U.S. Department of Health and Human Services 
Office of Inspector General 
Data Brief 
September 2021, OEI-02-19-00400 
 
States Reported Multiple Challenges With Using Telehealth To 
Provide Behavioral Health Services to Medicaid Enrollees 
Why OIG Did This Review 
Key Takeaways 
States are increasingly relying on telehealth to provide behavioral 
o  States reported multiple  health services to Medicaid enrollees.  Before the COVID-19 pandemic, 
challenges with using  telehealth was an important tool for States to increase access to 
telehealth to provide  behavioral health services for enrollees in rural or underserved areas 
behavioral health services  with provider shortages.  During the COVID-19 pandemic, States 
to Medicaid enrollees,  expanded their use of telehealth to help meet the needs of enrollees 
including:  
while also reducing the risks from community spread of the virus.  As 
  provider and enrollee  the Nation confronts the psychological and emotional impact of 
training,  COVID-19, the use of telehealth will be important in addressing 
behavioral health needs for Medicaid enrollees.   
  internet connectivity,   
 
  privacy of personal 
This data brief provides insight into States challenges as reported in 
information, and 
January and February 2020, before the expansion of telehealth due to 
  technology costs.    the COVID-19 pandemic.  It provides a useful foundation for the 
 
Centers for Medicare & Medicaid Services (CMS) and States by 
o  Sharing information that  highlighting longstanding challenges with the use of telehealth that 
addresses these challenges 
existed prior to the additional challenges caused by the pandemic.  
can help States meet the 
Understanding States challenges with using telehealth to provide 
behavioral health needs of 
behavioral health services can help States improve their Medicaid 
Medicaid enrollees. 
program and assist enrollees with accessing needed care.  Further, 
States expansion of telehealth during the COVID-19 pandemic has been largely on a temporary basis.  
As States consider making telehealth expansions permanent, they can use information in this data brief 
to develop effective programs and troubleshoot challenges in implementation.  This data brief is a 
companion report to a data brief that describes the extent to which States evaluate the effects of 
telehealth on access, cost, and quality of behavioral health services and the extent to which States 
oversee telehealth for fraud, waste, and abuse.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 challenges specific to managed 
care, the respondents focused on States challenges with using telehealth more generally.  
 
  What OIG Found  
Most States reported multiple challenges with using telehealth, including a lack of training for providers 
and enrollees, limited internet connectivity for providers and enrollees, difficulties with providers 
protecting the privacy and security of enrollees personal information, and the cost of telehealth 
infrastructure and interoperability issues for providers.  Some States also reported other challenges, 
including a lack of licensing reciprocity and difficulties with providers obtaining informed consent from 
enrollees.  These challenges limit States ability to use telehealth to meet the behavioral health needs of 
Medicaid enrollees.   
What OIG Recommends  
CMS plays an important role in facilitating the exchange of information among States to improve the 
use of telehealth for behavioral health services.  Sharing information among States will help ensure that 
States realize the benefits of telehealth and make informed decisions about how to address challenges 
with using telehealth.  We recommend that CMS share information to help States address the 
challenges they face with using telehealth.  This information could include examples from States that 
describe how they have responded to these challenges.  It could also include best practices from States 
as well as information about working with other State and Federal partners.  Further, CMS could collect 
information from States detailing their experiences and lessons learned in response to the COVID-19 
pandemic that address these challenges.  CMS concurred with our one recommendation. 
   
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
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees 
OEI-02-19-00400  Primer | 3  RESULTS 
 
This data brief provides insight into States challenges with using telehealth to provide 
behavioral health services to Medicaid enrollees as reported in 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 challenges reported by States that affect providers and 
enrollees in the Medicaid program.  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 
challenges specific to managed care, the respondents focused on States challenges 
with using telehealth more generally.  
Gaining an understanding of the challenges with using telehealth to provide 
behavioral health services can help States meet the needs of enrollees.  Further, 
insights into the challenges that were present prior to the COVID-19 pandemic 
provide an important foundation for understanding longstanding issues that may 
have been exacerbated by the pandemic.  As States consider how they will use 
telehealth once the pandemic subsides, CMS can play an important role in helping 
States to learn from other States experiences and to make informed decisions about 
how to address these challenges. 
Most States reported multiple challenges with using telehealth, 
including training, internet connectivity, privacy of personal 
information, and technology costs 
Most States (34 of 37) report multiple challenges with using telehealth to provide 
behavioral health to Medicaid enrollees.8  In fact, many States (27 of 37) report five or 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees 
OEI-02-19-00400  Results | 4  more challenges that affect providers and enrollees in the Medicaid program.  States 
most commonly cite: a lack of training for providers and enrollees, limited internet 
connectivity for providers and enrollees, difficulties with providers protecting the 
privacy and security of enrollees personal information, and the cost of telehealth 
infrastructure and interoperability issues for providers.  
Information about the challenges States face with using telehealth is crucial, especially 
as States turn to telehealth to provide behavioral health services during the COVID-19 
pandemic.  It is also helpful for States as they consider which services to deliver via 
telehealth on a more permanent basis once the pandemic has subsided, as well as 
which populations could most benefit from telehealth services in the future.  
Exhibit: Number of States Reporting Challenges With Using Telehealth To Provide 
Behavioral Health Services.   
Lack of training for providers and 
32
enrollees
Limited internet connectivity 31
Protecting privacy and security of 
27
personal information
High cost of telehealth infrastructure and 
26
interoperability issues
 
Source: OIG analysis of survey data, 2020. 
 
Lack of provider and enrollee training.  Most States (32 of 37) find 
that a lack of provider or enrollee training about telehealth is a 
challenge.  Educating providers and enrollees is important, as it can 
help with successfully managing telehealth programs while also 
addressing enrollees resistance to receiving services remotely. 
Many States report a lack of provider training, which can hinder the ability of 
providers to use telehealth as a regular part 
of their clinical practice.  One State notes  States that take the time to educate 
that providers generally have a limited  their providers have been more 
understanding about how to use telehealth  successful. 
technology.  In addition, stakeholders  - Telehealth Resource Center 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees 
OEI-02-19-00400  Results | 5  explain that a lack of education about which services are covered and confusion 
among providers about billing for telehealth services are problems.  One stakeholder 
notes that States face challenges with getting providers to correctly use modifiers that 
indicate the service was delivered via telehealth when submitting their claims. 
Similarly, States report a lack of training for enrollees, which can inhibit enrollees from 
receiving services remotely.  As one State notes, enrollees who are unfamiliar with 
technology need to be educated to increase uptake of telehealth for behavioral health 
services.  In addition, one stakeholder 
explains that managed care plans often 
[Education] is a neglected area that 
rely on providers to train enrollees on 
could be used to make [enrollees] 
how to use the technology, which is 
more comfortable using telehealth. 
something providers do not prioritize 
-  Telehealth Resource Center 
over many other responsibilities. 
   
To help address a lack of training for providers and enrollees, a few States report 
issuing guidance to managed care plans about educating providers and enrollees.  To 
educate providers on the use of telehealth, these States issue informational letters, 
bulletins, and newsletters highlighting best practices.  States also discuss 
collaborating with other stakeholders, including the Department of Health and 
Human Services (HHSs) Health Resources and Services Administration (HRSA), 
regional Telehealth Resource Centers, and public universities, to provide educational 
webinars on telehealth.   
Limited internet connectivity.  Most States (31 of 37) report that 
internet connectivity is a challenge with using telehealth to provide 
behavioral health services for both providers and enrollees.  For 
telehealth, internet 
Many areas have problems with 
connectivity is defined 
broadband coverage.  [Theres] no cell 
as high-speed internet 
servicecannot access the internet.  
access with sufficient bandwidth to 
remotely access services whether the  Some people are still using dial-up for 
enrollee is at home, at a providers office,  DSL or landlines. 
at a clinic, or at another facility.  This is  - Health Care Coordination Organization 
also referred to as broadband access.9      
Several States explain that a lack of internet access in rural areas is a challenge with 
using telehealth.  As one stakeholder notes, some clinics do not have broadband 
access at all, and many enrollees do not have sufficient bandwidth in their homes, 
which further impedes their ability to access care using telehealth.  
Although a lack of internet connectivity has not traditionally been considered a health 
care issue, the relationship between internet connectivity and health outcomes has 
recently been recognized as a health care issue, also known as a social determinant of 
health.10  Further, increased reliance on telehealth by enrollees emphasizes the 
importance of considering internet connectivity a health care issue.  As one 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees 
OEI-02-19-00400  Results | 6  stakeholder notes, broadband access has recently been included as a social 
determinant of health in their State. 
Protecting privacy and security of personal information.  Many 
States (27 of 37) note challenges with providers protecting the 
privacy and security of enrollees personal information when using 
telehealth.  To maintain privacy and security of personal information, 
providers must use software and devices that include controls on the 
collection, use, and disclosure of sensitive personal information.   
States note challenges with providers protecting enrollee health information.  These 
challenges may stem from the types of technology and methods of transmission used 
by providers and enrollees.  For example, certain methods of telehealth, such as store-
and-forward or text-only, can be transmitted via unencrypted devices or as 
unencrypted messages and thus could potentially be accessed by third parties.11  In 
addition, one State points out that protecting patient confidentiality is a particular 
concern for behavioral health services, especially when it comes to sharing sensitive 
health information, such as substance use.   
High cost of telehealth infrastructure and interoperability issues.  
Many States (26 of 37) cite the high cost of telehealth infrastructure 
or interoperability issues as a challenge for providers.  Telehealth 
infrastructure, including electronic equipment and software, can 
often be costly for providers.  As one State notes, providers may lack 
capital funds to develop the infrastructure and implement successful programs.  A few 
stakeholders further explain that the initial investment is often high, and connectivity 
costs for rural providers can be expensive.  As one stakeholder notes, part of the high 
cost of telehealth infrastructure is the initial cost of equipment.  Further, there are 
additional costs associated with the maintenance and repair of telehealth 
equipment.12 
A few States also report challenges with interoperability.  Providers are better able to 
communicate and coordinate enrollee care when the telehealth equipment and 
systems that providers and enrollees use are interoperable with enrollees electronic 
health records.13  According to one State, providers experience difficulties in 
navigating different telehealth systems due to incompatibility between the systems 
used by the provider and enrollee.  Similarly, another State reports problems with 
interoperability between telehealth systems and the electronic health record systems 
that providers use.  This State notes that health systems and provider offices would 
benefit from using health IT applications that allow for the creation of a health record 
generated from the telehealth visit that is accessible to the enrollees other providers. 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees 
OEI-02-19-00400  Results | 7  Some States reported other challenges, including a lack of 
licensing reciprocity and difficulties with obtaining informed 
consent 
In addition to the above challenges with using telehealth to provide behavioral health 
services to Medicaid enrollees, some States note other challenges, including a lack of 
licensing reciprocity between States and difficulty with providers obtaining informed 
consent from enrollees.  These challenges further inhibit States ability to use 
telehealth to meet the behavioral health needs of their enrollees.   
Lack of licensing reciprocity.  Some States (17 of 37) cite a lack of 
licensing reciprocity between States as a challenge with using 
telehealth for behavioral health services.  Telehealth increases 
opportunities for States to leverage providers from other States to 
offer services to enrollees.  Yet, many States require providers to be 
licensed in the same State where the enrollee is located.14  During 
the COVID-19 pandemic, however, most States have allowed out-of-State providers 
to deliver telehealth services to enrollees in their State on a temporary basis.15 
Licensing requirements can be burdensome for providers, as they often must pay a 
fee for each State license, in addition to the time spent and the administrative effort 
to acquire separate licenses and periodically renew them.16  States can potentially 
ease these burdens through licensing reciprocity, which allows practitioners who are 
licensed in one State to practice in another State without obtaining another license.  
Another option States use to 
allow providers to offer  Licensure compacts are 
services to enrollees in other  designed to ease the 
States is a licensure 
administrative burden of 
 
compact.  Several States 
obtaining multiple licenses. 
report that they are a 
member of at least one 
licensure compact.17  Such compacts allow licensed providers in member States to 
provide services in other member States without acquiring a separate license for each 
State.  The Nurse Licensure Compact, for example, allows State nursing boards to 
recognize individuals licensed as nurses from other participating States.18   
Another strategy States use is an arrangement among States that allows providers to 
go through an expedited licensure process.19  Some States report that they are a part 
of at least one expedited licensure arrangement.  Expedited licensing involves a 
streamlined application process that allows providers to acquire licenses in multiple 
States.  Although an expedited licensure process is not the same as licensing 
reciprocity, it can potentially help with making the licensing of out-of-State providers 
easier and less burdensome.    
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees 
OEI-02-19-00400  Results | 8  However, concerns exist about allowing licensing compacts, expedited licensing, and 
other arrangements.  As one stakeholder notes, participation in licensure compacts 
can be contentious, as certain States may be hesitant to cede control of their role in 
licensing practitioners.  This reluctance may be because States do not want to forgo 
the revenue they receive from licensure fees or do not want to increase competition 
for health care services in their State.20 
Difficulties with obtaining informed consent.  A few stakeholders 
and one State report that difficulties with obtaining informed 
consent are particularly challenging when delivering services via 
telehealth.  Informed consent ensures that enrollees know about 
the services they may receive so that they are able to make an 
informed decision about whether they would like to authorize the 
provider to deliver these services.  Many States require providers to obtain consent 
from enrollees prior to the delivery of medical services.  In addition, some States 
require providers to obtain specific consent for telehealth services.21  For example, 
consent for telehealth can include providers informing enrollees about what 
telehealth is, what to expect as a part of the telehealth visit, and what security 
measures are taken to ensure privacy. 
These difficulties may be exacerbated by varying policies for obtaining informed 
consent across States and the fact that States may not always clearly communicate 
these policies to their providers.  For 
example, some States allow providers to  One of the biggest challenges is that 
obtain verbal consent from enrollees  no one is telling providers how to get 
whereas others require written consent  consent...so providers then just make up 
prior to a telehealth visit.22  When written 
their own policies. 
consent is required, providers must either 
- Telehealth Resource Center 
have the enrollee mail in a signed form 
prior to the telehealth visit, have the enrollee email a signed form, or have the 
enrollee sign a virtual consent form through an online patient portal.  This can 
potentially cause delays in care and be a barrier to enrollees receiving behavioral 
health services via telehealth.  This patchwork of requirements across States and the 
difficulties with providers obtaining informed consent may impede the uptake of 
telehealth more broadly and contribute to improper billing as it makes provider 
compliance more difficult.
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees 
OEI-02-19-00400  Results | 9   
RECOMMENDATIONS 
 
 
States reported multiple challenges with using telehealth to provide behavioral health 
services to Medicaid enrollees.  They most commonly cite: a lack of training for 
providers and enrollees, limited internet connectivity for providers and enrollees, 
difficulties with providers protecting the privacy and security of enrollees personal 
information, and the cost of telehealth infrastructure and interoperability issues for 
providers.  States also reported other challenges, including a lack of licensing 
reciprocity and difficulties with providers obtaining informed consent from enrollees.    
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.23  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.  
With the expanded use of telehealth during the pandemic and potential changes to 
telehealth being considered by States, CMS has an opportunity to build on its prior 
initiatives and work with States to address the specific challenges with using 
telehealth to provide behavioral health services to Medicaid enrollees.  CMS plays an 
important role in facilitating the exchange of information about approaches to 
addressing these challenges among States.  Sharing this information among States 
will help ensure that States realize the potential benefits of telehealth and make 
informed decisions about how to address these challenges. 
We recommend that CMS: 
Share information to help States address challenges with 
using telehealth to provide behavioral health services to 
Medicaid enrollees 
CMS should share information to help States address the challenges they face with 
using telehealth.  This information could include examples from States that describe 
how they have responded to these challenges.  It could also include best practices 
from States as well as information about working with other State and Federal 
partners.  Further, CMS could collect information from States detailing their 
experiences and lessons learned in response to the COVID-19 pandemic that address 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees  
OEI-02-19-00400  Recommendations | 10  these challenges.  This information could address the following challenges, as well as 
any additional challenges that may have emerged during the pandemic and that CMS 
has identified in its ongoing work with States: 
  Lack of provider and enrollee training.  To successfully implement telehealth, 
it is important for providers to be trained to use telehealth and understand their 
role in addressing potential barriers to enrollees receiving services remotely.  CMS 
could share examples with States about ways to: engage providers, offer training 
that is accessible, work with managed care organizations to educate providers, 
and keep providers up-to-date on an ongoing basis.  Building off of the examples 
of provider training in the supplement to the Medicaid Telehealth Toolkit, these 
examples could include actions States have taken to educate providers in their 
State about the use of telehealth, as well as billing for services provided via 
telehealth.  CMS could also identify opportunities to work with other Federal and 
State partners and share this information with States.  For example, HRSA 
supports Telehealth Resource Centers, which provide educational materials to 
providers and administrators.  Additionally, the Assistant Secretary for 
Preparedness and Responses TRACIE program provides resources to train 
providers on the use of telehealth.24   
Similarly, a lack of training for enrollees can inhibit enrollees from receiving 
services remotely.  CMS could share examples with States about training enrollees 
on the use of telehealth.  These examples could include a checklist of topics to 
educate enrollees about, such as what services they can receive via telehealth, 
what technology they need to use telehealth, and how to use the technology 
necessary for a telehealth visit.  Similar to the examples of provider training in the 
supplement to the Medicaid Telehealth Toolkit, these examples could highlight 
strategies that States have used to educate enrollees in their State. 
  Limited internet connectivity.  High-speed, reliable internet connectivity is 
needed for health care providers and enrollees to benefit from telehealth.  CMS 
could share information with States about additional funding opportunities for 
internet connectivity and broadband-related projects, including options under the 
American Rescue Plan and other Federal programs that can fund projects in the 
areas of planning, public access, and deployment.25  To disseminate information 
about funding and improving internet connectivity, CMS could assist States with 
sharing their experiences.  For example, CMS could create a forum for States to 
share this information with other States.  CMS could also share this information 
during technical assistance calls, as well as post this information on its Medicaid 
telehealth webpage.   
  Protecting privacy and security of personal information.  Telehealth systems 
must ensure enrollees health information is private and secure.  CMS could 
coordinate with the HHS Office for Civil Rights (OCR), which is responsible for 
Health Insurance Portability and Accountability Act (HIPAA) enforcement, to 
ensure that as providers expand their use of telehealth they are aware of how 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees  
OEI-02-19-00400  Recommendations | 11  HIPAA standards for privacy and security apply to the delivery of behavioral health 
services via telehealth.26  This could include jointly hosting trainings for States 
about protecting privacy and security of protected health information when using 
telehealth, as well as responding to questions States may have about HIPAA 
standards for telehealth technology.   
  High cost of telehealth infrastructure and interoperability issues.  As they 
consider expanding the use of telehealth on a more permanent basis, there may 
be additional need for States to invest in the development and maintenance of 
technology and infrastructure that allows providers to connect to enrollees 
remotely and promotes interoperability between systems.  CMS could work with 
States to make sure that they are aware of the funding mechanisms available for 
these types of investments, as well as how to pursue them.27  As CMS notes in its 
Medicaid Telehealth Toolkit, States may pay for appropriate ancillary costs, such 
as technical support, transmission charges, and equipment necessary for the 
delivery of telehealth services.28  To claim Medicaid reimbursement, a State needs 
an approved State Plan Amendment that specifies the ancillary costs and 
circumstances under which those costs are payable.  To make this process easier 
for States, CMS could create a State Plan Amendment template, similar to its State 
Plan Amendment template for disaster relief.29  CMS could also gather 
information from States that have invested in telehealth infrastructure, including 
those that have done so during the COVID-19 pandemic, and share their 
experiences so that other States can learn from them.  CMS could also share 
information with States about interoperability, including examples of States that 
have taken action to ensure the interoperability of telehealth systems with existing 
health IT applications, such as electronic health records.  Ensuring the 
interoperability of telehealth systems should be a focus for States as they seek to 
expand their investments in new telehealth infrastructure, as well as invest in 
updating their current telehealth infrastructure.  
  Lack of licensing reciprocity.  Telehealth increases opportunities for States to 
leverage providers from other States to offer services to enrollees.  Yet, many 
States require providers to be licensed in the same State where the enrollee is 
located.  CMS could work with States to disseminate information about States 
perspectives and experiences with licensing reciprocity.  This effort could include 
identifying and disseminating information about lessons learned from States that 
have entered licensing compacts or expedited licensure arrangements.  CMS 
could gather information from States that have allowed out-of-State providers to 
deliver services to enrollees in their State during the COVID-19 pandemic and 
share their experiences so that other States can learn from them as they make 
decisions about their telehealth policies once the pandemic subsides.  
  Difficulties with obtaining informed consent.  The informed consent process 
helps ensure that providers explain what telehealth is and describes the expected 
benefits and risks, so enrollees are fully informed before receiving services.  CMS 
could work with States to share best practices about informed consent for 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees  
OEI-02-19-00400  Recommendations | 12  telehealth among States.  For example, best practices could include informing 
enrollees of their rights when receiving telehealth, including their right to refuse 
treatment; describing the responsibilities of enrollees when receiving telehealth 
services; and informing enrollees about what to do if technology or equipment 
fails during the telehealth session.30  In addition, these best practices could 
highlight ways to make the consent process faster and more efficient, such as 
allowing enrollees to consent virtually rather than having to mail in a signed 
consent form prior to the telehealth visit. 
 
 
 
 
 
 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees  
OEI-02-19-00400  Recommendations | 13  AGENCY COMMENTS AND OIG RESPONSE 
 
CMS concurred with our recommendation to share information to help States address 
challenges with using telehealth to provide behavioral health services to Medicaid 
enrollees.  CMS noted that it will take into account the broader concerns OIG 
identified with using telehealth in determining how it can further support States with 
using telehealth to ensure the provision of high-quality behavioral health services to 
Medicaid enrollees. 
We appreciate CMSs efforts to address these important issues.  Our findings indicate 
that there are common challenges across States that could impede Medicaid 
enrollees use of telehealth for behavioral health.  Importantly, these challenges 
existed prior to the additional challenges caused by the COVID-19 pandemic.  Sharing 
information among States will help ensure that States realize the benefits of 
telehealth and make informed decisions about how to address challenges with using 
telehealth, including lessons learned during the pandemic.  We ask that CMSin its 
Final Management Decisionprovide details on its plans and any progress toward 
implementing our recommendation.31   
For the full text of CMSs comments, see Appendix A.    
 
 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees  
OEI-02-19-00400  Agency Comments and OIG Response | 14   
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.32  We 
administered the survey electronically in January and February 2020.   
Our survey focused on States use of telehealth to provide behavioral health services 
to Medicaid enrollees.  As part of this survey, we requested information about the 
challenges that States face with using telehealth to provide these services.  In 
addition, in some cases States provided information about strategies they developed 
to address these challenges.  While we asked about challenges specific to managed 
care, the respondents focused on States challenges with using telehealth more 
generally. 
Structured Interviews With Stakeholders 
We conducted structured interviews with key stakeholders from a variety of 
organizations.  These stakeholders include representatives from national and regional 
Telehealth Resource Centers, health care coordination organizations, the HRSA, 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 challenges that States face with using 
telehealth to provide behavioral health services to Medicaid enrollees.  We also 
discussed the strategies States have developed to address these challenges.  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: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
Enrollees 
OEI-02-19-00400  Methodology | 15  APPENDIX A:  Agency Comments
DATE:  August 20, 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: States Reported Multiple 
Challenges with Using Telehealth to Provide Behavioral Health Services to 
Medicaid Enrollees (OEI-02-19-00400) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report.  
CMS recognizes the importance of collaborating with states to increase the availability of 
behavioral health services delivered via telehealth for Medicaid beneficiaries and appreciates 
OIGs effort in surveying State Medicaid Directors and various stakeholders to determine how 
states are using telehealth to provide these services to Medicaid beneficiaries. However, as these 
surveys were conducted from January to 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 detail states current perspectives on the use of telehealth for behavioral 
health services. 
The telehealth landscape has changed vastly and is continuing to rapidly evolve during the PHE. 
Notably, CMSs latest public data on telehealth utilization in Medicaid and CHIP reveals a 2745 
percent increase in services were delivered through telehealth from March 2020 to October 2020 
compared to the same period in 2019.1 As such, in response to the PHE, CMS has taken a number 
of actions to protect the health and safety of Medicaid beneficiaries. In 2020, CMS created a 
dedicated website for Medicaid-related COVID-19 information, which includes links to relevant 
information regarding COVID-19.2 As OIG noted, in April 2020, CMS released the Telehealth 
Toolkit that provides states with 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.3 The Telehealth Toolkit describes and discusses topics such as 
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 
1 Preliminary Medicaid & CHIP Data Snapshot, https://www.medicaid.gov/sites/default/files/2021-05/covid-19-
medicaid-data-snapshot.pdf  
2 COVID-19 Medicaid and CHIP Resources, https://www.medicaid.gov/resources-for-states/disaster-response-
toolkit/coronavirus-disease-2019-covid-19/index.html  
3 Telehealth Toolkit, https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit.pdf 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
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Agency Comments | 16
OEI-02-19-00400 APPENDIX A:  Agency Comments
adoption and implementation of telehealth as they begin to plan beyond PHE flexibilities by 
discussing topics such as communication strategies, telehealth operations and implementation tools, 
and shared experiences and examples from states and territories across the nation.4  
CMS is committed to providing opportunities for states to improve access to behavioral health 
care and through the efforts described above, we are assisting states and other stakeholders in 
meeting this goal throughout the PHE and beyond. Although the recent PHE has accelerated the 
interest in service delivery through telehealth, telehealth services have been available in many 
states for decades and CMS has long assisted states in their efforts to expand the use of telehealth 
for behavioral health services. For example, in order to assist states in developing their network 
adequacy and service availability standards, CMS formed a working group of states to discuss 
common access challenges and goals and created a forum for states to present their successful 
techniques for establishing and monitoring network adequacy in their programs. In addition, in 
April 2017, CMS published the Network Adequacy Toolkit, which provides technical assistance 
to states in the development and oversight of Medicaid managed care plan networks including 
mental health providers. 
Given the unique nature of each states Medicaid program, states are key players to develop 
meaningful and appropriate network adequacy and service availability standards, in keeping with 
federal guidelines, that reflect the scope of their programs, the populations served, and the 
demographics and characteristics of each state. States have broad flexibility to determine what 
services to deliver using telehealth and what they will pay for them. 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 delivery system specifically, and CMS 
will continue to work with states as issues arise.  
OIGs recommendation and CMS's response is below. 
OIG Recommendation 
Share information to help States address challenges with using telehealth to provide behavioral 
health services to Medicaid enrollees. 
CMS Response 
CMS concurs with this recommendation. While the landscape of telehealth has drastically changed 
and grown since the OIG conducted its survey, CMS will take into account the broader concerns 
OIG identified with telehealth in determining how CMS can further support states with using 
telehealth to ensure the provision of high quality behavioral health services to Medicaid enrollees. 
4 Telehealth Toolkit Supplement, https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-
toolkit-supplement1.pdf 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
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OEI-02-19-00400 Agency Comments | 17 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: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
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OEI-02-19-00400  Acknowledgments and Contact | 18   
 
ENDNOTES 
 
 
 
1 See OIG, Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid (OEI-02-
19-00401).   
2 See Medicaid and CHIP [Childrens Health Insurance Program] Payment and Access Commission (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 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, 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 Current industry standards recommend that health care providers have internet capability in line with U.S. Federal 
Communications Commission (FCC) broadband internet benchmarks.  Broadband download speeds are generally 25 Mbps for 
streaming ultra HD 4k video.  This is in line with the bandwidth needed to stream high-quality video generally.  See CMS, 
Report to Congress Reducing Barriers to Furnishing Substance Use Disorder (SUD) Services Using Telehealth and Remote 
Patient Monitoring for Pediatric Populations Under Medicaid: Final Report, May 15, 2020.  Accessed at 
https://www.medicaid.gov/medicaid/benefits/downloads/rtc-reducing-barriers-may-2020.pdf on March 18, 2021. 
10 The Centers for Disease Control and Prevention (CDC) notes that access to the internet is one of several factors that are 
related to health outcomes.  These factors, which include economic and social conditions, influence the health of individuals 
and are often referred to as social determinants of health.  See CDC, What Are Social Determinants of Health?.  Accessed at 
https://www.cdc.gov/nchhstp/socialdeterminants/faq.html on April 21, 2021.  
 
 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
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OEI-02-19-00400  Endnotes | 19 
   
 
11 See Substance Abuse and Mental Health Services Administration, TIP 60: Using Technology-Based Therapeutic Tools in 
Behavioral Health Services, November 2015.  Accessed at https://store.samhsa.gov/product/TIP-60-Using-Technology-Based-
Therapeutic-Tools-in-Behavioral-Health-Services/SMA15-4924 on June 24, 2021. 
12 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. 
13 See National Academy of Medicine, Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered 
Care.  Accessed at https://nam.edu/procuring-interoperability-achieving-high-quality-connected-and-person-centered-care/ 
on July 1, 2021.  See also FCC, Intergovernmental Advisory Committee to the Federal Communications Commission Advisory 
Recommendation No: 2019-2, In the Matter of State, Local Tribal, and Territorial Regulatory and Other Barriers and Incentives 
to Telemedicine.  Accessed at https://docs.fcc.gov/public/attachments/DOC-360696A5.pdf on June 24, 2021. 
14 These State requirements are enforced through medical practice requirements, payment conditions, or other laws and 
regulations.  See also 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 June 24, 2021.  
15 States are taking steps to modify licensure requirements in response to COVID-19.  See Federation of State Medical Boards, 
U.S. States and Territories Modifying Licensure Requirements for Physicians in Response to COVID-19, updated February 26, 
2021, and U.S. States and Territories Modifying Requirements for Telehealth in Response to COVID-19, updated March 2, 2021.  
Accessed at https://www.fsmb.org/siteassets/advocacy/pdf/state-emergency-declarations-licensures-requirementscovid-19.pdf 
and https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-
covid-19.pdf, respectively, on March 12, 2021. 
16 See Rural Health Information Hub, Licensing and Credentialing of Telehealth Programs.  Accessed at 
https://www.ruralhealthinfo.org/toolkits/telehealth/4/licensing-and-credentialing on February 24, 2021.  See also Health Affairs 
Blog, Doctors Without State Borders: Practicing Across State Lines, 2014.  Accessed at 
https://www.healthaffairs.org/do/10.1377/hblog20140218.036973/full/ on February 24, 2021. 
17 Examples include the Enhanced Nurse Licensure Compact, the Physical Therapy Interstate Compact, the Psychologist 
Interjurisdictional Compact, and the Recognition of EMS Personnel Licensure Interstate CompAct. 
18 See Nurse Licensure Compact, Facts about the NLC.  Accessed at https://www.ncsbn.org/NLC_Facts-FINAL.pdf on 
February 24, 2021. 
19 In addition to licensure compacts and expedited licensure arrangements, States may also have other licensing agreements, 
including physician consultation exceptions and emergency provisions.  These arrangements do not confer full licensure, but 
they allow providers to deliver services in limited ways or for a limited duration. 
20 See HRSA, Health Licensing Board Report to Congress.  Accessed at 
https://www.hrsa.gov/sites/default/files/ruralhealth2/about/telehealth/licenserpt10.pdf on February 24, 2021.  See also Federal 
Trade Commission and U.S. Department of Justice, Improving Health Care: A Dose of Competition, July 2004.  Accessed at 
https://www.ftc.gov/sites/default/files/documents/reports/improving-health-care-dose-competition-report-federal-trade-
commission-and-department-justice/040723healthcarerpt.pdf on February 24, 2021.  See also Health Affairs Blog, Doctors 
Without State Borders: Practicing Across State Lines, 2014.  Accessed at 
https://www.healthaffairs.org/do/10.1377/hblog20140218.036973/full/ on February 24, 2021. 
21 Telehealth consent requirements may be located in the States Medicaid program, or in statute or rules regulating health 
care professionals. 
22 See CCHP, State Telehealth Laws & Reimbursement Policies, Fall 2020.  Accessed at 
https://cchp.nyc3.digitaloceanspaces.com/files/2020-10/CCHP%2050%20STATE%20REPORT%20FALL%202020%20FINAL.pdf 
on June 23, 2021.  
 
Data Brief: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
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OEI-02-19-00400  Endnotes | 20 
   
 
23 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.  
24 See HHS Office of the Assistant Secretary for Preparedness and Response, Topic Collection: COVID-19 Telemedicine/Virtual 
Medical Care Resources.  Accessed at https://asprtracie.hhs.gov/technical-resources/116/covid-19-telemedicine-virtual-
medical-care-resources/99 on March 25, 2021. 
25 For examples of Federal funding sources, including grants funded by HHS, see FCC, Funding Broadband-Enabled Health 
Care.  Accessed at https://www.fcc.gov/general/funding-broadband-enabled-health-care on March 18, 2021.  Additionally, the 
2021 American Rescue Plan Act allocated $500 million to the U.S. Department of Agriculture to be used on grants for rural 
health care, including increasing telehealth capacity.  Section 1002 of the American Rescue Plan Act of 2021.  Accessed at 
https://www.congress.gov/bill/117th-congress/house-bill/1319/text on April 13, 2021. 
26 Although providers are not subject to penalties for HIPAA noncompliance in connection with the good faith provision of 
telehealth during the COVID-19 Public Health Emergency, once the Public Health Emergency ends the HHS Office for Civil 
Rights will be responsible for enforcing penalties related to HIPAA noncompliance.  
27 For example, the FCC provided $200 million to health care providers for telehealth-related infrastructure and equipment as a 
part of the Coronavirus Aid, Relief, and Economic Security (CARES) Act in June 2020.  The FCC announced a second round of 
COVID-19 telehealth funding for providers in March 2021.  See FCC, COVID-19 Telehealth Program (Invoices & 
Reimbursements).  Accessed at https://www.fcc.gov/covid-19-telehealth-program-invoices-reimbursements on April 13, 2021.   
28 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.   
29 See CMS, Medicaid State Plan Disaster Relief State Plan Amendments.  Accessed at https://www.medicaid.gov/resources-for-
states/disaster-response-toolkit/state-plan-flexibilities/index.html on April 13, 2021.  
30 For more information, see the 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. 
31 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.   
 
32 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: States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid 
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OEI-02-19-00400  Endnotes | 21