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.
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
- Medicare FFS: Scoring reflects post-Public Health Emergency (PHE) rules. The Consolidated Appropriations Act (CAA) 2023 extended many COVID-era telehealth flexibilities through 2024–2025; geographic and originating-site restrictions are partially reinstated for non-mental-health services. (CMS Telehealth)
- Mental Health: The CAA 2023 requires an in-person visit within 6 months before initiating Medicare mental health telehealth and annually thereafter. Home is an approved originating site for mental health.
- Audio-only: Medicare covers audio-only for mental health services. Private payer coverage varies significantly by plan and state.
- Store-and-forward: Covered under Medicare only in Alaska and Hawaii (federal telemedicine demonstration programs). Many state Medicaid programs and private plans cover it more broadly.
- RPM: Medicare CPT codes 99453, 99454, 99457, 99458 require ≥16 days of data per 30-day period and physician/NPP supervision.
- State Parity Laws: As of 2024, 43+ states have some form of telehealth coverage parity law. Payment parity (reimbursement equal to in-person) is less universal than coverage parity. (CCHP State Telehealth Laws)
- TRICARE: Covers synchronous telehealth broadly; audio-only and RPM have specific requirements. (TRICARE Telehealth)
- Substance Use Disorder: DEA Ryan Haight Act waivers (extended post-PHE) allow prescribing controlled substances via telehealth without prior in-person visit for SUD treatment.
- This tool is for informational purposes only and does not constitute medical or legal advice. Eligibility determinations are made by insurers and providers.