Telehealth Costs

As discussed in Availability of Telehealth, at present, generally only telehealth services where there is an existing and continuous relationship between the medical practitioner and patient are subsidised by Medicare and made available at no cost to the patient.

In relation to healthcare services that are outside the scope of Medicare, where previously, prior to the COVID-19 pandemic, private health insurers generally did not reimburse claims for healthcare services delivered remotely, an increasing number of private health insurers have since approved coverage for certain forms of telehealth services accessed by their members. However, what is permitted varies from insurer to insurer and is dependent on the terms and conditions of the policy.

Medical advice via phone or video-conference is reimbursed by the public health system. Private insurance companies have also started to offer telehealth packages. Teleconsultation in urgent cases under the telephone number 1450 and with doctors (including psychological urgent cases) are offered. It is possible to transfer data from medical devices or smartphone-sensors. The hotline 1450 is a general e health service tool and first point of contact, including during out of office hours.

Yes, the public health system does include certain telehealth services (as outlined under the public telehealth services heading in Fields of healthcare ) that are free of charge.

Since 1 August 2022, digital consultations are financed in the Belgian health system, which means that patients will be reimbursed for the consultations. Doctors can decide which platform they wish to use for the digital consultation and how they collect payment for it.

The number of reimbursed teleconsultations is unlimited. However, certain conditions must be met:

• the teleconsultation must take place with the patient’s regular doctor or a specialist recommended by them, or a general medical on-call service;
• it must take place at the patient’s request, with the doctor's agreement;
• the doctor must have access to the patient’s medical file; and
• the platform or application used must guarantee the security of the information.

Patients only pay a personal contribution of €4 for a video consultation and €2 for a telephone consultation.

Another novelty is the m-health platform (mHealthBELGIUM), which is the result of one of the test projects initatied by RIZIV/INAMI. This platform has been set up in order to grant a "trust stamp" to trusted applications. For each application, the platform stores information regarding its CE marking, data protection, security, data interoperability with other information systems, and also on how the application is financed.

mHealthBELGIUM has been designed as a 3-level validation pyramid. The applications available on the mHealthBELGIUM website will have at least reached level M1 (apps recognised as medical devices) and can gradually climb the hierarchy to level M2 (interoperability and connectivity of the apps with the core services of the eHealth platform) and then level M3 (apps which show a socio-economic added value and which are financed by RIZIV/INAMI, after a positive opinion of their application for reimbursement).

The Brazilian public health system ("SUS") provides telehealth services, in compliance with the Brazilian Telehealth regulation (i.e., Federal Law n. 14,510/2022). The Brazilian Ministry of Health’s Ordinance n. 1,348/2022 sets forth the terms for provision of telehealth services at the public health system level. It basically encompasses the same settings that the private health system offers to the patients, the main difference being in relation to costs – when provided in the context of the Brazilian public health system, telehealth services are free of charge for the patients.

On the other hand, telehealth services in the private sector are not free of charge. Patients, or eventually their private health insurance, must pay for the services digitally offered – according from an ethical perspective to the guidelines of the Professional Boards as well, such as the Professional Board of Medicine.

No.

Whether the public health system includes telehealth services will vary from province to province in Canada. Additionally, coverage of telehealth services varies from private health insurer to private health insurer.

It is noted that generally, most dental services are not covered by provincial health insurance. For example, the Ontario Health Insurance Plan ("OHIP") does not cover regular dental care such as checkups, cleanings, fillings, x-rays, root canals and tooth removal. Given that these services are not generally covered by provincial health insurance plans, it is unlikely that the public health system will cover virtual dental services.

Yes, the public health system includes telemedicine services. This has been made clear by Resolution No. 277/2011 and especially by the modification made by Resolution No. 54/2020, in the terms as discussed above.

Telemedicine services are partially or totally paid for by the State (the National Health Fund or "FONASA") through the issuance of medical vouchers. The coverage by FONASA depends on the economic situation of each patient, and whether they are or are not part of a special program that includes telemedicine services. It should be noted that as a consequence of the COVID-19 pandemic, several health benefits have been included in FONASA's free-choice tariff.

Also, for patients who have a private health insurance system ("Isapre"), the Superintendence of Health has issued resolutions through which obliges private insurers to provide direct coverage to the services rendered via telemedicine (subject to the specific coverage plan of the particular patient). In addition, the Superintendence of Health has established certain minimum coverage requirements that must be met by Isapre in the context of telehealth through circulars (the most important of which is Circular IF No. 358/2020).

The aforementioned administrative rules do not distinguish between public healthcare system and private healthcare system. Further, according to Guiding Opinion on Improving Pricing and Payment Policies by Healthcare Security for "Internet plus" Healthcare Service promulgated by National Healthcare Security Administration on August 17, 2019, both public and private medical institutions might provide internet plus medical services. The pricing of medical service provided by public healthcare system is regulated by government whereas that for private healthcare system is regulated by market. Further, Healthcare Security Administration at the provincial level determines the scope of service items to be covered by national healthcare insurance scheme. Several provinces have promulgated their own reimbursement policies. For example, Healthcare Security Administration of Shandong Province allows the follow-up consultation fees and certain refills of prescription drugs to be paid by healthcare security fund after confirmation by local Healthcare Security Administration. On the other hand, the fees associated with imaging, ultrasound and other testing services provided remotely via third party platform or entity shall be approved first prior to their incorporation into the public healthcare insurance scheme.

Yes, the Colombian public healthcare system states that any person shall have access to a public basic plan which includes the provision of telehealth services.

The public health system includes telehealth services. Pursuant to Article 128 (2) of the Healthcare Act, health institutions that perform professional and scientific activities within the framework of the rights and duties of the Republic of Croatia in the field of public health, occupational medicine, telemedicine, toxicology and anti-doping, transfusion medicine and emergency medicine fall within the scope of "state health institutes".

As it has already been mentioned above, some elements of telehealth (such as the ePrescription system and the eSick leave card) are implemented by Czech law and included in the public health system. Nevertheless, the core telemedicine services (i.e., the provision of remote health care services through digital tools) is recognized neither by the Health Services Act, nor by the Public Health Insurance Act (the Act No. 48/1997 Coll., on public health insurance, as amended). Even though the public health system does recognize and offer telemedicine services, some insurance companies already provide contributions to enable their policyholders to use telemedicine services (e.g., Ministry of the Interior Public Health Insurance Fund) or reimburse a certain number of long-distance consultations between their policyholders and healthcare professionals (e.g., General Health Insurance Company).

For the sake of completeness, it is further to be noted that the Ministry of Health of the Czech Republic has prepared the draft bill of the amendment to the Health Services Act (available in Czech only).   The draft bill provides, inter alia, a definition of telemedicine services and a general legal framework for their provision. It should also facilitate the integration of the telemedicine into the Czech public health system and the determination of reimbursement mechanisms. Currently, the draft bill is at the beginning of the legislative process (more precisely, the inter-ministerial comment procedure has been completed). Therefore, its wording is not final and may be amended significantly.

Several local doctors offer telehealth services such as online booking, email consultation and videoconference. The abovementioned app "Min læge" has been issued by the Danish Ministry of Health and the Organisation of General Practitioners (PLO) and allows people quick access to their personal doctors and the digital solutions they offer. Such services are free of charge within the free Danish healthcare system.

From the beginning of 2023, the responsibility for organising health services in Finland transferred from municipalities to wellbeing services counties. The key objective of the reform is to improve the availability and quality of services. There are 21 wellbeing services counties and in addition, the city of Helsinki is responsible for organizing health services within its area and the joint county authority for the Hospital District of Helsinki and Uusimaa (HUS) is responsible for organising demanding specialised healthcare separately laid down by law. The resources that wellbeing services counties have for organising the services vary. Wellbeing services counties are responsible to organise primary healthcare, specialised healthcare, and hospital services (see the above exception for city of Helsinki and HUS). Both private and public healthcare sector provide telehealth services e.g. a web doctor appointments. In addition, healthcare professionals answer phone calls as part of emergency services (Medical Helpline). Telehealth services have gotten increasingly common in Finland, provided both by the public and private health care providers.

Public healthcare services in Finland are financed primarily out of tax revenue. In Finland, the patient’s medical care costs are generally paid by the patient’s wellbeing services county. Depending on the service health and social services are free of charge, or there is a client charge which is either fixed or depends on the client’s income and family relations. The maximum charges for public healthcare and social welfare services are laid down in the Act on Client Charges in Healthcare and Social Welfare (734/1992, as amended) and the corresponding Government Decree (912/192, as amended). Wellbeing services counties (and the city of Helsinki and HUS) may opt to use lower rates or to provide services free of charge. They may not collect charges that exceed the production cost of the services. The above Act is also applicable to the service organized by the wellbeing services county as a purchase service. The service voucher, in turn, is regulated in the Service Voucher Act (569/2009, as amended). In the case of a service arranged with a service voucher, there is no customer charge, but the patient is responsible to pay deductible. The charges for public services, mainly health services, have an upper limit per calendar year beyond which clients do not have to pay charges. In 2022–2023, this upper limit is EUR 692. There is also an annual maximum limit on out-of-pocket medicine costs per calender year.  The fees shall be kept at a reasonable level and shall not form an obstacle to using healthcare services.

The National Health Insurance scheme is part of the Finnish social security system. It covers expenses, such as a share of private doctors’ fees including the fees from the usage of the telehealth services. Furthermore, the occupational health services scheme is complementary to the primary healthcare system in Finland. The occupational health service is preventive healthcare, which the employer has a duty to arrange by law. The aim of obligatory occupational healthcare is to promote working capacity of the employees. Employers may also organise additional healthcare services voluntarily, such as services relating to dental care. The public healthcare services and occupational healthcare are complemented by private healthcare services funded by both private insurances and out-of-pocket of the end users.

France runs a statutory health insurance system (“Assurance Maladie”) providing universal coverage for its residents. Most of the population (almost 95%) further has complementary private insurance (“mutuelle”).

The French public health system includes telehealth services, subject to applicable requirements. In particular:

• Teleconsultations
  Teleconsultations are reimbursed in the same way as a face-to-face consultations (i.e., up to 70% is covered by Assurance Maladie, with the remaining 30% generally covered by the insured person’s private complementary health insurance), subject to the fulfilment of 3 cumulative conditions:
• compliance with the coordinated care pathway (subject to limited exceptions);
• alternating consultations and teleconsultations. The patient must be known to the doctor performing the telehealth procedure and had at least one physical consultation with this professional during the 12 months preceding the online medical consultation;
• territoriality (geographical proximity between the doctor’s place of practice and the patient’s home), with exceptions in the case of difficulties in accessing care or insufficient supply of care.
• Tele-expertise
  Tele-expertise is billed directly to the Assurance Maladie by the healthcare professional and is covered at 100% by the Assurance Maladie. To date, it is billed at 20 euros per procedure (up to a limit of four procedures per year for the same patient) for the requesting physician, and 10 euros, again with the same annual limit, for the requesting physician. The agreement with the health insurance company provides for assistance with equipment.
• Tele-surveillance
  Two 2023 decrees established a permanent framework for tele-surveillance (i.e., remote medical monitoring) and a related protocol has been signed in March 2023 between was signed by the Minister of Health, the Snitem, France Biotech and France Digitale.
• Tele-care
  Tele-care procedures performed by speech therapists and orthoptists are reimbursed under the same conditions as in-person procedures.

In Germany, health insurance (either statutory or private) is compulsory. Approximately 90% of the population in Germany is covered by the Statutory Health Insurance ("SHI" – "GKV") and only about 10% (the gross income of which is above the income threshold for compulsory insurance) by the Private Health Insurance ("PHI" – "PKV").

The SHI provides for a number of reimbursable telehealth services. Generally, telehealth services must be listed in the German Uniform Value Scale ("EBM") of the SHI according to Sec. 87 para. 1 of the SGB V in order to be reimbursable as standard medical benefits by the SHI. Currently, inter alia, remote monitoring for patients with cardiac resynchronisation therapy (CRT) implants or implantable cardioverter defibrillators (ICD), conciliar case discussions of X-rays, CT scans & MRI’s as well as online video appointments are listed in the EBM. Furthermore, the reimbursement of telehealth services may be subject to further limitations. The EBM is regularly amended and other telehealth services may be included in the standard benefits of the SHI in the future.

As regards to telehealth services covered by the PHI, as a general rule, the medical benefits provided by the PHI in Germany are more extensive than those provided by SHI. Therefore, benefits reimbursed by the SHI are generally also reimbursed by the PHI. In principle, this also applies to telehealth services.

There are no specific provisions under Greek law providing for the inclusion – or the exclusion – of telehealth services in the public health system. The general provisions regulating the public and private health insurance are applicable.

The public health system includes a wide range of telehealth services provided by HA, which manages 43 public hospitals and institutions, 49 Specialist Outpatient Clinics and 73 General Outpatient Clinics in Hong Kong.

The provision of telehealth services is done via HA Go, a one-stop mobile app for patients to access the HA services launched on 12 December 2019. HA Go allows its users to check appointments made with HA hospitals or clinics, pay HA bills and drug charges (excluding self-financed items), book appointment for general outpatient services and new case of specialist outpatient services, view medication and perform rehabilitation exercise following prescriptions.

The use of HA Go is free of charge, however, it is limited to patients over 18 years old who possess a Hong Kong Identification Card ("HKID"). Patients must activate the app at designated HA hospitals and clinics before using it. HA has announced that it will expand availability of the app to those who do not have a HKID and currently excluded groups in the future. Via HA Go, patients can also download various mobile apps published by HA.

In addition, a suite of apps have been launched on clinical mobile devices to allow clinicians to access patient data in the Clinical Management System On-ramp ("CMS"), a clinical management system that allows sharing of patients’ clinical data with the Electronic Health Record Sharing System ("eHRSS") in Hong Kong.

Healthcare services reimbursed in case of telehealth are as follows:

• check-ups, consultations
• ECG and EEG with telemetry
• certain activities related to colonoscopy
• dental health teleradiograph services
• Pain monitoring and computer assessment/case
• psychiatric counselling by telephone

Services such as local GP clinics may offer videoconference appointments or other telehealth services, and a partial refund for the cost of the appointment may be claimed back in the usual way. The fact that the service was provided virtually does not impact on the ability to reclaim any refund due.

Telehealth services are also provided privately in Ireland, by medical clinics, health insurers and non-insurance businesses. There are several private health insurers who offer telehealth services as part of their package to policy holders and the provision of this service is covered by the premium.

Although telehealth services are still more commonly used in private practice, the rules and guidelines adopted over the last three (3) years are expected to bolster the implementation of telehealth in the public sector.

In particular, two Italian regions – Lombardy and Puglia – have been identified as "lead" regions as they are at the forefront of the implementation of telehealth solutions in compliance with the guidelines and rules issued by the Agenas and the MoH.

The Italian NHS is expected to regulate in detail the costs – and conditions for reimbursement – of telehealth services in the public sector.

Based on Article 15 of the Regulation of Minister of Health of the Republic Indonesia Number 20 of 2019 regarding the Organisation of Telemedicine Services through Health Service Facilities:

1. Telemedicine services fees shall be borne by the Consultancy-requesting Fasyankes (i.e. health facility).
2. The amount of Telemedicine Service fees for health insurance programs shall be determined by the Minister.
3. Other than the health insurance program, Fasyankes may determine the amount of Telemedicine Service fee through cooperation between Consultancy-Providing Fasyankes and Consultancy-Requesting Fasyankes.
4. The amount of telemedicine Services fees through agreements shall be in accordance with the fees guidance that is determined by the Minister.

Public health system does not cover telehealth except for the following special policies:

• Telehealth services of certain specific areas such as paediatrics and life-style related diseases covered by public health insurance.
• Some local governments such as the Saitama prefecture provide subsidies to encourage medical institutions to adopt telehealth systems.

Additionally, some insurance companies have announced that their insurance programs cover telehealth services.

As far as we know the Kenyan public health system is yet to provide telehealth services. However, the Ministry of Health in conjunction with the Communication Authority of Kenya commenced the development of the Digital Health Platform in 2022. This platform which will enable real-time collection of patient data and provide platforms for integration with other critical databases. The platform is part of a telemedicine program to be implemented across the country to improve access to healthcare, particularly in remote and marginalized regions. Piloting of the program will be conducted in two national hospitals.

Some private health insurance companies do provide coverage for telehealth services.

The public health system does not offer telehealth services. The private medical centres which offer certain services and price these in the same manner they price other services.

As discussed above, the public health system includes telehealth services. Any patient can use a teleconsultation platform (e.g. the eConsult platform).

Via the eConsult platform, the health professional and patient can establish contact during teleconsultation. After the teleconsultation, the health professional can send prescriptions electronically to the pharmacy where the patient can then pick up their medication. If applicable, the prescription for a COVID-19 screening test is also e-mailed to the laboratory or Advanced Care Centre (Centre de Soins Avancé). The same procedure also applies to the sending of the certificate of incapacity for work to the Luxembourg National Health Fund (Caisse nationale de santé or the "CNS"). The Honorary Memorandum (Mémoire d’honoraires) is also sent electronically.

The teleconsultation fee is generally in line with the fee for a face-to-face consultation with the relevant health professional. In general, the patient pays the health professional’s invoice directly and requests reimbursement from their competent health insurance fund. The reimbursement rate for teleconsultations is 88% of the fees for adults and 100% for children under 18 years old.

Medications, whether prescribed during a teleconsultation or not, are generally covered by the so-called "third party payment system", i.e., upon presentation of their social security card and the medical prescription, the patient pays only a part of the costs (i.e., those costs, which are not reimbursed by the CNS or which are excluded from the third party payment system). Medications are divided into three separate categories. For each category, there is a specific reimbursement rate of 40%, 80% or 100%.

Yes, the Mexican Social Security Institute ("IMSS") and the Institute for Social Security and Services for State Workers ("ISSSTE") provide telehealth services.

However, those services are limited to patients from difficult-to-access parts of the Mexican Republic who require medical attention in a certain medical specialty. Such services are part of the social security of Mexican workers.

Not applicable.

The public health system does not include any provision regarding telehealth.  In fact, there is currently no regulation, policies or plans dealing with telehealth.

Certain medical aid funds in Namibia have recognized the value of telehealth and covers the costs of certain telehealth services incurred by its members.

The reimbursement of telehealth services is not dependent on the physical of digital nature of the services. More so, certain health services and therapies are reimbursed through the obligatory basic health insurance package. If the patient has additional private insurance, additional health services may be reimbursed as well. A health service or therapy that would be reimbursed if it were face-to-face will also be reimbursed if the meeting is now digital. There are no specific exclusions that we are aware of.

Telehealth services are provided in public health systems through several provisions such as the e-Health/Telemedicine programme of the Federal Ministry of health at a federal level. State governments have also introduced telehealth services into public health systems especially as a response to the Covid 19 – Pandemic. Eg. The Lagos State government through the Lagos State Health Management Agency introduced the ‘Eko Telemed’, a Telemedicine initiative to cater for Health issues not related to COVID-19. These services are either free or subsidized for each programme.

Telehealth services in Nigeria have mainly been driven by the private sector. Several private sector entities offer telehealth services and as at such private health insurance companies would typically cover provisions for telehealth services to policy holders where the parties agree on it.

The Ministry of Health’s National Telehealth Services provides free telehealth services which mainly focus on addiction and other mental health issues. Registered nurses can also provide health triage and advice via telehealth. The National Telehealth Services also has specific services like a diver emergency service hotline, elder abuse response services, and family violence support.

Most of New Zealand’s District Health Boards are actively engaged with providing telehealth services across the adult and women’s health, allied health, ambulatory and clinical, mental health, and paediatrics sectors. Most treatment and services in the public healthcare system is either subsidised or free (depending on patient eligibility).

Insurance coverage will be limited by individual policies but we are not aware of such services being typically excluded. In response to COVID-19, there has been an increase in private mental health telehealth services being covered by insurers, and exceptions allowing patients to claim for their specialist consultations by video or phone.

Yes, the public health system includes several telehealth services, however generally on a voluntary basis. Telehealth services, where offered, are generally an integral part of the Norwegian healthcare system (where all residents are covered by the National Insurance Scheme (Folketrygden, NIS)), and some services are offered free of charge, some subsidised, some reimbursed and some must be paid privately in full.

Yes, please see the answer for the above inquiry. Omani citizens receive free healthcare from the state including the telehealth services, with residents paying their own healthcare costs or more typically relying upon insurance policies. However, for non-Omani employees, the employers are obligated to cover the medical expenses.

The public health system includes telehealth services in regard of certain types of healthcare services (e.g. primary health, outpatient services etc.) and subject to certain conditions laid down in the law and ordinances of the President of the National Health Fund.

The SNS includes telehealth services, notably appointments with medical doctors using videoconference, teleradiology, telecardiology,  telepsychiatry and tele-emergency. Telehealth services have been expanding since 2017, aiming to increase the number of SNS establishments providing such services and, for those already using telehealth, increasing the types of services available

The specific format of teleconsultations to be provided – teleconsultation in real time, teleconsultation in deferred time (stored and forwarded), and dermatologic tele-screening – is established by Dispatch of the Deputy Secretary of State of the Minister of Health. The   first consultation should be in the presence of the doctor / patient without prejudice of specific rules applicable to dermatology.

In primary healthcare, it is possible for patients to request a teleconsultation appointment, whilst within the scope of hospital healthcare, teleconsultation appointments are always subject to evaluation by healthcare professionals.

The provision of primary healthcare (specifically, appointments with a medical doctor, emergency hospital services, and additional diagnostic and therapeutic tests) when performed on services belonging to the SNS is for a fee. This standard user fee (and its exemptions) also applies to telehealth services. Payment for telehealth services provided by the SNS to its users can either be subsidised or reimbursed, as applicable.

The public healthcare system includes telehealth services (see Fields of healthcare).

Telehealth services on offer are available for all patients free of charge provided the patients are registered with PHCC and HMC and hold health cards.

GEO no. 196/2020 and its methodological norms apply to both public and private healthcare providers.

GEO no. 196/2020 provides that the telehealth services may be reimbursed from public funds in accordance with the general rules for reimbursement of medical services. This means that some telehealth services can be free of charge for patients, similar to face-to-face medical services.

Private health insurance, which can be taken up with private healthcare providers, may cover other telehealth services, depending on the package or offer of each private healthcare provider.

As discussed in Fields of healthcare, because of its limitations, telehealth services are not yet widely used in Russia. As of today, there is no established mechanism on providing subsidised or reimbursed telehealth services as distinct from other medical services. However, we are aware that some private health insurance companies consider coverage of telehealth services in scope of their insurance, but this is at early stage of development.

"Seha" is the Saudi e-health App issued by the Ministry of Health and is free of charge. The App provides visual medical consultations and allows all citizens anywhere to have face to face medical consultations with their doctors across KSA.

The Seha application is designed to enable audio-video communication during specific timings during weekdays and weekends.

South Africa's public health system does not include telehealth services.

Certain private insurers include various telehealth services in their insurance plans. The use of telehealth services will depend on the insurer and the specific insurance plan.

Patients may consult telehealth services and pay for the services privately.

Yes, the Smart Health Video Consultation ("SHVC") system, which leverages video conferencing technology to allow patients to remotely consult their care team online, has been implemented at most hospitals in Singapore, including the Singapore General Hospital, Tan Tock Seng Hospital and the National University Hospital. This platform will also be available at Ng Teng Fong General Hospital, Singapore National Eye Centre, National Neuroscience Institute and the National Healthcare Group Polyclinics soon. The SHVC system was implemented by the Integrated Health Information Systems ("IHiS"), the technology agency for Singapore healthcare.

Generally, regular consultation charges should apply unless otherwise stated. We also note that certain subsidies are only available for in-person consultations. However, we highlight that from 3 April 2020, patients who qualify for the Community Health Assist Scheme ("CHAS") and MediSave payments can attend their regular follow-ups of seven chronic conditions through video consultation and use their CHAS subsidies and Medisave to pay for such consultations. This will apply to patients with diabetes, hypertension, lipid disorder, major depression, schizophrenia, bipolar disorder and anxiety, and is meant to support safe distancing due to the current COVID-19 pandemic. This will remain in force until the deactivation of the Public Health Preparedness Clinic scheme, or as otherwise determined by the MOH.

Generally, telephone consultation means the provision of information to a patient or their legal representative in connection with a medical condition in case that the patient is unable to come to the clinic due to the current COVID-19 situation. The provided medical services are accepted by each health insurance company in Slovakia (Union, Dôvera, Všeobecná zdravotná poisťovňa) if the relevant medical advice or consultation is capable of being provided as telehealth service.

Generally speaking, the services provided in the context of the eVEM/eZdravje platform and services linked thereto are provided free of charge.

Private health insurers, on the other hand, may cover the costs of telehealth services, especially by way of providing their own telehealth services.

In principle, public assistance could also cover telehealth services, however, each autonomous region of Spain is entitled to organise this as it sees appropriate. Telehealth services provided to the public assistance would have the same conditions that face-to-face services have, in terms of free of charge, subsidised or reimbursed.

Withstanding the above, some private health insurance companies are currently offering in Spain telehealth services.

Telehealth in the form of digital healthcare visits is included in the public health system. Patients pay a patient fee (Sw: patientavgift) for such visits. The Swedish Regions and County Councils (Sw. Sveriges regioner och kommuner (SKR)) have issued recommendations for the public sector regarding minimum patient fees for such visits, available (only in Swedish) here. The price of the patient fee depends on the county council (region) in which the healthcare provider is registered.

Fees for veterinary care is generally covered by private health insurance.

There is yet to be a clear guideline or development in this area. How the public health system in Thailand makes use of this fast growing technology is something to watch in the future.

Similarly, whether or not such services are covered by private health insurance would depend on the terms of the insurance and the agreement between the insurer and the insured (e.g. whether or not "healthcare service" includes telemedicine). We have also seen cooperation between a hospital and an insurer in developing an application to provide telemedicine services to the patients / insured.

UAE citizens receive free healthcare from the state, with residents paying their own healthcare costs or more typically relying upon insurance policies. On this basis, we understand that each of the services listed below would be provided free of charge to citizens.

In December 2019, the Dubai HA launched a smart service called Doctor for Every Citizen. Under this service, individuals can access free consultations through voice and video calls, 24/7. The service covers initial consultation and follow-ups with Dubai HA-certified physicians. The physician can request for laboratory and radiology tests and issue electronic prescriptions. When launched, this service was for UAE citizens only. However, after the spread of COVID-19, the Dubai HA suggests that this service was extended to all residents of the emirate of Dubai (i.e., including expatriates living in Dubai). We understand however that this extension only relates to cases which related to COVID-19, and it is not clear whether there would be a cost for non-citizens to access such a service.

The AD DOH launched the DOH RemoteCare app through which people can receive healthcare at their own homes, without visiting a hospital or clinic physically. The app has a tool for examining symptoms, diagnosing non-emergency cases, booking appointments and getting teleconsultations with doctors via voice or video calls or text messages. We understand that the AD DOH's intention is for healthcare providers across the Emirate to make use of this platform, which would allow for residents to access services via the platform at a personal cost or at the cost of their insurance provider (subject to approval).

The Federal Ministry of Health and Prevention recently launched a chatbot service called "Virtual Doctor for COVID-19". Individuals can use the service to assess whether their symptoms may be associated COVID-19. The chatbot in the Virtual Doctor service asks questions relating to the persons' travel history, if they have come in contact with someone who has travelled and is sick and if they have come in contact with someone known to have COVID19. It also asks if the person is suffering from specific symptoms and about his health habits. Depending on the person’s answers, the chatbot will deduce if he / she is at risk. It will connect them to a doctor through the same service. It is not clear whether there would be any associated cost for this.

Since the COVID-19 pandemic, the Federal Ministry of Health, in conjunction with the Dubai HA and AD DOH, has launched the "Al Hosn" contact tracing and test result app. The app provides the user with their test results (if a test is taken) and can also monitor contacts with other app users. Users consent at registration to the use of the data on the app being made available to the health authorities on an anonymised basis. The contact functionality of the app relies on the phone's Bluetooth connectivity being kept on at all times and the transfer between app users of anonymised data showing contact. The individual's (and any dependents') data is kept in encrypted form on the app. Anonymised data regarding contacts with other Al Hosn app users that is older than 21 days is deleted from the app. Currently the Al Hosn app is voluntary. However a Federal Attorney General directive requires that people testing positive must quarantine and may need to use a tracking system.

The NHS (the UK’s public health system) is using telehealth to supplement its current provision of healthcare services and as an alternative during the COVID-19 pandemic. These services are free of charge and are part of the national health service coverage provided to UK citizens. During the COVID-19 pandemic, many consultations were carried out remotely, and via video conferencing.

The NHS has recognised the benefit of using technologies as part of healthcare for some time. It developed the Technology Enabled Care Services ("TECS") Resource for Commissioners in January 2015. The intention of this resource was to raise awareness of how the wide range of TECS can support commissioning intentions and benefit patients, families, health and social care professionals and provider managers. No specific examples of services are provided in the resource (although a TECS evidence database and TECS Case study database can be accessed separately), and it is instead designed to promote the use of technology including the use of telehealth services within the healthcare profession. This does, however, illustrate the NHS’s endorsement of telehealth and its appreciation that such can be used in the provision of healthcare.

Medicare

Coverage and reimbursement for telemedicine services in the federal Medicare Program are extremely restrictive. The Medicare Program provides coverage for U.S. seniors aged 65 and older and certain individuals with qualifying disabilities.  

The “telehealth services” definition at Social Security Act Section 1834(m), which governs Medicare coverage, includes multiple coverage limitations including for originating sites, geography, eligible practitioners, eligible services, and qualifying technology. For example, the “originating site” requirements prohibit most Medicare beneficiaries from receiving covered telemedicine services from sites such as private residences. During the pandemic, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) allowed the Centers for Medicare and Medicaid Services (“CMS”), the agency that administers the Medicare Program, to remove these requirements under broad waivers to expand telehealth adoption. However, these waivers apply only during the declared PHE. Now that the PHE is ending as of May 11, 2023, Congress needs to take action in order to permanently ease coverage restrictions on telehealth under the Medicare Program. 

Some Medicare telehealth reforms appear here to stay. These include the provision of mental health services via telehealth, so long as the provider sees the patient in-person once every six (6) months, and the use of remote patient monitoring and remote therapeutic monitoring for Medicare patients. We also note that the Consolidated Appropriations Act (CAA) of 2023 extended several temporary telehealth flexibilities through 2024, including the geographic and originating site requirements, the expanded range of provider types eligible to deliver telehealth services, and the ability for Federally Qualified Health Centers and Rural Health Clinics to be distant site providers.  During the PHE, CMS reimbursed telehealth at the same rates as in-person visits; however, absent further extension of the policy by lawmakers, these reimbursement rates are set to end this year. We expect continued development from at the Congressional and agency level with respect to Medicare coverage for telehealth services.  In addition, the U.S. Department of Health and Human Services Office of Inspector General (“OIG”) issued guidance allowing flexibility with regard to healthcare providers reducing or waiving cost-sharing amounts for Medicare beneficiaries receiving telehealth or remote patient monitoring services during the PHE; although, absent and extension or additional OIG guidance, this temporary flexibility also ends on May 11, 2023, with the end of the PHE.

Medicare coverage of telehealth, even where available, is not free for patients. Medicare typically covers 80% of the cost of the service and the beneficiary is responsible for paying the remaining 20%. We note that coverage for telehealth is available to some degree in other federal programs such as under the Veterans Benefit Administration and many Medicare Advantage plans. Medicare Advantage plans are available to Medicare beneficiaries for additional premium payments and are operated by private commercial insurance plans that receive capitated payments from the Medicare Program to provide care to enrolled beneficiaries. Medicare Advantage plans must offer the basic coverages available to traditional Medicare beneficiaries and may also offer additional services, such as expanded telehealth services. Beneficiaries in these plans will also have co-payment responsibilities for covered services.

Medicaid

State Medicaid Programs, which cover lower income and disabled individuals, as well as many private commercial insurance plans, often follow the Medicare coverage rules. However, telehealth coverage has been expanded in state Medicaid Programs despite the Medicare Program’s coverage limitations. That being said, coverage under Medicaid will differ based on each state and each state may have different requirements for what modality of telehealth is permitted and what provider-types may deliver services via telehealth. Unlike Medicare, Medicaid beneficiaries receiving covered telehealth services may not have any co-payment obligations. As Medicaid is a joint federal/state program, the extent of telehealth coverage and the reimbursement for such services will vary by state.

Commercial Insurance

Telehealth services may also be covered by private commercial insurance plans, which has expanded in recent years. Certain states have passed telehealth parity laws which require licensed insurers to cover services delivered via telehealth to the same extent as coverage for the same service when delivered in-person. Parity laws may relate to coverage of the service (i.e., telehealth services must be covered but need not be reimbursed at the same rate) or reimbursement of the service (i.e., telehealth services must be both covered and reimbursed at the same rate as in-person services). Additionally, parity laws may apply to the states’ Medicaid programs, Medicaid managed care organizations, state employee health programs, or commercial payors operating in the state. Apart from any state parity of coverage mandates, commercial payor coverage of telehealth services will vary by payor and any restrictions will often exist in provider agreements, provider manuals, or specific payor guidance.

The public health system is heavily subsidized by the Government, to the extent that numerous health care services are free of charge. In public health facilities, payment is often for standard fees such as registration. To the extent that medicinal drugs are available, these drugs are often dispensed at no charge. Following the enactment of the National Health Insurance Act no. 2 of 2018, there is a robust program to reinvigorate the provision of medical services in Zambia. The implementation of this statute, which commenced around two years ago, requires employers to provide a mandatory financial contribution to their employees of 1% of every employees annual pay to be used for any health services that the employee may require. This is largely anticipated to guarantee the provision of health services.

Where an individual accesses their private health insurance, whether such services are covered under that insurance is not determined by the method under which those services are provided (i.e. teleheath or otherwise) but, rather, is largely determined by the underlining cover of the individual. As such, if consultations were covered under the individual’s private health insurance, which is often the case, then this coverage will extend to telehealth and in-person consultations.

In 2021, the Ministry of Health reported that it launched the Impilo Virtual Health System which was intended to bolster and support “health-system and records management; health education and clinical decision-making; and support for behavioural changes related to public health priorities and disease management”. This system was to be government funded and therefore, free of charge.

Moreover, the Zimbabwe Telemedicine Network (ZTN) provides training for medical professionals using digital educational health solutions. In 2019, it was reported that the ZTN launched a digital health application which was expected to provide health education and other digital tools for use by health professionals.

Private health insurances companies cover telehealth services, so long as the services fall within the limits of the tariff provided by the private health insurance. Currently, one of Zimbabwe’s leading private health insurance providers provides cover for Dial-a-Doctor services.