CMS Should Assess Effect of Increased Telehealth Use on Beneficiaries' Quality of Care (GAO-22-104700)
Summary
A GAO report to congressional committees, GAO-22-104700, dated March 2022, on telehealth in Medicaid. It states that states expanded Medicaid coverage of telehealth to respond to the COVID-19 pandemic. GAO's analysis of Centers for Medicare & Medicaid Services (CMS) data in five selected states shows that the number and percentage of services delivered via telehealth increased exponentially at the beginning of the pandemic in March 2020. From March 2020 through February 2021, 32.5 million services were delivered via telehealth, according to that analysis. Its title states that CMS should assess the effect of increased telehealth use on beneficiaries' quality of care.
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United States Government Accountability Office
Report to Congressional Committees
MEDICAID
March 2022
CMS Should Assess
Effect of Increased
Telehealth Use on
Beneficiaries’ Quality
of Care
GAO-22-104700
March 2022
MEDICAID
CMS Should Assess Effect of Increased Telehealth
Use on Beneficiaries’ Quality of Care
Highlights of GAO-22-104700, a report to
congressional committees
Why GAO Did This Study What GAO Found
To respond to the COVID-19 GAO’s analysis of Centers for Medicare & Medicaid Services (CMS) data in five
pandemic, states have expanded their selected states shows that the number and percentage of services delivered via
coverage of telehealth in Medicaid, a telehealth and Medicaid beneficiaries receiving them increased exponentially at
jointly financed federal-state health the beginning of the COVID-19 pandemic in March 2020. From March 2020
care program for low-income and through February 2021, 32.5 million services were delivered via telehealth to
medically needy individuals. about 4.9 million beneficiaries in the five states, compared with 2.1 million
The CARES Act includes a provision services to about 455,000 beneficiaries in the 12 months prior to the pandemic.
for GAO to report on the federal
Percentage of Medicaid Beneficiaries Receiving at Least One of Their Services via Telehealth,
response to the pandemic. In addition, March 2019 through February 2020 and March 2020 through February 2021
GAO was asked to examine the use of
Medicaid flexibilities in response to
COVID-19. This report describes
selected states’ telehealth use before
and during the pandemic, and
experiences with and plans for
telehealth. It also evaluates, among
other things, CMS’s telehealth
oversight of quality of services.
GAO analyzed state-reported data on
telehealth use in six states selected, in
part, based on variation in geography,
Medicaid program size, and
percentage of population living in rural
areas. GAO reviewed federal oversight
documents, interviewed state and
federal Medicaid officials, and
assessed CMS oversight against CMS Note: GAO determined Tennessee’s data were not sufficiently reliable for purposes of this analysis.
guidance on using data to identify
disparities in health care and target Medicaid officials from all six selected states said expanding telehealth supported
improvements. beneficiaries’ access to care, but also identified some limitations. Officials
reported making or considering post-pandemic telehealth modifications.
What GAO Recommends CMS does not collect, assess, or report information about any effect delivering
GAO is making two recommendations services via telehealth has on the quality of care Medicaid beneficiaries receive
to CMS to (1) collect and analyze and has no plans to do so. Doing so is important, given concerns GAO has
information about the effect delivering raised about the quality of care provided via telehealth. It would also be
services via telehealth has on the consistent with how CMS has encouraged states to use data on quality of care to
quality of care Medicaid beneficiaries identify disparities in health care and target opportunities for improvement to
receive, and (2) determine any next advance health equity. These efforts could begin with data for quality measures
steps based on the results of the CMS already collects or through other means.
analysis.
CMS neither agreed nor disagreed with GAO’s recommendations. GAO
maintains it is crucial for CMS to collect and analyze information to assess
telehealth’s effect on the quality of care Medicaid beneficiaries receive.
View GAO-22-104700. For more information,
contact Carolyn L. Yocom at (202) 512-7114
or yocomc@gao.gov.
United States Government Accountability Office
Contents
Letter 1
Background 5
Selected States’ Provision of Medicaid Services Delivered via
Telehealth Increased Exponentially at the Pandemic’s Onset 12
Selected State Medicaid Officials Reported Positive Effects from
Pandemic Expansions of Telehealth, and Some States Have
Begun Adjusting Telehealth Policies 27
Selected States Used Various Activities to Oversee Medicaid
Telehealth; CMS Took Certain Fraud Risk Assessment Actions 33
CMS Has No Plans to Assess the Quality of Care for Services
Delivered via Telehealth and Selected States’ Plans to Do So
Varied 37
Conclusions 40
Recommendations for Executive Action 41
Agency Comments and Our Evaluation 41
Appendix I Scope and Methodology for the Transformed Medicaid
Statistical Information System Data Analysis 46
Appendix II Transformed Medicaid Statistical Information
System Data Differences and Limitations 50
Appendix III Examples of Questions Selected State Medicaid Officials
Asked Beneficiaries to Gauge Satisfaction with Telehealth 52
Appendix IV Comments from the Department of
Health and Human Services 53
Appendix V GAO Contact and Staff Acknowledgments 59
Tables
Table 1: Examples of State Telehealth Policies before and during
the COVID-19 Pandemic 8
Page i GAO-22-104700 Medicaid Telehealth During COVID-19
Table 2: Examples of CMS Activities to Mitigate Identified Risks in
Delivering Services via Telehealth 35
Table 3: Limitations Identified in Selected States’ T-MSIS Data 51
Table 4: Examples of Questions Arizona and Maine Medicaid
Officials Asked Beneficiaries to Gauge Satisfaction with
Health Care Services Delivered via Telehealth to Children 52
Figures
Figure 1: Types of Medicaid Telehealth Modalities Used to Deliver
Services 6
Figure 2: Number and Percentage of Medicaid Services Delivered
via Telehealth in Selected States, March 2019 through
February 2021 14
Figure 3: Percentage of Medicaid Beneficiaries in Selected States
Receiving at Least One of Their Services via Telehealth,
March 2019 through February 2020 and March 2020
through February 2021 16
Figure 4: Arizona: Number and Percentage of Medicaid
Beneficiaries Receiving Services via Telehealth, Overall
and by Selected Demographic Categories, March 2020
through February 2021 19
Figure 5: California: Number and Percentage of Medicaid
Beneficiaries Receiving Services via Telehealth, Overall
and by Selected Demographic Categories, March 2020
through February 2021 20
Figure 6: Maine: Number and Percentage of Medicaid
Beneficiaries Receiving Services via Telehealth, Overall
and by Selected Demographic Categories, March 2020
through February 2021 22
Figure 7: Mississippi: Number and Percentage of Medicaid
Beneficiaries Receiving Services via Telehealth, Overall
and by Selected Demographic Categories, March 2020
through February 2021 24
Figure 8: Missouri: Number and Percentage of Medicaid
Beneficiaries Receiving Services via Telehealth, Overall
and by Selected Demographic Categories, March 2020
through February 2021 26
Page ii GAO-22-104700 Medicaid Telehealth During COVID-19
Abbreviations
CMS Centers for Medicare & Medicaid Services
HHS Department of Health and Human Services
T-MSIS Transformed Medicaid Statistical Information System
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Page iii GAO-22-104700 Medicaid Telehealth During COVID-19
Letter
441 G St. N.W.
Washington, DC 20548
March 31, 2022
Congressional Committees
The COVID-19 pandemic has resulted in catastrophic loss of life and
disruption to the health care system, including in-person delivery of care.
Telehealth can provide certain clinical services that are typically provided
in person, but are instead conducted remotely via audio-only, audio-
video, or other telecommunication technologies. Since the COVID-19
pandemic was declared a national emergency in March 2020, telehealth
services have been used as a means of ensuring necessary health care,
while reducing patients’ risk of exposure to COVID-19. 1 Beneficiaries
enrolled in Medicaid, a federal-state health care financing program for
certain low-income and medically needy individuals, also had increased
access to telehealth services.
To assist states’ response to the pandemic, the Centers for Medicare &
Medicaid Services (CMS), the agency within the Department of Health
and Human Services (HHS) that oversees Medicaid, issued guidance to
states on implementing various flexibilities to expand their use of
telehealth in Medicaid. 2 CMS and states share responsibility for Medicaid
program integrity oversight activities that seek to protect Medicaid from
1On January 31, 2020, the Secretary of Health and Human Services declared a public
health emergency for the United States, retroactive to January 27. Subsequently, on
March 13, 2020, the President declared COVID-19 a national emergency under the
National Emergencies Act and a nationwide emergency under section 501(b) of the
Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act). See
50 U.S.C. § 1601 et seq. and 42 U.S.C. § 5121 et seq. The President has also approved
major disaster declarations under the Stafford Act for all 50 states, the District of
Columbia, and five territories.
2Medicaid covered an estimated 77 million people and spending totaled an estimated
$673 billion (total federal and state) in fiscal year 2020. These enrollments and
expenditures reflect increased federal spending for which all states and territories could
qualify by meeting certain conditions, such as ensuring that certain Medicaid enrollees are
treated as eligible for benefits through the end of the month in which the public health
emergency ends. Families First Coronavirus Response Act, Pub. L. No. 116-127, § 6008,
134 Stat. 178, 208-09 (2020).
Page 1 GAO-22-104700 Medicaid Telehealth During COVID-19
fraud, waste, and abuse, and for ensuring the quality of services delivered
to Medicaid beneficiaries. 3
The CARES Act includes a provision for us to conduct monitoring and
oversight of the federal government’s efforts to prepare for, respond to,
and recover from the COVID-19 pandemic. 4 We also received a request
to review the temporary changes HHS used to respond to the COVID-19
pandemic and the effects of these changes. In this report, we
1. describe the extent to which the provision of services delivered via
telehealth in Medicaid has changed in selected states from pre-
pandemic to during the pandemic;
2. describe selected states’ experiences with using telehealth in
Medicaid during the pandemic, and what their telehealth plans are
after the end of the pandemic;
3. examine efforts by selected states and CMS to oversee program
integrity risks in services delivered via telehealth in Medicaid; and
4. examine any efforts by CMS and selected states to oversee the
quality of care provided via telehealth in Medicaid.
For all four objectives, we focused on six states—Arizona, California,
Maine, Mississippi, Missouri, and Tennessee—selected for variation in
total Medicaid beneficiaries, total Medicaid beneficiaries living in rural
areas, the percentage of the state’s population without broadband
internet, and geography. We conducted open-ended interviews with
Medicaid officials in these states and reviewed state Medicaid
documents.
To describe the extent to which the provision of services delivered via
telehealth in Medicaid has changed in selected states from pre-pandemic
to during the pandemic, we analyzed data from the Transformed Medicaid
3The Medicaid program is on GAO’s High-Risk List, in part, due to concerns about fraud,
waste, and abuse. See GAO, High-Risk Series: Dedicated Leadership Needed to Address
Limited Progress in Most High-Risk Areas, GAO-21-119SP (Washington, D.C.: Mar. 2,
2021).
4Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). We have regularly issued
government-wide reports on the federal response to COVID-19. For the latest report, see
GAO, COVID-19: Significant Improvements Are Needed for Overseeing Relief Funds and
Leading Responses to Public Health Emergencies, GAO-22-105291 (Washington, D.C.:
Jan. 27, 2022). Our next government-wide report will be issued in April 2022 and will be
available on GAO’s website at https://www.gao.gov/coronavirus.
Page 2 GAO-22-104700 Medicaid Telehealth During COVID-19
Statistical Information System (T-MSIS), CMS’s initiative to improve state-
reported data available for overseeing Medicaid. 5 We analyzed T-MSIS
data for services, such as physician services and outpatient hospital
services, which are not provided by an inpatient hospital, long-term care
facility, or pharmacy. We included fee-for-service claims and managed
care encounters for Medicaid beneficiaries. 6 We accessed T-MSIS data
on October 18, 2021, for the 12 months prior to the start of the pandemic
(March 2019 through February 2020) and the first 12 months of the
pandemic (March 2020 through February 2021). We categorized services
as being delivered either via telehealth or not via telehealth; for example,
through in-person visits, based on states’ telehealth definitions, which
varied.
We did not independently verify the accuracy of the T-MSIS data;
however, we took steps to assess the reliability of the data. On the basis
of this review, we determined that the T-MSIS data in Arizona, California,
Maine, Mississippi, and Missouri were sufficiently reliable for our
purposes. We accounted for any limitation or discrepancy in these data
during our analyses. We also determined the T-MSIS data in Tennessee
were not sufficiently reliable for our purposes and excluded the state’s
data from our analysis. (See app. I and app. II for more detail on the
scope and methodology, and additional details about the T-MSIS data
limitations we identified.) After taking these steps, we determined (1) the
number and percentage of services delivered via telehealth; (2) the types
of services delivered via telehealth; (3) the number and percentage of
beneficiaries receiving services via telehealth, and (4) selected
demographic characteristics of those beneficiaries—age, gender, race/
ethnicity, and whether the beneficiary lived in an urban or rural area of the
state.
5Specifically, we reviewed data in CMS’s T-MSIS Analytic Files, a series of analytic-
optimized data sets, including those related to claims and demographic information about
Medicaid beneficiaries. For the purposes of our report, we refer to the T-MSIS Analytic
Files as T-MSIS data.
6We excluded other types of claims that cannot be directly tied to a service, such as
Medicaid supplemental payments, which are lump-sum payments that are not directly tied
to care for individual Medicaid beneficiaries, but may help offset costs of care for
beneficiaries. We also excluded beneficiaries enrolled in the Children’s Health Insurance
Program, a joint federal-state program that provides health coverage to low-income
children with family incomes that are too high to qualify for Medicaid, but may be too low
to afford private insurance.
Page 3 GAO-22-104700 Medicaid Telehealth During COVID-19
To describe all six selected states’ experiences with using telehealth
during the pandemic, and what their telehealth plans are after the end of
the pandemic, we reviewed state Medicaid documents and interviewed
state Medicaid officials.
To examine efforts by the six selected states and CMS to oversee
program integrity risks in services delivered via telehealth in Medicaid, we
interviewed CMS officials about how the agency is overseeing program
integrity risks and reviewed supporting documentation provided by CMS
officials. We compared CMS’s oversight efforts to the fraud risk
assessment process outlined in A Framework for Managing Fraud Risks
in Federal Programs. 7 Fraud risk exists when individuals have an
opportunity to engage in fraudulent activity, have an incentive or are
under pressure to commit fraud, or are able to rationalize committing
fraud. When fraud risks can be identified and mitigated, fraud may be less
likely to occur. 8 Assessing fraud risks generally involves the following five
actions: (1) identify inherent fraud risks affecting the program; (2) assess
the likelihood and impact of inherent fraud risks; (3) determine fraud risk
tolerance; (4) examine the suitability of existing fraud controls and
prioritize residual fraud risks; and (5) document the program’s fraud risk
profile.
7See GAO, A Framework for Managing Fraud Risks in Federal Programs, GAO-15-593SP
(Washington, D.C.; July 28, 2015). The Fraud Risk Framework helps managers meet their
responsibilities to assess and manage fraud risks, as required by federal internal control
standards. See GAO, Standards for Internal Control in the Federal Government,
GAO-14-704G (Washington, D.C.: Sept. 10, 2014). The leading practices of the Fraud
Risk Framework are also required to have been incorporated into Office of Management
and Budget guidelines and agency controls under the Fraud Reduction and Data Analytics
Act of 2015 and its successor provisions in the Payment Integrity Information Act of 2019.
The Fraud Reduction and Data Analytics Act of 2015, enacted in June 2016, required the
Office of Management and Budget to establish guidelines for federal agencies to create
controls to identify and assess fraud risks and to design and implement antifraud control
activities. Pub. L. No. 114-186, 130 Stat. 546 (2016). The act further required the Office of
Management and Budget to incorporate the leading practices from the Fraud Risk
Framework in the guidelines. The Payment Integrity Information Act of 2019, which
repealed the Fraud Reduction and Data Analytics Act, requires these guidelines to remain
in effect, subject to modification by the Office of Management and Budget as necessary
and in consultation with GAO. Pub. L. No. 116-117, 134 Stat. 113 (2020); see also Office
of Management and Budget, OMB Circular No. A-123, Management’s Responsibility for
Enterprise Risk Management and Internal Control, M-16-17 (July 2016).
8Fraud and “fraud risk” are distinct concepts. Fraud is challenging to detect because of its
deceptive nature.
Page 4 GAO-22-104700 Medicaid Telehealth During COVID-19
To examine any efforts by CMS and the six selected states to oversee the
quality of care provided via telehealth in Medicaid, we reviewed CMS
documents and interviewed CMS officials. We compared CMS’s oversight
efforts with its responsibility for ensuring the quality of services delivered
to Medicaid beneficiaries, and with CMS guidance on using data to
identify disparities in health care and target opportunities for improvement
to advance health equity. 9 In addition, we interviewed a non-generalizable
sample of stakeholders, including provider groups knowledgeable about
delivering services via telehealth, and a beneficiary advocacy group, as
well as an organization that endorses quality measures. We also
reviewed work conducted by the Department of Health and Human
Services Office of Inspector General. 10
We conducted this performance audit from January 2021 to March 2022
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
Delivery of Services via A variety of modalities exist for delivering health care services via
Telehealth telehealth, as shown in figure 1.
9See Centers for Medicare & Medicaid Services, Centers for Medicaid & CHIP Services,
2022 Updates to the Child and Adult Core Health Care Quality Measurement Sets,
Informational Bulletin (Baltimore, Md.: Dec. 10, 2021).
10Department of Health and Human Services, Office of Inspector General, Opportunities
Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in
Medicaid, OEI-02-19-00401 (Washington, D.C.: September 2021).
Page 5 GAO-22-104700 Medicaid Telehealth During COVID-19
Figure 1: Types of Medicaid Telehealth Modalities Used to Deliver Services
Each telehealth modality has different attributes to consider in delivering
services to beneficiaries. For example, according to CMS:
• Live video telehealth is the most widely available modality for
providers, but requires internet bandwidth and a smartphone, tablet,
or computer.
• Audio-only telehealth may be more feasible for beneficiaries who do
not have access to the necessary internet bandwidth or technology,
but limitations exist regarding the types of services that can be
delivered via audio-only telehealth. 11
11See Department of Health and Human Services, Centers for Medicare & Medicaid
Services, State Medicaid & CHIP Telehealth Toolkit, Policy Considerations for States
Expanding Use of Telehealth, COVID-19 Version: Supplement #1 (Baltimore, Md.:
October 2020).
Page 6 GAO-22-104700 Medicaid Telehealth During COVID-19
Telehealth in Medicaid and States have significant flexibility to determine any restrictions and
Flexibilities during limitations for the delivery of Medicaid services via telehealth, including
the services covered and how much providers are paid for delivering
Emergencies
telehealth services. These are documented in a state Medicaid plan and
amendments to that plan, which must be approved by CMS.
In certain emergency circumstances, the Secretary of HHS has the
authority to waive or modify application of certain federal health care
program requirements, including Medicaid requirements, to help ensure
the availability of care. 12 Since the beginning of the pandemic, CMS has
issued guidance to states on implementing various flexibilities—including
those related to the delivery of services via telehealth—and on resuming
normal activities once the public health emergency has ended. For
example, CMS issued
• a toolkit in April 2020 with policy considerations for states to
accelerate adoption of broader coverage of telehealth; 13
• a list of COVID-19 frequently asked questions for state Medicaid
agencies, including questions about delivering services via telehealth;
and
• a toolkit supplement in October 2020, which was updated in
December 2021, with additional information for states about
expanding coverage of telehealth and considerations for the use of
telehealth after the end of the pandemic. 14
Using existing authorities, our six selected states changed Medicaid
telehealth policies during the pandemic, such as expanding allowable
services and modalities, as shown in table 1.
12See 42 U.S.C. § 1320b-5 (authority to waive requirements during national emergencies).
13See Department of Health and Human Services, Centers for Medicare & Medicaid
Services, State Medicaid & CHIP Telehealth Toolkit, Policy Considerations for States
Expanding Use of Telehealth, COVID-19 Version (Baltimore, Md.: April 2020).
14See Department of Health and Human Services, Centers for Medicare & Medicaid
Services, State Medicaid & CHIP Telehealth Toolkit, Policy Considerations for States
Expanding Use of Telehealth, COVID-19 Version: Supplement #1 (Baltimore, Md.:
October 2020).
Page 7 GAO-22-104700 Medicaid Telehealth During COVID-19
Table 1: Examples of State Telehealth Policies before and during the COVID-19 Pandemic
Domains of telehealth policies Arizona California Maine Mississippi Missouri Tennessee
Services and Primary care ● ● ● ● ● ◑
payments
Behavioral health ● ●a ● ● ● ●
Physical,
occupational, and ●a ● ● ◑b ◑ ◑
speech therapies
Payment parity
between telehealth
and in-person ● ● ●a ● ● ●
services
Modalities Live video ● ● ● ● ● ●
Asynchronous ● ● ◑ ● ● ●
Remote patient
monitoring ● ◑ ● ● ● ●
Audio-only ●a ●a ● ◑ ◑ ◑c
Providers Services provided to
beneficiaries in their ● ● ●a ◑ ● ◑
homes
Out-of-state
providers allowed ●a ● ●a ● ◑ ●
Key:
◑ Permitted during the pandemic
● Permitted prior to and during the pandemic
Source: GAO analysis of interviews and documents from selected states, Centers for Medicare & Medicaid Services (CMS) documents, and Medicaid and CHIP Payment and Access Commission
documents. | GAO-22-104700
a
Available prior to the pandemic, but with more restrictions.
b
When permitted, this service was only available to established patients.
c
When permitted, this modality was only available for certain types of services.
Telehealth Program States and CMS are responsible for managing program integrity risks in
Integrity and Quality Medicaid, including services delivered via telehealth. States are
responsible for day-to-day Medicaid program oversight, such as actions
Oversight
aimed at preventing improper payments, including those that are a result
Page 8 GAO-22-104700 Medicaid Telehealth During COVID-19
of fraud. 15 CMS is responsible for managing fraud risks and implementing
practices for combating those risks, according to federal standards and
guidance.
As part of its responsibility to oversee states’ efforts to ensure the quality
of services provided to Medicaid beneficiaries, CMS also collects,
assesses, and reports on standardized measures of quality of care
provided to Medicaid beneficiaries. CMS does this primarily through the
Child and Adult Core Sets. These Core Sets include health care quality
measures related to primary and preventive care, behavioral health care,
and patients’ experiences of care. In 2021, there were 32 measures in the
Adult Core Set and 23 in the Child Core Set. States report Core Sets
measure results to CMS annually, and while state reporting is currently
voluntary, certain Core Sets measures are scheduled to become
mandatory in 2024. 16
Quality measures are composed of a number of clinical data elements, or
pieces of data, that are needed to calculate providers’ performance on
any given measure. The measure steward, the entity that typically has
developed the measure and is responsible for maintaining it, sets these
specifications. CMS is itself a steward for measures for which it has
sponsored their development, and it also draws on measures developed
and maintained by other agencies and organizations. For example:
• CMS is the measure steward for a Core Set quality measure about
the percentage of beneficiaries screened for depression when there is
15An improper payment is defined as any payment that should not have been made or that
was made in an incorrect amount (including overpayments and underpayments) under
statutory, contractual, administrative, or other legally applicable requirements. It includes
any payment to an ineligible recipient, any payment for an ineligible good or service, any
duplicate payment, any payment for a good or service not received (except for such
payments where authorized by law), and any payment that does not account for credit for
applicable discounts. Improper payments include payments made as a result of fraud,
which involves obtaining something of value through willful misrepresentation, though not
all improper payments are the result of fraud.
16Beginning with the state reports for 2024, states generally must report all measures
included in the Child Core Set and all behavioral health measures included in the Adult
Core Set. See 42 U.S.C. §§ 1320b-9a(a)(4)(B) (mandatory reporting of child health quality
measures), 1320b-9b(b)(3)(B) (mandatory reporting of adult behavioral health quality
measures).
Page 9 GAO-22-104700 Medicaid Telehealth During COVID-19
a medical reason, and if positive, for whom a follow-up plan is
documented. 17
• The Agency for Healthcare Research and Quality is the measure
steward for The Consumer Assessment of Health Care Providers and
Systems, a set of surveys that assess patients’ experiences of care
that are included in CMS’s Core Sets. States may supplement these
surveys by adding questions.
According to CMS, the Core Sets are a foundational tool for
understanding the quality of health care provided to, and the extent of
health disparities experienced by, Medicaid beneficiaries and for targeting
opportunities for improving health equity. 18 CMS assesses and publishes
state-specific performance on certain Core Set measures, which serves
to guide improvement in the quality of care provided to Medicaid
beneficiaries and advance health equity. 19 For example, CMS can work
with state Medicaid programs to use the Core Sets’ measures to identify
areas with potential for improvement, and to provide tools and technical
assistance for states’ quality improvement efforts.
During the pandemic, CMS provided states with updated information from
the Core Sets’ measure stewards, which clarified how to incorporate
services delivered via telehealth into existing quality measures—such as
the Adult Core Set and the Child Core Set—that previously were limited
to services provided in person. Specifically, in May 2021, CMS issued
technical assistance explaining the circumstances under which states
17This measure is in both the Adult Core Set and Child Core Set.
18See Centers for Medicare & Medicaid Services, Centers for Medicaid & CHIP Services,
2022 Updates to the Child and Adult Core Health Care Quality Measurement Sets,
Informational Bulletin (Baltimore, Md.: Dec. 10, 2021).
19CMS assesses state-specific performance for measures that are reported by at least 25
states and that met CMS standards for data quality.
Page 10 GAO-22-104700 Medicaid Telehealth During COVID-19
could include services received via telehealth together with services
provided in person when reporting measure results. 20 For example:
• For a measure related to follow-up when a beneficiary visits the
emergency department for alcohol or drug abuse, states are permitted
to include instances where the follow-up visit was conducted either via
telehealth or in-person when reporting results on this measure.
• For certain other measures, such as those assessing the proportion of
patients receiving influenza vaccinations, there were no services
available through telehealth that were relevant to performance on
those measures.
In 2017, the National Quality Forum—an organization that endorses
quality measures—issued a report that outlined a framework that
identifies measures and serves as a conceptual foundation for new
measures, where needed, to assess the quality of care provided using
telehealth modalities. 21 The framework included an initial list of existing
quality measures to assess the use of telehealth as a means of care
delivery and its effect on quality of care. Within that list were some
measures that are already included in the Core Sets, such as controlling
high blood pressure among those with a hypertension diagnosis and
conducting follow-up visits after an individual has an emergency
department visit due to a mental illness. The report noted that continual
assessment of access to clinical services and the overall experience of
receiving care through telehealth, among other things, can help ensure
that various modalities of telehealth provide quality care.
20The technical assistance noted 21 measures in the Adult Core Set and 14 measures in
the Child Core Set where states could include services received via telehealth together
with services provided in person when reporting measure results. See CMS, Allowance of
Telehealth in the 2021 Child, Adult, and Health Home Core Set Measure Specifications
(Baltimore, Md.: May 2021). The National Committee for Quality Assurance is the
measure steward for many of the measures used in the Child and Adult Core Sets. The
committee noted that it updated certain measures to include services delivered via
telehealth, in response to the increase in telehealth utilization during the pandemic and to
align with the changes CMS and other stakeholders made to telehealth policies during the
pandemic.
21See National Quality Forum, Creating a Framework to Support Measure Development
for Telehealth (Washington, D.C.: Aug. 31, 2017).
Page 11 GAO-22-104700 Medicaid Telehealth During COVID-19
Selected States’
Provision of Medicaid
Services Delivered
via Telehealth
Increased
Exponentially at the
Pandemic’s Onset
Medicaid Services According to our analysis of T-MSIS data, providers in five of our selected
Delivered via Telehealth in states delivered about 32.5 million total health care services via telehealth
from March 2020 through February 2021, the first 12 months of the
Selected States Increased pandemic. 22 This is an increase from 2.1 million in the year prior. 23 The
from about 2.1 Million to number of services delivered via telehealth from March 2020 through
about 32.5 Million in First February 2021 ranged from less than 1 million services in Mississippi and
Year of Pandemic Missouri to 21.3 million services in California. The services most-
commonly delivered via telehealth were evaluation and management
services, and mental and behavioral health services. 24
Despite the increase in services delivered via telehealth, the number of
services delivered overall for our five selected states (telehealth and non-
telehealth) decreased by nearly 64 million during the first 12 months of
the pandemic, as compared to the year prior. This suggests that despite
22The selected states were Arizona, California, Maine, Missouri, and Mississippi. We
determined that the T-MSIS data in Tennessee were not sufficiently reliable for the
purposes of our reporting and excluded the state’s data from our analysis. We analyzed T-
MSIS data for services, such as physician services and outpatient hospital services, which
are not provided by an inpatient hospital, long-term care facility, or pharmacy.
23The increase in the number of services delivered via telehealth during the first 12
months of the pandemic is similar to results found by FAIR Health in their National Private
Insurance Claims database of more than 32 billion privately billed medical and dental
claim records from more than 60 contributors nationwide. FAIR Health is an independent,
nonprofit organization that collects data for and manages a database of private health
insurance claims data. See FAIR Health, Monthly Telehealth Regional Tracker, accessed
Sept. 7, 2021, https://www.fairhealth.org/states-by-the-numbers/telehealth.
24Evaluation and management includes office visits, hospital visits, and consultations. Due
to limitations in categorizing services delivered via telehealth, we are unable to distinguish
between services delivered via live audio-visual telehealth and live audio-only telehealth.
Page 12 GAO-22-104700 Medicaid Telehealth During COVID-19
receiving more services delivered via telehealth, beneficiaries in our five
selected states likely forewent services during this time.
The percentage of Medicaid services delivered via telehealth in the
selected states was also higher during the pandemic than it was before
the pandemic, reaching a peak in April 2020 and leveling off at a rate
higher than before the pandemic. For example, in California, the
percentage of services delivered via telehealth each month during the 12
months prior to the pandemic was never higher than 0.2 percent. In April
2020, this percentage increased to 9.1 percent and has been between 5.7
percent and 7.3 percent since September 2020.
The increase in the percentage of services delivered via telehealth,
particularly at the beginning of the pandemic, coincided with state efforts
to promote physical distancing and limit time spent away from the home
that four of our five selected states had undertaken during most or all of
April 2020. 25 In addition, the inventory of personal protective equipment
and supplies (such as face masks and gloves) to protect responders and
to treat Americans sickened with COVID-19 was largely exhausted in
spring 2020, which meant health care providers may not have had the
necessary resources to provide care in-person in a safe manner. 26 (See
fig. 2 for the number and percentage of services delivered via telehealth
in our selected states prior to and during the pandemic.)
25For example, Arizona issued an executive order on March 30, 2020, to promote physical
distancing, while also encouraging social connectedness. Similar efforts were not
undertaken in Missouri, according to state Medicaid officials.
26See GAO, COVID-19: Opportunities to Improve Federal Response and Recovery
Efforts, GAO-20-625 (Washington, D.C.: June 25, 2020).
Page 13 GAO-22-104700 Medicaid Telehealth During COVID-19
Figure 2: Number and Percentage of Medicaid Services Delivered via Telehealth in Selected States, March 2019 through
February 2021
Notes: We categorized services as being delivered either via telehealth or not via telehealth (such as
through in-person visits) based on the selected states’ telehealth definitions. We analyzed T-MSIS
Page 14 GAO-22-104700 Medicaid Telehealth During COVID-19
data for health care services including, but not limited to, physician services; outpatient hospital
services; other physician services, such as chiropractors, podiatrists, psychologists, and optometrists;
clinic services; laboratory services; X-ray services; home health services; and personal support
services. We excluded health care services provided by an inpatient hospital, long-term care facility,
or pharmacy, as well as dental services. We analyzed fee-for-service claims and managed care
encounters for Medicaid beneficiaries, specifically those that can be directly tied to a service for a
specific beneficiary. Services delivered via telehealth are potentially underreported in California due
to limitations in how the place of service (either via telehealth or not via telehealth) was documented
for services delivered via telehealth in certain settings at the time of our report.
About 4.9 Million According to our analysis of T-MSIS data, about 4.9 million unique
Beneficiaries in Selected Medicaid beneficiaries in our five selected states received at least one
service via telehealth from March 2020 through February 2021. 27 This is a
States Received Services
more than tenfold increase from the approximately 455,000 unique
via Telehealth during the beneficiaries receiving at least one service via telehealth in the 12 months
First 12 Months of the prior to the pandemic (March 2019 through February 2020).
Pandemic
The percentage of unique beneficiaries receiving at least one service via
telehealth increased in all five selected states during the pandemic. For
example, in Arizona, 11 percent of unique beneficiaries received at least
one of their services via telehealth in the 12 months prior to the
pandemic, a percentage that increased to 43.8 percent during the first 12
months of the pandemic. Arizona officials said the state had been active
in delivering services via telehealth prior to the pandemic and had
updated their telehealth policy in October 2019, months prior to the
beginning of the pandemic. (See fig. 3 for the percentage of unique
beneficiaries receiving at least one of their services via telehealth in each
of the selected states in the year prior to and during the first year of the
pandemic.)
27A beneficiary receiving at least one service via telehealth in multiple months from March
2020 through February 2021 would count once toward this total.
Page 15 GAO-22-104700 Medicaid Telehealth During COVID-19
Figure 3: Percentage of Medicaid Beneficiaries in Selected States Receiving at
Least One of Their Services via Telehealth, March 2019 through February 2020 and
March 2020 through February 2021
Notes: We categorized services as being delivered either via telehealth or not via telehealth (such as
through in-person visits) based on the selected states’ telehealth definitions. For each 12-month
period, the percentage is the number of beneficiaries who received at least one service delivered via
telehealth divided by the number of beneficiaries receiving services by any means (for example, in-
person or via telehealth). A beneficiary receiving services in multiple months from March 2020
through February 2021 counts once toward this total. We analyzed T-MSIS data for health care
services including, but not limited to, physician services; outpatient hospital services; other physician
services, such as chiropractors, podiatrists, psychologists, and optometrists; clinic services;
laboratory services; X-ray services; home health services; and personal support services. We
excluded health care services provided by an inpatient hospital, long-term care facility, or pharmacy,
as well as dental services. We analyzed fee-for-service claims and managed care encounters for
Medicaid beneficiaries, specifically those that can be directly tied to a service for a specific
beneficiary. The percentage of beneficiaries receiving services delivered via telehealth are potentially
underreported in California due to limitations in how the place of service (either via telehealth or not
via telehealth) was documented for services delivered via telehealth in certain settings at the time of
our report.
In the four states with sufficiently complete data on the race and ethnicity
of beneficiaries (California, Maine, Mississippi, and Missouri), we found
that each race and ethnicity group experienced the same general pattern
of increases in telehealth use described previously—namely, that
telehealth use spiked in April 2020 and has decreased somewhat since
Page 16 GAO-22-104700 Medicaid Telehealth During COVID-19
then. 28 However, the percentage of eligible beneficiaries with unknown
race and ethnicity in the first 12 months of the pandemic in these four
states was between 8.1 percent and 13.3 percent each month, which can
obscure trends that may be occurring between different race or ethnicity
groups. 29
Our analysis found that in one state with generally reliable data, state T-
MSIS race and ethnicity data could not be used. According to our T-MSIS
analysis, race and ethnicity data in Arizona was reported as unknown for
over 30 percent of Medicaid beneficiaries in each of the first 12 months of
the pandemic. In January 2021, we reported that CMS asked states to
focus on improving the accuracy and completeness of beneficiary
eligibility data in T-MSIS, which includes beneficiaries’ race and
ethnicity. 30 We reported that 21 of 50 states had acceptable race and
ethnicity data for 2016. 31 We also noted in that report that we have made
at least 13 recommendations between July 2014 and September 2020
related to improving T-MSIS data and expediting their use for program
oversight. As of September 2020, CMS had taken action to address five
of these recommendations, and had not yet fully addressed eight.
Implementing these recommendations would help CMS strengthen
program oversight through improved T-MSIS data.
Accurate and complete race and ethnicity data are particularly important
in light of our recent work on health disparities experienced by racial and
ethnic groups. As we noted, complete reporting of race and ethnicity
information by states, and the routine analysis of health outcomes using
these data, can, in the case of Medicaid, help states and the federal
government better understand existing health disparities and take actions
28In these four states, the percentage of eligible beneficiaries with unknown race and
ethnicity in the first 12 months of the pandemic was below 15 percent each month.
29The percentage of unknown values for other demographic categories (age, gender, and
rural or urban area) was lower than for race and ethnicity. It was never higher than 6.2
percent in any state in any month.
30See GAO, Medicaid: Data Completeness and Accuracy Have Improved, Though Not All
Standards Have Been Met, GAO-21-196 (Washington, D.C.: Jan. 14, 2021).
31We referred to states’ data that CMS determined as having low data quality concern as
acceptable data. The 2016 T-MSIS files we reviewed at that time included data from 49
states and the District of Columbia (collectively referred to as states). CMS excluded
Arkansas from the 2016 files due to significant data quality issues.
Page 17 GAO-22-104700 Medicaid Telehealth During COVID-19
to promote health equity. 32 In addition, in November 2021, the CMS
Administrator noted the need for accurate race and ethnicity data and a
commitment to work with states to improve measurement of health
disparities in describing the agency’s strategic vision for Medicaid. 33
Our T-MSIS analysis of other demographic data in the five selected states
showed variation in the percentage of beneficiaries who received at least
one of their services via telehealth in a given month. Specifically:
• Age. In each state, the percentage of beneficiaries in the 65 years old
and older age group receiving at least one of their services via
telehealth in a given month was the lowest, and therefore, the
percentage receiving all of their services through other means—for
example, through in-person visits—was the highest. 34 T-MSIS data do
not include claims paid by Medicare for beneficiaries who are enrolled
in both Medicaid and Medicare.
• Gender. In three states, a larger percentage of male beneficiaries
received at least one of their services via telehealth in a given month
than female beneficiaries. 35
• Rural or urban area. In each selected state, a larger percentage of
beneficiaries living in urban areas received at least one of their
services via telehealth in a given month than beneficiaries living in
rural areas. 36
See figures 4 through 8 for more demographic information about the use
of health care services delivered via telehealth from each of our five
selected states during the first 12 months of the COVID-19 pandemic.
32See GAO, Health Care Capsule: Racial and Ethnic Health Disparities, GAO-21-105354
(Washington, D.C.: Sept. 23, 2021).
33See Health Affairs Blog, A Strategic Vision for Medicaid and The Children’s Health
Insurance Program (CHIP) (Nov. 16, 2021).
34We analyzed three age groups: under 19 years of age, 19 to 64, and 65 years of age
and older. How often these beneficiaries received services paid by Medicare via telehealth
was beyond the scope of our work.
35T-MSIS data include the following genders: male and female.
36To determine whether beneficiaries lived in a rural or urban area of their states, we
compared the county each beneficiary lives in, as reported in T-MSIS, to the CMS Core
Based Statistical Area state and county code, which we used to define rural and urban
areas.
Page 18 GAO-22-104700 Medicaid Telehealth During COVID-19
Figure 4: Arizona: Number and Percentage of Medicaid Beneficiaries Receiving Services via Telehealth, Overall and by
Selected Demographic Categories, March 2020 through February 2021
Notes: We categorized services as being delivered either via telehealth or not via telehealth (such as
through in-person visits) based on the state’s telehealth definitions. We analyzed T-MSIS data for
health care services including, but not limited to, physician services; outpatient hospital services;
other physician services, such as chiropractors, podiatrists, psychologists, and optometrists; clinic
services; laboratory services; X-ray services; home health services; and personal support services.
We excluded health care services provided by an inpatient hospital, long-term care facility, or
pharmacy, as well as dental services. We analyzed fee-for-service claims and managed care
encounters for Medicaid beneficiaries, specifically those that can be directly tied to a service for a
specific beneficiary.
Page 19 GAO-22-104700 Medicaid Telehealth During COVID-19
Figure 5: California: Number and Percentage of Medicaid Beneficiaries Receiving Services via Telehealth, Overall and by
Selected Demographic Categories, March 2020 through February 2021
Notes: We categorized services as being delivered either via telehealth or not via telehealth (such as
through in-person visits) based on the state’s telehealth definitions. We analyzed T-MSIS data for
Page 20 GAO-22-104700 Medicaid Telehealth During COVID-19
health care services including, but not limited to, physician services; outpatient hospital services;
other physician services, such as chiropractors, podiatrists, psychologists, and optometrists; clinic
services; laboratory services; X-ray services; home health services; and personal support services.
We excluded health care services provided by an inpatient hospital, long-term care facility, or
pharmacy, as well as dental services. We analyzed fee-for-service claims and managed care
encounters for Medicaid beneficiaries, specifically those that can be directly tied to a service for a
specific beneficiary. The percentage of eligible beneficiaries with unknown race/ ethnicity in the first
12 months of the pandemic was between 8.1 percent and 9.6 percent each month. Services delivered
via telehealth are potentially underreported in California due to limitations in how the place of service
(either via telehealth or not via telehealth) was documented for services delivered via telehealth in
certain settings at the time of our report.
Page 21 GAO-22-104700 Medicaid Telehealth During COVID-19
Figure 6: Maine: Number and Percentage of Medicaid Beneficiaries Receiving Services via Telehealth, Overall and by Selected
Demographic Categories, March 2020 through February 2021
Notes: We categorized services as being delivered either via telehealth or not via telehealth (such as
through in-person visits) based on the state’s telehealth definitions. We analyzed T-MSIS data for
Page 22 GAO-22-104700 Medicaid Telehealth During COVID-19
health care services including, but not limited to, physician services; outpatient hospital services;
other physician services, such as chiropractors, podiatrists, psychologists, and optometrists; clinic
services; laboratory services; X-ray services; home health services; and personal support services.
We excluded health care services provided by an inpatient hospital, long-term care facility, or
pharmacy, as well as dental services. We analyzed fee-for-service claims and managed care
encounters for Medicaid beneficiaries, specifically those that can be directly tied to a service for a
specific beneficiary. The percentage of eligible beneficiaries with unknown race/ ethnicity in the first
12 months of the pandemic was between 9.3 percent and 11.1 percent each month.
Page 23 GAO-22-104700 Medicaid Telehealth During COVID-19
Figure 7: Mississippi: Number and Percentage of Medicaid Beneficiaries Receiving Services via Telehealth, Overall and by
Selected Demographic Categories, March 2020 through February 2021
Notes: We categorized services as being delivered either via telehealth or not via telehealth (such as
through in-person visits) based on the state’s telehealth definitions. We analyzed T-MSIS data for
Page 24 GAO-22-104700 Medicaid Telehealth During COVID-19
health care services including, but not limited to, physician services; outpatient hospital services;
other physician services, such as chiropractors, podiatrists, psychologists, and optometrists; clinic
services; laboratory services; X-ray services; home health services; and personal support services.
We excluded health care services provided by an inpatient hospital, long-term care facility, or
pharmacy, as well as dental services. We analyzed fee-for-service claims and managed care
encounters for Medicaid beneficiaries, specifically those that can be directly tied to a service for a
specific beneficiary. The percentage of eligible beneficiaries with unknown race/ ethnicity in the first
12 months of the pandemic was between 12.1 percent and 12.5 percent each month.
Page 25 GAO-22-104700 Medicaid Telehealth During COVID-19
Figure 8: Missouri: Number and Percentage of Medicaid Beneficiaries Receiving Services via Telehealth, Overall and by
Selected Demographic Categories, March 2020 through February 2021
Notes: We categorized services as being delivered either via telehealth or not via telehealth (such as
through in-person visits) based on the state’s telehealth definitions. We analyzed T-MSIS data for
Page 26 GAO-22-104700 Medicaid Telehealth During COVID-19
health care services including, but not limited to, physician services; outpatient hospital services;
other physician services, such as chiropractors, podiatrists, psychologists, and optometrists; clinic
services; laboratory services; X-ray services; home health services; and personal support services.
We excluded health care services provided by an inpatient hospital, long-term care facility, or
pharmacy, as well as dental services. We analyzed fee-for-service claims and managed care
encounters for Medicaid beneficiaries, specifically those that can be directly tied to a service for a
specific beneficiary. The percentage of eligible beneficiaries with unknown race/ ethnicity in the first
12 months of the pandemic was between 8.1 percent and 13.3 percent each month.
Selected State
Medicaid Officials
Reported Positive
Effects from
Pandemic
Expansions of
Telehealth, and
Some States Have
Begun Adjusting
Telehealth Policies
Selected State Medicaid Medicaid officials from all six selected states we interviewed said the
Officials Reported increased use of telehealth during the pandemic supported their primary
goal of maintaining beneficiary access to health care services. Officials
Supporting Beneficiaries’
noted that expanding the use of telehealth during the pandemic often
Access to Care among mitigated pandemic-specific obstacles to receiving care. For example:
Telehealth’s Benefits, but
Identified Some • Reducing COVID-19 exposures. Officials from all six selected states
said providing services via telehealth during the pandemic allowed
Limitations people to receive those services remotely, lowering their risk of being
exposed to COVID-19.
• Providing alternative care sites. Officials in Arizona, California,
Mississippi, and Tennessee said telehealth helped maintain access to
services when in-person visits were not recommended or available,
such as continuing school-based therapies while schools were
closed. 37 Officials from Arizona and Mississippi noted that telehealth
37States may use their Medicaid programs to pay for certain health services provided to
eligible children by schools, including diagnostic screening, and ongoing treatment, such
as physical therapy.
Page 27 GAO-22-104700 Medicaid Telehealth During COVID-19
was particularly helpful for delivering services during stay-at-home
orders.
State Medicaid officials also provided the following examples of other
obstacles to accessing care that were mitigated by delivering services via
telehealth:
• Privacy. Officials from Maine and Mississippi said beneficiaries
reported feeling more comfortable receiving behavioral health
services at home than in-person. Maine officials said it was because
telehealth gave beneficiaries more privacy, and Mississippi officials
said it addressed beneficiaries’ concerns about visiting a mental
health center. According to officials from California, Maine, and
Mississippi, more beneficiaries sought behavioral health services via
telehealth during the pandemic than before the pandemic. 38 Maine
officials said more beneficiaries may have used behavioral health
services via telehealth either because of the psychological effects of
the pandemic or because telehealth increased access to behavioral
health services. As noted earlier, we found that behavioral health
services were among the services most-commonly delivered via
telehealth during the first 12 months of the pandemic. 39
• Child care and transportation issues. Officials from California and
Tennessee said beneficiaries could attend their medical appointments
more easily through various telehealth modalities, eliminating
obstacles for beneficiaries to in-person appointments, such as
arranging child care and transportation. Studies from the National
Committee for Quality Assurance, the American Psychiatry
Association, and the health care journal Telemedicine and e-Health
also found that delivering services via telehealth reduced no-show
38A recent CMS data snapshot noted that overall use of behavioral health services
declined during the pandemic, but did not discuss the use of behavioral health services
delivered via telehealth during the pandemic. See Department of Health and Human
Services, Centers for Medicare & Medicaid Services, Medicaid & CHIP and the COVID-19
Public Health Emergency (Baltimore, Md.: May 2021). As we noted previously, while the
number of services delivered via telehealth has increased during the first 12 months of the
pandemic, the number of services delivered overall has decreased during this time.
39A recent report from the HHS Office of Inspector General found that telehealth,
particularly live video telehealth, can be used to provide behavioral health services,
including mental health assessments, individual therapy, and medication management.
The report noted that telehealth could improve beneficiaries’ access to behavioral health
services, based on available state evaluations of telehealth during the pandemic. See
Department of Health and Human Services, Office of Inspector General, OEI-02-19-
00401.
Page 28 GAO-22-104700 Medicaid Telehealth During COVID-19
rates. 40 Officials from America’s Health Insurance Plans similarly told
us that telehealth saves patients time and money by reducing the
need to travel to appointments or find child care before seeing a
doctor.
Medicaid officials from all six selected states also cited limitations of
delivering services via telehealth. Examples cited by the officials included
the following:
• Less-comprehensive well-child visits. Officials in Arizona,
California, Maine, Missouri, and Tennessee raised concerns about
conducting well-child visits via telehealth. 41 For example, officials in
Arizona and California noted that a provider could not conduct a
comprehensive assessment of a child’s physical symptoms via
telephone, and it may be more difficult to hold a child’s attention
during a telehealth visit, particularly if the child has behavioral health
needs. Officials from Maine said well-child visits generally involve
services that providers can only deliver in person, such as vaccine
administration and physical examination. Maine officials said they
expected providers to follow-up each virtual well-child visit with an in-
person visit, to ensure that the child received all the services included
in a well-child visit. An official in Missouri said telehealth could not
provide children with the same level of care as a well-child visit
delivered in-person, so the state did not cover well-child visits
provided via telehealth.
• Limited effectiveness for physical therapy. Officials in Mississippi
and Tennessee said they had concerns about whether delivering
physical therapy services via telehealth was as effective as delivering
them in-person. Officials from Mississippi said they addressed this
limitation by only permitting established patients to receive physical
therapy via telehealth.
40See Taskforce on Telehealth Policy, National Committee for Quality Assurance, Findings
and Recommendations (September 2020); American Psychiatric Institute, Psychiatrists
Use of Telepsychiatry During COVID-19 Public Health Emergency Survey Results (July
2021); and Brenden Drerup et al., “Reduced No-Show Rates and Sustained Patient
Satisfaction of Telehealth during the COVID-19 Pandemic,” Telemedicine and e-Health,
vol. 27, no. 12 (2021): 1409-1415.
41According to the American Academy of Pediatrics, where community circumstances
require pediatricians to limit in-person well-child visits, the visits may be conducted
through telehealth, recognizing that some elements of the well-child exam should be
completed in-person once community circumstances allow.
Page 29 GAO-22-104700 Medicaid Telehealth During COVID-19
• Provider technological barriers. Officials from California and Maine
Federal Investments in Broadband
Internet during the Pandemic said providers initially struggled to acquire the proper equipment and
The federal government has taken action to develop an infrastructure to deliver services via telehealth. In
improve access to broadband internet response, officials from California said they gave providers additional
during the COVID-19 pandemic, but these supports through new grant opportunities and reimbursement of
actions are not specific to Medicaid. For
example: telehealth equipment, and officials from Maine reported providing
• The Department of Health and Human technical assistance support. In the December 2021 telehealth toolkit
Services awarded $8 million in January supplement CMS made available to states, CMS noted that states
2021 to fund the Telehealth Broadband
Pilot program, in an effort to identify
used a variety of methods to reach out and support providers,
rural communities’ access to broadband including written guidance, webinars, and phone calls. 42
internet and improve their ability to use
telehealth services. • Beneficiary technological barriers. Officials in Arizona, California,
• The Infrastructure Investment and Jobs Maine, Mississippi, and Tennessee said beneficiaries may lack the
Act included a provision creating the equipment necessary for live video, such as smartphones, computers,
Broadband Equity, Access, and
Deployment Program, which will offer or broadband internet. The HHS Office of Inspector General also
$100 million grants to each state and identified technological barriers to telehealth in its review of the use of
the District of Columbia for investments
in broadband internet. Under the
telehealth to deliver behavioral health services, including the cost of
program, grantees must detail the telehealth infrastructure and limited internet connectivity for both
alignment of their planned spending providers and beneficiaries. 43 Officials from Arizona, California,
with other connectivity efforts, including
telehealth. See Pub. L. No. 117-58, Mississippi, and Missouri said delivering services via audio-only
§ 60102(b), 135 Stat 429, 1183 (2021). telehealth helped ensure access to care for beneficiaries lacking
Source: GAO analysis of Department of Health and Human
Services document and federal law. | GAO-22-104700
access to broadband internet. Officials from Maine and Tennessee
said they preferred interactive telehealth provided via live video, but
allowed services to be delivered via audio-only telehealth when
interactive telehealth was not available.
Medicaid officials from our selected states provided examples of how
CMS actions, existing state policies, and Medicare and private health
insurers’ coverage of telehealth services helped them respond to the
pandemic.
• CMS and HHS actions and guidance. Officials highlighted several
CMS and HHS actions they found particularly helpful during the
pandemic, including CMS’s guidance on state plan amendments;
CMS’s prompt approval of emergency state plan amendments; and
HHS’s decision to exercise enforcement discretion to waive potential
42See Department of Health and Human Services, Centers for Medicare & Medicaid
Services, State Medicaid & CHIP Telehealth Toolkit, Policy Considerations for States
Expanding Use of Telehealth, COVID-19 Version: Supplement #1 (Washington, D.C.:
December 2021).
43See Department of Health and Human Services, Office of Inspector General, States
Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health
Services to Medicaid Enrollees, OEI-02-19-00400 (Washington, D.C.: September 2021).
Page 30 GAO-22-104700 Medicaid Telehealth During COVID-19
penalties for violations of Health Insurance Portability and
Accountability Act requirements against providers in certain
circumstances in connection with their provision of telehealth during
the COVID-19 public health emergency. 44
• Pre-pandemic state telehealth policies. Officials from Arizona,
California, and Maine said having established telehealth policies
before the pandemic made it easier for them to support providers’ use
of telehealth during the pandemic. For example, California officials
said pre-existing telehealth policies made them more prepared for the
pandemic and helped them expand the state’s telehealth
infrastructure during the pandemic.
• Medicare and private health insurance telehealth coverage.
Officials from Maine and Tennessee said Medicare and private
insurance coverage of telehealth services during the pandemic gave
providers more incentive to deliver services via telehealth to Medicaid
beneficiaries. 45 For example, officials from Tennessee said having
telehealth services covered by all insurers made it easier and more
cost-effective for providers to develop the processes to deliver
services via telehealth during the pandemic.
Selected State Medicaid Medicaid officials in our selected states reported that as of November
Officials Have Made or 2021 they had implemented or were considering various modifications to
how health care services delivered via telehealth will be covered and paid
Considered Post-
for when the pandemic ends. Officials said access to care; quality of care;
Pandemic Telehealth patient privacy; and risks of fraud, waste, and abuse for services
Modifications, Including delivered via telehealth were among the factors they were taking into
Changes for Audio-Only account when considering post-pandemic modifications.
Telehealth
• Audio-only telehealth. Officials from our selected states said they
had modified or were considering modifying coverage of audio-only
44The Health Insurance Portability and Accountability Act of 1996, as amended, provides
protections for the privacy and security of certain health information, including through
standards governing remote communications technologies. See Pub. L. No. 104-191, tit.
II, sub. F, 110 Stat. 1936, 2021. See also Department of Health and Human Services,
Office for Civil Rights, Notification of Enforcement Discretion for Telehealth Remote
Communications During the COVID-19 Nationwide Public Health Emergency
(Washington, D.C.: March 2020).
45Typically in Medicare, telehealth services may only be furnished under limited
circumstances; for example, in certain (largely rural) areas, to patients located in certain
medical facilities. In response to COVID-19, the Secretary of HHS has waived or modified
certain Medicare telehealth requirements, such as allowing Medicare telehealth services
to be furnished to patients nationwide (including nonrural areas) and at any location,
including patient homes. See GAO-20-625.
Page 31 GAO-22-104700 Medicaid Telehealth During COVID-19
telehealth after the pandemic. Arizona officials said the state limited
which services could receive reimbursement when delivered via
audio-only telehealth starting in January 2022. Mississippi officials
said the state stopped permitting any services to be delivered via
audio-only telehealth in November 2021. Examples of audio-only
telehealth changes the states were considering included the following:
• California officials said they were considering audio-only
telehealth limitations, because while audio-only telehealth
increased access to care, it could become vulnerable to fraud,
waste, and abuse.
• Maine officials said they expected to permit services to be
delivered via audio-only telehealth after the pandemic when live
video telehealth was unavailable, but said that their state
legislature would ultimately determine its post-pandemic policies
for audio-only telehealth.
• Some state officials also noted that any modifications to coverage
of audio-only telehealth would affect beneficiaries’ access to care,
because many beneficiaries lack access to a smartphone,
computer, or internet connection.
• Site and type of services. Some state officials told us they would
continue or were considering continuing modifications to the sites of
service and the types of services permitted to be delivered via
telehealth after the pandemic.
• Officials from Mississippi said they would continue allowing
Medicaid beneficiaries to receive telehealth services from their
homes after the pandemic.
• Maine officials said that while they allowed Medicaid beneficiaries
to receive telehealth services from their home before the
pandemic, they greatly loosened restrictions on receiving services
from their homes during the pandemic and would continue those
loosened restrictions after the pandemic. 46
• Tennessee officials said they were considering continuing to allow
telehealth services from beneficiaries’ homes after the pandemic.
• Officials from Maine and Mississippi said they planned to continue
allowing certain services to be delivered via telehealth after the
pandemic that had not previously been covered, such as physical
46Arizona, California, Maine, and Missouri permitted Medicaid beneficiaries to receive
telehealth services from their homes before the pandemic.
Page 32 GAO-22-104700 Medicaid Telehealth During COVID-19
therapy for established patients, virtual check-ins, and remote
consultations.
Selected States Used
Various Activities to
Oversee Medicaid
Telehealth; CMS Took
Certain Fraud Risk
Assessment Actions
Officials from Selected State Medicaid officials from all six selected states described conducting
States Described Activities program integrity activities related to risks of fraud, waste, and abuse that
may result from services delivered via telehealth. For example:
to Oversee Medicaid
Program Integrity Risks • Written guidance. Medicaid officials from the six selected states
Related to Telehealth discussed providing written guidance on telehealth. For example,
Arizona officials said they provide updates on telehealth policies on a
telehealth web page and through frequently asked questions.
California officials said they have a COVID-19 website with telehealth
information for providers and beneficiaries.
• Technical assistance. Medicaid officials from all six states discussed
how they offered technical assistance to providers on telehealth.
Maine officials said they conducted webinars to update providers on
telehealth billing and coding guidance. Mississippi officials said they
respond to provider questions about providing specific services via
telehealth, such as well-child visits.
• Data analysis. Medicaid officials from all six selected states
mentioned conducting data analysis related to ensuring program
integrity for services delivered via telehealth. Missouri officials said
they are reviewing data to ensure providers did not bill for services
delivered via telehealth when telehealth was not permitted.
Tennessee officials said they are reviewing data for outliers, such as
providers who billed for an excessive number of claims in a single
day.
Medicaid officials from some selected states discussed investigations of
services delivered via telehealth for possible fraud, waste, and abuse. For
example, officials from one state discussed investigating a provider who
billed the state Medicaid program for an unusually large number of
services delivered via telehealth. Officials from some of these states said
Page 33 GAO-22-104700 Medicaid Telehealth During COVID-19
the investigations so far determined no fraud occurred, but as of
November 2021, some states had ongoing investigations.
CMS Evaluated Certain CMS officials said evaluating and mitigating the fraud risks of telehealth
Fraud Risk Elements and became a primary focus for the agency once the pandemic began and
telehealth utilization increased. As noted earlier, fraud risk exists when
Implemented Mitigation
individuals have an opportunity to engage in fraudulent activity, have an
Strategies incentive or are under pressure to commit fraud, or are able to rationalize
committing fraud. In December 2020 and April 2021, CMS identified fraud
risks due to expanded telehealth use during the pandemic and
documented the agency’s findings. In taking this step, CMS incorporated
into its oversight some elements of the fraud risk assessment process
from A Framework for Managing Fraud Risks in Federal Programs. 47
CMS identified the following potential types of risk due to the expansion of
telehealth:
• Providers could bill states for services that are not medically
necessary or not provided.
• Providers could collect beneficiary information and use that
information for fraudulent billing.
• Providers could bill states incorrectly due to confusion about new
telehealth policies.
• States could pay for services that are not eligible for payment.
The types of risk CMS identified are not unique to telehealth. However,
we have previously reported that the delivery of services via telehealth
may pose increased fraud risks related to the potential for increased
spending and lack of complete data, even if the types of risk are not
unique to telehealth. 48 CMS also evaluated the risk level of each type of
fraud risk by identifying the effect and likelihood of financial harm and
patient harm and ranking them as low, medium, or high. CMS officials
47See GAO-15-593SP. Assessing fraud risks generally involves the following five actions:
(1) identify inherent fraud risks affecting the program; (2) assess the likelihood and impact
of inherent fraud risks; (3) determine fraud risk tolerance; (4) examine the suitability of
existing fraud controls and prioritize residual fraud risks; and (5) document the program’s
fraud risk profile.
48See GAO, Medicare and Medicaid: COVID-19 Program Flexibilities and Considerations
for Their Continuation, GAO-21-575T (Washington, D.C.: May 19, 2021).
Page 34 GAO-22-104700 Medicaid Telehealth During COVID-19
said agency officials and senior leadership determined these rankings
based on their knowledge of program integrity issues.
According to agency officials, CMS implemented activities to mitigate
each of the identified risks. The activities CMS implemented include some
identified as leading practices in A Framework for Managing Fraud Risks
in Federal Programs; specifically, data analytics and fraud-awareness
initiatives. (See table 2.)
Table 2: Examples of CMS Activities to Mitigate Identified Risks in Delivering Services via Telehealth
Type of leading practice Description of mitigation activity
Fraud-awareness • In July 2021, CMS provided states with an optional tool to evaluate fraud risks created by
initiatives COVID-19 flexibilities and waivers, including telehealth. CMS presented a suggested set of
questions states may consider when assessing fraud risks related to services delivered via
telehealth during a webinar about the tool.
• CMS hosted technical assistance calls that provided opportunities for states to share their
experiences regarding oversight of services. Several of these calls included discussion of
services provided via telehealth, such as strategies for conducting analysis.
• CMS conducted a training for states that explained how states could conduct their own fraud risk
assessment to identify the potential for fraud resulting from COVID-19 flexibilities, including
telehealth.
Data analytics • Unified Program Integrity Contractors analyzed claims data for indications of potentially
fraudulent activities, such as an unusually large number of claims for services delivered via
telehealth.a
• CMS used National Correct Coding Initiative edits—algorithms that identify service claims that
do not meet certain criteria—to prevent payment for services that are not covered, such as
services that should not be billed at the same time.b
Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) documents. | GAO-22-104700
a
The Unified Program Integrity Contractors perform activities to identify and prevent fraud, waste, and
abuse in Medicaid and Medicare. CMS instructed Unified Program Integrity Contractors to conduct
analyses of Medicaid claims using data from the Transformed Medicaid Statistical Information System
to the maximum extent possible as of August 2021.
b
CMS temporarily suspended National Correct Coding Initiative edits, but finished re-implementing
these processes as of January 2021.
As a result of these mitigation activities, CMS has opened investigations
into potential fraud related to services delivered via telehealth across
multiple states. CMS officials said they will continue to update their
processes for data analysis to identify new and emerging fraud trends
related to telehealth.
While CMS has implemented some elements of the fraud risk framework,
agency officials said they had not determined fraud risk tolerance—the
amount of fraud risk an agency is willing to accept, since fraud risk cannot
be completely eliminated—for services delivered via telehealth. As of
Page 35 GAO-22-104700 Medicaid Telehealth During COVID-19
September 2021, CMS had not determined fraud risk tolerance and had
no plans to do so. 49 CMS officials said they considered the risk of fraud
due to the use of services delivered via telehealth during the pandemic to
be minimal in comparison to the health risks of in-person services or
foregone care.
In December 2021 and February 2022—after CMS had identified fraud
risks due to expanded telehealth use during the pandemic and
documented the agency’s findings—CMS provided us with documentation
of a Medicaid risk assessment framework. This was in response to a
December 2017 recommendation that CMS conduct a fraud risk
assessment for the Medicaid program as a whole, to include fraud risk
profiles and plans for regularly updating the assessments and profiles. 50
Doing so would include determining the agency’s risk tolerance. The
framework CMS provided outlines the agency’s approach and
prioritization factors for conducting fraud risk assessments for specific
program areas within Medicaid using a standard format to document
vulnerabilities, risks levels, residual risks, and mitigation strategies,
among other topics. These actions meet the intent of our
recommendation. Therefore, we considered the recommendation
implemented as of March 2022. 51 We will continue to monitor how CMS
applies the framework, including determining a fraud risk tolerance, going
forward to other aspects of Medicaid.
49A Framework for Managing Fraud Risks in Federal Programs describes risk tolerance as
the acceptable level of variation in performance relative to the achievement of objectives.
Fraud risk tolerance does not mean that managers tolerate fraud. Rather, it means that
managers accept a certain degree of risk, based on an assessment of the likelihood and
effect of fraud. For example, an agency might have a high tolerance for fraud risk to
ensure access to the agency’s services in an emergency, such as the pandemic, but a low
tolerance for fraud risk once the emergency ends. See GAO-15-593SP.
50See GAO, Medicare and Medicaid: CMS Needs to Fully Align Its Antifraud Efforts with
the Fraud Risk Framework, GAO-18-88 (Washington, D.C.: Dec. 5, 2017). HHS concurred
with our recommendation.
51As of March 2022, CMS is continuing to work on another recommendation we made in
December 2017 that CMS use the results of the fraud risk assessment to develop an
antifraud strategy that includes an approach for monitoring and evaluation. See
GAO-18-88. HHS concurred with our recommendation. We will continue monitoring
CMS’s progress in this area.
Page 36 GAO-22-104700 Medicaid Telehealth During COVID-19
CMS Has No Plans
to Assess the Quality
of Care for Services
Delivered via
Telehealth and
Selected States’
Plans to Do So Varied
CMS Does Not Collect, Based on our interviews with agency officials and reviews of agency
Assess, or Report on How documentation, we found CMS does not collect, assess, or report
information about any effect delivering services via telehealth has on the
Telehealth Affects the
quality of care Medicaid beneficiaries receive. As noted earlier, CMS
Quality of Care Medicaid issued technical assistance in May 2021 explaining in which existing Core
Beneficiaries Receive and Sets’ measures states could include services received via telehealth, as
Has No Plans to Do So well as in person, when reporting measure results. However, states do
not separately report on existing Core Sets’ measure results by the way
the service was delivered (for example, in-person or via telehealth).
CMS officials said they do not plan to update existing state reporting
requirements on quality measures, such as those in the Core Sets, to
differentiate between the quality measure results obtained by
beneficiaries provided services via telehealth versus those receiving the
comparable service in person. Nor did they provide states with any
guidance about how to ensure the quality of care provided via telehealth.
Therefore, CMS lacks information on any effect the delivery of services
via telehealth has on quality compared with the quality of services
delivered in-person, or on any potential disparities in terms of those who
receive services via telehealth.
Assessing the effect that delivering services via telehealth has on the
quality of care Medicaid beneficiaries receive is important, given concerns
raised about the quality of care provided via telehealth. Telehealth
services have been used as a means of ensuring access to necessary
health care while reducing patients’ risk of exposure to COVID-19;
however, Medicaid officials in our six selected states also identified
possible limitations to providing certain services via telehealth, such as
circumstances in which telehealth services might be less comprehensive
or effective. Representatives from two provider associations told us
delivery of care via telehealth would not always provide the same quality
Page 37 GAO-22-104700 Medicaid Telehealth During COVID-19
as delivery of care in-person, concerns that we and others have
previously reported. For example:
• The HHS Office of Inspector General reported that state Medicaid
directors from 10 of 37 states expressed concerns about the quality of
behavioral health services delivered via telehealth, particularly visits
that include prescribing medications or are conducted via audio-
only. 52 Two of the 10 state Medicaid directors said training
providers—for example, on best telehealth practices—could improve
the quality of care provided via telehealth.
• In September 2021, we reported that some state Medicaid officials
expressed concerns about the quality of home- and community-based
service assessments conducted via telehealth during the pandemic. 53
State Medicaid officials provided examples where assessing
beneficiaries’ needs for equipment or care over the phone or video
rather than in person hindered the ability of providers or case
managers to observe beneficiaries’ living conditions and capabilities. 54
As a result, officials in one state said case managers identified
problems with beneficiaries’ quality of life or living conditions after
resuming in-person visits that could have been caught earlier through
in-person assessments; for example, unmet beneficiary needs for
additional durable medical equipment, home modifications, and
assistive technology.
Obtaining the information necessary to begin assessing the effect
delivering services via telehealth has on the quality of care Medicaid
beneficiaries receive would be consistent with CMS’s responsibility to
oversee states’ efforts to ensure the quality of services delivered to
Medicaid beneficiaries. It would also be consistent with how CMS has
52See Department of Health and Human Services, Office of Inspector General, OEI-02-19-
00401.
53Medicaid home- and community-based services provide Medicaid beneficiaries who are
aged or have disabilities with long-term services and supports, including assistance with
daily activities, such as eating, dressing, and bathing.
54See GAO, Medicaid Home- and Community-Based Services: Evaluating COVID-19
Response Could Help CMS Prepare for Future Emergencies, GAO-21-104401
(Washington, D.C.: Sept. 8, 2021).
Page 38 GAO-22-104700 Medicaid Telehealth During COVID-19
HHS Activities to Help Ensure Quality of encouraged states to use Core Set data to identify disparities in health
Care Provided via Telehealth care and target opportunities for improvement to advance health equity. 55
The Department of Health and Human
Services (HHS) has ongoing activities to
promote the quality of care provided via There are approaches CMS could use to begin assessing any effect that
telehealth, although these activities are not delivering services via telehealth has on the quality of care Medicaid
specific to Medicaid. beneficiaries receive, understanding that assessing telehealth’s effects
• The Health Resources and Services
Administration—the primary federal
will take time and effort. For example, CMS is the measure steward for a
agency within HHS for improving Core Set quality measure about the percentage of beneficiaries screened
health care for people who are for depression when there is a medical reason, and if positive, for whom a
geographically isolated, and
economically or medically vulnerable— follow-up plan is documented. The agency could develop a plan for
provided approximately $3.85 million to reporting this measure in a way that would promote assessing
11 organizations to help increase
access to telehealth services and to
telehealth’s effect on it.
assess the effectiveness of telehealth
care, through the Evidence-Based Based on the results of initial assessments of any effect delivering
Direct to Consumer Telehealth
Network Program. services via telehealth has on the quality of care Medicaid beneficiaries
• The Health Resources and Services receive, CMS could assess the value—relative to its other quality
Administration provided $6.5 million to reporting priorities—of conducting more-detailed assessments. These
two organizations to assess telehealth
strategies and services to improve assessments could take into consideration the results of the National
health care in rural medically Quality Forum’s framework to support measure development for
underserved areas with high chronic telehealth. 56 As noted earlier, the framework included an initial list of
disease prevalence and high poverty
rates, through the Telehealth Centers existing quality measures—some of which are in the Core Sets—to
of Excellence. assess the use of telehealth as a means of care delivery and its effect on
• HHS funded a 2017 National Quality quality of care. While the forum’s report was not focused on delivering
Forum report, which created a
framework for measuring the quality of services via telehealth to Medicaid beneficiaries, in July 2021, National
care for services delivered via Quality Forum officials confirmed that the measures are applicable across
telehealth and identified initial
measures to assess the quality of care. insurance programs, including Medicaid. The results of more-detailed
• The Centers for Medicare & Medicaid assessments could be used to develop guidance to assist states in
Services funded a 2021 National making decisions regarding which health care services they will cover and
Quality Forum report, which created a
framework to measure the quality of
pay for when those services are delivered via telehealth, among other
care provided via telehealth during things.
emergencies in rural areas. This built
on the forum’s 2017 work identifying
initial measures of telehealth quality.
Source: GAO analysis of HHS activities. | GAO-22-
104700.
55See Centers for Medicare & Medicaid Services, Centers for Medicaid & CHIP Services,
2022 Updates to the Child and Adult Core Health Care Quality Measurement Sets,
Informational Bulletin (Baltimore, Md.: Dec. 10, 2021).
56See National Quality Forum, Creating a Framework to Support Measure Development
for Telehealth (Washington, D.C.: Aug. 31, 2017).
Page 39 GAO-22-104700 Medicaid Telehealth During COVID-19
Selected State Medicaid Officials in four of the six selected states discussed various activities to
Officials Varied in Their assess the quality of care provided via telehealth. For example:
Assessments of the • Surveys. Arizona added supplemental questions to its Consumer
Quality of Care Provided Assessment of Healthcare Providers and Systems survey to obtain
via Telehealth information about the patient experience of services delivered via
telehealth. The initial results of the survey found that the majority of
beneficiaries considered the quality of care provided via telehealth to
be about the same as the quality of care provided in-person. Maine
officials said they integrated a subset of questions related to
telehealth into a survey sent to beneficiaries, but had not received the
results as of November 2021. (See app. III for sample questions on
patient experience with telehealth provided by Arizona and Maine.)
• Service use analysis. Tennessee officials said their own state
analysis of services found that beneficiaries who received services via
telehealth increased their adherence to medication prescriptions.
However, they could not determine through their analysis whether
increased adherence to prescribed medications was due to telehealth.
• External studies. California officials said the state is reviewing
external studies to assess the quality of care delivered via telehealth.
California and Missouri officials both said they plan to assess the quality
of care provided via telehealth in the future, but did not have details about
what those assessments will include. Mississippi officials said services
provided via telehealth are included in the state’s existing quality of care
assessments and they do not plan to assess the quality of care provided
via telehealth specifically.
The onset of the COVID-19 pandemic spurred sizable increases in the
Conclusions use of telehealth services as a means to maintain Medicaid beneficiaries’
access to care. Trends show sustained telehealth use that is significantly
higher than prior to the pandemic. Growing telehealth use requires
assessing the quality of care provided to beneficiaries beyond the
pandemic.
CMS regularly collects, assesses, and reports information about quality of
care provided to Medicaid beneficiaries. However, it lacks information
about the quality of care provided by the way health care services are
delivered (in-person or via telehealth), because states do not separately
report on existing Core Sets’ measure results by the way the service was
delivered, and CMS has no plans to update reporting requirements to do
so. This inhibits CMS’s ability to assess any effect that delivering services
via telehealth has on the quality of care Medicaid beneficiaries receive
Page 40 GAO-22-104700 Medicaid Telehealth During COVID-19
compared with the service delivered in-person. It also prevents the
agency from determining whether further quality assessments of
telehealth are warranted. Information about the effect of telehealth
services on quality care could then be shared with states making
coverage and payment decisions. Given that states are scheduled to
begin mandatory reporting of the Child Core Set and certain Adult Core
Set measures in 2024, this is an opportune time for CMS to ensure these
measures are reported with enough detail to assess the quality of health
care services delivered via telehealth.
Likewise, if CMS decides that the Core Sets are not appropriate for
measuring the effect that delivering services via telehealth has on the
quality of care Medicaid beneficiaries receive, now would be the time for
the agency to begin making other plans to do so. Given that telehealth
use has grown to represent a larger amount of services delivered, CMS
can take the opportunity to identify and plan for the data it will need in the
future to make assessments about the quality of telehealth care.
We are making the following two recommendations to CMS:
Recommendations for
Executive Action The Administrator of CMS should collect and analyze the information
needed to assess the effect delivering services via telehealth has on the
quality of care Medicaid beneficiaries receive. (Recommendation 1)
The Administrator of CMS should determine, based on the results of its
initial assessment, whether further assessments of the effect delivering
services via telehealth has on the quality of care Medicaid beneficiaries
receive are warranted, for the purposes of developing guidance to assist
states in making telehealth coverage and payment decisions.
(Recommendation 2)
We provided a draft of this report to HHS for comment, and its comments
Agency Comments are reprinted in appendix IV. HHS also provided technical comments,
and Our Evaluation which we incorporated as appropriate.
HHS neither agreed nor disagreed with the recommendations. In its
comments, HHS recognized the gaps in measures on the quality of care
Medicaid beneficiaries receive via telehealth, including measures on the
Child and Adult Core Sets. According to HHS, CMS does not have the
authority to modify the specifications of measures in the Core Sets’
measures for which it is not the measure steward.
Page 41 GAO-22-104700 Medicaid Telehealth During COVID-19
However, CMS is the measure steward for a Core Set quality measure
about the percentage of beneficiaries screened for depression when there
is a medical reason, and if positive, for whom a follow-up plan is
documented. The agency could develop a plan for reporting this measure
in a way that would provide information on any effect the way the service
is delivered (for example, in-person or via telehealth) has on the quality of
care Medicaid beneficiaries receive. For the measures for which CMS is
not the measure steward, CMS could assess the feasibility of alternatives
to current reporting. For example, CMS could work with other measure
stewards to determine the appropriateness of separately reporting results
for beneficiaries receiving services delivered via telehealth and in-person
when services delivered via telehealth are permitted to be included when
reporting a measure.
As HHS noted in its comments, telehealth has been a way to provide
certain services while maintaining social distance during the pandemic
and has potential to serve as an additional way for beneficiaries to
receive services when social distancing is no longer required. While HHS
said it was not aware of any existing stand-alone measures that focus
solely on the delivery of services through telehealth, we identified efforts
in four of the six selected states to assess the quality of care provided via
telehealth. These may merit further agency investigation. HHS also noted
it was premature to determine whether additional assessments of the
effect delivering services via telehealth has on the quality of care
Medicaid beneficiaries receive were warranted. The agency specifically
noted the rapidly evolving telehealth landscape due to the ongoing
COVID-19 pandemic and telehealth’s role in closing gaps in service
delivery during the pandemic. The pandemic is entering its third year. We
maintain it is crucial for CMS to collect and analyze information to assess
the effect delivering services via telehealth has on the quality of care
Medicaid beneficiaries receive, through the Core Sets or through other
means. Further, the results of these initial assessments should inform
whether further assessments are warranted to develop guidance to assist
states in making telehealth coverage and payment decisions.
Page 42 GAO-22-104700 Medicaid Telehealth During COVID-19
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, the
Administrator of the Centers for Medicare & Medicaid Services, and other
interested parties. In addition, the report is available at no charge on the
GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made key contributions to this report
are listed in appendix V.
Carolyn L. Yocom
Director, Health Care
Page 43 GAO-22-104700 Medicaid Telehealth During COVID-19
List of Committees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
Page 44 GAO-22-104700 Medicaid Telehealth During COVID-19
List of Committees Continued
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard E. Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
Page 45 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix I: Scope and Methodology for the
Appendix I: Scope and Methodology for the
Transformed Medicaid Statistical Information
System Data Analysis
Transformed Medicaid Statistical Information
System Data Analysis
To describe the extent to which utilization of health care services
delivered via telehealth in Medicaid has changed in six selected states
from pre-COVID-19 pandemic to during the pandemic, we analyzed data
from the Transformed Medicaid Statistical Information System (T-MSIS),
the Centers for Medicare & Medicaid Services’ (CMS) initiative to improve
state-reported data available for overseeing Medicaid. Specifically, we
reviewed claims and demographic data about Medicaid beneficiaries in
the Other Services and Annual Demographic and Eligibility T-MSIS
Analytic Files. These are a series of research-ready analytic files CMS
created to support analysis, research, and data-driven decisions on key
Medicaid topics, as well as program oversight. For the purposes of our
report, we refer to the data in the T-MSIS Analytic Files as T-MSIS data.
Prior to conducting our analysis, we selected the states, services,
beneficiaries, and time frame to include in our analysis, and developed
our definition of services delivered via telehealth.
• State selection. We selected six states—Arizona, California, Maine,
Mississippi, Missouri, and Tennessee—to achieve a range of
characteristics based on total population, total rural population, the
percentage of the state’s population without broadband internet, and
geographic variation. 1
• Services. We analyzed T-MSIS data for health care services
including, but not limited to, physician services; outpatient hospital
services; other physician services, such as chiropractors, podiatrists,
psychologists, and optometrists; clinic services; laboratory services;
X-ray services; home health services; and personal support services.
We excluded health care services provided by an inpatient hospital,
long-term care facility, or pharmacy, as well as dental services. We
analyzed fee-for-service claims and managed care encounters for
Medicaid beneficiaries, excluding other types of claims. For example,
we excluded other types of claims that cannot be directly tied to a
service, such as Medicaid supplemental payments, which are lump-
sum payments that are not directly tied to care for individual Medicaid
beneficiaries, but may help offset costs of care for beneficiaries.
• Beneficiaries. We analyzed T-MSIS data for beneficiaries enrolled in
Medicaid. For the purposes of our report, we excluded other
beneficiaries who also appear in the T-MSIS data. For example, we
excluded beneficiaries enrolled in the Children’s Health Insurance
1Percentage of the state’s population without wired broadband internet was determined
based on a 2021 Federal Communication Commission Broadband Deployment report.
See Federal Communications Commission, Fourteenth Broadband Redeployment Report
(Washington, D.C.: Jan. 19, 2021).
Page 46 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix I: Scope and Methodology for the
Transformed Medicaid Statistical Information
System Data Analysis
Program, a joint federal-state program that provides health coverage
to low-income children with family incomes that are too high to qualify
for Medicaid, but may be too low to afford private insurance.
• Time frame. We accessed T-MSIS data on October 18, 2021. This
provided for at least 6 months for states to submit data for the period
of our analysis—the 12 months prior to the start of the pandemic
(March 2019 through February 2020) and the first 12 months of the
pandemic (March 2020 through February 2021). However, data for
recent months are likely to be adjusted upward due to delays between
when a service occurs and when the claim or encounter for that
service is reflected in the data; thus, states’ data may have different
levels of completeness. 2
• Telehealth. We analyzed procedure codes, modifier codes, and place
of service codes in the T-MSIS data. 3 We then categorized services
as having been delivered either via telehealth or not via telehealth; for
example, through in-person visits. To do so, we compared these
codes to CMS and state documentation on identifying all health care
services delivered via telehealth, and interviewed CMS and state
officials to confirm our categorization. We determined that each state
identified services delivered via telehealth differently and adjusted the
codes used in our analysis accordingly.
We did not independently verify the accuracy of the T-MSIS data;
however, we reviewed how CMS assesses the quality of T-MSIS data
and develops T-MSIS files for research. We also checked the T-MSIS
data for obvious errors and omissions, compared analysis results to
reported information on utilization of services delivered via telehealth in
Medicaid, and interviewed CMS and state officials to resolve any
2According to CMS, there will always be a delay, or claims lag, between when a service
occurs and when the claim or encounter for that service is reflected in its database. The
length of the lag depends on the submitting state, claim type, and the delivery system.
Historically, at least 90 percent of both fee-for-service claims and managed care
encounters in the Other Services claim file (the name of the T-MSIS Analytic File in the T-
MSIS data we analyzed appears in) are submitted within 6 months, based on claims with
a March 2018 service date. There is significant variation across states in terms of claims
submissions. Some states submit 90 percent of all other services claims within only 4
months, while other states take nearly a year. It is possible that there is a longer claims
lag due to the pandemic.
3Health care providers use a series of codes to describe the services they provided when
they bill for a service. The procedure code captures the Current Procedural Terminology
or Health Care Procedural Coding System code that describes a service or good rendered
by the provider to a Medicaid beneficiary on the specified date of service. The modifier
code is used to add information or change a description of a service to improve accuracy
or specificity. The place of service code indicates where a service took place.
Page 47 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix I: Scope and Methodology for the
Transformed Medicaid Statistical Information
System Data Analysis
identified discrepancies. On the basis of this review, we determined the T-
MSIS data in Arizona, California, Maine, Mississippi, and Missouri were
sufficiently reliable for the purposes of this report, and we accounted for
any limitation or discrepancy in these data during our analyses. We also
determined that the T-MSIS data in Tennessee were not sufficiently
reliable for the purposes of our reporting and excluded the state’s data
from our analysis. At the time we conducted our analysis, the T-MSIS
data for Tennessee did not allow for reported services to be fully linked to
individual beneficiaries for claims from January 2020 through February
2021. See appendix II for additional details about the T-MSIS data
limitations we identified.
After taking these steps, we determined (1) the number and percentage
of services delivered via telehealth; (2) the types of services delivered via
telehealth; and (3) the number and percentage of beneficiaries receiving
services via telehealth, and selected demographic characteristics of those
beneficiaries.
To determine the number and percentage of services delivered via
telehealth, we analyzed T-MSIS data to identify whether each service was
delivered via telehealth. We then calculated the number and percentage
of services delivered via telehealth.
To determine the types of services delivered via telehealth, we analyzed
T-MSIS data on the procedure codes for each service delivered via
telehealth.
To determine the number and percentage of beneficiaries receiving
services via telehealth, and selected demographic characteristics of those
beneficiaries, we analyzed T-MSIS data, as well as the CMS Core Based
Statistical Area state and county code crosswalk to determine whether a
beneficiary lived in an urban or rural area. Overall and within each of our
demographic categories—age, gender, race/ ethnicity, and whether the
beneficiary lived in an urban or rural area of the state—we took the
following steps:
• Determined the number of enrolled Medicaid beneficiaries each
month.
• Determined how many of the enrolled Medicaid beneficiaries during a
particular month received a service.
• Determined the group to which each beneficiary who received a
service belonged: (1) beneficiaries who received at least one service
Page 48 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix I: Scope and Methodology for the
Transformed Medicaid Statistical Information
System Data Analysis
via telehealth, and (2) beneficiaries who received no services via
telehealth.
• Calculated for each month the number of beneficiaries who received
at least one service via telehealth as a percentage of (1) beneficiaries
who received a service, and (2) enrolled Medicaid beneficiaries.
In addition, we identified and organized demographic characteristics as
follows:
• Age. Beneficiary age in years as of the last day of the last month of
enrollment in the calendar year. 4 For purposes of our report, we
organized beneficiary ages into three age groups: under 19 years of
age, 19 to 64 years of age, and 65 years of age and older.
• Gender. Beneficiary’s biological sex or their self-identified sex. T-
MSIS data include the following values for gender: male and female.
• Race/ ethnicity. T-MSIS data includes the following values for race/
ethnicity that we identified in our analysis: American Indian and
Alaska Native, non-Hispanic; Asian, non-Hispanic; Black, non-
Hispanic; Hawaiian/ Pacific Islander; Hispanic, all races; White, non-
Hispanic; and null, which may occur, for example, if the beneficiary’s
race/ ethnicity was not reported.
• Rural/ urban area. To determine whether beneficiaries lived in a rural
or urban area, we compared the county each beneficiary lives in, as
reported in T-MSIS, to the CMS Core Based Statistical Area state and
county code crosswalk, which we used to define rural and urban
areas. 5
4According to CMS, if age is missing for all months of the calendar year, the most recent
non-missing age from the previous two Annual Demographic and Eligibility T-MSIS
Analytic Files is used.
5The Office of Management and Budget designates counties as Metropolitan,
Micropolitan, or Neither. A Metropolitan area contains a core urban area of 50,000 or more
population, and a Micropolitan area contains an urban core of at least 10,000 (but less
than 50,000) population. All counties that are not part of a Metropolitan Statistical Area are
considered rural. Micropolitan counties are considered non-Metropolitan or rural along
with all counties that are not classified as either Metropolitan or Micropolitan.
Page 49 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix II: Transformed Medicaid
Appendix II: Transformed Medicaid Statistical
Information System Data Differences and
Limitations
Statistical Information System Data
Differences and Limitations
To describe the extent to which utilization of health care services
delivered via telehealth in Medicaid has changed in our six selected
states from pre-pandemic to during the COVID-19 pandemic, we
analyzed data from the Transformed Medicaid Statistical Information
System (T-MSIS), the Centers for Medicare & Medicaid Services’ (CMS)
initiative to improve state-reported data available for overseeing
Medicaid. 1 The six states—Arizona, California, Maine, Mississippi,
Missouri, and Tennessee—were selected to achieve a range of
characteristics based on total population, total rural population, the
percentage of the state’s population without broadband internet, and
geographic variation.
To assess the reliability of the T-MSIS data in these states, we reviewed
how CMS assesses the quality of T-MSIS data and develops T-MSIS files
for research, checked the T-MSIS data for obvious errors and omissions,
compared analysis results to reported information on utilization of
services delivered via telehealth in Medicaid, and interviewed CMS and
state officials. Based on this review, we determined that each state
identified services delivered via telehealth differently and adjusted the
codes used in our analysis accordingly. We also identified limitations in
the data and accounted for them during our analyses. For example, we
did not analyze data on beneficiary income based on CMS’s assessment
of the quality of these data. See table 3 for additional limitations we
identified in our six selected states.
1For additional recent information about our work on T-MSIS, see GAO, Medicaid: Further
Action Needed to Expedite Use of National Data for Program Oversight, GAO-18-70
(Washington, D.C.: Dec. 8, 2017); and GAO-21-196.
Page 50 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix II: Transformed Medicaid Statistical
Information System Data Differences and
Limitations
Table 3: Limitations Identified in Selected States’ T-MSIS Data
State Limitation Resolution
Arizona Race/ ethnicity information was reported as unknown for over 30 Did not report race/ ethnicity information.
percent of Medicaid beneficiaries in each of the first 12 months of
the pandemic.
California Potential underreporting of services delivered via telehealth for Noted limitation in our report.
Federally Qualified Health Centers, Rural Health Centers, Tribal
638 Clinics, and the Local Educational Agency Medi-Cal Billing
Option Program services delivered via telehealth.
Race/ ethnicity information was reported as unknown for over 8 Reported the percentage of beneficiaries
percent of Medicaid beneficiaries in each of the first 12 months of with unknown race/ ethnicity.
the pandemic.
Maine Race/ ethnicity information was reported as unknown for over 9 Reported the percentage of beneficiaries
percent of Medicaid beneficiaries in each of the first 12 months of with unknown race/ ethnicity.
the pandemic.
Mississippi Race/ ethnicity information was reported as unknown for over 12 Reported the percentage of beneficiaries
percent of Medicaid beneficiaries in each of the first 12 months of with unknown race/ ethnicity.
the pandemic.
Missouri Race/ ethnicity information was reported as unknown for over 8 Reported the percentage of beneficiaries
percent of Medicaid beneficiaries in each of the first 12 months of with unknown race/ ethnicity.
the pandemic.
Tennessee Unable to fully link reported services to individual beneficiaries for Did not report T-MSIS data.
claims from January 2020 through February 2021.
Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) Transformed Medicaid Statistical Information System (T-MSIS) data. | GAO-22-104700
Page 51 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix III: Examples of Questions Appendix III: Examples of Questions Selected
State Medicaid Officials Asked Beneficiaries to
Gauge Satisfaction with Telehealth
Selected State Medicaid Officials Asked
Beneficiaries to Gauge Satisfaction with
Telehealth
Table 4 presents examples of questions that Medicaid officials from two
of our six selected states, Arizona and Maine, said they asked
beneficiaries about delivering health care services via telehealth for
children.
Table 4: Examples of Questions Arizona and Maine Medicaid Officials Asked Beneficiaries to Gauge Satisfaction with Health
Care Services Delivered via Telehealth to Children
Question topic Arizona Maine
General/ telehealth • In the last 6 months, did your child have • In the last 6 months, was a telehealth appointment
usage a healthcare visit by phone or video? offered for your child instead of an in-person
appointment?
• In the last 6 months, how often did you choose to use
telehealth for your child’s health care when it was
offered by a doctor or other health provider?
• Which of the following describes why you chose NOT
to use telehealth for your child’s health care?
• In the last 6 months, how many times did you have a
telehealth visit to get care, tests, or treatment for your
child?
Services Arizona did not ask questions related to • In the last 6 months, which of the following types of
services delivered via telehealth. telehealth services did your child receive?
Technology • What type of device was used for your • Which of the following devices did you use for your
child’s healthcare visit by phone or telehealth appointment(s)?
video? • What technical problems did you have?
• How easy or difficult has it been to use
technology during your child’s
healthcare visit by phone or video?
Privacy • In the last 6 months, how often were Maine did not ask questions related to telehealth privacy.
you concerned about privacy during
your child’s healthcare visit by phone or
video?
Quality • In the last 6 months, was the quality of • Compared to in-person healthcare visits, how
care your child received during phone or satisfied are you with the care your child received
video visits better or worse than the through telehealth?
care your child received during in- • Using any number from 0 to 10, where 0 is the worst
person visits? health care possible and 10 is the best health care
possible, what number would you use to rate your
child’s telehealth care in the last 6 months?
Future telehealth use Arizona did not ask questions related to • How likely are you to continue using telehealth during
future use of telehealth. the COVID-19 pandemic?
• How likely are you to continue using telehealth when
the COVID-19 pandemic is over?
Source: GAO analysis of questionnaire documents in Arizona and Maine. | GAO-22-104700.
Page 52 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix IV: Comments from the
Appendix IV: Comments from the Department
of Health and Human Services
Department of Health and Human Services
Page 53 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix IV: Comments from the Department
of Health and Human Services
Page 54 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix IV: Comments from the Department
of Health and Human Services
Page 55 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix IV: Comments from the Department
of Health and Human Services
Page 56 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix IV: Comments from the Department
of Health and Human Services
Page 57 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix IV: Comments from the Department
of Health and Human Services
Page 58 GAO-22-104700 Medicaid Telehealth During COVID-19
Appendix V: GAO Contact and Staff
Appendix V: GAO Contact and Staff
Acknowledgments
Acknowledgments
Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov.
GAO Contact
In addition to the contact named above, Lori Achman (Assistant Director),
Staff Peter Mangano (Analyst-in-Charge), Zhi Boon, Kerry Casey, Sonia
Acknowledgments Chakrabarty, Lauren Gomez, Drew Long, Eric Peterson, Vikki Porter, and
Jennifer Rudisill made key contributions to this report.
(104700)
Page 59 GAO-22-104700 Medicaid Telehealth During COVID-19
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