For many of the patients served by the Montpelier community health clinic All Brains Belong, being able to access health care through virtual and telehealth care appointments during and after the COVID-19 pandemic was a game changer.
When telehealth care became more widespread, “many patients were able to access health care that worked for them for the first time,” said Mel Houser, the founding physician of All Brains Belong, which focuses on providing care for patients with long Covid, chronic conditions or neurodevelopmental differences.
Even for the region’s large, mainstream providers, the broader flexibility for telehealth has proven crucial to many of their rural patients.
Dartmouth Health, among New England’s largest health care providers, has seen its online consulting with network specialists grow exponentially under new reimbursement rules that quickly became the norm for public and private insurers during the public health emergency.
But those federal rules changed overnight on Oct. 1, as some of the pandemic-era flexibilities that allowed Medicare to cover virtual appointments lapsed with the new federal fiscal year. Health care providers’ advocates nationwide have lobbied for years to make them permanent, and had at least hoped to see Congress approve further extensions as part of the next federal funding bill.
Now, with that funding bill still stalled — and large portions of the federal government shut down — the telehealth practices of small Vermont clinics and large hospital networks alike remain in limbo, along with the Medicare patients they serve. Nearly a quarter of the state’s population is on Medicare — 158,3600 individuals in 2025.
Separately, the lapse in authorization also means video or telehealth appointments can no longer count as the face-to-face encounters that Medicare requires for patients to be eligible for home health or hospice care.
Vermont state law requires that in-state insurers cover telehealth services to the same extent as they would cover the equivalent in-person services. But as a federal program, Medicare — the country’s health insurance program for people age 65 and older and those with certain disabilities — is not subject to that law.
Now that authorizations have reverted to pre-pandemic rules, Medicare covers telehealth — both audio-only and video interactions — only for mental health or substance use disorders, acute stroke treatment, or end-stage renal disease dialysis. For these conditions, updated rules allowing reimbursement for virtual care have been approved already through previous federal legislation.
But outside those specific kinds of treatments, telehealth visits are currently not eligible for Medicare coverage at all in metropolitan areas, which in Vermont means in and around Chittenden County. In the rural parts of the state, telehealth visits will be covered only if they occur in designated Medicare “originating sites” such as a local clinician’s office.
That rule negates many of the accessibility benefits telehealth opens up, Houser and other providers point out.
Many of her patients rely on the at-home format for a variety of reasons, she said. Some patients are thankful for the freedom from the risks of catching a virus in the clinic. Others appreciate avoiding sensory overload of visiting the office that can overwhelm some people with sensory issues. For another group, virtual visits remove the stress of needing to find or pay for transportation to the office.
Though commercial insurers may follow the standards Medicare sets, both insurers who sell plans on Vermont Health Connect, the state’s Affordable Care Act marketplace — Blue Cross Blue Shield of Vermont and MVP — are continuing to cover most telehealth care, spokespeople for each insurer confirmed to VTDigger. Vermont Medicaid coverage for telemedicine is also not changing.
At All Brains Belong, nearly half of the 350 patients her small clinic serves are on Medicare or Medicaid, Houser said.
While Vermont Medicaid and private health insurers are continuing to reimburse for virtual and telehealth services, Houser said she is now unable to bill Medicare for the care. For now, those patients can self-pay for the service, tapping into the sliding scale costs the clinic is able to offer with a mutual-aid Community Health Access Fund, or cover the cost of services with the clinic’s unique bartering service-exchange program.
“We are trying to catch people in the gaps,” Houser said. Still, for a small clinic, the loss of cashflow is substantial, she said.
Banking on a solution
The two largest providers for the state, Dartmouth Health and UVM Health, are continuing to provide telehealth services to Medicare patients and hold onto the bills, rather than seek other payments from Medicare patients. They are banking on the possibility that Congress will eventually act to expand the rules and approve the treatment retroactively.
Dartmouth Health has a broad range of telehealth care for patients in and out of the hospital, said Kevin Curtis, the medical director of Dartmouth Health’s Connected Care program. The network sees about 500 visits per week from Medicare beneficiaries using telehealth to their home, Curtis estimated. Nearly 200 of those patients are Vermont residents, he said.
At UVM Health, the Network has nearly 40,000 Medicare-related telehealth visits per year, said the network’s spokesperson Annie Mackin.
More than 6.7 million Medicare recipients used telehealth in 2024 — nearly 25% of the population eligible for it, according to claims data from the Centers for Medicare and Medicaid Services. Utilization in 2023 and 2022 was similar, while the pandemic years of 2020 and 2021 saw much higher use, with nearly half of those eligible taking advantage of Medicare coverage for telehealth.
Primarily, Dartmouth Health’s Curtis sees the need for telehealth care continuity as an access and equity issue, much as Houser at All Brains Belong does. The patients Curtis sees most benefit from at-home telehealth care are those with obstacles to getting to an in-person appointment, whether it’s a physical mobility challenge or no access to a bus or car to reach a clinic.
For some patients, in the remote reaches of New England that Dartmouth serves, specialty care could be a two-hour drive away, Curtis said. For others, the very nature of their medical condition — like an autoimmune condition — can make getting seen in person a higher-risk endeavor.
Also, Dartmouth Health has embraced telehealth as a great answer to many of the challenges that rural health care systems are facing, he said. It increases individuals’ access to specialists and helps make a hospital’s investment in those specialists more worthwhile.
Their providers have redesigned their physical office space around this hybrid model and now rely on telehealth and virtual appointments, making it difficult to shift their practices.
“You can’t just say ‘alright, let’s bring 40 patients back in a day.’ There’s no place for them,” Curtis said.
A barrier to home health care
For Vermont providers of home health care and end-of-life care, the loss of Covid-19 era flexibilities around virtual care has presented its own bevy of difficulties.
For Medicare to cover home health visits or hospice care at home, the federal insurance requires a face-to-face encounter with a provider — which previously could occur remotely, explained Eric Covey, the interim executive director of VNAs of Vermont, the trade association for visiting nurses and other home health care providers in the state.
He described a situation where, without telehealth, homebound Vermonters who may not have access to transportation may delay or forgo their visit with a provider that they need for the approval. “A chronic condition could worsen, and ultimately, they could end up in a situation where their condition worsens to a point that they need to be hospitalized,” he said.
That outcome is not just detrimental to the individual whose health is at risk, Covey said. It’s less expensive and taxing on the overall health care system to intervene earlier compared to sending someone to the emergency room or more acute care.
Many patients do receive referrals for home health or hospice care when they are being discharged from the hospital. However, for the small number of individuals who need these referrals through other means, the remote option can be crucial.
“The issue isn’t the volume. It’s the kind of severity and importance of the need that is about access to care for Vermonters,” Covey said.
It’s this element — the specific need each individual has for this care, rather than the sweeping breadth of all who use and stand to lose it — that concerns Curtis, the Dartmouth Health doctor.
“We talked about a lot of this in numbers and impact and 500 (visits) a week, but each one of these is a Medicare beneficiary. Each of these (statistics) is one person who is a Medicare beneficiary, who needs care in their rural setting,” he said. “There are still 500 people every week who we just need to get the care to, whatever it takes.”
This story was republished with permission from VtDigger, which offers its reporting at no cost to local news organizations through its Community News Sharing Project. To learn more, visit vtdigger.org/community-news-sharing-project.
