CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Telehealth

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This policy governs coverage, clinical criteria, limitations, provider requirements, and billing considerations for telehealth and telemedicine services across Commercial, BadgerCare Plus/Medicaid SSI, Family Health Center, Medicare Advantage, Medicare Supplement, and Third Party Administration products.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyTelehealth

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateFebruary 1, 2026

Last ReviewJan 5, 2026

Next Review DateN/A

Key ActionUse the current CMS telehealth services list and applicable Medicare guidance when determining Medicare Advantage telehealth coverage.

SourceLink

POLICY UPDATE CHANGES

Align, Align DSNP, and Great Plains Medicare Advantage health plans were added to the policy effective January 1, 2026.

The Medicare Advantage section was updated with the 2026 list of telehealth services.

6Product sections addressed

10Commercial telehealth service categories

13Eligible Commercial provider types

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CurrentSecurity Health Plan of Wisconsin, Inc.Policy N/A

Telehealth

Customize your policy alerts

Sign up for all security_health_plan_of_wisconsin_inc policy alerts

Know when security_health_plan_of_wisconsin_inc releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyTelehealth

Policy CodePolicy N/A

Change TypeMaterial update

Effective DateFebruary 1, 2026

Last ReviewJan 5, 2026

Next Review DateN/A

Key ActionUse the current CMS telehealth services list and applicable Medicare guidance when determining Medicare Advantage telehealth coverage.

SourceLink

POLICY UPDATE CHANGES

Align, Align DSNP, and Great Plains Medicare Advantage health plans were added to the policy effective January 1, 2026.

The Medicare Advantage section was updated with the 2026 list of telehealth services.

6Product sections addressed

10Commercial telehealth service categories

13Eligible Commercial provider types

Coverage Criteria

Commercial initial coverage criteria

Commercial telehealth services are covered when all applicable conditions are met.

Commercial telehealth requirements

Allowed member location
- The member is at home.
- The member is in a medical professional setting.
Allowed communication method
- The service uses real-time interactive audiovisual communication.
- The service is provided by telephone to an established patient.
- The service is provided through an established-care online patient portal or captured video or image option offered by the facility.

Commercial covered service types

The following Commercial services can be performed via telehealth when clinically appropriate.

Covered service categories: Office visits; consultations; behavioral health services, including mental health and substance abuse services; care management visits; medication management visits; diabetes education visits; nutritional counseling; speech therapy; occupational therapy; or physical therapy.

Services that independently require prior authorization, such as therapy, remain subject to that requirement.

Commercial provider eligibility

Commercial telehealth may be performed by the following provider types when otherwise qualified and when the service is appropriate for telehealth.

Eligible provider types: MD, DO, PA, NP, CNS, registered dietician or nutrition professional, pharmacist, speech therapist, physical therapist, occupational therapist, PhD, licensed professional counselor, or clinical social worker.

Services should be delivered at the best location for the member to receive the required service.

BadgerCare Plus/Medicaid SSI criteria

BadgerCare Plus/Medicaid SSI telehealth coverage follows applicable ForwardHealth requirements.

BadgerCare Plus/Medicaid SSI requirements: The service is payable under the ForwardHealth interactive fee schedule and meets applicable provider, specialty, place-of-service, telehealth, and supervision requirements.

The Health Plan will not be more restrictive than fee-for-service Medicaid under the BadgerCare Plus HMO contract. Providers should consult the ForwardHealth Physician's Handbook and applicable telehealth topics.

Family Health Center criteria

Family Health Center telehealth services are covered when the following product-specific conditions are met.

Family Health Center requirements: The service is provided through a contracted provider, is otherwise covered, is delivered in compliance with HIPAA and standard coding rules, and meets applicable clinical criteria.

Members may receive services at home. Family Health Center follows Commercial policy for its expanded telehealth services. Connection fees are not paid. Telehealth services completed in an emergency department are covered only when the emergency department service is also covered and the encounter does not result in surgery, cardiac catheterization, inpatient hospitalization, observation care, or extended recovery room care.

Medicare Advantage criteria

Medicare Advantage telehealth coverage follows Medicare guidelines and the applicable 2026 telehealth service list.

Medicare Advantage requirements: The service is a Medicare Part B service or an additional Health Plan telehealth benefit, is medically appropriate for telehealth, is furnished by a contracted network provider that offers the service via telehealth, and meets applicable Medicare and Health Plan requirements.

The applicable 2026 telehealth service list includes services such as skilled nursing facility, emergency and post-stabilization care, urgently needed services, partial hospitalization, home health, primary and specialty care, behavioral health and substance abuse services, therapy, diagnostic procedures and tests, outpatient hospital and observation services, ambulance services, kidney disease education, glaucoma screening, diabetes self-management training, preventive services, eye exams, and hearing exams. Services may be received in person or via telehealth when medically appropriate. Applicable cost sharing is the same as for the corresponding medical-facility service.

Medicare Supplement criteria

Medicare Supplement telehealth coverage follows Medicare guidelines.

Medicare Supplement requirements: The telehealth service meets applicable Medicare guidelines and the member's benefit coverage requirements.

TPA criteria

TPA coverage is determined first by the member's Summary Plan Description.

TPA requirements: The service is covered and is not limited or excluded by the member's Summary Plan Description, and the service meets applicable clinical authorization criteria.

If the Summary Plan Description has no specific guidelines or criteria, the Commercial criteria apply.

Commercial coverage excludes facsimile transmission; Skype, Facebook, chat, email, and text messaging; telephone or computer communications that do not meet telehealth requirements or use a secure site; internet consultations, visits, or services; installation or maintenance of telecommunication devices or systems; and software or applications for managing acute or chronic disease. Excluded communications and routine services also include provider- or member-initiated email, appointment or diagnostic-test scheduling, refilling or renewing existing prescriptions without a substantial clinical change, reporting test results, updating patient information, providing educational materials, appointment reminders, referral requests, clarification of simple instructions, and consultative messages followed immediately by an office visit. Coverage also excludes routine post-procedure follow-up without a complication or new condition, encounters followed by advice to obtain face-to-face care within 48 hours, services that would not be charged during a regular office visit, and otherwise noncovered telehealth services.

For permanent BadgerCare Plus/Medicaid SSI policy, supervision requirements must comply with applicable ForwardHealth policy and licensing or certification rules. Supervision of personal care workers and home health aides must be performed onsite and in person by the registered nurse; supervising providers must physically visit the member’s home and directly observe the paraprofessional providing services.

Family Health Center does not pay connection fees. Telehealth is not covered when the member is inpatient, under observation, or receiving extended recovery care. Telehealth completed in an emergency department is covered only when the emergency department service is covered and the encounter does not result in surgery, cardiac catheterization, inpatient hospitalization, observation care, or extended recovery room care.

Coding and Billing

Telehealth modifierModifier

95	Modifier 95 identifies services performed and provided through telehealth.

Provider Requirements and Operational Rules

Prior Authorization

Commercial Prior Authorization

No prior authorization is required for Commercial telehealth services. However, the member must meet the applicable clinical authorization criteria when the claim is submitted, or payment could be impacted.

Prior Authorization

Services With Separate Authorization Requirements

Telehealth does not waive independent authorization requirements. Services that require prior authorization under the applicable benefit or service policy must still be authorized, including therapy services.

Prior authorization remains required for services subject to separate authorization rules, including speech, occupational, and physical therapy when applicable.

Prior Authorization

BadgerCare Plus/Medicaid SSI Authorization

Background

Telehealth is a method of delivering health care, diagnosis, consultation, treatment, or medically relevant data through audio, video, or data communications. Interactive telehealth may be provided when the provider is not physically with the member, provided the use of telehealth does not reduce the quality, safety, or effectiveness of the service.

Definitions

Telehealth or telemedicine services

DefinitionA practice of health care delivery, diagnosis, consultation, treatment, or transfer of medically relevant data by audio, video, or data communications.

Delivery contextCommunications may be used during a patient visit or consultation.

Provider-to-provider useCommunications may transfer medically relevant data about a patient during a provider-to-provider consultation.

Interactive telehealth services

DefinitionA service delivered from outside the physical presence of a member using audio, video, or telecommunication technology.

Quality requirementThe service is interactive telehealth only if there is no reduction in quality, safety, or effectiveness.