Expired Federal Telehealth Waivers: Key Changes in Medicare Reimbursement Requirements for Telehealth Providers
Certain flexibilities that the federal government provided for telehealth services rendered to Medicare beneficiaries expired on Sept. 30, 2025, due to Congress failing to reach an agreement on government funding. By remaining compliant with key telehealth delivery standards, telehealth providers can avoid or mitigate exposure from changes in reimbursement requirements from Medicare.
Prior to Oct. 1, 2025, Medicare patients could receive certain telehealth services in their home, regardless of where the patient’s home was located. Beginning on Oct. 1, 2025, however, to be reimbursable by Medicare, non-behavioral/mental health telehealth services provided to Medicare beneficiaries now need to be either provided at an “originating site” (i) located in a rural health professional shortage area, or (ii) located in a county that is not included in a Metropolitan Statistical Area, or from an entity that participates in a federal telemedicine demonstration project. Originating sites include a provider’s office, a hospital, a skilled nursing facility and certain other designated sites (42 USC 1395(m)(m)(4)(C)(iii)). Additionally, as of Oct. 1, 2025, occupational therapists, physical therapists, speech-language pathologists and qualified audiologists are no longer considered “practitioners” qualified to provide telehealth services to Medicare beneficiaries (42 USC 1395(m)(m)(4)(E)).
Telehealth providers should utilize two-way, real-time audio-video technology to deliver services. However, if the patient does not have these capabilities or the patient does not consent to the use of them, then the provider may utilize two-way, real-time audio-only technology. If the exception is met and a provider utilizes two-way, real-time audio-only technology, then providers must either use CPT modifier “93” (if the provider is not a federally qualified health center or rural health center), or “FQ” (if the provider is a federally qualified health center or rural health center) (42 USC 1395(m)(m)(9) and 42 CFR 410.78(a)(3)).
Due to the expiration of the telehealth waivers, mental health providers must now fulfill slightly different requirements than other providers when delivering mental health services. As of Oct. 1, 2025, mental health providers are now required to provide an in-person, face-to-face visit with the patient within six months prior to the first time the beneficiary receives telehealth services (the Initial Visit) and every twelve months thereafter (the Follow-Up Visit), with a very limited exception (42 USC 1395(m)(m)(7)(B)). The Follow-Up Visit may be waived if the practitioner and patient agree that the risks and burdens of the in-person visit outweigh the benefits, and the same is documented by the practitioner in the patient’s medical record (42 CFR 410.78(b)(3)(xiv)). Also, the Initial Visit and the Follow-Up Visit may be conducted by another practitioner of the same specialty and in the same group if the practitioner who furnishes the telehealth services is unavailable 942 CFR 410.78(b)(3)(xiv)).
“Practitioner” is defined as any of the following:
- Physician
- Physician assistant
- Nurse practitioner
- Clinical nurse specialist
- Nurse-midwife
- Clinical psychologist
- Clinical social worker
- Registered dietitian
- Certified registered nurse anesthetist
- A practitioner who can appropriately bill for diabetes self-management training services
- Marriage and family therapist
- Mental health counselor (42 CFR 410.78(b)(2))
The Initial Visit and Follow-Up Visit requirements do not apply to an individual receiving treatment for a substance use disorder or a co-occurring mental health disorder (42 CFR 410.78(b)(3)(xii)). Federally qualified health centers and rural health centers can be reimbursed by Medicare for telehealth services provided to Medicare beneficiaries for mental health and behavioral health services without an in-person visit until Jan. 1, 2026(42 USC 1395(m)(m)(8) and CY 2025 PFS Final Rule).
There is, of course, a chance that Congress will pass governmental funding legislation that will extend the waivers, but there is no guarantee that it will take action, and there is also no guarantee that Medicare will retroactively reimburse for telehealth services that do not meet the requirements outlined above rendered between Oct. 1, 2025 and the effective date of any such extension, so immediate action is required to minimize exposure.
