Network Access for Telehealth-Only Providers

Telehealth-only practices face a structural problem: network adequacy rules mostly count in-person providers. Medicare Advantage gives plans credit for telehealth but does not count telehealth-only providers toward minimum numbers, and Medicaid wait-time surveys count telehealth appointments only from providers who also see patients in person. Here is how that shapes your pitch.

Plans often tell telehealth-only practices that they "do not credential virtual-only providers" or that the network is full. The first answer is a plan policy choice. The second can be true and still miss the point, because the rules that define a "full" network were written around office locations. Understanding how those rules treat telehealth tells you what a plan can gain from you and what it cannot.

How does Medicare Advantage treat telehealth providers?

Two provisions in 42 CFR 422.116 pull in opposite directions:

A credit toward time and distance. A plan "receives a 10 percentage point credit towards the percentage of beneficiaries residing within published time and distance standards" for a specialty and county when it contracts with telehealth providers offering additional telehealth benefits in listed specialties (422.116(d)(5)). The list includes dermatology, psychiatry, cardiology, neurology, otolaryngology, ophthalmology, allergy and immunology, nephrology, primary care, gynecology/OB/GYN, endocrinology, infectious diseases, clinical psychology, clinical social work, and outpatient behavioral health.
No credit toward minimum numbers. To count toward the minimum number standard, a provider must "not be a telehealth-only provider" (422.116(e)(1)(ii)).

So a telehealth-only clinician in a listed specialty can help a plan close a time and distance gap in a county, but cannot fill a minimum-number shortfall. If you also maintain an in-person location in that county, you can help with both.

Do Medicaid rules treat telehealth differently?

States must consider "the use of telemedicine, e-visits, and/or other evolving and innovative technological solutions" when developing network adequacy standards (42 CFR 438.68(c)(1)(ix)). Medicaid provider directories must show "whether the provider offers covered services via telehealth" (438.10(h)(1)(ix)).

The new appointment wait-time standards are stricter about telehealth. In the secret shopper surveys states must run, "appointments offered via telehealth can only be counted toward compliance with the appointment wait time standards ... if the provider being surveyed also offers in-person appointments" and must be identified separately (438.68(f)(2)(ii)). A virtual-only practice can still be valuable to a Medicaid plan as capacity, but it will not help the plan's measured compliance with wait-time standards. Our post on Medicaid's new wait-time standards covers timing.

Which arguments work for a telehealth-only practice?

Time and distance credit in a listed specialty, in counties where the plan is close to the line. A plan near 85 or 90 percent coverage has a reason to want the credit.
Behavioral health capacity. Psychiatry, clinical psychology, clinical social work and outpatient behavioral health are on the credit list, and Medicare Advantage plans have written wait-time standards for behavioral health (42 CFR 422.112(a)(6)(i)).
Language and niche coverage that the plan cannot find locally.
A hybrid footprint. Even one in-person location, or an affiliation with a practice that has one, changes how the plan can count you.

What should a telehealth practice's request include?

A plan's network team will want to see how you change its numbers, not just that you are available. A useful request lists:

The counties and specialties you would cover, matched against the specialties on CMS's telehealth credit list.
Licensure in each state where the plan's members would be located during visits.
Capacity: new-patient slots per week, first available appointment, evening and weekend hours, and languages.
Any in-person option, including a partner office where members can be seen when needed.
Directory details the plan would publish, since Medicaid directories must flag telehealth services (438.10(h)(1)(ix)) and Medicare Advantage directories must list addresses and phone numbers (422.120(b)(1)).

Pair that with evidence of local wait times for your specialty; our post on documenting an access gap covers how to collect it.

Where does licensing come in?

A plan will credential you only for states where you hold a license or other authorization to treat patients located there. Practices that serve members in several states need the license and enrollment work done state by state before a network dispute makes sense. White Glove Telemedicine covers state telehealth rules and coverage, including Medicaid telehealth coverage, and White Glove Credentialing covers credentialing for locum and telehealth clinicians.

What if the plan simply excludes virtual-only providers?

Ask for the policy in writing and for the reason. Medicare Advantage (42 CFR 422.205(a)) and Medicaid managed care (438.12(a)(1)) plans that decline a provider must give written notice of the reason. Federal nondiscrimination rules protect against exclusion solely by license type; they do not prohibit a plan from preferring providers with a physical location. Where a plan has a telehealth vendor or a separate virtual network, ask whether admission runs through that vendor instead. See your right to a written reason.

How do we help?

We check which specialties and counties the credit rules favor, map the plan's coverage where you are licensed, and prepare the letter and evidence. You review, sign and send it; we track the response. We do not represent providers or give legal advice. A Network Rejection Review is $249 and a Payer Network Dispute is $799 per payer; see pricing. Legal questions, such as what a contract term means or whether to pursue a hearing, belong with a healthcare attorney.

Common questions

Do telehealth-only providers count toward Medicare Advantage network adequacy?

Partly. Plans get a 10-percentage-point time and distance credit for telehealth providers in listed specialties, but a provider must not be telehealth-only to count toward the minimum number standard (42 CFR 422.116(d)(5) and (e)(1)(ii)).

Can a plan refuse to credential virtual-only practices?

Federal rules bar exclusion solely by license type and require a written reason from Medicare Advantage and Medicaid managed care plans, but they do not stop a plan from preferring providers with a physical location.

Do telehealth appointments count toward Medicaid wait-time standards?

In the required secret shopper surveys, only if the surveyed provider also offers in-person appointments to the plan's enrollees, and they must be reported separately (42 CFR 438.68(f)(2)(ii)).