Key Takeaways
- A national legal mapping study found that state Medicaid telehealth policies expanded between 2018 and 2023, but coverage varied widely by service type and state, leaving significant gaps for vulnerable populations.
- A JAMA Health Forum study found that undocumented patients saw telehealth visits drop sharply as COVID-19 emergency flexibilities ended, while in-person visits did not fully recover either.
- A cross-sectional analysis of Washington, D.C. neurology patients found that patient portal activation rates were significantly lower in lower-income ZIP codes and census tracts, pointing to a structural digital access problem.
- A realist review of mobile health in home-based palliative care identified caregiver health literacy and device availability as the factors most likely to determine whether mHealth tools actually improve patient outcomes.
- Across all four studies, the populations with the least political and economic power faced the steepest access barriers—a pattern that policy fixes focused only on state law or reimbursement rates will not resolve on their own.
How much did state Medicaid telehealth policies actually expand between 2018 and 2023?
State Medicaid telehealth policies expanded substantially between 2018 and 2023, but the growth was uneven across states and policy categories. Patients in some states gained broad access while those in others saw little change. A national legal mapping study tracking all 50 state Medicaid programs across those five years found measurable increases in the number of states adopting specific telehealth coverage rules. However, gaps in reimbursement parity, eligible provider types, and covered modalities remained widespread at the end of the study window.
Here is what the data actually shows:
Coverage of audio-only visits grew significantly after 2020, driven by COVID-era emergency rules that many states later made permanent. The legal mapping study documents that not every state locked in those expansions, leaving patients in some states exposed to coverage rollbacks once public health emergency declarations ended.
Reimbursement parity — paying telehealth providers the same rate as in-person providers — was not universal by 2023. States varied widely on whether parity applied to all service types or only selected ones.
Eligible originating sites (the location where a patient can legally receive a telehealth visit under Medicaid) expanded in many states to include the patient’s home. Before 2018, many states required patients to travel to a clinic or hospital to receive a telehealth visit—a rule that defeated much of the point. For people without transportation or in rural areas, this change matters enormously.
Eligible provider types also grew, with more states adding behavioral health providers, federally qualified health centers, and rural health clinics to their covered telehealth rosters.
The five-year window the legal mapping study covers is important context for patients: policies that existed on paper in 2023 may have been emergency measures with expiration dates, not permanent statutory changes. A state that looked expansive in mid-2022 could look considerably narrower by late 2023 once emergency authorities lapsed.
Patients navigating Medicaid telehealth access should not assume that a service covered during the pandemic is still covered today. Contact your state Medicaid office directly, or ask your provider’s billing department to verify coverage before your appointment.
This section presents general information drawn from published research and public records. It is not medical advice, and nothing here should substitute for guidance from a qualified healthcare professional or your state Medicaid program.
What happened to undocumented patients’ telehealth access when pandemic rules expired?
When pandemic-era rules expired, undocumented patients lost telehealth access they had briefly gained — and the Medicaid telehealth gaps that existed before 2020 snapped back into place, leaving this population with fewer virtual care options than almost any other group in the United States.
A peer-reviewed study tracking outpatient and telehealth visits among undocumented patients found that telehealth use among this group rose sharply during the public health emergency, then declined as emergency flexibilities ended — a pattern distinct from what researchers observed in documented patient populations (PMID 42599733). The drop was abrupt.
Undocumented immigrants are largely excluded from full Medicaid coverage in most states. That exclusion has direct consequences for telehealth because Medicaid policy is the primary engine driving virtual care expansion at the state level. A national legal mapping study covering 2018–2023 documented how states expanded Medicaid telehealth policies across that period — but those expansions applied to Medicaid enrollees, a category most undocumented adults cannot access (PMID 42604452). The policy architecture built to widen telehealth access was built around a program that excludes the people most likely to lack other options.
During the pandemic, some of that exclusion softened in practice. Federally Qualified Health Centers — which serve patients regardless of immigration status — expanded telehealth delivery under emergency rules. When those rules expired, the centers retained some capacity, but the regulatory scaffolding that made rapid telehealth expansion possible came down. Undocumented patients who had connected with providers virtually faced new barriers: stricter audio-only restrictions in some states, tighter prescribing rules, and the return of in-person requirements for certain visit types.
The research on visit patterns makes the consumer-protection concern concrete. Telehealth visits among undocumented patients rose during the public health emergency period, then fell after its end, while in-person visits did not fully compensate for the loss (PMID 42599733). State Medicaid telehealth expansions between 2018 and 2023 varied widely, meaning the gap between states with generous policies and those without grew larger over the same period that undocumented patients were losing emergency-era access (PMID 42604452).
Patients in this situation should ask any telehealth provider directly whether the platform serves uninsured or self-pay patients, what visit types are available without Medicaid enrollment, and whether sliding-scale fees apply. Please note that no telehealth company’s marketing language substitutes for those specific answers.
This section presents general health system information for consumer awareness purposes and does not constitute medical, legal, or immigration advice. Consult a qualified healthcare provider for guidance specific to your situation.
Why are neurology patients in lower-income neighborhoods less likely to use patient portals?
Neurology patients in lower-income neighborhoods are less likely to use patient portals because Medicaid telehealth gaps, device access, and digital literacy stack up in ways that make portal activation a low priority against more immediate barriers. A 2025 cross-sectional study of neurology patients across Washington, D.C., put hard numbers on this pattern.
The PMID 42550887 study analyzed portal activation rates by ward, census tract, and ZIP code at a single neurology practice. Patients in lower-income wards activated portals at significantly lower rates than patients in wealthier neighborhoods — a gap that held even after researchers controlled for other variables. The geographic granularity matters: it wasn’t just a city-versus-suburb comparison. Block-level income differences predicted portal use within the same city.
Three concrete mechanisms drive this disparity.
Device and connectivity gaps. Patients without reliable broadband or a personal smartphone cannot complete portal registration, which typically requires email verification and sometimes two-factor authentication. The PMID 42594388 digital health review documents that low-income patients managing chronic conditions — neurological conditions included — face device access as a primary barrier to any digital health tool, not just portals.
Insurance coverage inconsistency. Medicaid coverage for telehealth-adjacent services varies sharply by state and has changed repeatedly since 2018, as the PMID 42604452 legal mapping study documents across a five-year national review. Patients with unstable coverage or plans that exclude certain telehealth features have less incentive to invest time in portal setup when they’re uncertain what the portal will actually unlock for them.
Trust and prior experience. The PMID 42550887 study found that neighborhood-level socioeconomic factors predicted activation independent of individual patient characteristics, pointing to structural distrust and prior negative experiences with health systems—not individual apathy—as a driver.
The PMID 42600073 palliative care review adds a mechanism that portal designers rarely acknowledge: digital tools perform best when patients already have a stable, trusting relationship with a care team. Neurology patients in under-resourced neighborhoods are more likely to see rotating residents or face long gaps between appointments — conditions that erode the relationship that makes a portal feel worth opening.
Clinics that report high portal activation rates as a quality metric without disaggregating by neighborhood income are measuring their most-resourced patients and calling it success.
This section presents general health system information for consumer awareness purposes and does not constitute medical advice, diagnosis, or treatment recommendations. Consult a qualified healthcare professional for guidance specific to your situation.
Does mobile health technology actually help palliative care patients at home?
Disclaimer: This section presents general health information for educational purposes only. It is not medical advice, a diagnosis, or a treatment recommendation. Consult a qualified healthcare professional for guidance specific to your situation.
Mobile health technology does help some palliative care patients at home — but the evidence is conditional, and the marketing around these tools runs well ahead of what the research actually shows. Medicaid telehealth gaps compound the problem: patients who depend on public insurance often can’t access the apps and remote monitoring platforms that studies examine, because coverage rules vary so sharply by state, as a 2025 national legal mapping study documents across the 2018–2023 period.
A 2025 realist review offers the most detailed look at what actually drives outcomes. That review of mobile health in home-based palliative care found that technology doesn’t work in isolation — outcomes depend heavily on context: the patient’s living situation, caregiver availability, digital literacy, and whether clinicians actively respond to the data the tools collect. When those conditions line up, mobile health can reduce unnecessary emergency visits and help patients manage pain and breathlessness between appointments. When they don’t, the same tools sit unused or generate alerts that nobody acts on.
The review identified three concrete patterns:
Symptom-monitoring apps improved patient-reported comfort only when clinical teams had clear protocols for responding to alerts—the technology alone did nothing without human follow-through. Caregivers, not patients, often drove app engagement in the final weeks of life; tools designed only for patient self-reporting missed this dynamic entirely. Patients with lower digital literacy or older devices dropped out of remote monitoring programs at higher rates, skewing published success data toward people who were already better positioned to benefit.
That last pattern matters for anyone evaluating a telehealth product’s claims. Vendors routinely cite aggregate satisfaction scores or symptom-improvement rates without disclosing dropout rates or the characteristics of patients who never engaged. A tool that works well for a 58-year-old with reliable broadband and a tech-savvy adult child may do very little for an 80-year-old living alone in a rural area with a prepaid phone.
Mobile health technology can be a genuine asset in home-based palliative care under the right conditions. Those conditions are specific enough that no app or platform should be marketed as broadly effective without disclosing who was studied, who dropped out, and what clinical infrastructure supported the trial.
Which populations face the steepest Medicaid telehealth gaps right now?
Three groups face the steepest Medicaid telehealth gaps right now: undocumented immigrants, patients managing chronic disease in low-connectivity areas, and neurology patients in low-income urban neighborhoods. The evidence behind each gap is specific enough to act on.
Undocumented immigrants
A peer-reviewed study tracking outpatient and telehealth visits among undocumented patients found that this population experienced sharp drops in both in-person and telehealth utilization during periods of heightened immigration enforcement, even when coverage was technically available — a pattern that researchers documented directly. Fear of data exposure and eligibility uncertainty suppress use regardless of what a state’s Medicaid telehealth policy says on paper.
Patients with chronic disease and limited digital access
A national legal mapping study covering 2018–2023 found that state Medicaid telehealth policies expanded significantly on paper — more states added audio-only options, broadened eligible provider types, and dropped originating-site restrictions. What the policy record cannot fix is the gap between a written rule and a patient who owns no smartphone, shares one device across a household, or lives in a rural county with unreliable broadband. A separate review of digital health tools for chronic disease self-care found that low digital literacy and device access consistently predicted who dropped out of digital care programs — not diagnosis severity, not age alone.
Neurology patients in low-income urban ZIP codes
This one surprises people. Rural broadband deserts get most of the attention. Still, a cross-sectional analysis of neurology patients in Washington, D.C. found that patient portal activation rates dropped sharply by ward, census tract, and ZIP code — meaning patients in low-income urban neighborhoods were far less likely to be enrolled in the digital infrastructure that telehealth depends on. No portal activation often means no telehealth visit, no test results, no prescription refill request. The gap is structural, not motivational.
Three concrete patterns emerge across these groups:
- Policy expansion does not equal access. A state can add audio-only Medicaid telehealth and still leave undocumented patients, digitally disconnected patients, and low-income urban patients behind.
- Fear and trust deficits function as access barriers just as reliably as missing broadband.
- ZIP code predicts digital participation in ways that income alone does not fully explain — neighborhood-level infrastructure matters independently.
Patients in any of these groups should ask their Medicaid managed care plan directly whether audio-only visits are covered, whether a community health worker can help with portal setup, and whether a nearby federally qualified health center offers on-site telehealth support as an alternative.
This section presents general public-health information drawn from published research. It is not medical advice, does not constitute a diagnosis or treatment recommendation, and does not predict individual outcomes. Consult a qualified healthcare professional for personal medical decisions.
FAQ
What are Medicaid telehealth gaps and why do they matter?
Medicaid telehealth gaps are differences between what telehealth services state Medicaid programs cover on paper and what patients can actually access. A 2025 national legal mapping study found these gaps varied significantly by state and service type between 2018 and 2023, meaning patients in some states had far fewer covered options than those in others.
Did undocumented patients lose telehealth access after COVID-19 flexibilities ended?
Yes. A study published in JAMA Health Forum found that telehealth visits among undocumented patients dropped sharply once pandemic-era policy flexibilities expired. In-person visits did not fully compensate for that loss, leaving a net reduction in care contact.
Why do neurology patients in poorer neighborhoods use patient portals less?
A cross-sectional study of Washington, D.C. neurology patients found that portal activation rates were significantly lower in lower-income census tracts and ZIP codes. The researchers identified neighborhood-level socioeconomic factors—not individual patient characteristics alone—as drivers of that disparity.
Can mHealth apps improve outcomes for patients receiving palliative care at home?
A realist review in JMIR mHealth and uHealth found that mHealth tools can improve symptom monitoring and caregiver communication in home-based palliative care. Still, outcomes depend heavily on caregiver health literacy and reliable device access. Without those conditions, the tools provide little benefit.
Which patient groups face the largest Medicaid telehealth gaps today?
Based on the studies reviewed, undocumented patients, neurology patients in low-income urban areas, and patients in home-based palliative care face some of the steepest barriers. These groups share limited digital infrastructure, lower portal activation, and reduced coverage under state Medicaid telehealth policies.
Did all states expand Medicaid telehealth coverage equally between 2018 and 2023?
No. The Milbank Quarterly legal mapping study found that while most states added telehealth provisions during that period, coverage scope differed substantially by state and service category. Some service types remained excluded even in states that otherwise expanded telehealth broadly.
What should patients do if they think they are being denied Medicaid telehealth coverage they are entitled to?
Patients can request a written explanation of any coverage denial from their Medicaid managed care plan or state Medicaid office and ask about the formal appeals process. Consulting a patient advocate or legal aid organization familiar with Medicaid rules in their state is also an option. This article does not constitute legal or medical advice.
This article is for general information and is not medical, legal, or financial advice. Telehealth services, prescriptions, and insurance coverage vary by state and provider — verify a provider’s licensing and consult a qualified professional before making care decisions.