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U.S. Department of Health and Human Services
Office of Inspector General
Data Brief
September 2022, OEI-02-20-00522
Certain Medicare Beneficiaries, Such as Urban and Hispanic
Beneficiaries, Were More Likely Than Others To Use Telehealth
During the First Year of the COVID-19 Pandemic
Why OIG Did This Review
The COVID-19 pandemic created unprecedented challenges for how
Medicare beneficiaries access health care. In response, the Department
of Health and Human Services (HHS) and the Centers for Medicare &
Medicaid Services (CMS) took a number of actions to temporarily
expand access to telehealth for Medicare beneficiaries.1 CMS allowed
beneficiaries to use telehealth for a wide range of services and in
different locations, including in urban areas and from the beneficiary’s
home.
In a companion report, OIG found that the use of telehealth increased
dramatically during the first year of the pandemic.2 More than
28 million—about 2 in 5—Medicare beneficiaries used telehealth that
first year. In total, beneficiaries used 88 times more telehealth services
during the first year of the pandemic than they did in the prior year.
This data brief expands on that analysis and examines the
characteristics of beneficiaries who used telehealth during the first year
of the pandemic. This information sheds light on how the temporary
expansion of telehealth affected different groups of beneficiaries. This
information will help CMS, HHS, Congress, and other stakeholders
understand who benefited from the expansion and make decisions
about whether some of the temporary changes should become
permanent. It can also inform efforts aimed at ensuring that all
beneficiaries have appropriate access to telehealth.
This data brief includes beneficiaries in Medicare fee-for-service and Medicare Advantage. This data
brief is part of a series that examines the use of telehealth in Medicare and identifies program integrity
concerns related to telehealth during the pandemic.3
How OIG Did This Review
This analysis focuses on Medicare beneficiaries who used telehealth services during the first year of the
pandemic from March 1, 2020, to February 28, 2021. We based this analysis on Medicare fee-for
service claims data, Medicare Advantage encounter data, and data from the Medicare Enrollment
Database.
Key Takeaways
o Beneficiaries in urban areas
were more likely than
those in rural areas to use
telehealth.
o Dually eligible, Hispanic,
younger, and female
beneficiaries were also
more likely than others to
use telehealth.
o Almost one fifth of
beneficiaries used certain
audio only telehealth
services; the vast majority
of these beneficiaries used
them exclusively.
o Older beneficiaries were
more likely to use certain
audio only services, as
were dually eligible and
Hispanic beneficiaries.
What OIG Found
Beneficiaries in urban areas were more likely than those in rural areas to use telehealth during the first
year of the pandemic. Beneficiaries in Massachusetts, Delaware, and California were more likely than
beneficiaries in some other States to use telehealth. Dually eligible beneficiaries (i.e., those eligible for
both Medicare and Medicaid), Hispanic beneficiaries, younger beneficiaries, and female beneficiaries
were also more likely than others to use telehealth. In addition, beneficiaries almost always used
telehealth from home or other non-health-care settings. Furthermore, almost one-fifth of beneficiaries
used certain audio-only telehealth services, with the vast majority of these beneficiaries using these
audio-only services exclusively.4 Older beneficiaries were more likely to use these audio-only services,
as were dually eligible and Hispanic beneficiaries.
What OIG Recommends
As CMS, HHS, Congress, and other stakeholders consider permanent changes to Medicare telehealth
services, it is important that they balance concerns about issues such as access, quality of care, cost,
health equity, and program integrity. Doing so will ensure that the benefits of telehealth are realized
while minimizing risk. The data presented in this report demonstrate how the temporary expansions
improved access to telehealth for Medicare beneficiaries during the first year of the pandemic,
particularly for those who are medically underserved. Understanding who benefited from increased
access and how different groups used telehealth can inform policymakers and stakeholders as they
make decisions about telehealth.
Accordingly, we recommend that CMS: (1) take appropriate steps to enable a successful transition from
current pandemic-related flexibilities to well-considered long-term policies for the use of telehealth for
beneficiaries in urban areas and from the beneficiary’s home, (2) temporarily extend the use of audio-
only telehealth services and evaluate their impact, (3) require a modifier to identify all audio-only
telehealth services provided in Medicare, and (4) use telehealth to advance health care equity. CMS did
not explicitly indicate whether it concurred with our four recommendations.
Primer on:
Medicare Telehealth Services During the Pandemic
56789
•
Medicare telehealth services refer to services that are provided remotely using
technology between a provider and a beneficiary.5
•
The services that can be provided via telehealth include office visits, behavioral
health services, nursing home visits, and home visits, among others. Most of
these services can also be provided in person.
•
A group of services known as virtual care services is always provided remotely.6
An example of these services is a telephone call with a provider to discuss a
beneficiary’s medical condition.
•
During the pandemic, CMS allowed beneficiaries to use telehealth to access a wide
range of services in different locations, including in urban areas and from the
beneficiary’s home. Prior to the pandemic, beneficiaries were allowed to use
telehealth only from medical facilities located in rural areas, with a few exceptions.7
•
During the pandemic, CMS increased the types of services that beneficiaries could
use via telehealth, from 118 to 264 service types.8
•
During the pandemic, CMS expanded the use of audio-only for certain types of
telehealth services, such as office visits and behavioral health services. Prior to the
pandemic, only audio-video was allowed for the delivery of telehealth services, with
a few exceptions.9
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Primer | 3
RESULTS
The COVID-19 pandemic created disruptions in how Medicare beneficiaries accessed
health care. Because of concerns about the pandemic, HHS and CMS took a number
of actions to provide broader access to telehealth for Medicare beneficiaries. CMS
allowed beneficiaries to use telehealth for a wide range of services and in different
locations, including in urban areas and from the beneficiary’s home. Expanding
access to telehealth services was intended to help beneficiaries maintain access to
needed care while limiting community spread of COVID-19, as well as limiting the
exposure to other patients and staff members.
In a companion report, OIG found that the use of telehealth increased dramatically
during the first year of the pandemic.10 More than 28 million—about 2 in 5—
Medicare beneficiaries used telehealth that first year. In total, beneficiaries used
88 times more telehealth services during the first year of the pandemic than they did
in the prior year.
This data brief expands on that analysis and examines the characteristics of
beneficiaries who used telehealth during the first year of the pandemic from March
2020 through February 2021. It includes beneficiaries in Medicare fee-for-service and
in Medicare Advantage. In addition, this analysis looks at billing by individual
practitioners but not institutions, such as hospitals.
Understanding the characteristics of beneficiaries who used telehealth during the first
year of the pandemic can shed light on how the temporary expansion of telehealth
affected different groups of beneficiaries. This information will help CMS, HHS,
Congress, and other stakeholders understand who benefited from the expansion and
make decisions about whether some of the temporary changes should become
permanent. It can also inform efforts that are aimed at ensuring that all beneficiaries
have appropriate access to telehealth.
Beneficiaries in urban areas were more likely than those in rural
areas to use telehealth
Beneficiaries in urban areas were more likely than beneficiaries in rural areas to use
telehealth during the first year of the pandemic.11 Beneficiaries in urban areas have
not historically had access to telehealth. Prior to the pandemic, telehealth services
were limited to beneficiaries in rural areas, with some exceptions.12
In total, 45 percent of beneficiaries in urban areas used telehealth during the first year
of the pandemic. They accounted for more than 24 million of the 54 million
Medicare beneficiaries living in urban areas. In contrast, just 33 percent of
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Results | 4
beneficiaries in rural areas used telehealth. They accounted for more than 3 million of
the more than 11 million Medicare beneficiaries living in rural areas. See Exhibit 1.
Exhibit 1: Medicare beneficiaries in urban areas were more likely than those
in rural areas to use telehealth during the first year of the pandemic.
45%
of beneficiaries in
urban areas used
telehealth
33%
of beneficiaries in
rural areas used
telehealth
Source: OIG analysis of CMS data, 2022.
Beneficiaries in rural areas may face unique barriers to accessing telehealth. For
instance, rural populations are less likely than those in urban areas to have access to
broadband connectivity.13 Rural health care providers may also face challenges
providing telehealth to their patients, as equipment and internet connectivity can be
expensive.14
Beneficiaries almost always used telehealth from home, regardless of whether
they lived in urban or rural areas
Almost all beneficiaries who used telehealth during
the first year of the pandemic did so from home or
other non-health-care settings. Prior to the
pandemic, most beneficiaries were required to use
telehealth from a health care setting, such as a
doctor’s office or hospital, with some exceptions.15
Beneficiaries in Massachusetts, Delaware, and California were
more likely than beneficiaries in some other States to use
telehealth
The States with the highest percentages of Medicare beneficiaries who used
telehealth during the first year of the pandemic included Massachusetts (57 percent),
Delaware (57 percent), and California (52 percent). See Exhibit 2.
93%
of beneficiaries who used
telehealth did so from home or
other non-health-care settings.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Results | 5
1%
27%
25%
NH 44%
VT 41%
MA57%
26%
RI 47%
CT 50%
NJ 50%
DE 57%
MD50%
DC46%
45%
2
This varied greatly from some other States. The States with the lowest percentages of
beneficiaries who used telehealth included North Dakota (21 percent), Montana
(25 percent), Wyoming (25 percent), and Nebraska (25 percent). See Appendix A for
the percentage of beneficiaries who used telehealth in each State.
Exhibit 2: The percentage of beneficiaries who used telehealth during the first
year of the pandemic varied by State.
Source: OIG analysis of CMS data, 2022.
Notably, many beneficiaries in these four States live in rural areas. In Montana and
Wyoming, roughly two-thirds of Medicare beneficiaries live in rural areas. In North
Dakota, more than half of the Medicare population lives in rural areas. In Nebraska,
more than 40 percent of all Medicare beneficiaries live in rural areas. As mentioned
above, beneficiaries in rural areas may face unique barriers to accessing telehealth.
Dually eligible, Hispanic, younger, and female beneficiaries were
more likely than others to use telehealth
To better understand which groups of beneficiaries were more likely than others to
use telehealth during the first year of the pandemic, we analyzed the use of telehealth
among all beneficiaries enrolled in Medicare and the use of telehealth among those
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Results | 6
who used any telehealth-eligible service, either in-person or via telehealth. These
measures show the extent to which each group of beneficiaries used telehealth
overall and the extent to which each group used telehealth regardless of whether
these beneficiaries were more likely to use any service. In this report, we use the term
“any service” to refer to any telehealth-eligible service.
For each group of beneficiaries, we found that the likelihood of each group to use
telehealth was not impacted by the likelihood of using any service. See Appendix B
for detailed information about each group.
Beneficiaries dually eligible for Medicare and Medicaid were more likely to use
telehealth than Medicare-only beneficiaries. More than half of all dually eligible
beneficiaries used telehealth during the first year of the pandemic. Dually eligible
beneficiaries are enrolled in Medicare due to age or disability and in Medicaid due to
income. They typically have lower incomes and a higher prevalence of many health
conditions than Medicare-only beneficiaries.16
In total, 53 percent of dually eligible beneficiaries used telehealth during the first year
of the pandemic, compared to 40 percent of Medicare-only beneficiaries. See Exhibit
3. Notably, dually eligible beneficiaries were more likely than Medicare-only
beneficiaries to use telehealth regardless of race and ethnicity, and whether they lived
in rural or urban areas.
Exhibit 3: Dually eligible beneficiaries were more likely than Medicare-only
beneficiaries to use telehealth during the first year of the pandemic.
53%
40%
of dually eligible
of Medicare-only
beneficiaries
beneficiaries
used
used
telehealth
telehealth
Source: OIG analysis of CMS data, 2022.
Dually eligible beneficiaries were also more likely to use any service (telehealth or
in-person) than Medicare-only beneficiaries; however, this did not appear to explain
the relatively high use of telehealth by dually eligible beneficiaries. When accounting
for their increased likelihood of using any service, dually eligible beneficiaries were
still more likely to use telehealth services than Medicare-only beneficiaries.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Results | 7
Hispanic beneficiaries were more likely than beneficiaries in other groups to use
telehealth. Overall, 48 percent of Hispanic beneficiaries used telehealth during the
first year of the pandemic, which is a higher percentage than beneficiaries in other
racial and ethnic groups.17 In total, 45 percent of Black beneficiaries used telehealth,
while 42 percent of both Asian/Pacific Islander and White beneficiaries did so. See
Exhibit 4.
Exhibit 4: Hispanic beneficiaries were more likely than other groups to use
telehealth during the first year of the pandemic.
48%
Hispanic
45%
Black
Asian/Pacific Islander
42%
42%
White
Source: OIG analysis of CMS data, 2022.
It is important to note that Hispanic beneficiaries were more likely to use telehealth
than others regardless of whether the beneficiaries lived in rural or urban areas, or
whether or not they were dually eligible.
Unlike their use of telehealth during the first year of the pandemic, Hispanic
beneficiaries were less likely to use any service (telehealth or in-person) than White
beneficiaries and Black beneficiaries. Yet, even when accounting for their decreased
likelihood of using any service, Hispanic beneficiaries were still more likely to use
telehealth than White beneficiaries and Black beneficiaries. This suggests that
Hispanic beneficiaries—a medically underserved population—particularly benefited
from the expanded access to telehealth during the first year of the pandemic.
Beneficiaries under age 65 were more likely than beneficiaries in other age
groups to use telehealth. Overall, 49 percent of beneficiaries under the age of
65 used telehealth during the first year of the pandemic. These beneficiaries were
more likely to use telehealth than beneficiaries in other age groups. Beneficiaries
under the age of 65 usually qualify for Medicare because of a disability and are often
dually eligible.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Results | 8
Beneficiaries between the ages of 65 and 74 were less likely to use telehealth than
other age groups. Specifically, 38 percent of beneficiaries between 65 and 74 used
telehealth, while 47 percent of beneficiaries 75 and older did so. See Exhibit 5.
Unlike their use of telehealth, beneficiaries under 65 were less likely than beneficiaries
75 and older to use any service (telehealth or in-person). Yet, even when accounting
for their decreased likelihood of using any service, beneficiaries under 65 were still
more likely to use telehealth services than beneficiaries 75 and older. This suggests
that beneficiaries under 65 particularly benefited from the expanded access to
telehealth during the first year of the pandemic.
Exhibit 5: Medicare beneficiaries under age 65 were more likely than other
age groups to use telehealth during the first year of the pandemic.
49%
Under 65
38%
65-74
47%
75-84
47%
Over 84
Source: OIG analysis of CMS data, 2022.
Female beneficiaries were more likely than male beneficiaries to use telehealth.
In total, 46 percent of all female beneficiaries compared to 39 percent of male
beneficiaries used telehealth during the first year of the pandemic. Female
beneficiaries were more likely to use telehealth than male beneficiaries regardless of
age, race and ethnicity, whether they were in a rural or urban area, or whether or not
they were dually eligible.
Female beneficiaries were also more likely to use any service (telehealth or in-person)
than male beneficiaries; however, this did not appear to explain the relatively high use
of telehealth by female beneficiaries. When accounting for their increased likelihood
of using any service, female beneficiaries were still more likely than male beneficiaries
to use telehealth services.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Results | 9
Almost 1 in 5 beneficiaries used certain audio-only telehealth
services; the vast majority of these beneficiaries used them
exclusively
Almost 1 in 5 Medicare beneficiaries used certain telehealth services that were
available audio-only during the first year of the pandemic. These six audio-only
services do not include video. These services
consist of telephone calls with a provider for
Exhibit 6: The vast
various durations to discuss a beneficiary’s
majority of beneficiaries
medical condition.18 A total of 12.7 million
who used certain audio-
Medicare beneficiaries, or 19 percent of all
only services did not use
beneficiaries, used these audio-only services
any audio-video
during the first year of the pandemic.
telehealth services.
It is important to note that an additional
86 telehealth services are available either as
audio-only or audio-video, but Medicare data do
not distinguish between the two.19 Therefore, the
total number of beneficiaries who used any
audio-only services during the first year of the
pandemic is higher than 12.7 million.
The vast majority of beneficiaries—93 percent—
who used the six audio-only telehealth services
did so exclusively. These beneficiaries did not use
any audio-video telehealth services during the
first year of the pandemic.20 The remaining 7 percent of beneficiaries used both
audio-only and audio-video telehealth services. See Exhibit 6. Using audio-only
services exclusively may suggest that these beneficiaries prefer audio-only telehealth
services, or that they may face barriers to using audio-video telehealth.
Older beneficiaries were more likely to use certain audio-only
services, as were dually eligible and Hispanic beneficiaries
Older beneficiaries were more likely to use the six audio-only services compared to
younger beneficiaries during the first year of the pandemic. Specifically, 23 percent of
beneficiaries 75 and older used audio-only services, while only 21 percent of
beneficiaries under 65 did the same. This pattern is unlike that for all telehealth
services and may indicate that older beneficiaries prefer audio-only or have greater
difficulty accessing audio-video technology than their younger counterparts. See
Exhibit 7.
In addition, dually eligible beneficiaries and Hispanic beneficiaries were more likely to
use these audio-only services than other beneficiaries. More than 20 percent of
93%
of beneficiaries
who used certain
audio-only
services did so
exclusively
Source: OIG analysis of CMS data, 2022.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Results | 10
dually eligible beneficiaries and Hispanic beneficiaries used these audio-only services.
Beneficiaries in these groups were also more likely to use all telehealth services.
Furthermore, female beneficiaries were more likely to use these audio-only services
than male beneficiaries, and those in urban areas were more likely to use these audio-
only services than those in rural areas.
Exhibit 7: Certain beneficiaries were more likely to use these audio-only services
than others during the first year of the pandemic.
Over 84
23%
75-84
23%
65-74
16%
Under 65
21%
Hispanic
23%
Black
21%
White
19%
Asian/Pacific Islander
17%
Dually eligible
24%
Medicare-only
18%
Female
21%
Male
17%
Urban
20%
Rural
15%
Source: OIG analysis of CMS data, 2022.
Note: This analysis is based on the six audio-only services.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Results | 11
CONCLUSION AND RECOMMENDATIONS
The COVID-19 pandemic created unprecedented challenges for how Medicare beneficiaries
accessed health care. In response, HHS and CMS took a number of actions to temporarily
expand access to telehealth for Medicare beneficiaries.
In a companion report, OIG found that the use of telehealth increased dramatically during the
first year of the pandemic.21 More than 28 million—about 2 in 5—Medicare beneficiaries used
telehealth that first year. In total, beneficiaries used 88 times more telehealth services during
the first year of the pandemic than they did in the prior year.
This data brief expands on that analysis and found that, during the first year of pandemic, many
Medicare beneficiaries relied on using telehealth from locations and in ways not previously
allowed by Medicare, such as from urban areas, from home, and through audio-only.22 More
specifically, we found that beneficiaries in urban areas were more likely than those in rural areas
to use telehealth. Dually eligible beneficiaries and Hispanic beneficiaries were also more likely
than others to use telehealth. In addition, beneficiaries almost always used telehealth from
home or other non-health-care settings. Furthermore, almost one-fifth of beneficiaries used
certain audio-only telehealth services, with the vast majority of these beneficiaries using these
audio-only services exclusively.
As CMS, HHS, Congress, and other stakeholders consider permanent changes to Medicare
telehealth services, it is important that they balance concerns about issues such as access,
quality of care, cost, health equity, and program integrity. Doing so will ensure the benefits of
telehealth are realized while minimizing risk. The data presented in this report demonstrate how
the temporary expansion improved access to telehealth for Medicare beneficiaries, particularly
for those who are medically underserved. Understanding who benefited from increased access
and how different groups used telehealth can inform policymakers and stakeholders as they
make decisions about telehealth.
We recommend that CMS:
Take appropriate steps to enable a successful transition from
current pandemic-related flexibilities to well-considered long
term policies for the use of telehealth for beneficiaries in urban
areas and from the beneficiary’s home
Our findings demonstrate the important role that telehealth played in Medicare
beneficiaries’ access to care when telehealth became more broadly available during the
pandemic. This was especially true for beneficiaries in urban areas, as more than
24 million beneficiaries in urban areas used telehealth services from March 2020 through
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Conclusion and Recommendations | 12
February 2021. Furthermore, when given the option, more than 90 percent of all
beneficiaries (urban and rural) who used telehealth did so from home or other non-
health-care settings. Prior to the pandemic, many of these beneficiaries were not
allowed to use telehealth in urban areas or from home. However, unless policymakers
take action, millions of beneficiaries in urban areas, as well as millions of beneficiaries in
both urban and rural areas receiving care from home, will lose access to many telehealth
services once the temporary expansions to telehealth end.23
Congress has extended the temporary telehealth expansions for 5 months after the
public health emergency ends. If that deadline comes before long-term telehealth
policies have been enacted, CMS should seek additional authority from Congress to
temporarily continue access to telehealth services in urban areas and from the
beneficiary’s home. This will ensure that beneficiaries enrolled in Medicare
fee-for-service can continue to receive services via telehealth, regardless of geographic
location or ability to travel to a health care facility to receive care, while policymakers
deliberate and develop more permanent policies for telehealth.
As CMS develops proposals for long-term policies on telehealth, it should carefully
consider the impacts of telehealth flexibilities on beneficiary access to care, health equity,
quality, costs, and program integrity. CMS should take into account the analysis detailed
in this brief and consider building on it to further analyze access to care for medically
underserved beneficiaries, including how maintaining the availability of telehealth could
facilitate access to care for these beneficiaries. CMS should also use other OIG work,
including the other report in this series about program integrity concerns related to
telehealth, additional analysis it conducts, and feedback and data from other
stakeholders as it develops policy proposals.24
Temporarily extend the use of audio-only telehealth services
and evaluate their impact
CMS should temporarily extend the use of audio-only for telehealth services once the
temporary expansions to telehealth end, seeking statutory authority, if necessary. CMS
should then evaluate the impact of audio-only services on beneficiary access, equity,
cost, quality of care, and program integrity.25
During the first year of the pandemic, more than 12 million beneficiaries used certain
audio-only telehealth services; the vast majority of these beneficiaries used audio-only
telehealth services exclusively. These beneficiaries may prefer audio-only or face barriers
to accessing audio-video telehealth services, such as a lack of appropriate technology or
broadband access. Furthermore, certain beneficiaries such as older, Hispanic, and dually
eligible beneficiaries were more likely to use these audio-only services than other
beneficiaries during the first year of the pandemic.
Without further action, Medicare beneficiaries enrolled in Medicare fee-for-service will
no longer be allowed to use audio-only services (except in certain circumstances) once
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Conclusion and Recommendations | 13
the temporary expansions to telehealth end.26 In addition, there are questions about the
impact of these services on quality of care, among other issues.27
CMS should use the information in this brief, information from its evaluations, and
feedback and data from other stakeholders to determine whether to permanently
expand the use of audio-only services and what, if any, limitations should be placed on
these services. For example, CMS could allow audio-only telehealth services solely for
providers with whom the beneficiary has an established relationship or when the
beneficiary has periodic in-person visits with the provider.28
Require a modifier to identify all audio-only telehealth services
provided in Medicare
CMS is not able to identify all audio-only telehealth services. Currently, it can identify
6 services, but it is not able to identify whether audio-only services were provided for
86 other telehealth services. Not being able to identify these services when they are
provided as audio-only makes it difficult to assess the use of audio-only as well as its
impact on access, quality of care, equity, and program integrity.
Starting in 2022, CMS requires that providers use a modifier when billing for audio-only
telehealth services under certain circumstances.29 CMS should build upon this and
require providers to use this modifier to identify all telehealth services provided as
audio-only.30 This is important in the event CMS further expands the use of audio-only
telehealth on a more permanent basis. CMS should require that providers identify all
services that are provided as audio-only so that it can evaluate and monitor the use of
audio-only services.
Use telehealth to advance health care equity
Telehealth can be a valuable tool for increasing access to care, especially for certain
beneficiaries. We found that dually eligible, Hispanic, younger, and female beneficiaries
were more likely than others to use telehealth during the first year of the pandemic.
Furthermore, certain beneficiaries, such as Hispanic beneficiaries, were more likely to use
telehealth than other groups even though they were less likely to use any service,
suggesting they particularly benefited from the expansion of telehealth.
CMS is committed to advancing health equity and has developed a strategy to promote
equity across its programs.31 Telehealth can help increase access to care, especially for
beneficiaries who are medically underserved or face barriers to accessing in-person care.
CMS should take steps to promote the use of telehealth and use telehealth to address
the goals of its health equity strategy, as appropriate. For example, CMS could
incorporate telehealth as an action step to help close gaps in access among medically
underserved populations.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Conclusion and Recommendations | 14
In addition, CMS should provide additional outreach and education to assist beneficiaries
in accessing telehealth, particularly for beneficiaries with limited access to in-person care.
For example, CMS could direct its Quality Innovation Network-Quality Improvement
Organizations to provide resources that can assist in accessing telehealth as appropriate
and include additional information about telehealth in the Medicare handbook (i.e.,
Medicare & You).
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Conclusion and Recommendations | 15
AGENCY COMMENTS AND OIG RESPONSE
CMS did not explicitly indicate whether it concurred with our four recommendations.
In response to our first recommendation to take appropriate steps to enable a
successful transition from current pandemic-related flexibilities to well-considered
long-term policies for the use of telehealth for beneficiaries in urban areas and from
the beneficiary’s home, CMS noted that it has taken steps to implement telehealth
policies consistent with changes in legislation, such as expanding the originating sites
at which a beneficiary may be located for mental health telehealth services. CMS
stated that it will continue to implement policies consistent with its authority, adding
that further legislative change may be necessary to implement this recommendation.
In response, OIG recognizes that additional legislative action will be necessary for the
transition from current pandemic-related flexibilities, and that the President’s FY23
Budget supports extending telehealth coverage beyond the public health emergency
to study telehealth’s impact on utilization of services and access to care. OIG will
continue to monitor the implementation of the President’s FY23 Budget proposal and
its outcomes.
In response to our second recommendation to temporarily extend the use of audio-
only telehealth services and evaluate their impact, CMS noted that it established a
policy to allow mental health services to be provided via audio-only telehealth in
certain circumstances. CMS stated that it will continue to implement policies
consistent with its authority and that further legislative change may be necessary to
implement this recommendation. In response, OIG recognizes that additional
legislation will be needed to temporarily extend the use of audio-only telehealth for
most services. OIG also emphasizes that further assessment of the impact of audio-
only telehealth services on equitable access to care is critical given OIG’s findings on
the individuals who were most likely to use audio-only telehealth during the first year
of the pandemic.
In response to our third recommendation to require a modifier to identify all audio-
only telehealth services provided in Medicare, CMS noted that, in the Calendar Year
2023 Physician Fee Schedule proposed rule, it proposed requiring physicians and
other health care practitioners to include a modifier on claims for telehealth services
that were provided using audio-only technology. CMS added that it will take
feedback from the public comment period, as well as OIG’s recommendation, into
consideration as it determines appropriate next steps.
In response to our fourth recommendation to use telehealth to advance health care
equity, CMS indicated that it continues to evaluate opportunities to advance health
equity, drive innovation, and promote good fiscal stewardship for the Medicare
program based on the telehealth flexibilities implemented during the public health
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Agency Comments and OIG Response | 16
emergency, and will continue to implement policies consistent with its authority. CMS
added that it provided education to assist individuals with Medicare in accessing
telehealth and that it published a Coverage to Care Telehealth Toolkit that includes
general information, such as information about the types of care individuals can
receive through telehealth. CMS indicated that it will continue to provide education
to individuals with Medicare regarding their options for receiving services via
telehealth as appropriate. OIG appreciates CMS’s efforts and encourages CMS to
build upon these efforts by, for example, providing additional outreach and education
to assist beneficiaries in accessing telehealth.
We ask that CMS—in its Final Management Decision—provide details on any plans
and progress toward implementing our recommendations.
For the full text of CMS’s comments, see Appendix C.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Agency Comments and OIG Response | 17
METHODOLOGY
We based this data brief on an analysis of Medicare fee-for-service claims and
Medicare Advantage encounters for telehealth services from March 1, 2020, to
February 28, 2021. These data are similar to the data used in other reports in the
series about Medicare beneficiaries’ use of telehealth during the first year of the
pandemic.32
We used the Medicare Part B fee-for-service claims from the National Claims History
File and Medicare Advantage encounters from Part C Encounter data. When
identifying telehealth services, we reviewed services billed by individual practitioners;
we did not review services billed by institutional entities, such as hospitals and nursing
homes. We also used enrollment data for Medicare fee-for-service and Medicare
Advantage from the Medicare Enrollment Database.
We used these data to identify the characteristics of beneficiaries who used telehealth
services in Medicare fee-for-service and Medicare Advantage during the first year of
the pandemic.
Beneficiaries Who Used Telehealth
To conduct this analysis, we first identified the services that Medicare approved for
telehealth during the pandemic.33 These services are described using Current
Procedural Terminology codes and Healthcare Common Procedure Coding System
codes. These codes are included on the claim by a provider for reimbursement
purposes.
As part of our analysis, we included virtual care services as a type of telehealth service.
These services are also referred to as communication technology-based services.
These services are always delivered remotely and include virtual check-ins, e-visits,
remote monitoring, and telephone calls with a provider to discuss a beneficiary’s
medical condition.
We identified the services that were delivered via telehealth using a modifier (i.e., 95,
GT, GQ, or G0) or a place of service code (i.e., 02) that indicates the service was
delivered via telehealth. We considered the services that did not have any of these
modifiers or codes to be delivered in person.34
To identify the audio-only services, we focused on the six telehealth services that are
available exclusively as audio-only. These six audio-only services do not include
video. They consist of telephone calls with a provider for various durations to discuss
a beneficiary’s medical condition. We did not include the other telehealth services
that can be provided as audio-only because Medicare data for these services do not
distinguish between audio-only and audio-video use.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Methodology | 18
Analysis of Characteristics of Beneficiaries Who Used Telehealth
We analyzed the use of telehealth among beneficiaries with different characteristics.
We first examined the use of telehealth among beneficiaries who lived in urban and
rural areas. We determined whether a beneficiary lived in an urban or rural area by
matching the beneficiary’s ZIP code from the Medicare Enrollment Database with a
Census Bureau Core-Based Statistical Area (CBSA). We considered a beneficiary to
live in an urban area if they resided in a Metropolitan Statistical Area and in a rural
area if they resided in a Micropolitan Statistical Area or outside a CBSA.35
We also looked at the use of telehealth services among beneficiaries living in different
States. We determined a beneficiary’s State of residence based on the beneficiary’s
address. We also determined the extent to which beneficiaries used telehealth from
home and other non-health-care settings.36
Next, we looked at the use of telehealth among beneficiaries with certain
demographic characteristics. We based this analysis on information from the
Medicare Enrollment Database. We reviewed the following characteristics:
•
Age (Under 65, 65-74, 75-84, Over 84)
•
Sex (Male, Female)
•
Race and Ethnicity (White, Black, Hispanic, Asian/Pacific Islander)
•
Eligibility Status (Dually Eligible, Medicare-Only)
Note that the race and ethnicity information is based on data collected from the
Social Security Administration and an algorithm developed by the Research Triangle
Institute.37 This algorithm attempts to improve the quality of the Social Security
Administration’s data by amending the race data for certain groups based on name
and geography, as well as requests made by individuals for certain Government
materials to be provided in Spanish.
For each group described above, we calculated the percentage of beneficiaries who
used telehealth among all enrolled beneficiaries and the percentage of beneficiaries
who used telehealth among those who used any telehealth-eligible service, either
in-person or via telehealth (i.e., any service) during the first year of the pandemic.38
For example, we calculated the percentage of beneficiaries who used telehealth
among all enrolled Medicare beneficiaries in each age group during the first year of
the pandemic. We then compared these percentages to determine which age groups
were more likely to use telehealth during this time period. For each age group, we
then calculated the percentage of beneficiaries who used telehealth among
beneficiaries who used any service to determine the extent to which each group used
telehealth, regardless of whether they were more likely to use any service.
We conducted a similar analysis of the use of the six audio-only services that are
available exclusively as audio-only. For each group, we calculated the percentage of
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Methodology | 19
beneficiaries who used these services among all enrolled beneficiaries during the first
year of the pandemic. We then compared these percentages to determine which
groups of beneficiaries were more likely to use these audio-only services during this
time period. We also determined the extent to which beneficiaries used these audio-
only telehealth services exclusively.39
Limitations
While this study includes demographic data about those using telehealth services, it is
possible that other factors that were not included in this study could have influenced
an individual’s use of telehealth, such as their diagnoses, health status, or income,
among other factors. Understanding how these factors could have influenced the use
of telehealth is important for future work.
In addition, although the race and ethnicity information is currently the best available
for the entire Medicare beneficiary population, comparisons to self-reported data
(available in certain, limited circumstances) show that race and ethnicity are still
misclassified for some beneficiaries. As such, we did not report on beneficiaries
identified as American Indian/Alaska Native since this group is often misclassified.
Furthermore, although Hispanic is an ethnicity, Medicare’s data combine race and
ethnicity and limit beneficiaries to one category.40
Standards
We conducted this study in accordance with the Quality Standards for Inspection and
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Methodology | 20
APPENDIX A
Percentage of Beneficiaries in Each State Who Used Telehealth During the First
Year of the Pandemic
State
Percentage
Massachusetts
57%
Delaware
57%
California
52%
Connecticut
50%
Maryland
50%
New Jersey
50%
Rhode Island
47%
New York
47%
Arizona
47%
Florida
47%
District of Columbia
46%
New Mexico
46%
Hawaii
45%
Texas
45%
Pennsylvania
44%
New Hampshire
44%
Ohio
44%
Oregon
43%
Michigan
43%
Minnesota
42%
Indiana
42%
Virginia
42%
Kentucky
41%
Vermont
41%
North Carolina
41%
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Appendix A | 21
APPENDIX A (Cont.)
State
Percentage
Colorado
40%
Illinois
39%
Georgia
39%
Alabama
38%
Louisiana
38%
Washington
38%
Nevada
38%
Maine
38%
Mississippi
37%
Oklahoma
37%
South Carolina
36%
Utah
36%
Arkansas
36%
Alaska
35%
West Virginia
35%
Wisconsin
34%
Tennessee
30%
Iowa
30%
Idaho
30%
Missouri
29%
South Dakota
27%
Kansas
26%
Montana
25%
Wyoming
25%
Nebraska
25%
North Dakota
21%
Source: OIG analysis of CMS data, 2022
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Appendix A | 22
Number
Percentage
Beneficiaries
Beneficiaries who used
Beneficiaries
who used any
telehealth among those
Area
enrolled
service*
enrolled
Urban
54,393,561
44,910,462
45%
Rural
11,337,760
9,217,144
33%
*This refers to the number of beneficiaries who used any telehealth-eligible service, either in-person or via telehealth.
Source: DIG analysis of CMS data, 2022.
Beneficiaries who used
telehealth among those
who used any service
55%
41%
Number
Percenrage
Eligibility
Dually Eligible
Medicare-Only
Beneficiaries
enrolled
12,477,492
53,605,379
Beneficiaries
who used any
service*
11,049,080
43,079,920
Beneficiaries who used
telehealth among those
enrolled
53%
40%
*This refers to the number of beneficiaries who used any telehealth-eligible service, either in-person or via telehealth.
Source: DIG analysis of CMS data, 2022.
Beneficiaries who used
telehealth among those
who used any service
60%
50%
APPENDIX B
Characteristics of Beneficiaries Who Used Telehealth During the First Year of
the Pandemic
Exhibit B1: Medicare beneficiaries in urban areas were more likely than those in rural areas
to use telehealth.
Exhibit B2: Dually eligible beneficiaries were more likely than Medicare-only beneficiaries to
use telehealth.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Appendix B | 23
Number
Percentage
Beneficiaries
Beneficiaries who used
Beneficiaries who used
Beneficiaries
who used any
telehealth among those
telehealth among those
Race & Ethnicity
enrolled
service*
enrolled
who used any service
Hispanic
5,744,927
4,472,408
48%
61%
Black
7,010,304
5,632,552
45%
56%
Asian/Pacific Islander
2,388,933
1,773,416
42%
56%
White
48,663,596
40,538,574
42%
51%
' This refers to the number of beneficiaries who used any telehealth-eligible service, either in-person or via telehealth.
Note: Informatio n for beneficiaries identified as American Indian/ Alaska Native, Other, Unknown, or had missing race and ethnicity data are not included in
the table because of limitations with the data. Furthermore, although Hispanic is an ethnicity, Medicare's data combine race and ethnicity and limit
beneficiaries to one cat egory.
Source: OIG analysis of CMS data, 2022.
Number
Percentage
Beneficiaries
Beneficiaries who used
Beneficiaries
who used any
telehealth among those
Age
enrolled
service*
enrolled
Under 65
8,747,663
6,935,246
49%
65-74
33,184,295
25,545,589
38%
75-84
17,032,153
15,206,898
47%
Over 84
7,198,694
6,442,203
47%
' This refers to the number of beneficiaries who used any telehealth-eligible service, either in-person or via telehealth.
Source: OIG analysis of CMS data, 2022.
Beneficiaries who used
telehealth among those
who used any service
61%
49%
53%
53%
APPENDIX B (Cont.)
Exhibit B3: Hispanic beneficiaries were more likely than other groups to use telehealth.
Exhibit B4: Medicare beneficiaries under age 65 were more likely than beneficiaries in other
age groups to use telehealth.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Appendix B | 24
Percentage
Beneficiaries
Beneficiaries who used
Beneficiaries
who used any
telehealth among those
Sex
enrolled
service*
enrolled
Female
35,849,569
30,514,701
46%
Male
30,313,225
23,615,231
39%
•This refers to the number of beneficiaries who used any t elehealth-eligible service, either in-person or via telehealth.
Source: OIG analysis of CMS data, 2022.
Beneficiaries who used
telehealth among those
who used any service
54%
50%
APPENDIX B (Cont.)
Exhibit B5: Female beneficiaries were more likely than male beneficiaries to use telehealth.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Appendix B | 25
DATE:
July 29, 2022
TO:
Gregory E. Demske
Acting Principal Deputy Inspector General
Office of Inspector General
FROM:
Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
SUBJECT:
Office of Inspector General (OIG) Draft Data Brief: Certain Medicare
Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than
Others To Use Telehealth During the First Year of the COVID-19 Pandemic
(OEI-02-20-00522)
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and
comment on the Office of Inspector General’s (OIG) draft report.
CMS is committed to advancing health equity and recognizes that telehealth may be a useful tool
to address disparities. CMS is working to advance health equity by designing, implementing, and
operationalizing policies and programs that support health for all the people served by our
programs, eliminating avoidable differences in health outcomes experienced by people who are
disadvantaged or underserved, and providing the care and support that our enrollees need to
thrive.
At the beginning of the public health emergency (PHE), CMS issued waivers to prevent gaps in
access to care for patients affected by the COVID-19 PHE, including waivers for services
furnished via telehealth. These changes to payment and coverage policies were intended to allow
health care providers maximum flexibility to minimize the spread of COVID-19 among
Medicare beneficiaries, health care personnel, and the community at large and increase capacity
to address the needs of their patients.
On March 17, 2020, CMS announced the expansion of telehealth services on a temporary and
emergency basis pursuant to waiver authority added under section 1135(b)(8) of the Social
Security Act by the Coronavirus Preparedness and Response Supplemental Appropriations Act,
2020 (Pub. L. 116-123, March 6, 2020). Beginning on March 6, 2020, and for the duration of the
COVID-19 PHE, Medicare pays for telehealth services, including office, hospital, and other
visits furnished by physicians and other practitioners to patients located anywhere in the country,
including in a patient’s place of residence. In the context of the COVID-19 PHE, CMS
recognized that the use of telehealth could help address new challenges regarding potential
exposure risks, for people with Medicare, health care providers, and the community at large. To
facilitate the use of telecommunications technology as a safe substitute for in-person services,
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Agency Comments B | 26
CMS, on a temporary interim final basis, added many services to the list of eligible Medicare
telehealth services, eliminated frequency limitations and other requirements associated with
particular services furnished via telehealth, and clarified several payment rules that apply to other
services that are furnished using telecommunications technologies that can reduce exposure
risks.1
CMS has also taken steps to implement policies consistent with changes in legislation that take
effect after the COVID-19 PHE ends. For example, Section 123 of the Consolidated
Appropriations Act, 2021 removed the geographic restrictions and added the home of the
beneficiary as a permissible originating site for telehealth services furnished for the purposes of
diagnosis, evaluation, or treatment of a mental health disorder. Section 123 requires for these
services that there must be an in-person, non-telehealth service with the physician or practitioner
within six months prior to the initial telehealth service and requires the Secretary to establish a
frequency for subsequent in-person visits. CMS implemented these statutory amendments via the
Calendar Year 2022 Physician Fee Schedule Final Rule, specifying that an in-person, non-
telehealth visit must be furnished at least every 12 months for these services, that exceptions to
the in-person visit requirement may be made based on beneficiary circumstances (with the
reason documented in the patient’s medical record), while clarifying that more frequent visits are
also allowed under our policy, as driven by clinical needs on a case-by-case basis.2
In the Calendar Year 2022 Physician Fee Schedule Final Rule, CMS also established a
permanent policy to permit the use of an audio-only interactive telecommunications system for
mental health telehealth services furnished by practitioners who have the capability to furnish
two-way, audio/video communications, but the beneficiary is not capable of, or does not consent
to, the use of two-way, audio/video technology. CMS also specified that a designated modifier
must be used on claims for these services furnished using audio-only communications, which
would serve to verify that the practitioner had the capability to provide two-way, audio/video
technology, but instead, used audio-only technology due to beneficiary choice or limitations.
The Consolidated Appropriations Act, 2022 (Pub. L. 117-103) included several provisions that
extend certain Medicare telehealth flexibilities adopted during the PHE for 151 days after the end
of the COVID-19 PHE. These include allowing telehealth services to be furnished in any
geographic area and in any originating site setting, including the beneficiary’s home, allowing
certain services to be furnished via audio-only telecommunications systems, and allowing
physical therapists, occupational therapists, speech-language pathologists, and audiologists to
furnish telehealth services.
In the Calendar Year 2023 Physician Fee Schedule Proposed Rule, CMS provided notice of its
intent to issue program instruction or other subregulatory guidance to effectuate the changes to
telehealth enacted in the Consolidated Appropriations Act, 2022 to ensure a smooth transition
1 The list of these eligible telehealth services is published on the CMS website at
https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html.
2 Medicare Program; Calendar Year 2022 Payment Policies Under the Physician Fee Schedule and Other Changes to
Part B Payment Policies; Final Rule (86 FR 64996) (11/19/2021). Accessed at:
https://www.govinfo.gov/content/pkg/FR-2021-11-19/pdf/2021-23972.pdf
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Agency Comments B | 27
after the end of the PHE.3 CMS also proposed to extend the time that certain services are
temporarily available as telehealth services, which will allow more time for collection of data
that could support their eventual inclusion as permanent additions to the Medicare telehealth
services list.
CMS continues to evaluate the inclusion of telehealth services that were temporarily added to the
Medicare telehealth services during the COVID-19 PHE and evaluate opportunities to implement
policies that advance health equity, drive innovation, and promote good fiscal stewardship for
the Medicare program based on the telehealth flexibilities implemented during the PHE.
The OIG’s recommendations and CMS’ responses are below.
OIG Recommendation
The OIG recommends that CMS take appropriate steps to enable a successful transition from
current pandemic-related flexibilities to well-considered, long-term policies for the use of
telehealth for beneficiaries in urban areas and from the beneficiary’s home.
CMS Response
Section 301 of the Consolidated Appropriations Act, 2022 temporarily expands the scope of
telehealth originating sites to include any site in the United States where the beneficiary is
located at the time of the telehealth service, including an individual's home, for 151 days after
the end of the PHE for COVID-19. CMS has provided notice of its intent to issue program
instruction or other subregulatory guidance to effectuate the changes to telehealth enacted in the
Consolidated Appropriations Act, 2022 to ensure a smooth transition after the end of the PHE.
The President’s Fiscal Year (FY) 2023 Budget states that the Administration is committed to
supporting a temporary extension of broader telehealth coverage under Medicare beyond the
COVID-19 PHE declared by the Secretary to study its ability to promote proper use and access
to care.4
Additionally, as stated above, CMS has taken steps to implement policies consistent with
changes in legislation that take effect after the COVID-19 PHE ends, such as expanding the
originating sites at which a beneficiary may be located for mental health telehealth services. In
implementing these statutory changes, CMS also established a policy to allow mental health
services to be furnished via telehealth using audio-only telecommunications technology in
certain circumstances. We will continue to implement policies consistent with our authority,
however, further legislative change may be necessary to implement this recommendation.
OIG Recommendation
The OIG recommends that CMS temporarily extend the use of audio-only telehealth services and
evaluate their impact.
CMS Response
Section 305 of the Consolidated Appropriations Act, 2022 extends the flexibilities related to
furnishing certain telehealth services using audio-only telecommunications technology for 151
3 Medicare Program; Calendar Year 2023 Payment Policies under the Physician Fee Schedule and Other Changes to
Part B Payment Policies; Proposed Rule (87 FR 45860) (07/29/2022). Accessed at:
https://www.govinfo.gov/content/pkg/FR-2022-07-29/pdf/2022-14562.pdf
4 Department of Health and Human Services Fiscal Year 2023 Budget in Brief. Accessed at:
https://www.hhs.gov/sites/default/files/fy-2023-budget-in-brief.pdf
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Agency Comments B | 28
days after the end of the COVID-19 PHE. The President’s Fiscal Year (FY) 2023 Budget states
that the Administration is committed to supporting a temporary extension of broader telehealth
coverage under Medicare beyond the COVID-19 PHE declared by the Secretary to study its
ability to promote proper use and access to care.
Additionally, as stated above, CMS has taken steps to implement policies consistent with
changes in legislation that take effect after the COVID-19 PHE ends, such as expanding the
originating sites at which a beneficiary may be located for mental health telehealth services. In
implementing these statutory changes, CMS also established a policy to allow mental health
services to be furnished via telehealth using audio-only telecommunications technology in
certain circumstances. We will continue to implement policies consistent with our authority,
however, further legislative change may be necessary to implement this recommendation.
OIG Recommendation
The OIG recommends that CMS require a modifier to identify all audio-only telehealth services
provided in Medicare.
CMS Response
In the Calendar Year 2023 Physician Fee Schedule proposed rule we proposed that beginning
January 1, 2023, a physician or other qualified health care practitioner billing for telehealth
services furnished using audio-only communications technology shall append CPT modifier “93”
(Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive
Audio-Only Telecommunications System) to Medicare telehealth claims for those services for
which the use of audio-only technology is permitted under § 410.78(a)(3), to identify them as
having been furnished using audio-only technology. We will take the feedback received from the
public comment period, as well as the OIG’s recommendation, into consideration as we
determine appropriate next steps.
OIG Recommendation
The OIG recommends that CMS use telehealth to advance health care equity.
CMS Response
CMS is committed to advancing health equity for people with Medicare through operations and
policies in the Traditional Medicare, Medicare Advantage and Part D programs, ensuring that
services are culturally and linguistically appropriate, care is high-value and person-centered,
underserved communities have access to quality care, disparities are eliminated, and social needs
are addressed.
As stated above, we continue to evaluate opportunities to advance health equity, drive
innovation, and promote good fiscal stewardship for the Medicare program based on the
telehealth flexibilities implemented during the PHE and will continue to implement policies
consistent with our authority.
CMS has provided education to assist individuals with Medicare in accessing telehealth. For
example, CMS has provided information about telehealth to individuals with Medicare in the
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Agency Comments B | 29
Medicare & You Handbook, Medicare.gov, and through social media.5, 6 CMS has also published
a Coverage to Care Telehealth Toolkit which includes general information about types of care
individuals can receive through telehealth, how to prepare for an appointment, what to expect
during a visit, and more.7 The Coverage to Care Telehealth Toolkit is available in eight
languages. CMS will continue to provide education to individuals with Medicare regarding their
options for receiving services via telehealth as appropriate.
5 Medicare & You 2022. Accessed at: https://www.medicare.gov/media/10991
6 Medicare.Gov. Accessed at: https://www.medicare.gov/coverage/telehealth
7 Telehealth: What To Know For Your Family. Accessed at: https://www.cms.gov/About-CMS/Agency-
Information/OMH/equity-initiatives/c2c/consumer-resources
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Agency Comments B | 30
ACKNOWLEDGMENTS AND CONTACT
Acknowledgments
Vincent Greiber served as the team leader for this study. Others in the Office of
Evaluation and Inspections who conducted the study include Aaron Plotke and John
Gordon. Office of Evaluation and Inspections staff who contributed to the study
include Miriam Anderson, Robert Gibbons, and Michael Novello.
This report was prepared under the direction of Jodi Nudelman, Regional Inspector
General for Evaluation and Inspections in the New York regional office, and Nancy
Harrison and Meridith Seife, Deputy Regional Inspectors General.
Contact
To obtain additional information concerning this report, contact the Office of Public
Affairs at Public.Affairs@oig.hhs.gov. OIG reports and other information can be found
on the OIG website at oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Acknowledgments and Contact | 31
ENDNOTES
1 HHS and CMS were able to temporarily expand access to telehealth because of their waiver authority under section 1135 of
the Social Security Act, subsequent legislation, and the Secretary’s declaration of a public health emergency due to
COVID-19. The public health emergency was announced on January 31, 2020. See HHS, Determination that a Public Health
Emergency Exists, January 31, 2020, accessed at https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019
nCoV.aspx on April 8, 2022. See also Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020,
accessed at https://www.congress.gov/bill/116th-congress/house-bill/6074/text/rds on November 23, 2021. See also Families
First Coronavirus Response Act, accessed at https://www.congress.gov/bill/116th-congress/house-bill/6201/text on April 15,
2022. See also CARES Act, accessed at https://www.congress.gov/bill/116th-congress/house-bill/748/text on November 23,
2021.
2 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic,
OEI-02-20-00520, March 2022.
3 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic,
OEI-02-20-00520, March 2022; OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they
had an established relationship, OEI-02-20-00521, October 2021; OIG, Medicare Telehealth Services During the First Year of the
Pandemic: Program Integrity Risks, OEI-02-20-00720, September 2022; Pandemic Response Accountability Committee,
Telehealth Services in Select Federal Health Care Programs, OEI-02-22-00150, forthcoming.
4 These beneficiaries did not use any audio-video telehealth services during this time period. They may have used in-person
services.
5 For the purposes of this report, we refer to the services that can be delivered either via telehealth or in-person—as well as
services that are always provided remotely—as telehealth services.
6 These services are also referred to as communication technology-based services. For the purposes of this report, we refer to
them as virtual care services. CMS does not include communication technology-based services in its formal definition of
telehealth services.
7 For example, prior to the pandemic, beneficiaries were allowed to use virtual care services as well as telehealth services to
address substance use disorder or end-stage renal disease from home and in urban areas. In addition, beginning in 2020,
Medicare Advantage plans were able to allow their beneficiaries to use telehealth services from home and in urban areas.
8 For the purposes of this study, we included the telehealth services approved for payment by Medicare as of February 28,
2021.
9 Prior to the pandemic, beneficiaries could receive certain virtual care services, such as virtual check-ins, through audio-only.
10 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic,
OEI-02-20-00520, March 2022.
11 Beneficiaries residing within a Metropolitan Statistical Area were classified as urban; all others were classified as rural. See
the methodology for more information.
12 Prior to the pandemic, beneficiaries living in urban areas were allowed to use virtual care services as well as telehealth
services to address substance use disorder or end-stage renal disease. In addition, beginning in 2020, Medicare Advantage
plans were able to allow their beneficiaries to use telehealth services in urban areas.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Endnotes | 32
13 According to a 2019 report, the Federal Communications Commission estimated that 26 percent of rural residents did not
have access to broadband internet service, while 1.7 percent of urban residents also did not have access in 2017. Accessed at
https://docs.fcc.gov/public/attachments/FCC-19-44A1.pdf on December 17, 2020.
14 OIG, States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid Enrollees,
OEI-02-19-00400, September 2021.
15 Prior to the pandemic, beneficiaries using telehealth services to address substance use disorder or end-stage renal disease,
as well as beneficiaries using virtual care services, were allowed to receive services from home. In addition, beginning in 2020,
Medicare Advantage plans were able to allow their beneficiaries to receive services from home.
16 For more information about how beneficiaries become eligible for both Medicare and Medicaid, see Medicaid and CHIP
Payment and Access Commission, Eligibility: Dually Eligible Beneficiaries, accessed at https://www.macpac.gov/subtopic/dually
eligible-beneficiaries-eligibility/ on February 22, 2021. For information about the health status of dually eligible beneficiaries,
see CMS, People Dually Eligible for Medicare and Medicaid, accessed at https://www.cms.gov/Medicare-Medicaid-
Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination
Office/Downloads/MMCO_Factsheet.pdf on December 17, 2020. Also see CMS, Medicare-Medicaid Coordination Office FY 2019
Report to Congress, accessed at https://www.cms.gov/files/document/mmco-report-congress.pdf on December 17, 2020.
17 This analysis uses the race and ethnicity information from Medicare’s enrollment database, which is based on data collected
from the Social Security Administration and an algorithm. Note that information for beneficiaries identified as American
Indian/Alaska Native, Other, Unknown, or that had missing race and ethnicity data are not included because of limitations with
the data. Furthermore, although Hispanic is an ethnicity, Medicare’s data combine race and ethnicity and limit beneficiaries to
one category. Although this information is currently the best available for the entire Medicare beneficiary population,
comparisons to self-reported data (available in certain, limited circumstances) show that race and ethnicity is still misclassified
for some beneficiaries. In particular, Medicare beneficiaries with a race and ethnicity of American Indian/Alaska Native,
Asian/Pacific Islander, or Hispanic are more likely to be misclassified. For further discussion on these topics, see OIG,
Inaccuracies in Medicare’s Race and Ethnicity Data Hinder the Ability To Assess Health Disparities, OEI-02-21-00100, June 2022.
18 Three of these codes are telephone evaluation and management codes (99441, 99442, 99443) and the other three are
telephone assessment and management codes (98966, 98967, 98968).
19 CMS does not distinguish between audio-only and audio-video for these 86 services. In addition, Medicare Advantage plans
can offer “supplemental telehealth benefits” that may include audio-only services that cannot be identified in the data.
Furthermore, effective January 1, 2022, CMS will require providers to use a modifier to identify audio-only services for the
treatment of certain mental health conditions. See Medicare Learning Network CY2022 Telehealth Update Medicare Physician
Fee Schedule, accessed at MM12549 - CY2022 Telehealth Update Medicare Physician Fee Schedule (cms.gov) on February 1,
2022. See also 86 FR 64996 (November 19, 2021).
20 These beneficiaries did not use any audio-video telehealth services during this time period. They may have used in-person
services.
21 OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic,
OEI-02-20-00520, March 2022.
22 Prior to the pandemic, there were limited circumstances in which Medicare beneficiaries could access telehealth services in
urban areas, from home, and through audio-only.
23 On November 19, 2021, CMS expanded access to telehealth services to treat mental health conditions for beneficiaries in
Medicare fee-for-service. This expansion allows beneficiaries in urban areas and those seeking care from home to access
telehealth services that treat mental health conditions. See 86 FR 64996 (November 19, 2021). In addition, the Consolidated
Appropriations Act of 2022 extends most telehealth flexibilities for 151 days after the public health emergency expires. See
Consolidated Appropriations Act, 2022, accessed at https://www.congress.gov/bill/117th-congress/house-bill/2471 on
March 22, 2022.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Endnotes | 33
24 OIG, Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks, OEI-02-20-00720, September
2022.
25 This is similar to a recommendation made by the Medicare Payment Advisory Commission. See Medicare Payment Advisory
Commission, March 2021 Report to the Congress: Medicare Payment Policy, accessed at March 2021 Report to the Congress:
Medicare Payment Policy – MedPAC on September 15, 2021.
26 CMS expanded access to audio-only telehealth services to treat mental health conditions for beneficiaries in Medicare fee-
for-service after the public health emergency expires. See 86 FR 64996 (November 19, 2021). The Consolidated
Appropriations Act of 2022 also extends the use of audio-only telehealth services for 151 days after the public health
emergency expires. See Consolidated Appropriations Act, 2022, accessed at https://www.congress.gov/bill/117th
congress/house-bill/2471 on March 22, 2022.
27 See Medicare Payment Advisory Commission, March 2021 Report to the Congress: Medicare Payment Policy, accessed at
March 2021 Report to the Congress: Medicare Payment Policy – MedPAC on September 15, 2021.
28 Along with its permanent expansion of audio-only telehealth services for mental health conditions, CMS implemented a
periodic in-person requirement through which a beneficiary is required to see a provider in person within 6 months prior to
their initial audio-only visit and within 12 months for subsequent audio-only visits, with certain exceptions. This in-person
requirement applies to audio-video and audio-only telehealth services for mental health conditions. The Consolidated
Appropriations Act, 2022 delayed implementation of the required in-person visits until 152 days after the end of the public
health emergency.
29 Effective January 1, 2022, CMS requires providers to use a modifier to identify audio-only services for the treatment of
mental health conditions. See Medicare Learning Network CY2022 Telehealth Update Medicare Physician Fee Schedule,
accessed at MM12549 - CY2022 Telehealth Update Medicare Physician Fee Schedule (cms.gov) on February 1, 2022. See also
86 FR 64996 (November 19, 2021).
30 The Medicare Payment Advisory Commission, in its March 2022 Report to the Congress: Medicare Payment Policy, also
recommended CMS require that providers use a claims modifier to identify all audio-only telehealth services. Report accessed
at MedPAC March 2022 Report to the Congress on March 22, 2022.
31 See CMS fact sheet accessed at https://www.cms.gov/files/document/health-equity-fact-sheet.pdf on April 22, 2022.
32 OIG, Most Medicare beneficiaries received telehealth services only from providers with whom they had an established
relationship, OEI-02-20-00521, October 2021; OIG, Telehealth Was Critical for Providing Services to Medicare Beneficiaries
During the First Year of the COVID-19 Pandemic, OEI-02-20-00520, March 2022; OIG, Medicare Telehealth Services During the
First Year of the Pandemic: Program Integrity Risks, OEI-02-20-00720, September 2022.
33 The codes used in the analysis for this data brief include those on the list available on the CMS website as of February 28,
2021, which can be found at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-
Codes. These codes also include the communication technology-based services that were allowed during the first year of the
pandemic. See 85 F.R. 19230 (April 6, 2020) and 85 F.R. 84472 (December 20, 2020).
34 All virtual care service codes were considered as being provided via telehealth as they can only be provided remotely.
35 CBSAs are comprised of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and non-CBSAs. A Metropolitan
Statistical Area is an urbanized area of 50,000 or more people. A Micropolitan Statistical Area is an urbanized cluster of at least
10,000 people but less than 50,000 people.
36 For this analysis, we reviewed claims submitted by individual professionals and institutions. If a beneficiary’s claims did not
include an originating site facility fee and the beneficiary had received at least one telehealth service, we considered that
beneficiary to have used telehealth from home or a non-health-care setting.
37 Medicare data combines race and ethnicity and limits beneficiaries to one category.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Endnotes | 34
38 We determined enrollment based on beneficiaries enrolled in Medicare fee-for-service or Medicare Advantage as of
February 28, 2021.
39 These beneficiaries did not use any audio-video telehealth services during this time period. They may have used in-person
services.
40 For further discussion on these topics, see OIG, Inaccuracies in Medicare’s Race and Ethnicity Data Hinder the Ability To Assess
Health Disparities, OEI-02-21-00100, June 2022.
Data Brief: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use
Telehealth During the First Year of the COVID-19 Pandemic
OEI-02-20-00522
Endnotes | 35