U.S. Department of Health and Human Services 
Office of Inspector General 
Data Brief 
 
September 2021, OEI-02-19-00401 
 
 
 
Opportunities Exist To Strengthen Evaluation and Oversight of 
Telehealth for Behavioral Health in Medicaid  
Why OIG Did This Review 
Key Takeaways  States are increasingly relying on telehealth to provide behavioral 
health services to Medicaid enrollees.  Before the COVID-19 pandemic, 
o  A few States reported being 
unable to identify which  telehealth was an important tool for States to increase access to 
services are provided via  behavioral health services for enrollees in rural or underserved areas 
telehealth, limiting their  with provider shortages.  During the COVID-19 pandemic, States 
ability to evaluate and  expanded their use of telehealth to help meet the needs of enrollees 
oversee telehealth.  while also reducing the risks from community spread of the virus.   
As the Nation confronts the psychological and emotional impact of 
o  Only a few States have 
COVID-19, the use of telehealth will be important in addressing 
evaluated the effects of 
telehealth on behavioral  behavioral health needs for Medicaid enrollees.   
health services.    
This data brief provides insight into State evaluations and oversight of 
o  Despite concerns about  telehealth for behavioral health services as of January and February 
fraud, waste, and abuse, 
2020, before the expansion of telehealth due to the COVID-19 
many States do not conduct 
pandemic.  It provides a useful foundation to inform the Centers for 
monitoring and oversight 
Medicare & Medicaid Services (CMS) and State decisions about how 
specific to telehealth.   
to evaluate the impacts of telehealth on access, cost, and quality of 
behavioral health services and to strengthen oversight of program 
integrity.  Evaluating the effects of telehealth on access, cost, and quality is particularly important in 
helping States make decisions about how best to use telehealth and about which populations benefit 
most from these services.  Understanding States efforts to oversee telehealth can help States protect 
their Medicaid programs.  Further, States expansion of telehealth during the COVID-19 pandemic has 
been largely on a temporary basis.  As States consider making telehealth expansions permanent, States 
can use information in this data brief to help determine which services best support enrollees.  This data 
brief is a companion report to a data brief that describes the challenges States reported with using 
telehealth to provide behavioral health services to Medicaid enrollees.1   
 
How OIG Did This Review 
States commonly provide behavioral health services to Medicaid enrollees through managed care 
organizations.  We conducted a survey of State Medicaid Directors from 37 States that provide 
behavioral health services via telehealth through managed care organizations.  We also conducted 
structured interviews with relevant stakeholders.  While we asked about efforts specific to managed 
care, the respondents focused on States efforts to evaluate and oversee the use of telehealth more 
generally.     
 
 
    What OIG Found  
While most States can identify which services are provided via telehealth, a few reported being unable 
to, limiting their ability to evaluate and oversee telehealth.  In addition, only a few States have evaluated 
the effects of telehealth in their State; these States found increased access and reduced costs.  Based on 
their own experiences, other States believe that telehealth increases access, has uncertain impacts on 
costs, and raises concerns about quality.  Further, despite concerns about fraud, waste, and abuse, many 
States do not conduct monitoring and oversight specific to telehealth.   
 
What OIG Recommends  
CMS and State efforts to evaluate and oversee telehealth are critical to meeting Medicaid enrollees 
behavioral health needs and to safeguarding the Medicaid program from potential fraud, waste, and 
abuse.  These efforts are particularly important as the telehealth landscape continues to evolve. 
Accordingly, we recommend that CMS: (1) ensure that the three States that are unable to distinguish 
telehealth from in-person services implement indicators to identify which services are provided via 
telehealth, (2) conduct evaluations, and support State efforts to evaluate the effects of telehealth on 
access, cost, and quality of behavioral health services, and (3) conduct monitoring for fraud, waste, and 
abuse, and support State efforts to oversee telehealth for behavioral health services.  CMS concurred 
with the first recommendation but did not explicitly indicate whether it concurred with the other two 
recommendations.  
     
 
Primer on: 
Telehealth for Behavioral Health in Medicaid  
 
  Telehealth can be used to provide behavioral health services, including mental 
 
health assessments, individual therapy, and medication management. 
 
  Telehealth for behavioral health is most commonly provided through live, two-way 
  video between a provider and an enrollee.  
    Telehealth can also be provided through store-and-forward transmission of 
recorded videos and digital images and through remote patient monitoring that 
 
collects personal health data and transmits it to the provider.  States may also allow 
  use of audio-only, text-only, or email communications to deliver behavioral health 
services via telehealth. 
 
  Medicaid enrollees experience higher rates of behavioral health disorderswhich 
  include both mental health disorders and substance use disordersthan the 
general population.  About one-fifth of all Medicaid enrollees have a behavioral 
 
health diagnosis, and many more enrollees may go undiagnosed.2 
 
  States commonly provide behavioral health services to Medicaid enrollees through 
  Medicaid managed care organizations.  Managed care is the primary delivery 
system for Medicaid services, covering over 82 percent of the Medicaid 
  population.3   
    In most States, an enrollee can receive telehealth services from the enrollees 
home, particularly for behavioral health services.4 
 
  In response to the COVID-19 pandemic, States have increasingly relied on 
 
telehealth to provide behavioral health services to Medicaid enrollees, including 
  temporarily expanding the types of services, providers, and technologies, as well as 
the locations where enrollees can access telehealth services.5   
 
 
 
 
2345 
 
 
 
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RESULTS 
 
 
This data brief provides insight into State evaluations and oversight of telehealth for 
behavioral health services for Medicaid enrollees as of January and February 2020, 
before the expansion of telehealth due to the COVID-19 pandemic.  States have 
broad flexibility to use telehealth to provide these services.  In addition, CMS has  
taken several steps to support the implementation and expansion of telehealth in 
Medicaid, particularly during the COVID-19 pandemic.   
Along these lines, a State can determine whether to use telehealth to provide 
behavioral health services.  A State can also determine the types of services that are 
allowed, where telehealth may be used, which technology can be used, and which 
types of providers may deliver services via telehealth.  States commonly provide 
behavioral health services through managed care organizations.6  These organizations 
contract with providers to deliver services to Medicaid enrollees.   
This data brief describes the results of States' efforts to evaluate the effects of 
telehealth on access, cost, and quality, as well as the experiences of States with using 
telehealth.  It also describes States oversight of telehealth to detect fraud, waste, and 
abuse of behavioral health services.  It is based on a survey of State Medicaid 
Directors from States that provide behavioral health services via telehealth through 
managed care organizations and interviews with key stakeholders.  (Hereinafter, we 
refer to these State Medicaid Directors as States.)  These stakeholders include 
representatives from organizations that have direct experience with using telehealth 
to provide these services, such as health care coordination organizations, managed 
care organizations, and Telehealth Resource Centers.7  While we asked about efforts 
specific to managed care, the respondents focused on States efforts to evaluate and 
oversee the use of telehealth more generally.   
Understanding States efforts to evaluate and oversee telehealth to provide behavioral 
health services can help States improve and protect their Medicaid programs and 
better serve enrollees.  States play an important role in conducting such evaluation 
and oversight of telehealth for behavioral health services.  It is essential that States 
overseeand coordinate with managed care organizations to overseetelehealth 
services to ensure that their Medicaid programs deliver quality services, and that 
funds are not misused for fraud, waste, or abuse.  CMS also plays an important role by 
working with States to evaluate and oversee telehealth for behavioral health services. 
 
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While most States can identify which services are provided via 
telehealth, a few are unable to, limiting their ability to evaluate 
and oversee telehealth  
The ability to identify which specific services are provided via telehealth is critical to 
understanding the effects of telehealth on access, cost, and quality and to monitoring 
and providing oversight of these services.  Despite this, a few States (3 of 37) are 
unable to distinguish which services are provided via telehealth from those delivered 
in-person.8  These States cannot do any analysis on the effects of telehealth, nor do 
they have the ability to perform basic monitoring and oversight specific to telehealth 
services, which are essential to ensuring the fiscal integrity of the Medicaid program 
and to protecting Medicaid enrollees.  
In contrast, the other 34 States are able to distinguish between specific services 
provided via telehealth and in-person.  To indicate when services are delivered via 
telehealth, these States typically require the use of a modifier, a place of service code, 
or telehealth-specific procedure codes on the claim.  These States are able to conduct 
analysis on the effects of telehealth, as well as monitoring and oversight specific to 
telehealth.  For example, such analysis could include identifying providers that are 
outliers in billing for telehealth services. 
Although the ability to identify services delivered via telehealth is a critical first step, 
there are concerns about incomplete data that may hinder States ability to evaluate 
and oversee telehealth.  Providers may not use the appropriate modifiers or other 
indicators consistently, especially when payment for services is not contingent on 
inclusion of a modifier.  This may be the case when telehealth services are paid at the 
same rate as those provided in-person.9  As one stakeholder notes, modifiers may be 
left off the claim due to errors on the part of providers or a lack of clarity in State 
policies. 
Only a few States have evaluated the effects of telehealth in 
their State; these States found increased access and reduced 
costs 
States are responsible for ensuring access to care, controlling costs, and addressing 
the quality of care when providing behavioral health care services to Medicaid 
enrollees.10  As States increasingly shift toward the use of telehealth to provide these 
services, it is critical to evaluate the effects of telehealth on each of these measures.  
To evaluate the effects of telehealth on access, cost, or quality, States report 
conducting evaluations or collecting data from analyses conducted by managed care 
organizations in their State.    
In total, two States have evaluated the effects of telehealth specifically on access to 
behavioral health services for Medicaid enrollees.  One State found that, prior to the 
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pandemic, the percentage of enrollees who used telehealth for behavioral health 
services was 70 percent in rural counties, versus just 24 percent in urban counties in 
one of its managed care plans.  This State notes that, absent telehealth, enrollees in 
rural areas would likely have had to travel or be transported a significant distance to 
urban centers in order to receive behavioral health care.  Additionally, a second State 
found that telehealth increased access to certain types of providers, such as 
psychiatrists, psychologists, and nurse practitioners specializing in mental health. 
Further, only one State evaluated the effects of telehealth specifically on cost.  This 
Stateone of the States that also analyzed its data on accessfound that, prior to 
the pandemic, telehealth produced savings of $8,600 in emergency room avoidance 
for one managed care plan, as well as $484,000 in reduced transportation costs for 
another managed care plan.   
No State has evaluated the effects of telehealth specifically on the quality of 
behavioral health services.  For example, no State reported looking at the effects of 
telehealth on continuity of care or patient safety. 
Given the increased use of telehealth during the COVID-19 pandemic, it is important 
that States evaluate the effects of telehealth specifically.  Such analyses could help 
States ensure the effective use of telehealth and improve health outcomes for 
different populations.  For example, one State plans to present future analyses on the 
cost of telehealth services to its State legislature to determine the types of telehealth 
services that the State would like to continue, or begin, reimbursing to best serve its 
Medicaid population.   
 
Analysis can help States make decisions about 
 
which behavioral health services should be allowed 
  via telehealth on a permanent basis. 
 
Based on their experiences, other States believe that telehealth 
increases access, has uncertain impacts on cost, and raises 
concerns about quality 
States have experience with using telehealth, including firsthand knowledge of the 
impacts of telehealth on access, cost, and quality of behavioral health services.  
Although it is important that States move beyond program observations and more 
rigorously evaluate the effects of telehealth, it is also valuable to highlight States 
experiences so that stakeholders can understand the context for State decisions as 
many take steps to change their telehealth policies in the wake of the COVID-19 
pandemic.    
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Some States report telehealth increases access to care   
Although they have not evaluated the effects, some States (17 of 37) report that 
telehealth increases access to care based on program observations.  Several States 
report that telehealth facilitates access to an increased number of providers.  For 
example, one State observes that the number of behavioral health providers seeking 
approval to provide services via telehealth is increasing, adding that there are now 
behavioral health providers approved for telehealth in every county of the State.  
Access to an increased number of providers is particularly important for States with 
areas experiencing provider shortages.  Another 
State notes that its enrollees are able to access  Patients are getting care quicker, 
services from a broader range of behavioral  especially for behavioral health, 
health providers, including physicians,  where wait time [for in-person 
psychiatrists, psychologists, and social workers,  services] can exceed 4 to 6 months. 
as these types of providers are now available in  -  Health Care Coordination Organization 
all areas of the State, including those with   
provider shortages.  Additionally, one State reports that telehealth has expanded 
access to specialists for enrollees living in rural and frontier areas of the State, while 
another State notes that telehealth has increased access to prescribing for enrollees 
living in rural areas. 
 
In addition, a few States report that telehealth increases access by potentially 
reducing barriers to care.  For example, one State notes that allowing enrollees to 
receive care at various sites, including the enrollee's home, school, community-based 
settings, or traditional telehealth sites helps increase access to behavioral health 
services.  In addition, another State reports that telehealth may increase access by 
reducing barriers related to a lack of transportation, while another State notes that 
access may be increased with telehealth through shorter wait times for behavioral 
health services.  Further, a few stakeholders note that telehealth helps circumvent the 
stigma related to receiving behavioral health services.  For example, enrollees living in 
small, tightly knit communities, where someone may notice their car in the parking lot 
of a therapist or other mental health professional, may avoid getting the care they 
need as they are concerned about being unfairly stigmatized or marginalized.   
Several States report uncertain impacts of telehealth on cost  
Several States (6 of 37) suggest that the impact of telehealth on cost is largely 
uncertain.  A few States cite the fact that, in their State, telehealth is reimbursed at the 
same rate as in-person services, which makes the overall impact on cost unclear.  One 
State notes that services rendered through telehealth may help offset costs of non-
emergency medical transportation and provider travel reimbursement.  Additionally, 
one stakeholder notes that if telehealth increases access it may increase costs, 
although there are a few instances where the reduction in transportation costs 
outweighs the increase in costs from increased access.  
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Some States highlight concerns about the effects of telehealth on 
quality of care 
Some States (10 of 37) note concerns about 
It can be challenging for providers 
the quality of services that are delivered via 
telehealth, particularly for certain types of  to pick up on an enrollees social, 
behavioral health services, such as prescribing,  non-verbal cues...which could lead 
and for services that are delivered audio-only  to misdiagnosis. 
versus audio-video.  For example, one State  -  Health Care Coordination Organization 
raises concerns about quality, but notes that   
that these concerns can be minimized through appropriate clinical practice as well as 
provider training on best telehealth practices.  Similarly, another State reports that the 
effects of telehealth on quality of services appear to be largely dependent on the 
training of providers to effectively deliver these services via telehealth.  According to 
the State, providers without such training more frequently have patients that request 
other options or providers.  
Despite concerns about fraud, waste, and abuse, many States do 
not conduct monitoring and oversight specific to telehealth  
Many States (23 of 37) report that 
Examples of fraud and abuse complaints 
fraud, waste, and abuse is a concern 
OIG has received specific to telehealth 
with using telehealth to provide 
include:   
behavioral health services.  States 
report uncovering fraud schemes that    providers instructing staff to cold call 
are unique to telehealth, as well as  beneficiaries via telephone and bill for a 
those that expand on schemes that  telehealth visit; 
have occurred with the use of in-   upcoding telehealth visits by billing 
person services.  These schemes  for visits longer than they lasted, or 
include: providers inappropriately  providing basic services and billing for 
billing for both delivering the  more complex visits; 
telehealth service remotely and    billing for services not rendered to the 
facilitating the telehealth service at the  patient; 
enrollees location, providers billing for    billing for an impossible number of 
services that were not rendered, and  telehealth visits over a day or shorter 
providers located outside of the United  period of time; and 
States delivering services.  Further, the    using overseas providers to provide 
schemes identified by States are similar  telehealth services. 
to complaints received by the Office of   
Inspector General (OIG).  (See text box.)  OIG  has also noted an uptick of complaints 
 
related to telehealth since the beginning of 2020.    
Despite concerns about telehealth, only 11 States conduct monitoring and oversight 
to detect fraud, waste, and abuse that is specific to telehealth.  States are responsible 
for monitoring their Medicaid program and are the first line of defense against fraud, 
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waste, and abuse.11  However, several States explain that their program integrity 
efforts include little or no additional efforts that specifically target telehealth.  
According to one State, telehealth is monitored like any other service, but specific 
monitoring is currently being developed.  A few States further note the difficulty of 
overseeing and verifying that telehealth services are provided appropriately.   
The States that conduct monitoring specific to telehealth employ strategies similar to 
their other program integrity efforts.  These strategies include reviewing medical 
records, analyzing claims data, conducting outlier reports, and investigating 
complaints.   
Several States (6 of 37) also note that managed care organizations in their State 
conduct program integrity functions, such as monitoring and oversight, specific to 
telehealth.12  It is important for the State to be aware of these program integrity  
efforts and their results.  If not, the State cannot effectively understand the program 
integrity risks across managed care organizations, take appropriate actions, and 
improve their Medicaid programs.  
 
We do not see a large amount of proactive activity to monitor and 
oversee their [telehealth] programs for fraud. 
-Telehealth Resource Center 
   
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RECOMMENDATIONS 
 
 
Given the importance of telehealth in Medicaid during the pandemic, States need to 
identify the services provided via telehealth so that they can better understand the 
effects of telehealth on access, cost, and quality of behavioral health services for 
Medicaid enrollees.  It is increasingly important that States evaluate the effects of 
telehealth to inform their decisions about how they will use telehealth in the future.  
Further, States also need to monitor and provide oversight of telehealth, as expanding 
the use of telehealth may present additional risk for fraud, waste, and abuse.   
States have broad flexibility to determine how they use telehealth in their Medicaid 
programs.  In addition, CMS has taken several steps to support the implementation 
and expansion of telehealth, particularly during the COVID-19 pandemic.  It maintains 
a webpage on telehealth in Medicaid and has issued a toolkit with a supplement to 
help States respond to the COVID-19 pandemic and expand their use of telehealth in 
Medicaid.13  This toolkit includes Frequently Asked Questions, resources for States, 
and examples from States about their telehealth programs.  It also includes a 
template that outlines potential policy areas for States to consider addressing as they 
make decisions about which telehealth policies to continue on a more permanent 
basis once the pandemic subsides.  
States experiences with telehealth expansion during the COVID-19 pandemic offer a 
valuable opportunity for evaluating what worked well and what could be improved 
with using telehealth for behavioral health, while safeguarding against poor quality of 
care or inappropriate billing for these services.  To leverage this opportunity, CMS 
should continue to build on its efforts and work with States to gain a better 
understanding of the effects of telehealth on access, cost, and quality and to monitor 
and oversee telehealth for behavioral health services for Medicaid enrollees.  The 
need for additional research is further supported by the Medicaid and CHIP Payment 
and Access Commission (MACPAC), which observes that there is currently limited 
information about the effects of telehealth on outcomes, cost, and program integrity 
within the Medicaid program.14  MACPAC concludes that CMS could do more to 
facilitate research to help States, providers, and other stakeholders gain a more robust 
understanding of the effects of telehealth on access to care, quality of care, and cost 
of care for Medicaid enrollees.  
CMS and States play important roles in evaluating and overseeing Medicaid 
telehealth services.  Evaluating the effects of telehealth on access, cost, and quality of 
behavioral health services is particularly important in helping States make decisions 
about how best to use telehealth and about which populations benefit most from 
these services.  In addition, this information can help States decide which policies 
should be made permanent after the pandemic subsides, such as those regarding 
services and where enrollees can receive telehealth.   
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We recommend that CMS: 
Ensure that the three States that are unable to distinguish 
telehealth from in-person services implement indicators to 
identify which services are provided via telehealth  
The ability to identify the services that are provided via telehealth is essential to 
evaluating the effects of telehealth on access, cost, and quality.  It is also critical to 
performing basic monitoring and oversight specific to telehealth services to protect 
Medicaid enrollees and ensure the fiscal integrity of the Medicaid program.  To meet 
these needs, CMS should work with the three States that are unable to identify which 
services are provided via telehealth to ensure that they use indicators allowing them 
to distinguish services provided via telehealth from those delivered in-person.   
Conduct evaluations, and support State efforts to evaluate the 
effects of telehealth on access, cost, and quality of behavioral 
health services 
To ensure telehealth is able to meet the needs of enrollees, CMS should conduct 
evaluations of the impact of telehealth on access, cost, and quality of behavioral 
health services for Medicaid enrollees.  Building off of the Medicaid telehealth analysis 
included in CMSs COVID-19 data snapshot, CMS could conduct national evaluations 
that include specific detail on the effects of telehealth on access, cost, and quality of 
behavioral health services.15  
CMS should also work with States to encourage them to initiate evaluations of 
telehealth that assess its effects on access, cost, and quality for Medicaid enrollees.  
CMS should look for ways to support States in developing such evaluations, including 
partnering with other agencies, researchers, or other entities.  One way to do this is to 
incorporate telehealth-focused reviews related to access, cost, and quality for the 
organizations that are responsible for monitoring each States Medicaid managed 
care program.16   
In addition, CMS should share information and best practices with States about how 
to evaluate the effects of telehealth on access, cost, and quality.  CMS should also 
share information with States about the results of CMSs and States evaluations of 
telehealth so that States can learn from these efforts and use them to develop their 
telehealth programs.  States could benefit from State-to-State learning, data 
collection, and analyses.17 
 
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Conduct monitoring for fraud, waste, and abuse, and support 
State efforts to oversee telehealth for behavioral health services 
Expanding the use of telehealth may present additional risk for fraud, waste, and 
abuse.  States report uncovering schemes specific to telehealth, such as providers 
inappropriately billing for both delivering the telehealth service remotely and 
facilitating the telehealth service at the enrollees location.  Additionally, these 
schemes are similar to complaints received by OIG.  CMS should take into account 
these schemes and build on its own efforts to conduct monitoring and oversight 
specific to telehealth for behavioral health services to identify potential fraud, waste, 
and abuse in Medicaid.  CMS should focus analyses on identifying providers that are 
using telehealth in a suspicious manner, as well as identifying specific behavioral 
health services that may be particularly subject to fraudulent or wasteful billing.  For 
example, CMS should apply additional scrutiny to providers that are outliers in terms 
of billing for telehealth services compared with other providers.  CMSs role in 
conducting monitoring and oversight specific to telehealth is particularly important as 
CMS is able to take a national view and identify schemes that may be common across 
State Medicaid programs.  
Additionally, CMS should work with States to expand their efforts to oversee and 
monitor telehealth for behavioral health services specifically.  This should include 
supporting States efforts to work with their program integrity units and Offices of 
Medicaid Inspectors General, as appropriate.  CMS should share information and 
provide assistance to States, including providing information to States on program 
integrity concerns specific to telehealth services, as well as sharing best practices of 
States with robust oversight of telehealth.  In addition, this should include supporting 
States efforts to communicate and coordinate with managed care organizations to 
conduct oversight of telehealth services and ensure that these organizations have 
processes in place to identify fraud, waste, and abuse specific to telehealth.18 
 
 
 
  
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AGENCY COMMENTS AND OIG RESPONSE 
 
 
CMS concurred with one recommendation but did not indicate whether it concurred 
with the other two recommendations.   
CMS concurred with our recommendation to ensure that the three States that are 
unable to distinguish telehealth from in-person services implement indicators to 
identify which services are provided via telehealth.  CMS stated that it will reach out to 
the three States to ensure that they are informed about the ways to distinguish 
telehealth services from in-person services in the claims and encounter systems.  OIG 
appreciates these efforts and looks forward to additional detail in CMSs Final 
Management Decision. 
CMS did not explicitly indicate whether it concurred with our recommendation to 
conduct evaluations and support State efforts to evaluate the effects of telehealth on 
access, cost, and quality of behavioral health services.  CMS noted that it provided the 
States with a toolkit and supplement and has provided technical assistance.  It further 
stated that it will consider the results from this study to determine how it can further 
support State and managed care organization efforts to evaluate the effects of 
telehealth.  We ask that CMSin its Final Management Decisionprovide details on 
any plans and progress toward implementing our recommendation.19  
CMS also did not explicitly indicate whether it concurred with our recommendation to 
conduct monitoring for fraud, waste, and abuse, and support State efforts to oversee 
telehealth for behavioral health services.  CMS noted that it is currently monitoring 
the impact of the COVID-19 pandemic on behavioral health services delivered via 
telehealth by managed care organizations and has provided States with a Risk 
Assessment Template to assist State efforts in identifying and addressing program 
risks.  CMS stated it will consider the results from OIGs study to develop ways to 
support State efforts to oversee behavioral health services delivered via telehealth by 
managed care organizations.  We ask that CMSin its Final Management Decision
provide details on any plans and progress toward implementing our 
recommendation.   
In its response, CMS noted that there is more work to be done to determine how to 
effectively conduct monitoring for fraud, waste, and abuse, and support State efforts 
to oversee behavioral health services delivered via telehealth by managed care 
organizations.  OIG agrees, and we stress to CMS the importance of its role and the 
need to be active in evaluating and overseeing the use of telehealth.  OIGs findings 
show that, prior to the pandemic, there were opportunities for States to do more to 
evaluate and oversee the use of telehealth for behavioral health services.  Given the 
growth of, and increased dependence on, telehealth during the pandemic, these 
opportunities have become even more critical to address, warranting additional steps 
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by CMS to support and supplement State efforts to evaluate and oversee telehealth.  
Building on its current efforts in these ways will help CMS to ensure that telehealth 
meets the behavioral health needs of Medicaid enrollees while protecting the 
integrity of the Medicaid program.   
For the full text of CMSs comments, see Appendix A.   
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METHODOLOGY 
 
Survey of State Medicaid Directors 
We based this data brief on a survey of State Medicaid Directors and a review of 
relevant documentation to support their responses.  This is the same survey that is the 
basis of the companion data brief. 
We conducted the survey with State Medicaid Directors from 37 States that provide 
behavioral health services through managed care organizations and use telehealth to 
provide these services.  We identified these States by surveying State Medicaid 
Directors in all 50 States, Puerto Rico, and the District of Columbia.20  We 
administered the survey electronically in January and February 2020.   
Our survey focused on the use of telehealth to provide behavioral health services for 
Medicaid enrollees.  As part of this survey, we asked about whether States are able to 
distinguish between services provided via telehealth and in-person, and what 
methods they use (e.g., a modifier or a place of service code on the claim, or 
telehealth-specific procedure codes).  We also asked about States efforts to evaluate 
the effects of telehealth on access, cost, and quality of services provided to Medicaid 
enrollees.  While we asked about efforts specific to managed care, the respondents 
focused on States efforts to evaluate and oversee the use of telehealth more 
generally. 
Finally, we asked about States activities to monitor and oversee telehealth for 
behavioral health services.  This included information about State analyses and any 
audits or other activities that the State conducts.  In addition, we asked States to 
describe any specific fraud or abuse schemes related to telehealth that they have 
identified.   
Structured Interviews With Stakeholders 
We conducted structured interviews with key stakeholders from a variety of 
organizations.  These include representatives from national and regional Telehealth 
Resource Centers, health care coordination organizations, the Health Resources and 
Services Administration, HHSs Office of the Assistant Secretary for Planning and 
Evaluation, a State health department, a Medicaid managed care organization, and a 
Medicaid provider.  As part of these interviews, we asked about the effects of 
telehealth on access, cost, and quality for behavioral health services.  We also asked 
about any concerns, as well as successful strategies, for using telehealth to improve 
access, cost, and quality of behavioral health services for Medicaid enrollees.  Finally, 
we asked stakeholders about monitoring and oversight of telehealth and any fraud 
Data Brief: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid 
OEI-02-19-00401  Methodology | 15  and abuse schemes related to telehealth.  We conducted these interviews throughout 
the course of the study. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
Data Brief: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid 
OEI-02-19-00401  Methodology | 16  APPENDIX A: Agency Comments
DATE:  August 24, 2021 
TO:  Christi A. Grimm 
Principal Deputy Inspector General 
Office of Inspector General 
FROM:  Chiquita Brooks-LaSure 
Administrator 
Centers for Medicare & Medicaid Services 
SUBJECT:  Office of Inspector General (OIG) Draft Data Brief: Opportunities Exist to 
Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in 
Medicaid (OEI-02-19-00401) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report.  
CMS appreciates OIGs effort in surveying State Medicaid Directors and various stakeholders to 
determine how states are overseeing behavioral health services delivered via telehealth for 
Medicaid beneficiaries. However, as these surveys were conducted in January and February of 
2020, before the widespread expansion of the use of telehealth in response to the COVID-19 
Public Health Emergency (PHE), this information may not reflect states current efforts in 
monitoring and evaluating telehealth for behavioral health services; specifically, such services 
provided through managed care organizations (MCOs), which provided the basis of the OIGs 
findings and recommendations.  
The telehealth landscape has vastly changed and is continuing to rapidly evolve during the PHE. As 
such, in response to the PHE, CMS has taken a number of actions to support states in their efforts to 
continue providing care to Medicaid beneficiaries during this tumultuous time, including in those 
states that use MCOs to administer Medicaid and Childrens Health Insurance Program (CHIP) 
benefits. For example, in 2020, CMS created a dedicated website for Medicaid-related COVID-19 
information, which includes links to relevant information regarding COVID-19.1 As OIG noted, in 
April 2020, CMS released the Telehealth Toolkit that provides states with statutory and regulatory 
infrastructure information to consider as they evaluate the need to expand their telehealth 
capabilities and coverage policies, with a section dedicated to telehealth coverage for pediatric 
behavioral health services.2 The Toolkit describes and discusses challenges regarding topics such as 
patient populations eligible for telehealth, coverage and reimbursement policies, providers and 
practitioners eligible to provide telehealth, technology requirements, and pediatric considerations. 
Furthermore, in October 2020, CMS released the Telehealth Toolkit Supplement in order to provide 
additional support to states in their adoption and implementation of telehealth as they begin to plan 
beyond PHE flexibilities by discussing topics such as communication strategies, telehealth 
1 COVID-19 Medicaid and CHIP Resources, https://www.medicaid.gov/resources-for-states/disaster-response-
toolkit/coronavirus-disease-2019-covid-19/index.html 
2 Telehealth Toolkit, https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit.pdf 
Data Brief: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid 
Agency Comments | 17
OEI-02-19-00401 APPENDIX A: Agency Comments
operations and implementation tools, and shared experiences and examples from states and 
territories across the nation.3  
CMS continues to discuss telehealth with states on regularly scheduled all-state calls, and will 
continue to provide one-on-one technical assistance support to states, often through review of the 
states submitted State Plan Amendments and discussion of specific state questions on telehealth 
requirements. CMS also provides technical assistance to states on an ongoing basis on all Medicaid 
topics including telehealth, and has assigned a State Lead for each state to serve as the central point 
of contact for any assistance states would need. 
In an effort to address vulnerabilities that may arise from the new waivers and flexibilities 
granted during this time period, while also protecting Medicaid beneficiaries, CMS has built a 
suite of analyses to detect and address vulnerabilities in the rapidly-changing telehealth 
landscape. As part of this effort, CMS Vulnerability Collaboration Council used the 
Government Accountability Offices Fraud Risk Framework to evaluate the various telehealth 
waivers and flexibilities issued to states during the PHE to assess associated program integrity 
risks (including likelihood, financial impacts, and beneficiary impacts) and determine 
appropriate mitigation activities. Using the results of these risk assessments, CMS also 
developed a Risk Assessment Template to support state Medicaid agencies efforts to identify 
and address program risks associated with COVID-19 PHE waivers, flexibilities, and other 
requirements.4 Specifically, the Risk Assessment Template is a flexible document designed to 
serve as a starting point for states to implement a risk assessment process by providing a 
suggested step-by-step approach for identifying, assessing, prioritizing, and addressing program 
integrity risks that can be tailored as needed to fit each states unique Medicaid program. The 
Risk Assessment Template is not limited just to COVID-19 PHE waivers, flexibilities, and other 
requirements, but can also be used to conduct a risk assessment on any aspect of a states 
Medicaid program, including the continued expansion of telehealth services after the PHE, 
should the state choose to make certain flexibilities permanent. 
While CMS maintains close communication with states regarding the administration of their 
Medicaid programs, states are responsible for overseeing MCOs in a managed care delivery system. 
As noted above, all 37 states surveyed by the OIG use MCOs to provide behavioral health services 
via telehealth. Because these services are provided by MCOs and not directly by the state, the 
MCOs bear the first-line responsibility for maintaining oversight of their services and providers. 
States primary oversight responsibilities are to ensure effective oversight of the MCOs, who are in 
turn conducting such oversight of the services and providers described in the OIGs report. Given 
that the OIGs surveys are based solely on states perspectives, it remains unclear to what extent 
MCOs are conducting oversight of behavioral health services delivered via telehealth. Including the 
critical MCO perspective in the OIGs report would have provided a more complete and effective 
analysis of oversight efforts of behavioral health services delivered via telehealth in these 37 states.  
Given that many states provide behavioral health telehealth services through MCOs, states have 
broad flexibility to conduct oversight of such services. However, as detailed above, CMS meets 
regularly with, and has provided a significant amount of guidance and assistance to states about 
telehealth in general and in the managed care setting specifically, and CMS will continue to work 
with states as issues arise and as the PHE continues to evolve. 
3 Telehealth Toolkit Supplement, https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-
toolkit-supplement1.pdf 
4 COVID-19 Risk Assessment Template. https://www.medicaid.gov/state-resource-center/downloads/risk-
assessment-template.docx 
Data Brief: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid 
Agency Comments | 18
OEI-02-19-00401 APPENDIX A: Agency Comments
OIGs recommendations and CMS's responses are below. 
OIG Recommendation 
Ensure that the three States that are unable to distinguish telehealth from in-person services 
implement indicators to identify which services are provided via telehealth. 
CMS Response 
CMS concurs with this recommendation. CMS will reach out to the three states identified by the 
OIG to ensure that they are informed about the ways to distinguish telehealth services from in-
person services in the claims and encounter systems, if the state has not already done so during the 
intervening 18 months since the interviews were conducted. 
OIG Recommendation 
Conduct evaluations, and support State efforts to evaluate the effects of telehealth on access, 
cost, and quality of behavioral health services. 
CMS Response 
CMS has supported state telehealth efforts by providing states with a toolkit, including a 
supplement, of resources regarding implementing and delivering Medicaid services via telehealth. 
CMS will continue to provide technical assistance to states on an ongoing basis on all Medicaid 
topics, including behavioral health services delivered via telehealth by MCOs. The telehealth 
landscape is continuing to evolve in the ongoing PHE, and states oversight efforts have changed 
drastically since the OIG conducted their state surveys in January and February of 2020. However, 
CMS will consider the results from the OIGs surveys to determine how CMS can further support 
state and MCO efforts to evaluate the effects of telehealth on access, cost, and quality of behavioral 
health services. 
OIG Recommendation 
Conduct monitoring for fraud, waste, and abuse, and support State efforts to oversee telehealth 
for behavioral health services. 
CMS Response 
CMS is currently monitoring the impact of the COVID-19 PHE on behavioral health services 
delivered via telehealth by MCOs and has provided states with a Risk Assessment Template to 
assist state efforts in identifying and addressing program risks associated with PHE waivers, 
flexibilities, and other requirements. CMS appreciates the OIGs work in this pre-PHE area, but 
believes there is more work to be done to conclusively determine how to effectively conduct 
monitoring for fraud, waste, and abuse, and support state efforts to oversee behavioral health 
services delivered via telehealth by MCOs. The telehealth landscape is continuing to evolve in the 
ongoing PHE, and states oversight efforts have changed drastically since the OIG conducted their 
state surveys in January and February of 2020. However, CMS will consider the results from the 
OIGs surveys to determine their relevance in the current telehealth landscape and develop ways to 
support state efforts to oversee behavioral health services delivered via telehealth by MCOs.  
Data Brief: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid  
Agency Comments | 19
OEI-02-19-00401  
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Vincent Greiber served as the team leader for this study.  Others in the Office of 
Evaluation and Inspections who conducted the study include John Gordon.  Office of 
Evaluation and Inspections headquarters staff who provided support include 
Kevin Farber, Kevin Manley, and Christine Moritz. 
This report was prepared under the direction of Jodi Nudelman, Regional Inspector 
General for Evaluation and Inspections in the New York regional office, and 
Nancy Harrison and Meridith Seife, Deputy Regional Inspectors General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Data Brief: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid 
OEI-02-19-00401  Acknowledgments and Contact | 20   
ENDNOTES 
 
 
 
 
1 See OIG, States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees (OEI-02-19-00400). 
2 See MACPAC, Report to Congress on Medicaid and CHIP, Chapter 4: Behavioral Health in the Medicaid ProgramPeople, 
Use, and Expenditures, June 2015.  Accessed at https://www.macpac.gov/wp-content/uploads/2015/06/Behavioral-Health-in-
the-Medicaid-Program%E2%80%94People-Use-and-Expenditures.pdf on December 11, 2020. 
3 This represents individuals enrolled in any Medicaid managed care program, including comprehensive managed care, limited 
benefit managed care, and Primary Care Case Management.  See Centers for Medicare and Medicaid Services (CMS), Medicaid 
Managed Care Enrollment and Program Characteristics, 2018.  Accessed at https://www.medicaid.gov/medicaid/managed-
care/downloads/2018-medicaid-managed-care-enrollment-report.pdf on December 11, 2020. 
4 In this report, we refer to medical services delivered via telehealth as telehealth services. 
5 See Center for Connected Health Policy (CCHP), COVID-19 Related State Actions.  Accessed at https://www.cchpca.org/covid-
19-related-state-actions on March 18, 2021. 
6 Managed care organizations include organizations that administer prepaid inpatient health plans, prepaid ambulatory health 
plans, comprehensive managed care plans, limited benefit managed care, and Primary Care Case Management. 
7 As described in the methodology, among the stakeholders we interviewed were representatives from health care coordination 
organizations.  These organizations assist providers with activities such as deploying telehealth programs and transitioning to 
alternative payment models.  We also interviewed representatives from Telehealth Resource Centers, which assist providers 
and States with developing and implementing telehealth programs.  Telehealth Resource Centers are funded by the HRSA and 
are a part of the National Consortium of Telehealth Resource Centers.  Accessed at https://www.telehealthresourcecenter.org/ 
on December 11, 2020.  
8 This analysis is based on 37 States that responded to our survey indicating that they provided behavioral health services 
through managed care organizations and used telehealth to provide these services prior to the COVID-19 pandemic.  The 
number of States that provide these services via telehealth may have increased during the COVID-19 pandemic.   
9 For more information about concerns with the use of modifiers, see MACPAC, Report to Congress on Medicaid and CHIP, 
Chapter 2: Telehealth in Medicaid, March 2018.  Accessed at  https://www.macpac.gov/publication/march-2018-report-to-
congress-on-medicaid-and-chip/ on November 30, 2020.  
10 Federal regulations require States to have a written strategy for assessing and improving the quality of health care services 
offered by all managed care organizations, including required standards for access to care (see 42 CFR  438.202(a) and 42 CFR 
 438.206(b)(1)).  Further, CMS requires States to demonstrate that payment amounts are reasonable, appropriate, and 
attainable.  Finally, States are responsible for ensuring that payments for Medicaid services are directly linked to quality 
improvement.  See CMS, RE: Additional Guidance on State Directed Payments in Medicaid Managed Care, January 8, 2021.  
Accessed at https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd21001.pdf on March 18, 2021. 
11 See CMS, Comprehensive Medicaid Integrity Plan for Fiscal Years 2019  2023.  Accessed at 
https://www.cms.gov/files/document/comprehensive-medicaid-integrity-plan-fys-2019-2023.pdf  on January 27, 2021. 
12 In addition to State responsibilities, managed care organizations also have responsibilities to conduct oversight and 
monitoring.  Through its contract with a managed care organization, the State must require that the managed care 
organization implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and 
abuse.  See 42 CFR  438.608. 
 
Data Brief: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid 
OEI-02-19-00401  Endnotes | 21   
 
13 See CMS, State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth, COVID-19 
Version.  Accessed at https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html on October 21, 2020.  CMS also 
issued a supplement titled State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of 
Telehealth, COVID-19 Version: Supplement #1.  Accessed at 
https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html on November 17, 2020.  The CMS Medicaid telehealth 
webpage can be accessed at https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html.  
14 See MACPAC, Report to Congress on Medicaid and CHIP, Chapter 2: Telehealth in Medicaid, March 2018.  Accessed at  
https://www.macpac.gov/publication/march-2018-report-to-congress-on-medicaid-and-chip/ on November 30, 2020. 
15 See CMS, Medicaid and CHIP COVID-19 Summaries, Preliminary Medicaid & CHIP Data Snapshot.  Accessed at 
https://www.medicaid.gov/state-resource-center/downloads/covid19-data-snapshot.pdf on June 23, 2021.  
16 These organizations are known as External Quality Review Organizations, or EQROs.  EQROs must conduct four mandatory 
activities each year.  There are also six optional activities, including focus studies on quality of care.  The State has discretion to 
determine which optional activities, if any, to conduct.  For more information about these organizations see: 
https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care/quality-of-care-external-quality-
review/index.html.   
17 See MACPAC, Report to Congress on Medicaid and CHIP, Chapter 2: Telehealth in Medicaid, March 2018.  Accessed at  
https://www.macpac.gov/publication/march-2018-report-to-congress-on-medicaid-and-chip/ on November 30, 2020. 
18 In a prior report, OIG recommended that CMS provide assistance to States to help facilitate improvement of communication 
and coordination between managed care organizations and State-level program integrity entities.  These entities include 
Medicaid Program Integrity Units, State Offices of Inspectors General, State auditors, and others.  See OIG, Weaknesses Exist in 
Medicaid Managed Care Organizations Efforts To Identify and Address Fraud and Abuse (OEI-02-15-00260), July 2018, 
available at https://oig.hhs.gov/oei/reports/oei-02-15-00260.pdf. 
19 The Final Management Decision is provided by CMS within 6 months of the release of the data brief and details what actions 
CMS plans to take to address each recommendation, including the timeline for taking these actions.   
 
20 Of these, 11 State Medicaid Directors reported that managed care organizations in their respective States did not use 
telehealth to provide behavioral health services to enrollees and 4 State Medicaid Directors did not respond to the survey.  A 
total of 36 States and the District of Columbia responded to our survey; for the purposes of this report, we refer to these 37 
entities as States. 
Data Brief: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid 
OEI-02-19-00401  Endnotes | 22