Many states have written virtual care into their RHTP plans – the next move is getting all payers on board.
Written by: Libby Sagara
A rural FQHC patient waits months for a dermatology referral because the nearest specialist is two counties away. Meanwhile, a patient down the hall is finding out for the first time that they are no longer covered under Medicaid, not because her income changed, but because a form did not arrive in time. Multiply that across every rural clinic in the country, and the access problem becomes clear: it is no longer only about geography. Accessing needed health care services is increasingly about paperwork, fear, and a coverage system that tests eligibility more often than ever before.
Medicaid leaders now have a funding opportunity that can address these challenges through virtual care.
E-consult is the electronic, asynchronous exchange between a primary care provider and a specialist, conducted for the benefit of a patient, reducing wait time and travel. This is one of the fastest, least expensive interventions on the table. It does not require new brick-and-mortar infrastructure, licensing compacts, or years of workforce pipeline building. It requires a primary care provider, a specialist and a platform. Medicaid payer engagement is the key to addressing reimbursement challenges.
States are demonstrating commitment
The Rural Health Transformation Program (RHTP) is a five-year, $50 billion initiative , with CMS distributing funds to all 50 states beginning in 2026. States were required to submit implementation plans, and in these, every state included initiatives to expand access to health technologies in rural areas. States were incentivized in the application process to commit to policy actions related to virtual care, including expanding Medicaid coverage for telehealth.
California’s plan names e-consult as part of its rural hub-and-spoke care model, alongside perinatal psychiatry access programs. Tennessee’s first RHTP funding opportunity supports a Perinatal and Pediatric Behavioral Health Teleconsultation and Education project. Arkansas structured part of its $209 million THRIVE initiative around expanded telehealth access. States must obligate their first-year RHTP funds by October 30, 2026, with most subrecipient spending extending into 2027. The discretionary half of each year’s $10 billion pool is recalculated annually based on each state’s implementation progress and performance, meaning states who are unable to deploy year-one funds or meet reporting milestones risk a smaller allocation in year two. Getting money out the door quickly protects the next year’s award. That timeline is best suited to interventions that can launch within months, such as e-consult.
Under H.R. 1 – the same federal budget package that created RHTP – states must simultaneously implement six-month eligibility redeterminations and implement Work and Community Engagement Requirements for most adults in the Medicaid expansion population. The Congressional Budget Office has estimated the changes could push millions of additional people off Medicaid rolls, not only because they became ineligible, but because of documentation errors or missed deadlines. For rural clinics, that means a growing population of patients reluctant to come in at all: afraid of a coverage gap, immigration presence at the clinic, or a bill they cannot pay if the visit is not covered. E-consult gives a primary care provider a way to get a specialist’s input on that patient’s case without an unnecessary visit to an unfamiliar provider, or traveling to an appointment that took months to schedule.
State policies have been shifting to support e-consult for the past decade. CMS clarified in 2023 that Medicaid and CHIP programs may cover interprofessional e-consults, and California’s Department of Health Care Services added e-consult billing code 99452 to the Medi-Cal fee schedule in October 2024, aligning state policy with Medicare. In 2026, there is a new funding mechanism for rural providers with a sense of urgency behind it.
Why this matters for state Medicaid leaders and managed care plans
For state Medicaid leaders, RHTP creates a rare moment: money that has to move, tied to virtual care. That combination does not happen often. The practical takeaway is to include e-consult in this year’s budget cycle, and if it is not, build the case for next year now.
Funding a one-time pilot and sustaining ongoing reimbursement are different problems, however, and this is where managed care plans (MCPs) come in. E-consult only works at the clinic level if every payer covers it.
A clinic that gets paid for e-consult by one plan and not another cannot build it into a standard workflow. The referral coordinator should not have to determine which coverage applies before deciding whether e-consult is an option. Multi-payer alignment is the only way the model functions at scale. E-consult is meant for routine and non urgent referral requests – not for every referral – but it produces real savings by keeping patients out of more expensive acute settings, like the emergency room or an inpatient stay.
A California-wide study conducted in partnership with the UCSF Center for Innovation in Access and Quality showed 148,685 e-consults completed across 518 clinics in a single year, avoiding an estimated 942,000 specialty wait days and generating nearly $29 million in savings. These numbers answer the question, “why should our plan pay for this?”
In the near term, State Medicaid leaders can confirm e-consult is reflected in this year’s RHTP obligations. Health plans should treat multi-payer e-consult coverage as an imperative. Clinic and provider leaders should raise e-consult directly with their state’s RHTP decision-makers and their contracted plans, as this funding window is limited.
What the E-Consult Workgroup has learned about coalition-building
Over the past decade, BluePath Health has convened the E-Consult Workgroup engaging state Medicaid agencies, health plans, and provider organizations on multi-payer alignment. The Workgroup started by tracking early state and CMS policy movement on e-consult reimbursement. Now, our work is about how states are actually running programs, so other states can learn from what has worked. The operational question “how do you get a state Medicaid agency, several MCPs, and a network of rural clinics to agree on a shared referral and billing workflow?” remains the key barrier to widespread e-consult adoption.
E-consult technology adoption is not the challenge. The hard part is getting every payer to the table and working toward sustainability.
For a state Medicaid leader planning for rural health transformation, the key is to bring in payers early. For a health plan weighing whether to support e-consult, it is a reminder that waiting for other plans to move first is how these programs stall. Coalitions succeed when partners move these conversations forward rather than waiting for incentives to be perfectly aligned.
Further reading
CMS, Rural Health Transformation Program overview — medicaid.gov/resources-for-states/rural-health
Council of State Governments South, on RHTP’s annual performance-based funding — csgsouth.org/policies/rural-health-transformation-program
BluePath Health’s E-Consult Workgroup resource library — econsultworkgroup.com
About BluePath Health
BluePath Health is a healthcare consulting firm and the convener of the E-Consult Workgroup, a national coalition of state Medicaid agencies, health plans, and provider organizations working to expand e-consult access and reimbursement. BluePath combines deep policy and technical expertise with hands-on coalition facilitation to help states, plans, and providers turn funding opportunities like RHTP into programs that endure.