Expansion of State Medicaid Policies Related to Telehealth, 2018-2023: A National Legal Mapping Study

Policy Points Telehealth increases access to health care services for patients, including rural and underserved communities, and a 50-state survey of telehealth policies can further the study of the impact of telehealth on patient outcomes. This legal mapping study tracked telehealth policies by state Medicaid programs and found widespread adoption, especially in reimbursement for audio-only telehealth (adopted by 0 to 43 states from 2018 to 2023). State adoption of telehealth policies appeared to be independent of rurality, health professional shortage, Medicaid expansion, broadband internet availability, and any tested state factor (e.g., demographics, unemployment, COVID-19 cases).

Telehealth can improve access to medical and mental health care for rural and under-resourced communities. US states rapidly expanded policies enabling telehealth care delivery during the COVID-19 pandemic, possibly driven by certain state factors, such as rurality. Variation in state policies regarding Medicaid, the largest US health insurance program by enrollment, enables the naturalistic study of telehealth care expansion and health outcomes for underserved individuals. This study aimed to identify state policies addressing Medicaid telehealth care delivery and to examine explanatory state factors associated with telehealth adoption.

Legal mapping (50-state survey) methods were used to identify US state laws and policies addressing telehealth for Medicaid populations in effect up to December 31, 2023. Two researchers independently abstracted relevant information and analyzed data, guided by a supervising public health attorney and physician. The main outcome was the count of (equally weighted) policies in effect during each month by state. Multivariable regressions were used to examine the data for associations between policy counts and several potential explanatory state factors from 2018 to 2023.

A mean of 2.7 telehealth policies (standard deviation, 1.4; range, 0-6) were in effect across state Medicaid programs during the study period. Most adoption occurred during 2020 and 2021, with an audio-only reimbursement policy being the most rapidly adopted, increasing from 0 to 43 states over the course of 5 years. State adoption of telehealth policies appeared to be independent of rurality, health professional shortage, Medicaid expansion, broadband internet availability, and any tested state factor (e.g., demographics, income, unemployment, COVID-19 cases and deaths).

States rapidly enacted many Medicaid policies to facilitate telehealth care delivery, which was not driven by any singular state factor. Policy plays an important role in the implementation of evidence-based health care tools, such as telehealth. This 50-state survey can be used to understand policy effects on patient care access and quality for rural and underserved populations.