Medicare Telehealth Provisions

As of today, telehealth in-person visit requirements for patients with Medicare are waived through 9/30/25. The House proposed a continuing resolution that would extend these flexibilities through 11/21/25. However, it is unclear at this time if the Senate will pass this measure. Absent congressional action, Medicare will require an in-person visit within six months before initiating telehealth-based mental health services, with follow-up in-person visits at least every 12 months. Due to the possibility that the current Medicare telehealth waivers are not extended or changed, organizations should start planning for the in-person visit requirements to start on October 1, 2025.

If these requirements take effect, an exception exists for the ongoing 12-month in-person visit but not for the initial in-person visit within six months of starting telehealth services. As outlined in the 2022 Final Physician Fee Schedule Rule, the annual in-person requirement may be waived if the patient and practitioner jointly determine that the risks and burdens of an in-person visit outweigh its benefits. However, the initial six-month in-person visit must be completed by the same practitioner who will provide telehealth services, while the annual follow-up visit may be conducted by a different practitioner in the same specialty.

How do the in-person requirements apply to existing patients?

There is currently no clear guidance on how these requirements will apply to existing patients, leaving organizations to interpret federal law and guidance and to carefully consider their own risk tolerance when determining how to handle the ongoing provision of telehealth services for Medicare beneficiaries.

The Department of Health and Human Services (HHS) provided an overview of the current status of telehealth flexibilities which indicates those flexibilities are extended through September 30, 2025. Organizations should bookmark this site for reference on October 1, if there is no congressional action extending the telehealth flexibilities.

The National Council shared guidance from the 2023 PFS final rule, where CMS clarified that it does not believe the six-month in-person requirement applies to beneficiaries who began receiving mental health services in their homes during the public health emergency. However, the public health emergency ended on May 11, 2023. It is unclear if patients who initiated telehealth without an in-person visit outside of their home or after the PHE would be considered existing patients. This interpretation stems from an older version of the PFS and the National Council has also sought clarification from CMS to confirm if it still applies.

The Center for Connected Health Policy shared their interpretation of the statutory language, which is that 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.

The National Council also noted, that while Congressional action is needed for an extension of in-person requirement flexibilities, 42 USC 1834(m)(7)(A) states that when a beneficiary has substance use disorder or co-occurring mental health and substance use disorder diagnoses, the telehealth service is not subject to an in-person prerequisite. The National Council has sought clarification from CMS on whether a given service for someone with co-occurring diagnoses would also include services solely for the mental health condition.

The Medicare telehealth waiver policies specifically address Medicare fee-for-service (also referred to as Original Medicare). If your patients are covered by Medicare Advantage, the telehealth waivers expiring may not impact which telehealth services are covered. This is because Medicare Advantage plans are allowed to offer telehealth coverage that goes beyond Original Medicare. However, many health plans do simply replicate Original Medicare policy, as that is all they are required to do, and in that instance the waivers may impact the telehealth services eligible to be covered under the plan. Organizations should verify telehealth policies with the Medicare Advantage plans they contract with.

Organizations should prepare for the possibility that these in-person requirements will be effective October 1st and have conversations about the requirements with staff and Medicare patients receiving services through telehealth. This may mean rescheduling ineligible telehealth visits as in-person appointments or waiting to hold the telehealth visit at a later date entirely. The Ohio Council will provide updates to members on the status of these requirements and additional guidance as they become available in the coming days.