enrolling large numbers of patients.

Why Telehealth Claims Get Denied

A telehealth claim denial does not necessarily mean telehealth is not covered.

Often, something in the claim does not match the payer's rules.

Several problems appear repeatedly.

The Service Is Not Eligible

A healthcare service may be covered in person but not qualify through the particular telehealth modality that was used.

The Wrong Modifier Was Submitted

An audio-only encounter, for example, should not be represented as an audio-video encounter.

The Wrong Place-of-Service Code Was Used

POS 02 and POS 10 communicate different patient locations.

The Provider Is Not Properly Credentialed

A healthcare professional can be properly licensed and still not be credentialed with the patient's insurance plan.

Licensure and insurance credentialing are different things.

The Patient's Plan Has Different Rules

This is particularly important with commercial insurance, Medicare Advantage, managed Medicaid and self-funded employer plans.

The Documentation Does Not Support the Claim

The medical record should support both the service billed and the way the service was provided.

The solution is not to treat every telehealth denial as a one-off problem.

Track them.

Patterns usually tell you something.

What Should Be Documented During a Telehealth Visit?

Telehealth documentation should meet the same basic clinical standards expected from an in-person encounter.

The record should also make the remote nature of the visit clear.

Depending on the service and payer, documentation may include:

• patient identity;
• patient's physical location;
• provider location;
• date of service;
• whether the encounter used video or audio only;
• patient consent when required;
• relevant history;
• examination findings that can reasonably be obtained remotely;
• medical decision-making;
• time when the service is billed based on time;
• technical limitations affecting the examination; and
• follow-up or escalation to in-person care when appropriate.

Telehealth does not lower the standard for keeping a useful medical record.

It changes how some of the information is collected.

Privacy and technology also matter. See our guide to telehealth security and HIPAA for more on protecting patient information during virtual care.

A Better Way to Handle Telehealth Billing

Providers should not discover whether a patient's telehealth visit is covered after the appointment is over.

A better workflow starts before the patient logs in.

1. Identify the Payer

Determine whether the patient has traditional Medicare, Medicare Advantage, Medicaid, managed Medicaid, commercial insurance or another form of coverage.

2. Verify the Actual Plan

Do not stop at the name of the insurance company.

Determine which plan the patient actually has.

3. Confirm Telehealth Eligibility

Check whether the planned service can be provided remotely under that payer's current rules.

4. Confirm the Modality

Video, audio-only, asynchronous care and remote monitoring are not necessarily reimbursed the same way.

5. Confirm the Patient's Location

Know where the patient physically is.

This can matter for both reimbursement and licensure.

6. Code the Service Actually Performed

Start with the underlying healthcare service.

7. Apply the Correct Telehealth Billing Information

Use the modifier and place-of-service information required by the payer.

8. Document the Encounter

Make the medical record match what happened.

9. Track the Result

Paid claims tell you something.

Denied claims tell you something too.

A provider doing significant telehealth volume should learn from both.

Build a Telehealth Payer Matrix

A medical practice conducting a handful of virtual appointments may be able to verify each patient's coverage individually.

A large telehealth operation cannot efficiently rediscover the same rules every day.

Build a payer matrix.

At a minimum, track:

Payer	Video	Audio-Only	Modifier	POS	Special Rules	Last Verified
Payer A	Verify	Verify	Verify	Verify	Plan-specific	Date
Payer B	Verify	Verify	Verify	Verify	Plan-specific	Date

One column deserves particular attention:

Last Verified.

Telehealth reimbursement changes.

A beautifully organized billing matrix filled with rules from three years ago can be worse than having no matrix at all.

For major payers, periodically verify:

• eligible services;
• eligible provider types;
• audio-video coverage;
• audio-only coverage;
• required modifiers;
• place-of-service rules;
• reimbursement methodology;
• prior authorization requirements; and
• major policy changes.

This turns reimbursement knowledge into an operating system instead of tribal knowledge held by one billing employee.

Does Telehealth Pay Less Than an In-Person Visit?

Sometimes.

There is no single national rule requiring every health plan to reimburse every telehealth service at exactly the same amount as the equivalent office visit.

Medicare follows federal payment rules.

Medicaid varies by state.

Commercial reimbursement depends on applicable state law, health-plan design and the provider's contract.

That is why the distinction between coverage parity and payment parity matters so much.

A service can be covered without being paid at the same rate.

For a provider considering a large telehealth program, reimbursement analysis should happen before major investments are made in staffing, technology and marketing.

Utilization is only half of the equation.

What you actually collect matters too.

What Patients Should Know About Telehealth Insurance

Patients do not need to become medical billers to use telehealth.

They should know enough to ask the right questions.

Before a virtual appointment, consider asking the insurance company or provider:

• Is this healthcare professional in network?
• Is this type of telehealth visit covered?
• Does the appointment need to include video?
• Is telephone-only care covered?
• Will I owe a copay?
• Does my deductible apply?
• Is my cost different from an office visit?

Do not assume that because a previous telehealth appointment was covered, every future virtual service will be covered the same way.

The service matters.

The provider matters.

The plan matters.

Telehealth Reimbursement Is Becoming Infrastructure

The early telemedicine conversation focused heavily on whether patients and doctors would actually use virtual care.

That question has largely been answered.

They will.

The more important question now is how virtual care fits into the permanent infrastructure of American healthcare.

Reimbursement is a major part of that answer.

Medicare has moved far beyond its pre-2020 telehealth model.

States have continued developing Medicaid telehealth policies.

Commercial insurers have incorporated virtual care into mainstream health-plan design.

Remote patient monitoring has created reimbursement models that do not depend on a traditional office visit at all.

But the system is still fragmented.

That is unlikely to disappear overnight.

Providers that succeed with telehealth will therefore need to do something less exciting than buying new technology:

They need to understand how they get paid.

The Bottom Line

Telehealth reimbursement is no longer a temporary experiment.

It is part of modern healthcare.

But there is still no single reimbursement rule that applies to every patient, provider and health plan.

Medicare operates under federal rules.

Medicaid varies by state.

Commercial insurance depends on state law, individual plans and provider contracts.

The safest workflow is straightforward:

Verify the payer. Verify the service. Verify the modality. Verify the patient's location. Then bill what actually happened.

For organizations building virtual-care programs, reimbursement should be designed into the operation before the first patient logs in.

Not investigated after the first hundred claims are denied.

For the operational side of getting there, see How to Start a Telemedicine Program.