Telehealth & Medicare Mental Health Services: The In-Person Catch

And, the special series continues!  In case you haven’t yet seen, this summer the Center for Connected Health Policy (CCHP) is running a series in our weekly #TelehealthTuesday newsletters on what Medicare telehealth policy could look like if the current temporary waivers expire as scheduled on September 30, 2025.

Each article in this series takes into account both:

• The potential expiration of the current Medicare telehealth waivers September 30, 2025, and
• The proposals included in the 2026 Physician Fee Schedule (PFS), as released by the Centers for Medicare and Medicaid Services (CMS) in July 2025 (assuming they are finalized without major changes).

It is important to emphasize that much can still change. Congress could act again to extend the waiver deadline or modify requirements. Therefore, please note that everything in this analysis applies only to Medicare and only if the September 30, 2025 deadline arrives with no further congressional or regulatory action, and the CMS 2026 PFS is finalized as proposed. While earlier editions of this series reviewed the Location and Eligible Provider rules, this week’s issue will focus in on what the reversion back to permanent rules will mean for Telehealth Mental Health Services in Medicare.

WHY MENTAL HEALTH IS DIFFERENT

Under permanent Medicare law, telehealth services are normally limited by geographic and site restrictions. More specifically, patients must be located in a rural Health Professional Shortage Area (HPSA), a non-Metropolitan Statistical Area (non-MSA), or a CMS-approved telemedicine demonstration site in order to qualify. In addition, the patient generally must receive the telehealth service while physically present at an “originating site,” such as a hospital, physician’s office, skilled nursing facility, or rural health clinic. See CCHP’s August 5^th newsletter edition on eligible Locations for more details on the geographic and site requirements.

Mental health services, however, have been granted special exceptions to the above-mentioned requirements. Even if/when the waivers finally do expire, patients receiving treatment for a mental health condition will not have to meet these rural or originating site requirements – however, there is a catch! If the location requirements are not met, coverage will instead hinge on meeting the in-person visit requirements (explained in more detail below), making mental health telehealth policy distinct from other Medicare telehealth services.

ELIGIBLE PROVIDERS & SERVICES

When the time comes that the waivers do expire, only provider types specifically named in statute will remain eligible to bill Medicare for telehealth services. The statute includes a broad list of practitioners, but for mental health services, the relevant providers are:

• physicians (including psychiatrists),
• psychologists,
• nurse practitioners,
• licensed marriage and family therapists (LMFTs), and
• clinical social workers (CSWs).

(See statute for the complete list of eligible practitioners.)

Moreover, both Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are not directly listed in statute as eligible providers. However, in the 2022 PFS, CMS changed the definition for a “mental health visit” to create a permanent avenue for these facilities to include services delivered through live video or audio-only technology, enabling them to continue offering and billing for telemental health visits under their normal payment systems. However, this coverage avenue for FQHCs/RHCs also hinges on meeting the aforementioned in-person requirements, though they have been waived consistent with statutory telemental health waivers the past few years. The 2025 PFS extended the delay of the in-person requirements (discussed further below) for RHCs and FQHCs through the end of 2025. At the same time, CMS noted that it intends to align the in-person requirement with the federal statutory in-person requirement for other types of providers, which currently only applies through September 30, 2025. This complicated scenario has created some uncertainty, as the allowance for FQHCs/RHCs without meeting in-person requirements could technically end as early as that date. For a broader discussion of provider eligibility, see CCHP’s August 19^th edition of this newsletter series drilling down on Eligible Providers.

With provider eligibility established, attention turns to the services themselves. CMS maintains a public list of telehealth-covered services on its website, updated annually through the Physician Fee Schedule process. This list includes a wide range of behavioral health and psychotherapy codes, which are expected to remain largely available through 2026. Furthermore, the proposed 2026 PFS, just released last month, expands mental health coverage slightly, adding services such as multiple-family group psychotherapy and group behavioral counseling.

THE IN-PERSON REQUIREMENTS

Therefore, the most significant change for Medicare mental health telehealth services, if the waivers expire, will be the need to meet the in-person visit requirements for the first time. Should the expiration deadline for the temporary waivers come to pass, then beginning October 1, 2025, technically patients must have received a Medicare covered/Medicare eligible service in-person from the telehealth provider within six months prior to the first telehealth mental health service, and then at least once every 12 months thereafter (with exceptions detailed below). This policy was first established in the Consolidated Appropriations Act of 2021 (H.R. 133) as a way to expand access to telehealth for mental health by exempting mental health services from Medicare’s restrictive geographic and originating site rules (detailed above). However, the requirement has never taken effect because of the public health emergency (PHE) waivers, which Congress has repeatedly extended, but that are now set to expire on September 30, 2025. While originally intended to expand access to telehealth for mental health services, the in-person requirement may now feel like an added burden, as providers have become accustomed to the more flexible policies in place during the PHE.

This in-person visit requirement is detailed in federal statute at 42 U.S.C. § 1395m(m)(7)(B). The statute reads:
 

There are, however, several exceptions that should be noted:

• Patients located in a rural area and in an eligible originating site as defined under permanent law do not need to meet the in-person requirement.
• Patients and providers may agree to waive the 12-month in-person visit if the risks and burdens of travel outweigh the benefits of an in-person encounter.
• Patients receiving treatment for a substance use disorder (SUD) or a co-occurring mental health condition are exempt from both the geographic and in-person requirements.

RHCs and FQHCs are technically exempt from the in-person rules through December 31, 2025. However, CMS has indicated it intends to align their policy with the broader federal statutory requirement, which currently is only waived through September 30, 2025. As a result, the in-person requirement for FQHCs and RHCs could also take effect as early as October 1, 2025.
 
CMS has also provided some flexibility by allowing the required in-person service to be furnished by a colleague in the same subspecialty within the same group practice if the original practitioner is unavailable. Importantly, this in-person service must be a Medicare-billable visit so that it is accurately recorded in CMS’s claims processing system.
 

 

WHAT ABOUT EXISTING PATIENTS?

One of the most frequent questions CCHP has received from providers regarding the upcoming in-person requirement is whether existing patients will need to complete an in-person visit before October 1, 2025 in order to continue to receive telehealth services. Based on the statutory language, the “first telehealth visit” after September 30, 2025, may be treated as the initial visit for compliance purposes, meaning that any in-person visit intended to meet the requirement must occur on or after March 30, 2025 to be valid.  However, CMS has not explicitly addressed this issue and may provide additional clarification as the deadline approaches. It is also possible that CMS could allow continued coverage for patients already receiving telehealth services prior to the expiration of the waiver without meeting the initial 6-month in person requirement, though the annual 12-month in-person requirement would likely still apply.

IMPACT ON PROVIDERS

Providers have regularly raised concerns to CCHP within submitted technical assistance requests about whether they will need to secure physical office space to accommodate the in-person visit requirement, and how this would be burdensome particularly for patients who live far away. For telehealth-only providers providing mental health services, maintaining office space may indeed become necessary in order to continue receiving Medicare reimbursement in these instances. That said, it is important to note that Congress has repeatedly delayed the in-person rule, and several bills currently under consideration would eliminate the requirement altogether. (See CCHP’s July 29^th newsletter on Federal Legislation, as well as our federal pending legislation tracking tool for more information.)

If no changes are made and providers or patients are unable to meet the in-person requirement, one option may be for the provider or facility delivering the service to issue an Advance Beneficiary Notice (ABN) of noncoverage. This notice allows Medicare patients to pay out-of-pocket for telehealth services if Medicare is expected to deny coverage. It is also worth emphasizing that this rule applies only to Medicare. Most Medicaid programs and commercial insurers do not impose the same in-person requirement, meaning providers could continue to deliver telehealth services to those patients. However, requirements vary by payer, so providers should confirm coverage and compliance obligations with each insurer. Additionally, providers should be mindful that prescribing, particularly of controlled substances, has its own set of federal and state in-person requirements, which may apply separately from Medicare coverage rules.  CCHP tracks Medicaid reimbursement policies, private payer laws, and prescribing rules by jurisdiction and topic area in our online telehealth policy finder.

LOOKING AHEAD

The future of Medicare telehealth requirements for mental health care remains uncertain, hinging on whether Congress extends the waivers or allows them to expire this fall. If no action is taken, providers and patients will need to navigate the geographic, facility, and in-person requirements, as well as narrower provider eligibility, even as some exceptions remain in place. While these changes could present real challenges, it is worth remembering that Congress has acted before to preserve access and may do so again. Until then, providers should be aware of the rules that could soon apply and plan accordingly, while keeping a close eye on policy developments in the months ahead. CCHP will continue to monitor these areas in the coming weeks as the current waiver expiration date draws near.

See original resource at : https://mailchi.mp/cchpca/telehealth-medicare-mental-health-services-the-in-person-catch