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Texas is urging patients to seek remote health care. Some insurance plans won't pay for it.

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Because of concerns over COVID-19, Julien Gomez wanted to move to online therapy sessions. Eddie Gaspar/The Texas Tribune

Julien Gomez speaks without reservation about how much they value their therapist.

“My mental health services have saved my life,” said Gomez, 27, who uses gender-neutral pronouns. “With everything that’s going on right now, I definitely want to keep seeing my therapist.”

There’s just one problem: Gomez says the COVID-19 pandemic has made in-person sessions at the therapist’s Central Austin office impossible because the therapist has a compromised immune system. But when the therapist suggested they connect via the Internet instead, Gomez said an insurance representative inaccurately told them the plan would only pay the therapist for in-person sessions.

As millions of Texans isolate themselves in an attempt to limit the spread of COVID-19, the disease caused by the new coronavirus that has killed more than 110 people in the U.S., state officials are working to ramp up the use of telemedicine, which allows patients to talk to health care workers by phone or video chat.

Doctors this week applauded a sweeping emergency rule from Gov. Greg Abbott, which requires state-regulated health plans to pay doctors for virtual visits at the same rate they would pay for an in-person visit. Meanwhile, the federal government is loosening restrictions on telemedicine in Medicare, the public insurance program for the elderly. The goal is to keep more people at home and reduce the risk of spreading infection at a doctor’s office.

Still, interviews with patients, doctors, therapists, insurers and regulators suggest that there is widespread confusion about which services will be covered as throngs of quarantined patients clamor for virtual appointments.

Texans’ ability to access telemedicine depends largely on the kind of insurance they have — if they have insurance at all.

Roughly half of Texans have employer-funded insurance plans that have wide latitude not to cover telehealth services, according to the Texas Department of Insurance. Abbott’s order only applies to state-regulated health plans, which cover about 16% of Texans.

Abbott also suspended a rule last week that required patients to have a face-to-face meeting with a doctor to initiate care. In a statement, the governor said allowing doctors to establish a physician-patient relationship via phone or video call would lead to an “increased supply of health care professionals who will be able to provide ... telemedicine services to Texans across the state.”

Christopher Crow, president of the Catalyst Health Network, which includes 600 primary care doctors, many who perform virtual visits, said government telemedicine regulations are changing so quickly, it’s difficult to keep up.

Crow says his network is moving at breakneck speed to help doctors make the switch to more online visits. “We’re having to do that, rather than over a period of years, we’re doing it over a period of days and weeks,” he said.

“Their business model is at risk otherwise,” he said. “We’re right in the middle of a historic transformation.”

Coverage confusion

Gomez, who has a state-regulated health plan from Blue Cross Blue Shield of Texas, appears to be eligible to have teletherapy services covered. A Texas law passed last year requires that state-regulated plans cover telehealth services “on the same basis and to the same extent” that plans cover in-person services.

A spokeswoman for the insurer told The Texas Tribune that plans like Gomez’s cover telehealth services provided by in-network clinicians. That was welcome news to Gomez, whose therapist is in the network — but contrary to what another representative from the same company had said, according to Gomez.

“They flat out told me that ... my sessions won’t be covered,” Gomez said, because even though their therapist was covered for office visits, she was not part of a limited telehealth network that Blue Cross contracts with.

A co-owner of the counseling group where Gomez is a client said she had not received a clear answer from Blue Cross Blue Shield of Texas about whether the insurer would pay her employees for remote appointments.

“There’s a lot of uncertainty with everything going on, in more ways than just our business, but in terms of our business, this is really hard because our clients are needing to be supported,” said Arielle Larson, co-owner of Yellow Chair Counseling.

“A lot of clients are scared, especially with a lot of them losing income, that if it’s not covered, they will be responsible for the balance,” she said. “It’s hard for me as a business owner to say, ‘Oh, no, don’t worry about that.’”

A spokeswoman for Blue Cross Blue Shield of Texas said the insurer is “evaluating our existing coverage for medical and behavioral health telemedicine and telehealth visits” in response to COVID-19. Late Wednesday, the insurer announced it would stop charging its fully insured members copays for telemedicine services.

Ann Robison, executive director of the Montrose Center, an LGBTQ community center in Houston that provides behavioral health services, said her organization was “running up against insurers not wanting to pay” for teletherapy.

The Montrose Center has more than 500 insured clients with varying types of coverage: Medicare, Medicaid, employer plans, state-regulated plans. Because of infectious disease fears, the center is transitioning to more remote counseling.

“What we’re telling clients is we will attempt to bill [insurance], and we’re going to tell the truth about it being telehealth, and if [the insurers] don’t pay us, then we’re going to have to come back to them” and ask for payment on a sliding scale, Robison said.

Before Abbott’s emergency rule, the Texas Department of Insurance heard from rural doctors “who were concerned about caring for their patients if they needed to quarantine or self-isolate,” agency spokeswoman Stephanie Goodman said.

The rule change “should make it far easier to treat patients and reduce the risk of infection,” she said, but she noted that it only applies to the 16% of Texans with state-regulated health plans.

A spokeswoman for the trade association representing employer-funded health plans did not respond to emailed questions.

Medicine by webcam

For Stacy Prince, a telemedicine appointment with a family doctor was an easy way to get her 16-year-old daughter medicine for strep throat.

Prince, 50, returned home to Plano last week after a family trip to New Orleans, where her daughter began to feel sick. A doctor asked about doing an appointment virtually because the office was trying to reduce foot traffic amid the COVID-19 outbreak.

The doctor sent Prince a link to open in her web browser. The doctor diagnosed strep throat and prescribed an antibiotic after examining the 16-year-old’s throat, illuminated by a flashlight, through a webcam.

“All they asked me was, ‘Are you still with your Aetna insurance?’ And they said OK, then that will be covered,” Prince said. “I would definitely do it again.”

Back in Austin, Gomez decided this week to try a teletherapy appointment — their first — without having confirmation that their insurance would pay for it. They turned on their laptop at home and spoke to their therapist through an online portal for an hour.

“It was great,” Gomez said. “I really love my therapist. It’s too important for me to not go.”

As far as billing goes, the therapy business owner said she’s hoping for the best.

“I won’t really believe it until I submit a bill and it comes back covered,” Larson said. “We’re hoping [Abbott’s] decree gives us some way, if they do get denied, to fight back against it.”

Disclosure: Blue Cross Blue Shield of Texas has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.