The Center for Connected Health Policy (CCHP) is running a series of newsletters focusing on what will happen to federal Medicare telehealth policy should the current temporary telehealth waivers expire, as they are now set to do on September 30, 2025. This series will appear in our weekly #TelehealthTuesday newsletters, however our regular multi-item newsletters that appear the second week of each month will remain a typical full newsletter. Additionally, each newsletter in this series will also specifically take into consideration what the telehealth Medicare policy landscape would look like if the proposals that the Centers for Medicare and Medicaid Services (CMS) made in the 2026 Physician Fee Schedule (PFS) are adopted as proposed. It is important to highlight that as we move forward, much can still happen to alter what CCHP is laying out in each #TelehealthTuesday edition. For example, Congress could again extend the waiver deadline to a date beyond September 30, 2025. Therefore, please keep in mind that what is written below only applies to Medicare if:
- The September 30, 2025 deadline comes to pass and no other action is taken on the telehealth policies, and
- The CMS 2026 Physician Fee Schedule proposals released in July 2025 are unchanged when they are finalized later this year.
Each #TelehealthTuesday email in this series will focus in on a specific item of Medicare telehealth policy that is currently subject to a temporary waiver expansion. The last edition of this series, released on August 5th, concentrated on “Location”. In today’s issue, we focus in on “Eligible Providers.”
PERMANENT MEDICARE TELEHEALTH POLICY ON ELIGIBLE PROVIDERS
Readers are likely aware that the temporary Medicare telehealth waivers, initially instituted in 2020 during the public health emergency (PHE), allow for all providers to use telehealth to provide services if:
- The provider was an eligible Medicare provider who could independently bill Medicare, and
- The service being delivered via telehealth was on the Medicare Telehealth Services List and is also a service that the provider would be eligible to provide.
In contrast, under permanent Medicare telehealth policy, there is a specific list of providers who are eligible to use telehealth to provide services and be reimbursed by Medicare. This specific list is embedded in federal law in the Social Security Act Section 1834(m)(m)(1) which states:
“The Secretary shall pay for telehealth services that are furnished via a telecommunications system by a physician (as defined in section 1861(r)) or a practitioner (described in section 1842(b)(18)(C)) to an eligible telehealth individual enrolled under this part notwithstanding that the individual physician or practitioner providing the telehealth service is not at the same location as the beneficiary.”
Therefore, given what is written in statute, should the current temporary waivers expire, the health care professionals who will still be able to provide services via telehealth and be reimbursed by Medicare, according to sections 1861(r)) and 1842(b)(18)(C)), are:
- Physicians
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- Nurse-midwives
- Clinical nurse specialists (CNSs)
- Certified registered nurse anesthetists
- Clinical psychologists (CPs) and clinical social workers (CSWs)
- Registered dietitians or nutrition professionals
- Marriage and Family Therapists and Counselors
Without having the waivers in place, the pool of eligible health care professionals who will be reimbursed by Medicare if they use telehealth to deliver an eligible service would be significantly reduced. Practitioners such as physical and occupational therapists, as well as speech language pathologists and audiologists, would no longer be reimbursed by Medicare if they use telehealth to treat a Medicare enrollee. Additionally, since this policy is embedded in federal statute, there is very little CMS can do through regulatory/administrative channels.
FEDERALLY QUALIFIED HEALTH CENTERS & RURAL HEALTH CLINICS
Currently, federally qualified health centers (FQHCs) and rural health clinics (RHCs) also fall under the Medicare telehealth waivers as eligible distant site providers. However, should the waivers expire and no other action is taken by Congress, FQHCs and RHCs will still be able to provide services using telecommunications technology. Readers may be questioning how this is possible if there is no statutory change. First, we must separate out the provision of mental health services from the provision of medical services by these entities. This is because for FQHCs and RHCs, there is a specific definition of what constitutes a “medical visit” and “mental health visit.” These definitions are not embedded in federal law. The definitions are created by CMS, and because CMS is the origin of the definition, CMS does not have to wait for Congress to make changes to that definition. In the 2022 PFS, CMS changed the definition of a “mental health visit” for FQHCs and RHCs to include the use of live video and audio-only to provide those services. The definition reads in federal regulations, section 405.2463(b)(3), as: A mental health visit is a face-to-face encounter or an encounter furnished using interactive, real-time, audio and video telecommunications technology or audio-only interactions in cases where the patient is not capable of, or does not consent to, the use of video technology for the purposes of diagnosis, evaluation or treatment of a mental health disorder, including an in-person mental health service, beginning January 1, 2026, furnished within 6 months prior to the furnishing of the telecommunications service and that an in-person mental health service (without the use of telecommunications technology) must be provided at least every 12 months while the beneficiary is receiving services furnished via telecommunications technology for diagnosis, evaluation, or treatment of mental health disorders, unless, for a particular 12-month period, the physician or practitioner and patient agree that the risks and burdens outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reasons for this decision in the patient's medical record, between an RHC or FQHC patient and one of the following:
(i) Clinical psychologist.
(ii) Clinical social worker.
(iii) Marriage and family therapist.
(iv) Mental health counselor.
(v) Other RHC or FQHC practitioner, in accordance with paragraph (b)(1) of this section, for mental health services.As a result of the mental health visit definition change, for the last few years, FQHCs and RHCs have been able to use live video and audio-only to provide mental health services and be reimbursed at their usual rates, not the calculated telehealth rate created by CMS to pay for telehealth visits. Therefore, it is because CMS changed the definition of a “mental health” visit that FQHCs and RHCs are able to receive their Prospective Payment System (PPS) rate/All Inclusive Rate (AIR), not because FQHCs/RHCs became permanent telehealth distant site providers. In CMS’ eyes, FQHCs and RHCs are not providing a “telemental health service,” but rather a “mental health visit” and are entitled to their usual rate. This also means these “mental health visits” that just happen to be delivered via live video/audio-only are not subject to permanent telehealth restrictions because again, FQHCs and RHCs are only providing a “mental health” visit. Therefore, should the September 30, 2025 expiration date pass and no changes be made, it will not impact an FQHC or RHC’s ability to use live video and audio-only to provide mental health services, though they must follow any additional rules they typically would related to providing a mental health visit. Additionally, starting at least in 2026, FQHCs and RHCs will also need to meet prior and subsequent in-person visit requirements for mental health visits in the patient’s home, as the waiver on those requirements for FQHCs and RHCs is currently set to expire on December 30, 2025. While the 2025 PFS delayed the mental health in-person requirements for FQHCs/RHCs through the entirety of 2025, CMS notes that they will be updating that policy in the 2026 PFS consistent with federal statutory waivers of general telemental health in-person requirements, which currently only apply through September 30, 2025. Medical visits via telecommunications technology are a little different for FQHCs and RHCs, however. Unlike mental health visits, there has been no permanent definition change specific to a “medical visit” for FQHCs and RHCs to include the use of telecommunications technology. In the 2025 PFS, however, CMS extended through December 31, 2025 an FQHC and RHC’s ability to use telecommunications technology to provide medical visit services. The reimbursement rate is the calculated amount CMS has made available for telehealth services reimbursement for these entities since 2020. FQHCs and RHCs are expected to bill medical visit services with G2025 and do not receive their usual PPS/AIR rate. However, CMS has solicited comments regarding a potential permanent change similar to that provided for mental health visits. Additionally, in the 2026 PFS, CMS is proposing to extend the temporary policy on medical visit services for an additional year, through December 31, 2026. What is not currently clear related to medical visits, is whether FQHCs/RHCs will be required to meet the other permanent telehealth requirements if the temporary waivers expire and no other policy changes have occurred, for example the location restrictions. Therefore, with no additional changes by Congress, and if the proposed 2026 PFS proposals remain unchanged, FQHCs and RHCs can continue to use telecommunications technology to provide services for mental health visits (permanent policy, if certain requirements like the prior/subsequent in-person requirements are met) and medical visits (temporary policy, until December 31, 2026, but not reimbursed at PPS rates).
MEDICARE ELIGIBLE PROVIDER REQUIREMENTS
(chart is current as of August 12, 2025) |
| |
Temporary Waiver Policy |
Permanent Policy |
2026 PFS |
| Eligible Providers |
All eligible Medicare providers |
- Physicians
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- Nurse-midwives
- Clinical nurse specialists (CNSs)
- Certified registered nurse anesthetists
- Clinical psychologists (CPs) and clinical social workers (CSWs)
- Registered dietitians or nutrition professionals
- Marriage and Family Therapists and Counselors
|
N/A |
| FQHCs/RHCs |
Eligible providers |
Can use telehealth to provide mental health services, if meet prior and subsequent in-person visit requirements. Will receive PPS/AIR rate. |
Will be able to use telecommunications technology to provide medical visit services through December 31, 2026. Will need to bill using G2025 and will receive a weighted rate, not PPS/AIR.
|
In summary, should the waivers on telehealth in Medicare expire and no other actions be taken to change permanent Medicare telehealth policy, there will be a significant reduction in which providers will be eligible to utilize telehealth to provide services to enrollees while still being eligible to be paid by the program. Additionally, while FQHCs and RHCs will not completely have the ability to use telecommunications technology to provide services to Medicare enrollees past September 30, 2025 taken away, their abilities will be limited, and some aspects of utilization will still be up against an additional deadline. CCHP will continue to monitor these areas in the coming weeks as the current waiver expiration date draws near.
Next Tuesday will be another edition in this special series: The focus will be on the utilization of telehealth to provide Mental Health services!
Stay tuned – you won’t want to miss this one!!
Check the original resource at : https://www.cchpca.org/topic/home-eligible/
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