A permanent telehealth benefit with an in-person clock attached

The week

For an older adult living with depression or anxiety, getting to a therapist can be the hardest part of treatment. It may mean a long drive, a bus ride, a day off for a family member, or simply the effort of leaving the house on a bad day. During the pandemic, many patients discovered that they could see their clinician from their own living room. In July 2021, Medicare took a significant step toward making that permanent for mental health care.

On July 13, 2021, CMS, the Centers for Medicare & Medicaid Services, which runs Medicare, released its proposed Medicare Physician Fee Schedule for calendar year 2022. The fee schedule is the annual rule that sets what Medicare pays clinicians and under what conditions. It is long, technical and full of provisions. Among them was a proposal for how to implement a change Congress had already made in the Consolidated Appropriations Act, 2021, signed in December 2020.

Some background explains why that change mattered. Medicare’s telehealth statute had long limited coverage to patients in certain rural areas, seen at an approved clinical site such as a physician’s office, hospital or rural health clinic. The patient’s home was not on the list. Congress had made one exception before the pandemic. The SUPPORT Act of 2018 removed the geographic limits and allowed the home as a site for treating substance use disorders and co-occurring mental health conditions, starting in July 2019.

The pandemic then swept the limits aside temporarily. Emergency waivers from March 2020 let Medicare pay for telehealth wherever the patient was, including at home, and CMS added audio-only coverage for some services, including certain behavioral health services, that spring. All of that was tied to the public health emergency and would lapse when it ended.

The December 2020 law did two things for mental health in particular. It removed the geographic restrictions on telehealth for the diagnosis, evaluation and treatment of mental health disorders, so patients no longer had to live in particular areas to qualify. And it allowed the patient’s home to serve as the originating site, which is Medicare’s term for where the patient is during a telehealth visit.

The benefit came with strings. As the law required, the proposal tied it to an in-person, non-telehealth visit within six months before the first telehealth mental health service. CMS also proposed further in-person visits every six months after that. Treatment for substance use disorders, already covered at home under the 2018 law, did not carry the new in-person condition.

The six-month condition worked differently for new and existing patients. A patient starting mental health care by telehealth would need to be seen in person first. A patient already in treatment would need an in-person visit on record within the window. The audio-only proposal was limited to established patients, so a first meeting by telephone alone would not qualify.

The proposal also addressed patients without video. It proposed allowing audio-only care, essentially a telephone visit, for mental health services to established patients at home. The condition was that the clinician could offer video but the patient could not use it or did not consent to it. That would be a permanent change to Medicare’s definition of the technology a telehealth visit may use, which had required two-way audio and video.

Most other pandemic telehealth flexibilities remained tied to the public health emergency, meaning they would expire when the emergency ended. CMS proposed to keep certain services it had added to the telehealth list during the emergency through the end of 2023, to gather evidence on them. Mental health stood apart as the one area with a permanent statutory footing.

CMS finalized these provisions in November 2021. It relaxed the follow-up visit to at least every 12 months, with documented exceptions. It created a claim modifier to flag audio-only services. It also let rural health clinics and federally qualified health centers be paid for mental health visits delivered by real-time telecommunications, including audio-only, on the same terms.

Before the pandemic, Medicare paid for telehealth only in narrow circumstances. The patient generally had to be in a rural area and at a clinical site such as a clinic or hospital, not at home. Emergency waivers in 2020 removed those limits temporarily, and every other telehealth flexibility in 2021 still had an expiry date attached to the public health emergency.

Mental health was different. Congress had made home-based telehealth for mental health permanent in late 2020, and the July 2021 proposal set out how it would work.

For patients, the change was large. A Medicare beneficiary in a city could now see a therapist or psychiatrist from home, indefinitely. But the benefit arrived with conditions, and each condition depends on a fact the practice must record at every visit. Continuity of care for a patient now rested on three records: where the patient is, how the visit is delivered, and when the patient was last seen in person. A practice that cannot produce any one of them reliably risks denied claims, interrupted care, or both.

The sections below first show how conditions in a rule become fields on a claim, then take the three records in turn. They follow one visit through a practice, set out what goes wrong when a record is missing, and end with the design principle that ties the three together.

Conditions become boxes on a claim

When a clinician sees a Medicare patient, the practice sends Medicare a claim: an electronic bill describing who was seen, what was done and under what circumstances. Medicare checks the claim against its rules and pays, or denies it. A claim is less like an invoice and more like a form with boxes that must all be filled in correctly. Miss a box, or fill one in wrongly, and payment is delayed or refused.

Telehealth claims carry extra information. They indicate that the visit was virtual, where the patient was, and, in some cases, whether it was audio-only. That information is communicated through codes and modifiers, short codes added to a claim to describe special circumstances.

The conditions Congress and CMS attach to a benefit do not stay in the rulebook. They become fields in a claim, which means they must first become fields in the medical record and in the scheduling system. A rule that says “the patient must have been seen in person within a certain period” is, in practice, a requirement that someone, somewhere, knows the date of that visit and can prove it.

The electronic health record, or EHR, is the software where clinicians document visits. The practice management system handles scheduling and billing. In many practices these are linked; in others they are separate products from different vendors. Each of the three records discussed below has to flow cleanly through both.

Three layers of rules, one claim form

The Medicare fee schedule is only one rule set a practice must follow. Medicare Advantage plans, which are private plans paid by Medicare, have been allowed since 2020 to offer additional telehealth benefits beyond traditional Medicare’s. Medicaid telehealth policy is set state by state. Commercial insurers write their own policies, and many states have their own telehealth payment laws.

For a single behavioral health practice, the same video session with the same clinician can therefore be subject to different location rules, modality rules and documentation rules depending on the patient’s coverage. A practice cannot hard-code “the Medicare rule” into its workflow and expect it to hold for every patient. The rules must be configurable by payer, and the facts captured at the visit must be complete enough to satisfy the strictest of them.

Where each fact enters the system

Each fact on a telehealth claim enters at a different point. Coverage and demographics come in at registration. The patient’s location for the day is confirmed at check-in or at the start of the session. The modality, and the reason for any audio-only visit, belong in the clinician’s documentation. Codes and modifiers are applied at charge capture or coding. A claim scrubber, software that checks claims against payer rules before they go out, is the last line of defense.

Errors usually come from the hand-offs. A location captured in a free-text note never reaches the claim. A modality chosen at scheduling is changed during the visit when the video fails, and nobody updates the record. A scrubber that does not know the in-person rule cannot catch a lapse. Designing for the three records means designing the hand-offs as well as the fields.

Where the patient is: location as a clinical and legal fact

The home could now serve as the originating site for mental health care. That made the patient’s location at the time of each visit a billable fact rather than a matter of convenience.

It also made it a licensure fact. Medicare decides what it pays for; states decide who may practice. During the emergency, many states had relaxed licensure rules so clinicians could see patients across state lines. As those waivers ended through 2021, licensure followed the patient again. A psychiatrist treating a patient who had moved, was traveling or lived across a border needed a license in the state where the patient was located during that session.

That last point surprises many executives. The rule is not about where the patient lives, or where the practice is located. It is about where the patient physically is, at the moment of the visit. A patient who usually joins from home in one state but logs on from a relative’s house in another state over the holidays has, for that session, moved the visit into a different legal jurisdiction.

Location also matters for safety. A clinician seeing a patient at home needs to know where that patient is in order to send help in a crisis. In mental health care, that is not a hypothetical concern. The safer habit is to confirm the patient’s physical address and a local emergency contact at the start of each session, not once at registration.

Capturing location so software can use it

The operational answer has two parts. One is a structured field in the visit record, completed by the clinician or check-in staff each time. “Structured” means a defined box with a defined format, not a sentence buried in a clinical note, so that software can read and check it. The other is a rule in the scheduling system that compares the patient’s stated location with the clinician’s licensed states before the visit starts.

The licensure check needs its own data. A practice must keep a current list of each clinician’s active state licenses, with expiry dates, and connect it to scheduling. Credentialing teams often hold that list in a spreadsheet or a separate credentialing system. Making it available to the scheduler, and keeping it current when licenses lapse or are added, is unglamorous work that prevents the most serious of the location errors.

The location field also feeds the claim. Medicare and other payers use place-of-service codes and modifiers to show where a telehealth patient was. A new place-of-service code for telehealth delivered in the patient’s home was introduced in 2022. Practices that captured location in a structured way could map it to whatever code each payer required. Practices that relied on a note had to code by hand.

What the compacts cover and what they leave out

Interstate compacts for psychologists and professional counselors offered partial relief. A compact is an agreement among participating states that makes it easier for a professional licensed in one to practice in the others. But coverage varied by state and profession, so the check could not be skipped.

The compacts also differ in what they grant. The psychology compact, PSYPACT, had begun operating in 2020 and lets participating psychologists practice telepsychology into other member states under an authorization. The Interstate Medical Licensure Compact, used by psychiatrists and other physicians, offers an expedited path to separate licenses in member states rather than a single multistate privilege. The nurse licensure compact covers registered and practical nurses, not psychiatric nurse practitioners. A counseling compact was being enacted by states from 2022 onward, and it took years to move from enactment to issuing privileges.

The result is a matrix: profession by state by compact status. A large health system with clinicians in several states needs that matrix in software. A solo psychiatrist near a state border needs it in her head and in her scheduling rules. A community mental health center that serves one county may rarely face the question, until a patient moves.

Patients who move with the seasons

Medicare patients are more mobile than their addresses suggest. Many retirees spend part of the year in another state, near family or somewhere warmer. A practice serving older adults may find that a noticeable share of its telehealth patients are, for several months each year, in a state where its clinicians are not licensed.

A practice has three options for those months. It can license its clinicians in the states where its patients travel, which costs fees and administrative time. It can pause telehealth sessions and resume when the patient returns, which risks a gap in care. Or it can arrange a warm handoff to a local clinician, which is clinically sound but disrupts the relationship. Each option is defensible. The weak option is not knowing, which happens when location is captured only at registration.

Registration data can help plan. A practice that records seasonal addresses can see in advance which states its patients spend time in, and decide which licenses are worth adding before the season starts.

Location in a crisis

The safety use of location is different from the billing use and deserves its own process. A patient may disclose intent to harm themselves during a video or phone session. The clinician then needs a confirmed address, a local emergency number that works from the clinician’s location, and a support person the patient has named. Telehealth platforms do not pass the patient’s location to emergency services the way a landline call to 911 does.

Practices that handled this well wrote it into the start-of-session script and trained staff to treat a missing address as a reason to pause. They also recorded which clinicians were trained in remote crisis protocols, because not every therapist who moved to telehealth during the pandemic had been.

How the visit is delivered: audio-only as an access decision

The proposal to allow audio-only mental health care recognized something the pandemic had made plain. Many older and lower-income patients lacked broadband, a suitable device or confidence with video. For some of them, a telephone call was the only workable form of virtual care. For a Medicare population, that group is large.

CMS attached conditions. The clinician had to be capable of video, and audio-only was allowed only when the patient could not use video or did not consent to it. That turns modality, the format of the visit, into a documented choice. The record should show that video was offered and why the visit took place by phone. Claims needed to carry the correct modifier to signal audio-only delivery. CMS created that modifier in the final rule; on professional claims it is modifier 93.

What “capable of video” means

The capability condition sounds trivial and is not. It means the clinician had working video at the time, through a platform the practice was entitled to use, and offered it to the patient. A therapist who works from a location without reliable bandwidth, or a practice whose video licenses do not cover every clinician, may not meet it on a given day.

The platform matters for another reason. During the emergency, the HHS Office for Civil Rights said it would not penalize good-faith use of everyday video apps for telehealth, even when they did not meet all HIPAA requirements. That discretion was always temporary. A practice that built its telehealth service on a consumer app in 2020 would need a platform covered by a business associate agreement once the discretion ended. Moving patients to a new platform is itself a disruption, and it is easier to do in a calm year than in the last weeks before a deadline.

Designing the patient experience around modality

The patient experience design follows from those rules. Outreach should offer video first and make it easy, with help for patients setting it up. The phone option should stay available without the patient having to argue for it. Scheduling templates should record the modality agreed for each patient, so that a patient who always uses the phone is not sent a video link they cannot open. For the patient, the best channel is the one that works on the day.

Consider a community mental health practice whose front desk sends every telehealth patient the same automated reminder with a video link. An 82-year-old patient with no smartphone receives a text she cannot act on, assumes the appointment is canceled, and misses it. A clinician calls her afterward, but the session is lost, and the record does not show that video was offered and declined, so a later phone session is coded inconsistently. The fix is simple: record her preference once, send her a phone reminder, and document the reason each time. The cost of getting it wrong is a missed session for a patient who may be struggling, and a claim at risk.

Visits also change modality midstream. A session starts on video, the connection fails, and the clinician finishes by phone. The record should show what happened and why, and the practice should decide in advance how such visits are coded. Leaving the choice to each clinician produces inconsistent claims that are hard to defend in an audit.

The case against audio-only, and why it held

Audio-only care had serious critics. A clinician on the phone cannot see a patient’s appearance, movement or surroundings, which carry clinical information in mental health assessment. Program integrity reviewers worried that phone visits were easier to inflate or fabricate. HHS’s Office of Inspector General went on to publish reviews of pandemic telehealth billing that flagged program integrity risks.

The counter-argument was continuity. For a patient who cannot or will not use video, the realistic alternative to a phone visit was often no visit at all. CMS’s answer was to allow audio-only as a fallback, with video first and the reason documented. That design puts the burden of proof in the record. A practice that documents well can defend its audio-only care; one that does not leaves its most vulnerable patients’ care open to challenge.

When the patient was last seen in person: a clock on every chart

The third condition was the most contested. The law required an in-person visit within six months before the first telehealth mental health service, and CMS proposed follow-up in-person visits every six months. In the final rule it settled on at least every 12 months, with exceptions where the clinician and patient agree the risks of an in-person visit outweigh the benefits and document why.

The rationale was clinical oversight and program integrity, meaning protection against fraud and against care that drifts without anyone ever seeing the patient. The objection was that it rebuilt part of the travel barrier telehealth had removed, especially for patients far from a clinic or unable to travel.

Whatever the policy merits, the condition created a running clock on every telehealth patient’s chart. A practice needs to know, for each patient, the date of the last qualifying in-person visit, by which clinician or practice, and when the next one is due. That information is often scattered across separate systems or separate organizations. A patient’s last in-person visit may have been with a different practice, or recorded in a different EHR, before the patient switched to telehealth.

What counts as a qualifying visit

Not every in-person contact counts. The visit has to be a non-telehealth service with the clinician who furnishes the telehealth care. CMS allowed some flexibility, such as a visit with another practitioner of the same specialty in the same group when the treating clinician is unavailable. A visit to a primary care doctor down the hall, or a lab draw, does not meet the condition.

That definition has consequences for how practices are organized. A telepsychiatry service that contracts with a rural hospital may have no in-person presence at all. A multi-specialty group must check that the in-person visit was with the right specialty. A practice that hires a new clinician to take over a panel of telehealth patients needs to know whose visit started each patient’s clock.

Exceptions need evidence

The exception process is where clinical judgment meets record-keeping. CMS allowed the in-person visit to be skipped when the clinician and patient agree that the risks and burdens outweigh the benefits, with the reason documented in the record. Reasons might include the patient’s frailty, the distance and cost of travel, or the clinical risk of disrupting a stable treatment relationship.

An exception recorded as “patient prefers telehealth” is weak. One that records the specific circumstances and the clinician’s judgment, and is revisited when circumstances change, is the kind an auditor can accept. The practice should decide where in the record exceptions live, so a report can find them without anyone reading through notes.

Patients who change practices

Patients move between practices more often than the rule’s drafters may have expected. A patient whose therapist retires, or who switches to a practice with an opening, arrives with a history of telehealth care and no qualifying in-person visit with the new clinician. Under the rule, the new clinician’s relationship starts the clock again. Intake staff should ask about it and the registry should record it from the first appointment.

Using the visit well

There is a clinical case for the in-person visit that the access debate tended to obscure. Patients on some psychiatric medications need periodic checks of weight, blood pressure or lab values, and some need physical examination for side effects. An annual in-person visit that is planned around those needs is clinically useful. One booked only to satisfy a rule, with no plan, wastes the patient’s journey.

Practices that framed the visit as an annual review, with labs, vitals and a care plan update arranged in advance, turned a compliance obligation into better care. That framing also made the visit easier to explain to patients who resented the trip.

Without a reliable report, practices face two bad outcomes: claims denied because the in-person visit lapsed, or patients brought in unnecessarily because nobody could confirm the date. The first costs revenue and creates billing rework. The second costs patients time, travel and sometimes distress, and wastes appointment slots that other patients need.

The registry

The fix is a registry: a maintained list of patients who share a characteristic, kept so that a practice can act on them as a group. In this case, flag each patient receiving telehealth mental health services, compute the due date for the next in-person visit, surface it to schedulers well ahead, and record any documented exception. The registry is cheap to build and expensive to lack. It also made practices ready for whatever date the requirement would finally bite, which, as it turned out, kept moving.

A good registry has a small number of fields: patient, treating clinician, date and type of last qualifying in-person visit, exception status and reason, next due date, and the payer rules that apply. It runs nightly, feeds a scheduler work queue, and produces a monthly count of patients due within 60 days. The due date should be computed from a configurable rule rather than fixed in code, because the rule’s start date was always uncertain.

Following one visit through the practice

The three records come together in a single, ordinary appointment at a well-run practice.

A week before. The scheduling system runs its nightly check of the telehealth registry. It notices that a patient, a retired bus driver who has been seeing his psychiatrist from home, is approaching the date by which he needs an in-person visit. It flags this to the scheduler, who calls him and books an in-person appointment at a time when his daughter can drive him. No claim is at risk, and he has weeks of notice rather than days.

The day before. His reminder arrives by phone call rather than text, because his record shows he uses audio-only visits: video was offered, he does not have a device that supports it, and that is documented. Nobody sends him a link he cannot use.

At the start of the session. The clinician confirms where he is today. He mentions he is staying with his sister for a week. The clinician checks: is that in a state where she is licensed? The scheduling system already raised the question when the location changed, so the answer is ready. She also confirms a local emergency contact for that address.

After the session. The visit is documented with location, modality and the reason for audio-only in structured fields. The claim goes out with the right codes and modifier. It is paid without rework.

Run the same appointment at a practice without these records. The in-person deadline passes unnoticed, and claims start to be denied weeks later. The patient receives a video link and misses the session. The clinician does not ask where he is, and treats him while he is in a state where she is not licensed. The billing team spends hours reconstructing what happened. Nobody acted in bad faith and the clinical care was sound; every failure is one of record-keeping, and each lands on the patient, the clinician and the practice’s finances at once.

The same patient at different kinds of organization

The appointment looks different depending on who provides it. At a large health system, the registry, licensure check and modality preference can be built into a shared EHR, but the work competes with every other EHR request. A federally qualified health center bills Medicare mental health visits under its own payment system, and the November 2021 rule applied the same in-person conditions there. A telepsychiatry company serving hospitals may need its hospital clients to supply location and in-person data it cannot capture itself. A small private practice may rely on a practice management product whose vendor decides when the fields appear.

Each of these organizations faces the same three records. What differs is who controls the systems that hold them, and therefore who must be persuaded, paid or contracted to build them.

What separates the two practices in the story above is whether the conditions of the benefit were turned into routine steps that the systems prompt and the staff follow.

Denials, licensing and interrupted treatment

Each of the three records decides whether a claim is paid, and an audit that finds one missing can end in a repayment demand.

Revenue. Each of the three records feeds directly into whether a claim is paid. Errors are rarely dramatic; they show up as a steady trickle of denials and rework that consumes staff time and delays cash.

Compliance. A clinician who treats a patient located in a state where the clinician is not licensed may face a professional licensing problem on top of a billing one. Audits that find missing documentation of why a visit was audio-only can lead to repayment demands.

Patients. Mental health care depends on continuity. A missed session because of a wrong reminder, or a lapse in eligibility because an in-person visit was not scheduled in time, can interrupt treatment at exactly the wrong moment.

Staff. Clinicians and front-desk teams already carry heavy administrative loads. Asking them to remember these rules without system support increases errors and frustration. Building the checks into the scheduling and documentation tools removes that burden.

Reputation. For a health system that has promoted its virtual mental health services, a wave of disrupted care when a requirement takes effect would be a visible failure.

What an auditor asks for

Medicare reviews claims through several kinds of contractor: the Medicare Administrative Contractors that process claims, Recovery Audit Contractors, and Unified Program Integrity Contractors that investigate suspected fraud. A request for records for a telehealth mental health claim will look for the same three facts. The reviewer wants evidence of where the patient was, how the service was delivered and why, and, once the requirement applies, when the qualifying in-person visit took place or why an exception was documented.

Because repayment demands can be extrapolated from a sample to a wider set of claims, a documentation gap that looks minor on one claim can become expensive across a year. A practice should be able to pull those three facts for any visit in minutes, from structured fields, without reading through notes.

A second clock for prescribers

Psychiatrists and psychiatric nurse practitioners faced a separate rule that is easy to confuse with Medicare’s. The Ryan Haight Act generally requires an in-person medical evaluation before a controlled substance is prescribed through telemedicine. During the emergency, the Drug Enforcement Administration waived that requirement, which allowed stimulants, some anxiety medications and buprenorphine to be started by video.

That rule applies to every patient, whatever their coverage, and its timetable is set by the DEA and HHS, not by Congress’s telehealth extensions. A practice that prescribes controlled substances needs its registry to track both clocks, because a patient can satisfy Medicare’s condition and still fall foul of the DEA’s, or the reverse.

Every condition is a data element

The three records share one design principle. Each condition attached to the benefit is a data element, captured at the visit, checked before the claim, and visible to the people who schedule care. Practices that treated them as such could offer patients a stable virtual service while Medicare policy shifted around it.

In practice that means:

• A structured location field completed at every telehealth visit, checked automatically against clinician licenses.
• A recorded modality preference for each patient, with video offered first and the reason for audio-only documented.
• A registry showing every telehealth mental health patient’s last in-person visit and next due date, visible to schedulers.
• Documented exceptions recorded in a consistent place, with the clinical reasoning.
• A named owner who tracks policy dates and updates the rules in the systems when they change.

Configure, don’t hard-code

The most useful technical choice is to make dates and rules settings rather than code. The in-person requirement’s effective date, the interval between visits, the payers to which it applies and the modifier each payer expects should all be values an analyst can change. When Congress moves a date, the practice changes one setting and reruns the registry.

Many practices depend on their EHR or practice management vendor for this. The questions to put to the vendor are concrete: whether location and modality can be captured as discrete fields, whether the registry logic can read them, and whether the in-person rule is configurable by payer and date. A vendor that can only offer a free-text template leaves the practice doing the work by hand.

Measures a manager can watch

A small set of measures shows whether the system works. Two are documentation rates: the share of telehealth visits with a structured location recorded, and the share of audio-only visits with a documented reason. The others are the number of registry patients due for an in-person visit in the next 60 days, and telehealth mental health denials broken down by reason. Watched monthly, these catch drift before it reaches patients or claims.

The usual errors include recording location only at registration, relying on clinicians to remember licensure boundaries, treating audio-only visits as a lesser service rather than an access decision, keeping in-person dates in free-text notes where no report can find them, and building processes around a single expected effective date instead of a configurable one.

A checklist for the practice manager

1. At every telehealth visit, do we record where the patient physically is, in a field our systems can check?
2. Does our scheduling system warn us before a visit if the patient’s location is in a state where the clinician is not licensed?
3. For audio-only visits, does the record show that video was offered and why the patient used the phone instead?
4. Can we produce, today, a list of telehealth mental health patients with their last in-person visit date and next due date?
5. Who tracks the changing effective dates for these requirements, and how quickly can we update our systems when they move?

With hindsight

CMS finalized the mental health telehealth provisions in November 2021, with the follow-up in-person visit set at least every 12 months and room for documented exceptions. Audio-only mental health care at home became a permanent part of Medicare’s definition of telehealth, flagged with its own modifier. Rural health clinics and federally qualified health centers gained the ability to deliver mental health visits by telecommunications on similar terms.

The in-person requirement itself never settled into place. In March 2022, Congress extended the broader telehealth flexibilities for 151 days after the end of the public health emergency, and delayed the in-person condition for that period. At the end of 2022 it extended them again, through the end of 2024. The public health emergency ended in May 2023.

After that, Congress repeatedly extended the broader telehealth flexibilities a few months at a time. They lapsed during the federal government shutdown in October and November 2025, and briefly at the end of January 2026. Each extension also postponed the in-person requirement for mental health, typically to the day after the broader flexibilities were due to expire, so the two deadlines moved together. For practices, that meant a long series of near-deadlines, each of which could have triggered a wave of in-person scheduling before being pushed back again.

Practices that rushed to schedule in-person visits ahead of the early expected dates spent staff time and patient trips on a requirement that kept moving away. The more durable investment was in the records: knowing each patient’s status, so that outreach could begin when a date became firm.

The Consolidated Appropriations Act, 2026, signed in February, extended the flexibilities through the end of 2027 and delayed the in-person requirement to January 1, 2028, so organizations should confirm the current dates. The requirement written into law in late 2020 has, in practice, not yet bitten.

Other pieces moved around it. The HIPAA enforcement discretion for telehealth ended with the emergency, with a transition period that closed in August 2023, so practices still on consumer video apps had to move. From January 2024, marriage and family therapists and mental health counselors could bill Medicare directly, which widened the pool of clinicians to whom the same telehealth rules applied. Many of them were new to Medicare billing, and had to learn its location, modality and documentation conventions from scratch. The DEA and HHS extended the pandemic flexibilities for prescribing controlled substances by telemedicine several times, most recently through the end of 2026, while permanent rules remained under development.

Mental health is where Medicare telehealth became most firmly embedded, and the in-person clock is the condition that never quite started. Audio-only care remained important for older and lower-income patients. Behavioral health has kept a far higher virtual share than most specialties. Program integrity scrutiny of telehealth billing also continued, through reviews by HHS’s Office of Inspector General, which kept documentation of location and modality relevant even while the in-person clock stayed paused. That durability suggests the July 2021 decision to treat mental health differently matched how patients and clinicians actually wanted to work.

Practices that built location, modality and in-person tracking into their records in 2021 have absorbed each extension and lapse without disrupting patients. A system built that way lets a moved deadline be handled by changing a date in one setting. Practices relying on memory and manual lists face a scramble each time, unsure which patients would be affected.

Health policy rarely arrives once and stays put. Benefits are extended, conditions are delayed and dates shift, sometimes with little notice. Organizations that turn each condition into a recorded, checkable data element, with someone responsible for keeping the dates current, can keep care steady for patients while the rules around them continue to move.