Telehealth Eligibility Checker

ANA›Life Services Authority›National Calculator Authority›Telehealth Eligibility Checker

.calc-container { max-width: 640px; margin: 2rem 0; padding: 1.5rem; background: #fff; border: 1px solid #ddd; border-radius: 8px; box-shadow: 0 1px 3px rgba(0,0,0,0.06); font-family: system-ui, -apple-system, sans-serif; } .calc-container h3 { font-family: Georgia, serif; font-size: 1.15rem; color: #1a1a1a; margin-bottom: 1rem; padding-bottom: 0.5rem; border-bottom: 2px solid var(--ac, #3d5a80); } .calc-row { display: flex; align-items: center; gap: 0.75rem; margin-bottom: 0.75rem; flex-wrap: wrap; } .calc-row label { min-width: 160px; font-size: 0.9rem; color: #333; font-weight: 500; } .calc-row input[type="number"], .calc-row select { flex: 1; min-width: 120px; max-width: 200px; padding: 0.5rem 0.6rem; border: 1px solid #ccc; border-radius: 4px; font-size: 0.9rem; font-family: system-ui, sans-serif; color: #1a1a1a; background: #fafaf8; } .calc-row input:focus, .calc-row select:focus { outline: none; border-color: var(--ac, #3d5a80); box-shadow: 0 0 0 2px rgba(26,74,138,0.12); } .calc-row .unit { font-size: 0.82rem; color: #888; min-width: 30px; } .calc-btn { display: inline-block; margin-top: 0.5rem; padding: 0.55rem 1.5rem; background: var(--ac, #3d5a80); color: #fff; border: none; border-radius: 4px; font-size: 0.9rem; font-weight: 600; cursor: pointer; font-family: system-ui, sans-serif; } .calc-btn:hover { opacity: 0.9; } .calc-result { margin-top: 1.25rem; padding: 1rem 1.25rem; background: #f0f6fc; border-left: 3px solid var(--ac, #3d5a80); border-radius: 0 6px 6px 0; display: none; } .calc-result.visible { display: block; } .calc-result-label { font-size: 0.78rem; text-transform: uppercase; letter-spacing: 0.06em; color: #666; margin-bottom: 0.25rem; } .calc-result-value { font-size: 1.6rem; font-weight: 700; color: var(--ac, #3d5a80); } .calc-result-detail { font-size: 0.85rem; color: #555; margin-top: 0.5rem; line-height: 1.5; } .calc-note { margin-top: 1rem; font-size: 0.8rem; color: #888; font-style: italic; } .calc-grid { display: grid; grid-template-columns: 1fr 1fr; gap: 0.75rem; margin-top: 0.75rem; } .calc-grid-item { padding: 0.6rem 0.8rem; background: #f8f9fa; border-radius: 4px; border: 1px solid #eee; } .calc-grid-item .label { font-size: 0.75rem; color: #888; text-transform: uppercase; letter-spacing: 0.04em; } .calc-grid-item .value { font-size: 1.1rem; font-weight: 600; color: #1a1a1a; } @media (max-width: 720px) { .calc-row { flex-direction: column; align-items: flex-start; gap: 0.3rem; } .calc-row label { min-width: auto; } .calc-row input[type="number"], .calc-row select { max-width: 100%; width: 100%; } .calc-grid { grid-template-columns: 1fr; } } .calc-chart { margin: 1rem 0; text-align: center; } .calc-chart svg { max-width: 100%; height: auto; } .calc-chart-legend { display: flex; flex-wrap: wrap; justify-content: center; gap: 0.6rem 1.2rem; margin-top: 0.6rem; font-size: 0.8rem; color: #555; } .calc-chart-legend span { display: inline-flex; align-items: center; gap: 0.3rem; } .calc-chart-legend i { display: inline-block; width: 10px; height: 10px; border-radius: 2px; font-style: normal; } .calc-related { max-width: 640px; margin: 2rem 0 1rem; padding: 1.25rem 1.5rem; background: #f8f9fa; border: 1px solid #e8e8e8; border-radius: 8px; } .calc-related h3 { font-family: Georgia, serif; font-size: 1rem; color: #1a1a1a; margin: 0 0 0.75rem; padding-bottom: 0.4rem; border-bottom: 2px solid var(--ac, #3d5a80); } .calc-related-list { list-style: none; padding: 0; margin: 0 0 0.75rem; display: grid; grid-template-columns: 1fr 1fr; gap: 0.4rem 1.5rem; } .calc-related-list li a { font-size: 0.88rem; color: var(--ac, #3d5a80); text-decoration: none; } .calc-related-list li a:hover { text-decoration: underline; } .calc-browse-all { margin: 0.5rem 0 0; font-size: 0.9rem; font-weight: 600; } .calc-browse-all a { color: var(--ac, #3d5a80); text-decoration: none; } .calc-browse-all a:hover { text-decoration: underline; } @media (max-width: 720px) { .calc-related-list { grid-template-columns: 1fr; } }

Telehealth Eligibility Checker

Determine your likely eligibility for telehealth (telemedicine) services based on your insurance coverage, location, visit type, and clinical criteria. Results are estimates based on federal and common state guidelines.

Insurance Type

-- Select -- Medicare (Traditional/FFS) Medicare Advantage Medicaid Private / Commercial Insurance TRICARE (Military) Uninsured / Self-Pay

Patient Location at Time of Visit

-- Select -- Rural area (HPSA or non-MSA) Urban / Suburban area Home (any location) Approved originating site (clinic, hospital, etc.)

Type of Telehealth Visit

-- Select -- Synchronous (live video) Audio-only (phone call) Asynchronous (store-and-forward) Remote Patient Monitoring (RPM)

Service / Specialty Type

-- Select -- Primary Care / General Medicine Mental Health / Behavioral Health Chronic Disease Management Specialist Consultation Urgent Care Substance Use Disorder Treatment

Patient-Provider Relationship

-- Select -- Established patient (prior in-person visit) New patient (no prior relationship)

Does your state have a telehealth parity law?

-- Select -- Yes – state requires coverage parity No / Unknown

Check Eligibility

function telCalc() { const insurance = document.getElementById('tel-insurance').value; const location = document.getElementById('tel-location').value; const visitType = document.getElementById('tel-visit-type').value; const service = document.getElementById('tel-service').value; const established = document.getElementById('tel-established').value; const stateLaw = document.getElementById('tel-state-law').value; const resultDiv = document.getElementById('tel-result');

// --- Input validation --- if (!insurance || !location || !visitType || !service || !established || !stateLaw) { resultDiv.innerHTML = '⚠ Please complete all fields before checking eligibility.'; return; }

// ------------------------------------------------------- // SCORING ENGINE // Each criterion adds/subtracts from an eligibility score // and populates a findings array. // ------------------------------------------------------- let score = 0; // 0–100 scale const findings = []; const warnings = []; const tips = [];

// --- 1. Insurance base score --- const insuranceScores = { medicare: 55, // geographic restrictions still apply for non-PHE periods medicare_advantage:75, medicaid: 60, private: 65, tricare: 70, uninsured: 40 // self-pay always possible but cost is barrier }; score += insuranceScores[insurance];

const insuranceLabels = { medicare: "Medicare (Traditional)", medicare_advantage:"Medicare Advantage", medicaid: "Medicaid", private: "Private Insurance", tricare: "TRICARE", uninsured: "Uninsured/Self-Pay" }; findings.push("Insurance: " + insuranceLabels[insurance]);

// --- 2. Location modifier --- // Traditional Medicare: rural/HPSA or approved originating site required (outside PHE) if (insurance === "medicare") { if (location === "rural" || location === "facility") { score += 15; findings.push("Location: Meets Medicare originating-site requirement (rural/HPSA or approved facility)."); } else if (location === "home") { // Post-CAA 2023: home allowed for mental health after in-person visit if (service === "mental_health" && established === "established") { score += 10; findings.push("Location: Home allowed for Medicare mental health telehealth (post-CAA 2023) with established relationship."); } else { score -= 20; warnings.push("Traditional Medicare generally requires an approved originating site; home visits have limited coverage outside mental health or PHE waivers."); } } else { score -= 15; warnings.push("Urban/suburban locations may not meet Medicare's originating-site requirement for traditional FFS."); } } else { // Non-Medicare: location is rarely a barrier if (location === "home") { score += 10; findings.push("Location: Home-based telehealth is widely supported for this insurance type."); } else { score += 5; findings.push("Location: Facility or rural location further supports eligibility."); } }

// --- 3. Visit type modifier --- const visitTypeModifiers = { synchronous: 15, audio_only: 5, // some payers restrict audio-only async: 0, // limited payer support rpm: 10 }; score += visitTypeModifiers[visitType];

if (visitType === "audio_only") { warnings.push("Audio-only visits have variable coverage. Medicare covers audio-only for mental health; many private plans restrict it."); tips.push("Confirm audio-only coverage with your insurer before the visit."); } if (visitType === "async") { warnings.push("Store-and-forward (asynchronous) telehealth is primarily covered in Alaska and Hawaii under Medicare, and varies widely by state for other insurers."); } if (visitType === "rpm") { tips.push("RPM requires at least 16 days of data collection per 30-day period for Medicare billing (CPT 99454)."); }

// --- 4. Service type modifier --- const serviceModifiers = { primary_care: 10, mental_health: 20, // strongest federal/state support chronic: 15, specialist: 8, urgent: 5, substance: 18 }; score += serviceModifiers[service];

if (service === "mental_health") { findings.push("Service: Mental health telehealth has the broadest federal and state coverage mandates."); } if (service === "substance") { findings.push("Service: Substance use disorder treatment via telehealth expanded under the SUPPORT Act and DEA Ryan Haight waivers."); }

// --- 5. Patient-provider relationship --- if (established === "established") { score += 10; findings.push("Relationship: Established patient — most payers allow telehealth without prior in-person requirement."); } else { // New patient if (insurance === "medicare" && service === "mental_health") { score -= 10; warnings.push("Medicare mental health telehealth requires an in-person visit within 6 months before initiating telehealth, and annually thereafter (CAA 2023)."); } else if (insurance === "medicare") { score -= 5; warnings.push("Some Medicare services require an established relationship; new patients may need an initial in-person visit."); } else { score += 5; findings.push("Relationship: New patients are generally accepted for telehealth under this insurance type."); } }

// --- 6. State parity law --- if (stateLaw === "yes") { score += 10; findings.push("State Law: Your state has a telehealth parity law, requiring insurers to cover telehealth services at the same rate as in-person care."); tips.push("Parity laws vary — some cover payment parity, others only coverage parity. Verify with your insurer."); } else { findings.push("State Law: No confirmed state parity law. Coverage depends entirely on your plan's telehealth benefits."); tips.push("Check your state's Medicaid telehealth policy at medicaid.gov or your insurer's telehealth benefit summary."); }

// --- 7. Cap score to 0–100 --- score = Math.max(0, Math.min(100, score));

// --- 8. Eligibility tier --- let tier, tierColor, tierIcon, tierLabel; if (score >= 75) { tier = "high"; tierColor = "#27ae60"; tierIcon = "✓"; tierLabel = "Likely Eligible"; } else if (score >= 50) { tier = "moderate"; tierColor = "#f39c12"; tierIcon = "⚠"; tierLabel = "Possibly Eligible (Verify with Insurer)"; } else if (score >= 30) { tier = "low"; tierColor = "#e67e22"; tierIcon = "⚠"; tierLabel = "Limited Eligibility — Barriers Exist"; } else { tier = "unlikely"; tierColor = "#c0392b"; tierIcon = "✗"; tierLabel = "Unlikely Eligible Under Current Criteria"; }

// --- 9. Build result HTML --- let html = ''; html += '### ' + tierIcon + ' ' + tierLabel + ' '; html += 'Eligibility Score: ' + score + ' / 100

';

// Score bar html += ''; html += '';

// Findings html += 'Key Findings:'; findings.forEach(function(f) { html += ''; }); html += '';

// Warnings if (warnings.length > 0) { html += '⚠ Potential Barriers:'; warnings.forEach(function(w) { html += ''; }); html += ''; }

// Tips if (tips.length > 0) { html += '💡 Recommendations:'; tips.forEach(function(t) { html += ''; }); html += ''; }

html += 'ⓘ This tool provides an estimate only. Always verify coverage with your insurance provider before scheduling a telehealth visit.

'; html += '';

resultDiv.innerHTML = html; }

#### Formula & Scoring Logic

The eligibility score (0–100) is computed as a weighted sum of six criteria:

Score = InsuranceBase + LocationModifier + VisitTypeModifier + ServiceModifier + RelationshipModifier + StateLawModifier

InsuranceBase: Medicare FFS = 55 (geographic restrictions apply) Medicare Advantage = 75 Medicaid = 60 Private Insurance = 65 TRICARE = 70 Uninsured/Self-Pay = 40

LocationModifier (Medicare FFS): Rural/HPSA or approved facility = +15 Home (mental health, established) = +10 Home (other) = -20 Urban (non-facility) = -15 LocationModifier (all others): Home = +10 Facility/Rural = +5

VisitTypeModifier: Synchronous (live video) = +15 Audio-only = +5 Asynchronous (store-and-forward) = 0 Remote Patient Monitoring (RPM) = +10

ServiceModifier: Mental Health = +20 Substance Use Disorder = +18 Chronic Disease Management = +15 Primary Care = +10 Specialist Consultation = +8 Urgent Care = +5

RelationshipModifier: Established patient = +10 New patient (Medicare mental hlth)= -10 New patient (Medicare other) = -5 New patient (non-Medicare) = +5

StateLawModifier: State parity law = Yes = +10 No / Unknown = 0

Eligibility Tiers: Score ≥ 75 → Likely Eligible Score 50–74 → Possibly Eligible (verify with insurer) Score 30–49 → Limited Eligibility — barriers exist Score < 30 → Unlikely Eligible under current criteria

#### Assumptions & References

More Calculators

References

Related Authorities

Life Services Authority › Professional Services Authority › Trade Services Authority › United States Authority ›