AMA Future of Health issue brief: Commercial Payer Coverage for Digital Medicine Codes

Achieving fair, equitable and transparent coverage and payment of digital medicine services remains a challenge. These issues ultimately affect the widespread adoption and accessibility of digital medicine services for both patients and physicians.

The AMA Future of Health report (PDF) identified foundational pillars for optimizing digitally enabled care. One of those pillars is to improve and develop new payment models that incentivize high-value care. As part of the AMA’s ongoing work to drive the future of health care, the AMA, in collaboration with Manatt Health, did a landscape analysis of commercial payer coverage of digital medicine CPT codes. This research shows coverage by code for several commercial payers across the country and summarizes key themes.

The primary goal of this research is to provide a comprehensive understanding of the coverage landscape for digital medicine codes by commercial payers, shedding light on which services are funded and identifying untapped opportunities to bolster digitally enabled care. 

This issue brief (PDF) includes a detailed comparison of digital medicine code coverage across 16 commercial payers and presents key insights into the existing landscape of commercial payer coverage for digital medicine codes and services, as well as the decision-making processes behind coverage determinations.

• There is a lack of alignment across commercial, Medicare and Medicaid plans regarding coverage of digital medicine CPT codes. This lack of alignment makes it difficult for physicians to reliably provide digital services and for consumers to know what services are accessible to them.
• Within the commercial market, there is inconsistent adoption of new digital medicine CPT codes.
• The level of transparency regarding coverage of digital medicine services is highly variable across commercial health plans.
• There are varying processes and timelines for adopting new CPT codes across health plans.
• There is limited widespread utilization of most new digital health CPT codes, and health plans are eager for research on the impact and quality of digital medicine services.
• Health plans often partner with health tech companies directly to provide digital health services to members, but these directly contracted services are often disconnected from a patient’s medical home.