A Longitudinal Analysis of Medicaid Telehealth Policies and Coverage of Maternal Health Care Services, 2017-2023

• In Event: Reproductive Health

Abstract

The COVID-19 pandemic drove rapid changes in healthcare delivery, with a significant increase in telehealth usage. States expanded Medicaid coverage of telehealth abruptly, with substantial variation in the extent of coverage and the modalities covered. Concurrently, states faced a worsening maternity care shortage, with over 2.3 million women living in maternity care deserts (March of Dimes 2024). Although telehealth can improve maternity care access and utilization, the impact of expanded telehealth coverage on maternal health outcomes remains unclear. The post-pandemic heterogeneous reimbursement landscape presents a unique opportunity to examine this gap. While there is documentation of state-level coverage for select years, no study has comprehensively characterized how Medicaid telehealth reimbursement policies evolve over time and across modalities, or their application to maternal health care. Further, studies to date have not considered the interplay between policy enactment and uptake (e.g., payor-specified reimbursement codes).
We conducted a structured review of Medicaid telehealth reimbursement policies across all 50 U.S. states from 2017 to 2023, examining four modalities: live video, audio-only, store-and-forward, and remote patient monitoring (RPM) within general (unspecified) and maternity care settings. We developed a classification protocol with explicitly defined modalities, coding categories, and rules to handle ambiguity and distinguish policy presence from reimbursement evidence. Two coders reviewed annual state documentation including statutes, regulations, plan amendments, provider guidance documents, archived state websites, and credible databases (e.g. CCHP and MACPAC). A third reviewer independently double-coded a randomly selected subset of states. Discrepancies were assessed by an external reviewer and resolved through group discussion.
While Medicaid telehealth coverage overall expanded from 2017–2023, we found significant heterogeneity by modality and type of care. Prior to the pandemic, live video was already widely covered across general (N=47) and maternal (N=39) care. All other modalities increased sharply after the pandemic, with general care coverage being notably more widespread. Audio-only had the most substantial increase in coverage for general (2 to 46 states) and maternal (2 to 33 states) care. Importantly, while expansions in general care coverage were largely sustained or increased post-pandemic, maternal care coverage retracted for live video (47 to 42 states), audio-only (35 to 33 states), and remote patient monitoring (28 to 24 states). Additionally, we identified evidence of delayed implementation of policy; for example, in New Jersey, telehealth policy existed as of 2017, but Medicaid billing codes and provider manual references did not appear until 2020.
To our knowledge, this is the first longitudinal, modality-specific analysis of telehealth reimbursement policies across all US states. This research fills a critical gap needed to inform the future policy landscape of telehealth and is particularly relevant as states navigate unprecedented pressures on Medicaid programs and a persistent maternal health crisis. Retraction of maternal care telehealth coverage demands further investigation. Forthcoming analysis will incorporate state-level data (e.g. maternal health outcomes, Medicaid penetrance), to contextualize trends and identify correlates of expansion of telehealth coverage. These findings lay the foundation for our team’s future research examining the impact of telehealth coverage expansion on maternal health care outcomes.

Author

• Thais Costa Macedo de Arruda, Children's Hospital of Philadelphia
  Presenting Author