BOX 6-2Audio-Only Coverage and Payment

Prior to the COVID-19 public health emergency, audio-only telehealth visits were typically not covered and were often excluded from the definition of telehealth. During the federal public health emergency, all states and the District of Columbia took advantage of CMS’s Medicaid telehealth flexibilities and allowed for audio-only telehealth visits. Regulators found that the audio-only option was especially important for older patients, those unfamiliar with audio-visual technology, and individuals with behavioral health conditions who found audio-only visits more comfortable. For example, California safety net organizations reported that during the COVID-19 pandemic, 23 percent of visits were in person, 63 percent via phone calls, and 14 percent via video (Uscher-Pines et al., 2021).

A key reason for the need for audio-only visits is that some people do not have access to broadband internet in their homes. As of January 2024, between 73 and 86 percent of adults, depending on where they lived, had broadband access at home computer (Gelles-Watnick, 2024). Individuals aged 65 and older and people experiencing poverty were less likely to own a smartphone or to have broadband internet access. In addition, only 58 percent of Black individuals and 57 percent of Hispanic individuals owned a computer. Because of this variation, many states made their coverage of audio-only visits permanent.

Since the public health emergency ended, at least 20 states have acted to allow or require insurers to cover telephone visits, sometimes with limitations (Volk et al., 2022). For now, telephone visits may be needed to reach the millions of people who lack broadband, and Medicaid programs in 43 states and the District of Columbia will reimburse for audio-only telehealth visits, with some caveats and restrictions. Fourteen states introduced legislation pertaining to audio-only coverage in 2023, and some of those proposals were aimed at establishing reimbursement rates for audio-only services (AMA, 2023). However, Medicare will not reimburse for audio-only visits after 2024, except for behavioral health visits (South Central Telehealth Resource Center, 2023).

There is still a lack of evidence on differences in care quality and outcomes for telephone versus video visits. Understanding these differences, if any exist, will be important for guiding policy and balancing the need for access to care and quality of care.