Telehealth and Your Insurance: What’s Covered, What’s Not, and How to Make It Work for You

Telehealth is no longer an experimental add-on to traditional medicine — it has become essential. But coverage varies wildly, billing can be confusing, and patients can easily face unexpected costs. This article walks through how telehealth interacts with different types of health insurance, what services are typically covered, how billing works, common pitfalls, and practical steps to ensure telemedicine visits are affordable and fully supported by your plan.

What is telehealth and why does it matter for insurance?

Telehealth refers to the remote delivery of health care services using technology: video visits, phone consultations, asynchronous messaging (store-and-forward), remote patient monitoring, and even some diagnostic and therapeutic services delivered outside a clinic. Insurance coverage matters for telehealth because it determines who pays, how much the patient owes at the point of care, and whether the visit counts toward deductibles or out-of-pocket maximums.

How telehealth works with health insurance

At its core, telehealth visits are health care encounters — they generate claims, require appropriate coding, and are processed through the same benefits systems your insurer uses for in-person care. However, telehealth has unique billing codes, modifiers, and sometimes different rules for networks, prior authorization, and cost-sharing. Whether a visit is covered depends on your plan type, state regulations, provider contracts, and the reason for the visit (routine follow-up vs. new problem vs. emergency).

Types of telehealth services insurers commonly recognize

Understanding categories helps predict coverage:

• Live interactive video visits — real-time audio-video connections between provider and patient.
• Audio-only (telephone) visits — some insurers cover phone visits, typically with stricter limits or different reimbursement rates.
• Asynchronous (store-and-forward) — patients submit images or messages for later clinician review; commonly used in dermatology and remote triage.
• Remote patient monitoring (RPM) — ongoing collection of biometric data (e.g., blood pressure, glucose) that supports chronic disease management.
• Tele-ICU and remote specialist consults — used in hospital settings to extend specialty access.

Billing and coding basics for telehealth

Telehealth claims use standard CPT codes for the visit type, often paired with telehealth-specific modifiers (like modifier 95) or place-of-service codes. Insurers rely on these codes to determine coverage and member cost sharing. A correct claim includes the CPT code, telehealth modifier/place-of-service, and accurate diagnosis codes. Mistakes or missing modifiers can result in denials, improper patient billing, or a claim being processed as out-of-network.

Coverage across major insurance programs

Telehealth coverage is not uniform. Knowing how your insurance program approaches telemedicine helps set expectations.

Employer-sponsored and private insurance plans

Private plans vary by insurer and by the employer contract. Since the COVID-19 pandemic, many employers expanded telehealth coverage, often keeping lower copays and broader provider networks for virtual visits. However, benefits can depend on the plan design: some plans treat telehealth like any in-person office visit, while others impose visit limits or different cost-sharing. Check your Summary of Benefits and Coverage (SBC) and any employer communications to confirm the rules for your plan.

Individual and ACA marketplace plans

Marketplace plans must cover essential health benefits, which can include telehealth where it substitutes for in-person care. Coverage details and cost-sharing for telehealth are plan-specific; bronze plans may have higher cost-sharing than silver or gold plans. Additionally, state-level rules can influence availability and parity.

Medicare and Medicare Advantage

Medicare historically limited telehealth coverage, but recent policy changes dramatically expanded access. Original Medicare (Parts A & B) covers many telehealth services under certain conditions, especially for beneficiaries in rural areas or during public health emergencies; coverage has expanded to include mental health, chronic care management, and certain RPM services. Medicare Advantage (Part C) plans often go further — many MA plans include broader telehealth benefits, lower or waived cost-sharing for virtual visits, and additional remote services as part of plan design. If you’re on Medicare, review both Original Medicare rules and your specific Medicare Advantage plan’s telehealth benefits.

Medicaid and CHIP

Medicaid coverage for telehealth is determined by each state’s Medicaid agency. Many states reimburse live video and some audio-only services; reimbursement for RPM and asynchronous care varies. During public health emergencies, state Medicaid programs often expand telehealth coverage temporarily, so it’s important to check current state guidance. CHIP programs also vary but usually mirror Medicaid’s approach for children’s services.

Short-term, catastrophic, and limited-benefit plans

Short-term or catastrophic plans might offer limited or no telehealth benefits, or they may impose high cost-sharing. If telehealth access is essential to you, review these plans carefully — low monthly premiums often mean restricted benefits and higher out-of-pocket risk.

Costs: copays, deductibles, coinsurance, and out-of-pocket limits

How much a telehealth visit costs you depends on plan rules. Some insurers waive copays for telehealth visits or charge lower copays, while others apply the same cost-sharing as an in-person visit. Deductible status is important: if a visit is subject to your deductible, you’ll pay more until the deductible is met. Coinsurance — a percentage of the allowed amount — may apply for specialist telehealth visits or certain services.

Parity laws and cost-sharing parity

Some states have telehealth parity laws that require insurers to cover telehealth services on par with in-person care, including similar reimbursement rates to providers. Parity helps ensure patients aren’t charged higher coinsurance or denied coverage based solely on the telemedicine format. However, parity laws differ in scope; not all states require cost-sharing parity, and federal programs like Medicare set their own rules.

Using HSAs and FSAs for telehealth costs

Qualified medical expenses that are eligible under IRS rules may be paid with HSA or FSA funds, including telehealth visits and prescribed treatments. If the telehealth service results in prescriptions, those pharmacy costs might also be eligible. Keep receipts and EOBs; plan administrators may require documentation to reimburse telehealth expenses.

Network issues: in-network vs out-of-network telehealth

Network status matters for telehealth as much as it does for in-person care. Many insurers contract with telehealth vendors and networks; using an in-network telehealth provider usually results in lower cost-sharing and protection from balance billing. However, because telemedicine crosses geography, verifying that the provider is in your plan’s network before the visit is essential.

Licensing, interstate care, and reciprocity

Providers must be licensed where the patient is located during the encounter. That means if you travel to another state or live near a state border, a provider licensed only in their home state may be unable to treat you. During public health emergencies, states sometimes relax licensure rules temporarily, and multistate licensure compacts (e.g., for nurses and physicians) can ease cross-state practice. For routine telehealth, always confirm the provider’s licensure and that your location is acceptable for the intended service.

Prior authorization, referrals, and prescription rules

Some insurers require prior authorization for certain telehealth services (e.g., specialty consults, advanced remote monitoring) or for care that otherwise needs prior approval in-person. Referrals may be necessary depending on your plan type (for example, HMOs often require a primary care referral for specialist telehealth visits). Prescribing controlled substances via telehealth follows federal and state laws; certain medications may require an in-person visit before a teleprescription can be issued.

What telehealth typically covers — and what it often does not

Telehealth is excellent for many needs, but it isn’t a universal substitute for in-person care. Insurers generally cover services that can be safely and effectively delivered remotely, but diagnostic limitations apply.

Mental health and substance use treatment

Mental health care via telehealth has been one of the largest success stories: therapy, counseling, psychiatric medication management, and even group therapy are widely covered. Many insurers expanded coverage and permitted audio-only visits for behavioral health. Substance use treatment, including medication-assisted treatment (MAT), may be available via telehealth, but prescribing controlled medications has special regulatory rules and may require in-person steps.

Chronic condition management and remote monitoring

Telehealth plus RPM is increasingly covered for conditions such as hypertension, diabetes, COPD, and heart failure. RPM services are often billed with specific codes and may involve devices supplied to the patient. Coverage can include monitoring device costs, clinician time for data review, and coordination of care — though insurers may limit duration, qualifying conditions, or reimbursement rates.

Physical exams, imaging, and procedures

Telehealth cannot replace procedures that require hands-on care, imaging (X-rays, MRIs), or certain essential physical examinations. An insurer may cover a telehealth triage visit that then directs the patient to in-person services. Emergency care — trips to the ER — are rarely appropriate for telehealth-only management though initial triage may be supported remotely.

Claims, EOBs, and billing mistakes to watch for

Because telehealth is still evolving, billing mistakes are common. Understanding claims and how to read an Explanation of Benefits (EOB) can prevent surprises.

How to read an EOB for a telehealth visit

An EOB shows what was billed, what the insurer allowed, what the insurer paid, and what portion is your responsibility. Key items to check:

• Service date and provider name — confirm accuracy.
• CPT or service code — ensure the correct telehealth code/modifier was used.
• Allowed amount — the insurer’s negotiated rate with the provider.
• Amount paid by insurer and the patient responsibility (copay, deductible, coinsurance).
• Notes on denials, adjustments, or billing edits — these clarify why a service was processed a certain way.

Common billing errors and how to dispute them

Frequent mistakes include missing telehealth modifiers, using incorrect place-of-service codes, or the claim being processed as out-of-network. If you spot an error:

• Contact the provider’s billing office first — ask them to review and resubmit the claim with correct codes/modifiers.
• If the provider resubmits and the insurer still denies, request a written explanation from the insurer and follow your plan’s internal appeal process.
• Keep detailed records: dates, names, claim numbers, and copies of bills and EOBs.

Balance billing and the No Surprises Act

If you receive care from an out-of-network provider without prior notice, you could face balance billing — being charged the difference between the provider’s fee and what the insurer paid. The No Surprises Act gives protections against many surprise bills for emergency services and certain non-emergency out-of-network care at in-network facilities. Telehealth encounters with out-of-network clinicians can still create exceptions depending on state law and plan contracts, so verify network status beforehand to avoid unexpected bills.

Choosing a plan with good telehealth coverage: a checklist

When comparing plans, use this checklist to ensure telehealth needs are met:

• Does the plan explicitly list telehealth benefits in the Summary of Benefits?
• Are telehealth copays lower, equal to, or higher than in-person copays?
• Does the plan cover audio-only visits and asynchronous services?
• Are mental health telehealth visits covered similarly to medical telehealth?
• Does the plan have a contracted telehealth vendor or network you prefer?
• What are the rules for RPM, including device coverage and duration limits?
• Does the plan limit the number of telehealth visits per year or require prior authorization?
• Is cross-state telehealth allowed, and what are the licensure restrictions?
• How are prescriptions handled after telehealth visits, particularly controlled substances?

Practical tips to use telehealth effectively and avoid surprises

Follow these steps to reduce friction and unexpected costs.

Before the visit

1) Verify coverage: Call your insurer or check your plan portal to confirm the telehealth visit is covered and whether the provider is in-network. 2) Confirm the provider’s licensure for your state if you’re physically located outside your home state. 3) Ask about payment: is there a copay, and will the visit apply to your deductible? 4) Share your preferred pharmacy with the provider in advance and ask how prescriptions will be transmitted.

During the visit

1) Confirm provider identity and credentials. 2) Ask the clinician to include telehealth modifiers and place-of-service codes in the claim (or ensure their billing department does). 3) If the clinician recommends labs, imaging, or an in-person follow-up, verify whether those services are at in-network locations to avoid balance billing. 4) Get a visit summary and any orders in writing via secure message or portal.

After the visit

1) Monitor your insurer portal for claim submission and EOB. 2) Review the EOB carefully; if the claim is denied or processed out-of-network, contact the provider’s billing office to correct and resubmit. 3) If you face an unexpected bill, use the insurer’s appeal process, and if needed, escalate to your state insurance department or an external review organization.

Telehealth for specific populations and use cases

Telehealth’s reach expands across many populations, but coverage nuances matter.

Mental health care

Teletherapy and telepsychiatry are widely reimbursed by both commercial insurers and public programs, often with parity to in-person visits. Audio-only options are frequently allowed for behavioral health, which increases accessibility for patients without reliable video connections.

Rural and underserved communities

Telehealth can increase access to specialists and reduce travel burden, but digital divide issues — broadband access, device availability, and digital literacy — remain barriers. Some programs and community clinics offer telehealth kiosks or support to bridge this gap.

Children and adolescents

Pediatric care via telehealth — including well-child triage, behavioral health, and chronic condition follow-up — is increasingly supported. For vaccines, in-person visits remain necessary, but telehealth can provide counseling and follow-up care.

Seniors and Medicare beneficiaries

Seniors benefit from telehealth for chronic disease management, medication reviews, and behavioral health. Medicare expanded telehealth coverage, but specifics (audio-only acceptance, RPM eligibility) vary. Many Medicare Advantage plans add stronger telehealth benefits, so compare MA plan telehealth features if you prioritize virtual care.

Telehealth trends and the future of insurance coverage

Telehealth continues to evolve. Key trends shaping insurance coverage include:

• Payment model shifts — movement toward value-based care encourages insurers to support telehealth if it reduces total cost of care.
• Permanent regulatory changes — some temporary flexibilities from public health emergencies may become permanent, expanding cross-state practice and reimbursement.
• Integration of RPM and digital therapeutics — insurers are increasingly covering wearable-driven care and app-based therapies for chronic disease and mental health.
• AI-assisted triage and virtual care platforms — insurers may reimburse for AI-assisted services or require their use in care coordination.
• Stronger consumer expectations — as patients demand convenient, virtual-first options, insurers will face pressure to standardize telehealth benefits.

AI, digital health, and insurer partnerships

Insurers are partnering with digital health companies to provide curated telehealth networks, remote monitoring programs, and app-based coaching. These partnerships can broaden covered services but also require careful oversight to protect privacy, ensure clinical quality, and avoid fragmentation of care.

Navigating denials and appeals for telehealth claims

If a telehealth claim is denied, the process to resolve it mirrors other medical claims but has telehealth-specific hooks:

• Confirm the reason for denial — was a modifier missing, was the provider out-of-network, or is the service considered non-covered by policy language?
• Ask the provider to resubmit with corrected coding if the denial was administrative (modifier/place-of-service error).
• If the denial is coverage-based (service not covered), file an internal appeal with your insurer, documenting medical necessity and including supporting clinician notes.
• If internal appeals fail, external review options or state consumer protection agencies can sometimes overturn denials, especially when coverage language is ambiguous.

Privacy, security, and consent in telehealth

Telehealth platforms must comply with HIPAA and state privacy laws. Use secure, encrypted platforms recommended by your provider. Insurers and providers should obtain informed consent for telehealth visits, documenting limitations (e.g., inability to perform a hands-on exam) and privacy considerations. Be cautious about using public Wi-Fi for sensitive conversations and ask about the platform’s security features if you have concerns.

Common myths and misconceptions about telehealth coverage

Myth: Telehealth is always cheaper. Reality: Telehealth can save time and travel costs, but if a visit is subject to the same copay or deductible as in-person care, savings may be limited. Myth: All insurers reimburse phone visits. Reality: Audio-only coverage is insurer- and state-dependent. Myth: Telehealth always avoids balance billing. Reality: If the provider is out-of-network or improperly billed, you can face surprise charges. Verify network status and billing codes to reduce risk.

Checklist: Questions to ask before scheduling a telehealth visit

Use this quick script to get clarity:

• Are you in-network with my insurance for telehealth?
• Will this visit be billed as a telehealth service with the correct modifiers?
• What will my copay or coinsurance be today? Will the visit apply to my deductible?
• Can you prescribe medications if needed, and will there be restrictions?
• If referral or imaging is needed, can you direct me to in-network facilities?
• How will follow-up be handled — secure messages, phone, or another tele-visit?

Telehealth offers strong potential to expand access, lower friction, and improve chronic disease management — but its value depends on smart coverage, correct billing, and clear patient-provider communication. Before you rely on virtual care, verify coverage details, know your network, and document the encounter. When insurers, regulators, and providers align telehealth policy, it becomes a sustainable, equitable option for routine and specialty care alike. With a little preparation and awareness of billing rules, telemedicine can be a seamless, affordable part of your health care toolkit.