Telehealth Reimbursement for Seniors: What You Pay, What Insurance Covers, and How Claims Work

When you set up telehealth for an elderly parent, one question comes up quickly: who pays for this? The answer is less complicated than it sounds, but the details matter — especially if your parent is on Medicare, Medicaid, or a Medicare Advantage plan with its own rules.

This guide explains how telehealth visits are billed, what your parent is likely to pay out of pocket, and what changed in 2025 that makes telehealth permanently more accessible.

How Telehealth Billing Works (The Basic Mechanics)

Telehealth visits are billed almost identically to in-person office visits. The physician submits a claim to the insurance plan using standard billing codes (CPT codes), with a modifier that indicates the service was delivered via telehealth rather than in person.

For Medicare, the most common modifier is "95" (synchronous telecommunications technology) or "GT" depending on the claim type. Your parent does not need to do anything differently — the billing happens on the provider's end.

What this means practically: a telehealth visit with a primary care physician for a medication review is billed and reimbursed the same way as if your parent walked into the office. The cost-sharing (copay, coinsurance, deductible) is the same.

Medicare Telehealth Coverage in 2025: What Is Now Permanent

Medicare telehealth coverage expanded significantly during the pandemic under temporary waivers. Some of those expansions have now been made permanent, while others remain subject to annual Congressional reauthorization.

What is permanently covered (no expiration):

• Mental health telehealth visits, including from home, with no in-person requirement (this geographic restriction was permanently lifted for behavioral health services)
• Audio-only visits for mental health services, permanently allowed for patients who cannot use video
• The patient's home as a valid "originating site" for mental health telehealth
• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) as distant sites for behavioral health

What has been extended through 2026 (requires periodic renewal):

• Telehealth for non-mental health services from home (not just rural areas)
• Coverage for services like physical therapy and occupational therapy via telehealth
• Hospital-at-home and acute hospital care services
• Certain monitoring services

The practical upshot for most families: as of 2025, Medicare will cover telehealth visits with your parent's primary care doctor or specialists from home, whether they live in a city or a rural area. The geographic restriction that previously limited telehealth to rural originating sites has been waived for nearly all services.

If Congress does not extend these waivers, some coverage could revert. This is a live policy issue — it is worth confirming current coverage directly with your parent's plan before assuming a specific specialty visit will be covered.

What Your Parent Actually Pays: The Cost-Sharing Rules

Under Original Medicare (Parts A and B):

• Telehealth visits are covered under Medicare Part B
• Your parent pays the Part B deductible first ($257 in 2025), then 20% of the Medicare-approved amount for each telehealth visit
• There is no additional cost for using telehealth vs. an in-person visit — the coinsurance percentage is the same

If your parent has a Medigap (Medicare supplement) plan, it typically covers the 20% coinsurance, leaving little or no out-of-pocket cost per telehealth visit.

Example: A telehealth visit with a primary care physician billed at $150 (Medicare-approved amount) results in Medicare paying $120 and your parent paying $30 — the same as if they had driven to the office.

Medicare Advantage Telehealth Benefits

Medicare Advantage plans often offer telehealth benefits that go beyond Original Medicare:

• Many plans offer $0 copays for telehealth visits with in-network providers
• Some plans include access to 24/7 virtual urgent care services at no cost
• Plan-specific telehealth platforms (like Teladoc or MDLive) may be included as an extra benefit

The catch: your parent must use in-network providers or the plan's designated telehealth platform to get these lower costs. A telehealth visit with an out-of-network provider may be billed at the full out-of-network cost-sharing rate.

Check your parent's Summary of Benefits and Coverage or call the plan's member services line to confirm:

1. Which telehealth platforms are covered at $0
2. Whether their specific doctors are covered for telehealth under the plan
3. Whether there are visit limits on telehealth services

Medicaid Telehealth Coverage

All 50 states cover at least some telehealth services under Medicaid, but the specifics — which services, which providers, what cost-sharing applies — vary considerably by state.

Key points that apply in most states:

• Low-income seniors who qualify for both Medicare and Medicaid (dual eligible) often have their Medicare cost-sharing covered by Medicaid, meaning telehealth visits may cost nothing out of pocket
• Medicaid managed care plans (common in most states) may have their own telehealth networks and platforms
• Audio-only telehealth is more broadly covered under Medicaid than it was pre-pandemic, though policies vary by state

If your parent is on Medicaid, contact the state Medicaid office or the managed care plan directly to confirm which telehealth services are covered and what, if anything, they will pay.

Private Insurance and Employer Coverage

For seniors under 65 or those on a spouse's employer plan, private insurance telehealth coverage depends entirely on the plan. Since 2020, most major commercial insurers have maintained or expanded telehealth coverage.

Things to verify with private insurance:

• Is the specific provider your parent uses in-network for telehealth?
• Is there a different copay for telehealth vs. in-person visits?
• Are there visit limits per year?
• Is the platform (e.g., Zoom-based visit through the doctor's office) covered, or only visits through the insurer's proprietary telehealth app?

How to Handle a Denied Telehealth Claim

Telehealth claims can be denied for a few common reasons:

The provider billed with the wrong modifier. This is a provider-side error. Contact the physician's billing office, explain the visit was a telehealth visit, and ask them to correct and resubmit.

The service was not covered under the current waivers. For Medicare, check the current list of covered telehealth services at CMS.gov. Some specialty services may have limited coverage.

Out-of-network provider. If your parent used a telehealth platform or doctor outside the plan's network, coverage may be reduced or denied. In this case, you can appeal, but winning is not guaranteed.

The plan requires prior authorization. Some Medicare Advantage plans require prior authorization for telehealth visits above a certain frequency or for specialist visits. Check the plan's prior authorization list before booking.

To appeal a denial:

1. Request the denial in writing with the specific reason code
2. Contact Medicare (1-800-MEDICARE) or the plan's appeals department
3. Submit an appeal within the timeframe specified in the denial letter (typically 60–120 days for Medicare)

Telehealth and Cost-Sharing for Mental Health Visits

This deserves special mention because the rules changed significantly. Under current Medicare rules:

• Mental health telehealth visits from home are permanently covered
• Audio-only is permanently allowed for mental health (important for parents who cannot manage video)
• The same 20% coinsurance applies as for in-person mental health visits
• The in-person visit requirement that was briefly discussed during rulemaking was ultimately not implemented for Medicare — your parent does not need to have an in-person visit first to establish telehealth mental health care

For a parent with depression or anxiety, this means access to a therapist or psychiatrist via phone or video with no transportation required — and the same cost-sharing as any other Medicare visit.

What to Do Before the First Telehealth Visit

To avoid billing surprises, run through this checklist:

• [ ] Confirm the provider accepts Medicare assignment (they agree to Medicare's approved amount)
• [ ] Verify the provider is in-network for your parent's Medicare Advantage plan, if applicable
• [ ] Ask the provider's office explicitly: "Is this telehealth visit covered by my parent's insurance?"
• [ ] If your parent has a Medigap plan, confirm it is active and will cover the 20% coinsurance
• [ ] After the visit, review the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) to verify the claim was processed correctly

The MSN arrives by mail roughly every three months. You can also check claims in real time through Medicare.gov or through the patient portal if the provider uses one.

The Bottom Line

For most elderly parents on Medicare, telehealth visits cost the same as in-person visits — 20% of the approved amount after the deductible, or $0 with a good Medigap plan. Medicare Advantage often makes it even cheaper. The rules became significantly more favorable in 2025, and the home is now a permanently valid location for most services.

The most common financial mistakes: assuming a telehealth visit is free without checking the plan, using an out-of-network provider without realizing it, and not appealing denied claims that were billed incorrectly.

Our Telehealth Parent Guide includes a complete walkthrough of setting up telehealth for an elderly parent — from choosing the right device to coordinating with insurance, managing prescriptions, and running the visits remotely. Download the guide here.