Some Medicare patients could lose coverage for virtual doctor’s visits at end of month

Rodney Figueroa couldn’t figure out why he was experiencing back pain in late 2017. The doctors couldn’t either.

They did multiple X-Rays and discovered fractures in his spine, but it was months before they diagnosed him with Stage 3 multiple myeloma, a cancer that forms in white blood cells and can build up in bone marrow. 

Figueroa traveled from Maui to O‘ahu to see a specialist, then spent three months undergoing treatment in Seattle. But when the pandemic hit in 2020, instead of having to fly to his specialty doctor or see physicians in person on Maui, many of his appointments went virtual.

“It helps a lot,” Figueroa said.

Many patients have benefited from the boom in telemedicine that became crucial during the the first years of the pandemic. Virtual health care became so popular the federal government eased restrictions to allow Medicare to reimburse providers in more areas for more telehealth services.

But now some patients on Medicare may lose coverage for virtual health as early as Sept. 30.

If Congress doesn’t act, Medicare patients in non-rural areas will have to pay the full cost of telehealth appointments or shoulder the extra cost of traveling to the doctor.

“I think it’s a mistake,” said Cliff Alakai, administrator of Maui Medical Group, which serves about 30,000 patients across five offices. “I think it’s going to make things busier and make health care more cumbersome.”

Virtual appointments are a service that many patients have come to rely on. Since 2019, the year before the pandemic struck, telemedicine use among physicians shot up from 15.4% in 2019 to 86.5% in 2021, according to the U.S. Centers for Disease Control and Prevention.

They tend to be cheaper, too. The Center for Telehealth and e-Health Law reported that telehealth visits cost $79 on average, compared to $146 for traditional in-person visits.

As Congress grapples over spending bills and a potential government shutdown looms, health care facilities are left wondering whether their patients will be affected. 

“We have, as a company, talked to people to try to figure out what’s going on, but everybody’s telling us ‘we don’t know,’” Alakai said. “We don’t know which direction it’s going.”

THE DOCTOR IS ONLINE

Patrick “PK” Higa has been on a waiting list for a liver transplant for the past two years. The 54-year-old Upcountry resident earned a medical retirement last year after nearly three decades as a teacher, coach, vice principal and athletic director at King Kekaulike High School. 

Queen’s Medical Center on O‘ahu has the only organ transplant facility in the state, and Higa travels there at least once a year to do blood work, imaging and other work to make sure he’s still eligible and ready for a transplant. He also has virtual appointments. 

“For me, it’s huge, because one meeting or conference, it saves me a lot of time,” Higa said.

When he flies off island, he has to rent a car and wrangle Honolulu’s traffic for appointments that can sometimes last as little as 20 minutes. 

“I think I spend more on parking in the facility than I do with the doctors,” Higa said. 

Higa and Figueroa don’t have Medicare, so they won’t be affected by the federal program changes, but they’re examples of the many Maui residents who have come to depend on telehealth services.

“It’s like house calls,” said Keali‘i Lopez, executive director of AARP Hawai‘i. “We’re kind of going full circle. It’s the doctor coming to your home now out of the convenience of your telephone.”

In 2024, Maui County had a major shortage of 174 physicians, or 41%, the worst rate in the state, according to a University of Hawai‘i annual report. The vacancy rate for non-physician health care positions that same year was 32% on Lāna‘i, the highest in the state, 15% on Maui and 14% on Moloka‘i, according to a Healthcare Association of Hawai‘i report.

“Telehealth is an important part of our healthcare system and should remain available for patients, nursing home residents, and Medicare recipients who would otherwise face obstacles to receiving the care they need,” the Healthcare Association of Hawai‘i said in an email to the Hawai‘i Journalism Initiative last week. 

The association’s national affiliates were among more than 300 advocacy groups and health care providers who sent a letter to leaders in Congress urging them to ensure Medicare beneficiaries are able to access the same telehealth services that they have been relying on for the past five years.

“While we strongly support making Medicare telehealth access permanent, if that’s not achievable at this time, we urge Congress to approve the longest possible extension,” the letter stated. “At a minimum, a two-year extension is needed to ensure stability and provide clarity for patients, providers, and the health care system as a whole.”

Telehealth services earn support across the aisle. In April, Democratic U.S. Sen. Brian Schatz of Hawai‘i led a bipartisan group of 60 senators to introduce a bill that would make the expanded telehealth provisions permanent. Republican and Democratic lawmakers in the U.S. House of Representatives sponsored a companion bill.

Democratic U.S. Rep. Jill Tokuda, whose district includes Maui County, said Republicans have proposed extending the coverage through Thanksgiving, but “that falls far short of what our communities need.”

She wanted to see a more long-term solution through the House bill that “would make permanent Medicare telehealth reimbursement at community health centers and rural clinics, including audio-only visits for patients without broadband access.”

“If Congress fails to act, many vulnerable populations in Hawai‘i and across the country, including seniors, rural residents, and those with limited mobility, will lose critical access to convenient, affordable care,” Tokuda said Wednesday in a statement to the Hawai‘i Journalism Initiative. “Telehealth was a lifeline during the pandemic. We cannot let these gains slip away.”

Democratic U.S. Sen. Mazie Hirono of Hawai‘i said Medicare coverage for telehealth services has “expanded access to health care for many seniors and patients with disabilities,” especially those in rural communities. She said she’d push to make it permanent.

“The success of Medicare telehealth coverage underscores the need for Congress to make it permanently available,” Hirono said Wednesday in a statement to the Hawai‘i Journalism Initiative. “Millions of people — including tens of thousands of patients in Hawai‘i — rely on telehealth services and they should not have to face continuous uncertainty about their access to health care.”

If Congress doesn’t act by Sept. 30, Medicare would tighten its rules to require that patients be physically located in a medical office or health facility in a rural area of the U.S. to receive most telehealth services, according to the State Health Insurance Assistance Program, also known as Hawaii SHIP.

Medicare will still allow certain telehealth services from any location, including the patient’s home. But they have to for one of the following treatments: monthly end-stage renal disease visits for home dialysis patients; acute stroke services for diagnosis, evaluation or treatment, including in mobile stroke units; and mental and behavioral health care, including treatment for substance use disorders. 

“All we can really do is just make sure people are clear about qualifications to get covered,” Hawaii SHIP program specialist Candace Nakamoto said. “We were encouraging folks to utilize their telehealth benefits starting from last year because of the change.”

Nationwide, there are 68.9 million people enrolled in Medicare, with 90% older than 64, according to the Centers for Medicare and Medicaid Services. The State of Hawai‘i had 310,594 total Medicare beneficiaries as of May, the latest month for which data is available. In Maui County, there were 35,314 beneficiaries. 

Not all beneficiaries will be affected by the changes. It depends on a person’s plan, clinic used and medical services needed.

Hawaii SHIP recommends that people talk to their doctors about how their plan may be affected, check if their health care facilities are located in rural-designated areas, and find out whether their services could fall under the exceptions.

Nakamoto said affected patients can talk to their legislators or consider switching to a different plan. Other Medicare programs may offer more telehealth benefits.

Maui Medical Group, which has clinics in Kahului, Kīhei, Nāpili, Pukalani and Wailuku, is not considered a rural health center and thus would be affected, Alakai said. 

Telehealth appointments have “now become part of the way we practice medicine.” The group’s five clinics see an average of 1,000 patients a day, and Alakai estimated that about 5% to 10% of all visits are video visits. About 3,000 of Maui Medical Group’s patients are on Medicare. 

“It’s actually worked out to be really, really good for a lot of patients, especially the less mobile and homebound type of patients,” Alakai said. “It also decompresses the volume in the actual practice. So we are strong advocates and encouraging that to continue.”

Virtual appointments require less staff and help primary care providers who are already “overwhelmed with patients,” Alakai said. They make space in the clinic for some of the sicker patients and allow patients with more minor symptoms to get the checkups they need from home. He pointed out that virtual appointments work best as follow-ups for established patients whose medical history is already in the clinic’s system.

Alakai said the biggest beneficiaries of virtual visits are elderly patients who lack mobility or transportation, and younger patients who would rather skip a visit to the doctor than go through the trouble of an in-person appointment. 

He said the full cost of a telehealth appointment would depend on the type of treatment or service the patient is seeking and what is negotiated with insurance. 

Overall, he’s worried the changes will create a “disjointed” system of insurance coverage in an already confusing field. 

With many private health plans following guidelines by the Centers for Medicare & Medicaid Services, Alakai is concerned that if those guidelines “turn off the ability for televisits or video visits, then other health insurers may follow that and not allow that service.”

Kaiser Permanente, one of the biggest health providers and insurance companies in the state, said it provided 5.5 million phone and video visits to its Medicare patients in 2023. Overall, telehealth use at Kaiser is almost three times higher than it was before the pandemic, said Mats Olson, Hawai’i and California Medicare business line leader.

“Kaiser Permanente’s Medicare Advantage plans have always had more flexibility to offer a wider array of telehealth services to Medicare members,” Olson said in a statement. “Kaiser Permanente will continue to provide telehealth services to members under their current benefits, regardless of changes to telehealth coverage under Original Medicare.”

Members can check their evidence of coverage for more details.

Hawaii Medical Service Association, another large health insurer who offers plans with a Medicare contract, said it would continue to cover telehealth services on the Original Medicare Telehealth list when done by an in-network provider at any location including the member’s home, with no geographic restrictions.

“There are no changes to telehealth benefits for non-Medicare HMSA members,” said Kim Takata Endo, assistant vice president of Medicare Programs with HMSA.

Takata Endo said HMSA was the first health plan in Hawai‘i to offer a telehealth platform to its members in 2009. Between 2019 and 2020, HMSA saw “an exponential growth in telehealth usage.” Since then, there have been more than 1 million telehealth visits each year between HMSA members and providers.

BETTER ACCESS, BETTER HEALTH CARE

If there’s anything good that came out of the pandemic, it was the accessibility of telehealth, said Lopez, the AARP Hawai‘i director.

Before her mom passed away two years ago, Lopez said it would take 10 wheelchair transfers just to get her from her home in Wai‘anae to her doctor’s appointment in Honolulu roughly an hour away. She’d get motion sickness just from being moved so much, and sometimes she wouldn’t even want to go. 

“When we were able to do telehealth, it was so much better, because it was such a good deal for her,” Lopez said.

If they had to pay for transportation services to pick her mom up, it would’ve set them back about $300 for just one trip, Lopez said. 

It’s not just homebound or immobile folks who benefit, Lopez added. It’s also kūpuna who are caregivers or look after their grandchildren and would have to bring them to the doctor’s office. She used to think telehealth was more of a convenience, but now she thinks it’s about equal access and making sure people stay on top of their health through preventative care and chronic disease management, which pays off in the long run. 

“If you’re going to your doctor regularly, following through on your regimen, making sure you’re taking care of all the things you need to do, and that’s something you’re more likely to do because your doctor comes into your own home (virtually) … it’s going to be a quality of health, health care improvement,” Lopez said.

AARP backs both of the bills in Congress to extend the telehealth provisions, and Lopez said she thinks it’s “shortsighted in letting this exemption expire at the end of the month.” 

But Lopez said passing the bills will be difficult with Congress dealing with a looming government shutdown.

“There’s no reason to not do it,” Lopez said. “It’s a matter of timing and Congress taking action.”

For more information, beneficiaries can call 1-800-MEDICARE (633-4227), or contact Hawaii SHIP online at hawaiiship.org or by phone at 808-586-7299 or toll free at 888-875-9229.”