The Telehealth Policy Cliff: Preparing for April 1, 2025

Photo credit: https://www.flickr.com/photos/chad_k/3767365155
https://creativecommons.org/licenses/by/2.0/ (no changes were made)

Introduction

April 1, 2025, might feel like an April Fool’s joke—but for healthcare providers and patients who rely on Medicare telehealth services, it could be anything but. Without Congressional action, key telehealth flexibilities that have been in place since the COVID-19 pandemic will expire on March 31, 2025. The extension of these flexibilities were tied to the federal continuing resolution.  With ongoing political uncertainty and a large number of competing priorities, there’s a real possibility that Congress may not act in time to prevent a return to pre-pandemic restrictions.

What does this mean? If the policy cliff isn’t addressed, Medicare beneficiaries may no longer be able to receive reimbursed telehealth visits from their homes. Rural and facility restrictions will be reinstated. Critical programs like Hospital at Home could face disruption. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) will lose their ability to serve as distant site providers for most telehealth services. And while the DEA has extended flexibilities for prescribing controlled substances via telehealth until December 2025, providers may struggle to sustain telehealth-based care if reimbursement disappears.  Click here to read about all the Federal Medicare Telehealth Waivers that will be impacted.

Healthcare organizations, practices, and providers cannot afford to wait and hope for a last-minute fix—now is the time to prepare. Every Monday between now and March 31 (or until Congress takes action to extend the waiver), we’ll break down the specific telehealth flexibilities at risk, examining their impact on clinical practice and providing actionable checklists for contingency planning and communication. At a minimum, having a clear communication strategy in place will help both staff and patients understand and navigate these potential changes.

The Return of Physical and Geographic Location and Modality Requirements

Physical Location of the Patient Will Matter Again

Under pre-pandemic Medicare rules, patients must be located at an approved originating site to receive telehealth services. These approved originating sites include:

• -Physician or practitioner offices
• -Hospitals
• -Critical Access Hospitals (CAHs)
• -Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) – for RHCs and FQHCs, mobile units are considered extensions of the facility 
• -Hospital-based or CAH-based Renal Dialysis Centers (including satellites)
• -Skilled Nursing Facilities (SNFs)
• -Community Mental Health Centers (CMHCs)
• -Renal Dialysis Facilities (under specific circumstances)
• -Mobile Stroke Units (under specific circumstances) 
• -Rural Emergency Hospitals (REHs)

Exceptions:  The patient’s home is considered an eligible originating site for the following services:

• -Treatment for Substance Use Disorder (SUD) and co-occurring mental health disorders
• -Provision of mental health services (as long as additional requirements are met)
• -Home dialysis for patients with End-Stage Renal Disease (ESRD) 

Geographical Location of the Patient Will Matter Again

In addition to physical location requirements, Medicare’s pre-pandemic rules also impose geographic restrictions on originating sites. To be eligible for Medicare telehealth reimbursement, the originating site must be:

• -Located in a non-Metropolitan Statistical Area (non-MSA county) OR
• -Located in a rural Health Professional Shortage Area (HPSA)
  OR
• -Participating in a Federal telemedicine demonstration project 

Exceptions:  There are no geographic restrictions for the following services:

• -Treatment for Substance Use Disorder (SUD) and co-occurring mental health disorders
• -Provision of mental health services (as long as additional requirements are met)
• -Home dialysis for patients with ESRD 
• -Treatment and diagnosis of acute stroke.

Modality of Telehealth Will Matter Again

In addition to physical and geographic location requirements, Medicare’s pre-pandemic rules also impose modality restrictions. Physicians and practitioners must use 2-way, interactive, audio-video technology to deliver Medicare telehealth services. 

CMS recently revised the definition of an interactive telecommunications system to include audio-only technology for telehealth services when the provider is able to use live video but the patient cannot or is unwilling to use live video. This only applies when furnished to a patient in their home.  

Exceptions:

• For behavioral health/mental health visits, the delivery of services via live video or audio-only will be allowed (as long as additional requirements are met) 

Contingency Planning and Communications Checklist

• Assess the Impact on Your Patients
  • Identify how many patients currently receive telehealth services outside of an approved originating site (excluding behavioral health/mental health services and home dialysis for ESRD related services)
  • Determine how many of these patients might face barriers to in-person care if telehealth were no longer an option.
    • Determine how many of these patients are dual-eligibles (covered by both Medicare and Medicaid).
    • Assess how many of these patients would be able/willing to self-pay in order to retain the benefit of a telehealth visit.
• Evaluate Your Financial Risk.
  • If after March 31, Medicare will no longer reimburse telehealth visits for patients outside of an approved originating site, decide whether your practice will:
    • Continue offering telehealth to these patients without reimbursement.
    • Allow all existing telehealth appointments to proceed but stop scheduling new ones.
    • Allow existing telehealth appointments to proceed up to a certain date to allow time for transition communication, and sending cancellation notices for affected telehealth visits after that date.
    • Send immediate cancellation notices for all affected telehealth visits.
  • Assume that if the waiver is reinstated after a gap in time, you will NOT be able to retroactively bill for services provided after the March 31, 2025 expiration.
  • For dual-eligible patients, check whether your state’s Medicaid program covers the needed services via telehealth and if the clinician is an enrolled Medicaid provider in the State.
  • Consider the possibility of some private insurers following Medicare’s lead.
• Prepare Patient, Provider and Staff Communications
  • Draft clear and proactive patient notices explaining upcoming changes to telehealth services. Consider including an Advance Beneficiary Notice of Non-coverage (ABN) with those communications.  
    • Why include an ABN?  While not required, providing an ABN with your patient communications is a courtesy to alert the patient about their financial liability.  By being fully transparent, you give patients the option to continue telehealth services on a self-pay basis if they choose, ensuring transparency about costs and billing expectations. 
  • Ensure providers and schedulers understand the new requirements.
  • Plan for multiple distribution channels (e.g., email, patient portals, office signage, website updates).
• Identify Alternative Care Options
  • For patients unable to visit in person, research alternative care locations that may be more accessible.
  • Identify eligible originating sites (e.g., FQHCs, RHCs, rural hospitals) that may be more accessible to your patients.
  • Explore partnership opportunities to facilitate continued telehealth access, including drafting simple agreements with these sites to support serving as telehealth access points.  
• Use the Medicare Telehealth Payment Eligibility Analyzer
  • To check if a site qualifies for Medicare telehealth reimbursement:
    • Enter the street address into the Medicare Telehealth Payment Eligibility Analyzer.  
    • Click “Search” to determine eligibility

By proactively assessing your patients’ needs, financial implications, and communication strategies, you can better navigate the transition should telehealth flexibilities change.

The End of the Hospital at Home Waiver

What Does This Mean?

The Hospital-at-Home (H@H) model allows patients to receive acute care at home instead of in a hospital.  Without another extension of the waiver: 

• Hospitals will no longer be able to bill Fee for Service (FFS) Medicare or FFS Medicaid for H@H services beyond March 31, 2025.   Any hospital continuing H@H care for these patients must absorb financial risk. 
• Billing will still be allowed for private payors, Managed Care Medicaid plans and self-pay patients,  
• If the waiver is reinstated after a gap in time, hospitals will NOT be able to retroactively bill for services provided after the March 31, 2025 expiration.

Preparing for the Transition: Contingency Planning and Communications Checklist

• Patient, Caregiver & Staff Communication:
  • Draft messaging for patients, caregivers and staff about the potential need to transition H@H patients back to brick-and-mortar hospitals by March 31, 2025.
  • Determine how and when these communications will be delivered.  
• Logistical & Staffing Preparations:
  • Plan for transport and bed availability to ensure a smooth transition of H@H patients back to hospital care.  
  • Assess staffing needs to accommodate these patients in hospital settings starting March 31, 2025 and beyond.  

Note:  When reporting on these patient transitions, they should not be classified as escalations.

Implications on Prescribing of Controlled Substances

Take action before March 18, 2025 11:59 pm EDT to provide feedback on the proposed changes to prescribing controlled substances by telehealth!!

On January 17, 2025, the Drug Enforcement Agency (DEA) and the Department of Justice (DOJ) published a notice of proposed rulemaking – Special Registrations for Telemedicine and Limited State Telemedicine Registrations.

To submit electronic comments:

• Go to http://www.regulations.gov/ .
• Check the Tips on Writing an Effective Comment to ensure your comments can be as impactful as possible.
• If helpful, craft your comments in a Word document using the considerations listed below.
• Enter “Special Registrations for Telemedicine and Limited State Telemedicine Registrations” in the search option.
• Select the Comment button.
• Type your Comments in the required field.
• Upload your Word document (not required).
• Provide the required information.
• Select Submit Comment.
• Follow the ‘‘Submit a comment’’ instructions. Comments are due no later than March 18, 2025, at 11:59 pm EDT.

The American Telemedicine Association (ATA) and its advocacy arm, ATA Action, have expressed several concerns regarding the Drug Enforcement Administration (DEA)’s proposed rule on Special Registrations for Telemedicine and Limited State Telemedicine Registrations. Their primary issues are outlined in ATA Action Calls for MeaningfulChanges to DEA’s Special Registration for Telemedicine and Limited State Telemedicine Registrations Proposed Rule. Those concerns include the following and are also listed in ATA Action’s letter to DEA Acting Administrator, DerekMaltz. There are additional concerns included below that are not included in the ATA Action’s letter.

Complexity with having Three Types of Special Registration and Registrant Eligibility. The three types of registrations are Telemedicine Prescribing Registration, Advanced Telemedicine Prescribing Registration, and Telemedicine Platform Registration. This adds complexity that could increase administrative burden as well as cost due to the fees for each type of registration.

Exclusion of Primary Care Providers. The rule appears to exclude primary care physicians and general practitioners from obtaining advanced telemedicine prescribing registrations unless they meet the “most compelling use case” by demonstrating why they need to prescribe Schedule II controlled substances. Given that these providers often serve as the initial point of contact for patients requiring controlled substances, this exclusion could impede access to necessary treatments, especially in underserved areas. This is contrary to the efforts to integrate behavioral health with primary care and may result in higher healthcare costs if patients need to be referred from primary to specialty care to receive the medications they need (e.g., medications for attention deficit hyperactivity disorder (ADHD)).

Restrictive Prescribing Limits. The proposed rule mandates that special registrants’ prescriptions for Schedule IIcontrolled substances must constitute less than 50% of their total prescriptions monthly. This limitation could hinder specialists, such as psychiatrists and pain management professionals, who frequently prescribe these medications as part of standard care and fails to account for many counties that lack a single licensed psychiatrist.

Requirement to be Physically Located in the Same State as the Patient. ATA Action notes that this will worsen provider shortages, especially in states and locations that already face healthcare shortages such as rural communities.

Ambiguity in Telemedicine Platform Registration. The requirement for telemedicine platforms to register under the proposed rule lacks clear legal authority and raises questions about the logistics of such registrations. Clarification is needed regarding which entities must register and how the attestation process should be conducted.

Unfeasible Nationwide PDMP Checks. The proposal requires a nationwide Prescription Drug Monitoring Program (PDMP) check before prescribing, which is currently impractical due to technical and operational barriers, although the DEA proposes a three-year phase-in period.

Excessive Application Fees and Administrative Burdens. The proposed registration fees and the necessity to register with the DEA in every state in which a prescriber is tele-prescribing controlled substances, could impose significant financial and administrative burdens on telehealth providers, potentially limiting access to healthcare. The proposed Special Registration fee is $888 and would add up quickly for providers prescribing controlled substances in multiple states.

Potential Delays in Registration Processing. There is concern that the anticipated volume of special registration applications could overwhelm the DEA’s already limited administrative capacity, leading to processing delays. Such delays might disrupt patient care, as providers could be unable to prescribe necessary medications in a timely manner.

Geographic “Red Flag” Issues. The ATA Action “…urges the DEA to issue clear guidance stating that the physical location of the prescriber in relation to the patient or pharmacy should not be an automatic red-flag, to clarify enforcement policies to reduce pharmacy uncertainty, and to collaborate with pharmacy organizations and state boards to align policies and prevent unnecessary prescription denials.” (ATA Action Calls for Meaningful Changes to DEA’s Special Registration for Telemedicine and Limited State Telemedicine Registrations Proposed Rule)

Patient Identity Verification Requirements. Prescribers would be required to “…verify the identity of a patient seeking treatment via telemedicine by requiring that the patient present a state or federal government-issued photo identification card through the camera of the audio- video telecommunications system. At the first telemedicine encounter, the clinician special registrant would also be required to capture a photographic record of the patient presenting their federal or state-issued photo identification card or other acceptable documents and use the photographic records to confirm the patient’s identity in subsequent telemedicine encounters.” (Special Registrations for Telemedicine and Limited State Telemedicine Registrations p. 6557)

Implications for Provider Eligibility

Providers Who Will Still Be Eligible for Telehealth

Pre-pandemic Medicare regulations included the following as eligible distant site providers, with additional permanent provider types added over time:

• Physicians
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Nurse-midwives
• Certified registered nurse anesthetists
• Clinical psychologists
• Clinical social workers
• Registered dietitians or nutrition professionals
• Marriage and family therapists, and mental health counselors (newly added as permanent practitioners in 2024)

Providers Who Will Lose Telehealth Eligibility 

Without additional legislative intervention, providers who received temporary allowance will no longer be eligible to provide telehealth services to Medicare beneficiaries. This includes:

• Occupational therapists
• Physical therapists
• Speech-language pathologists
• Audiologists

Contingency Planning and Communications Checklist

• Assess Provider Eligibility
  • Identify all telehealth service providers and determine whether they remain eligible to offer telehealth services after March 31, 2025. This includes verifying if their specific provider type continues to be covered under Medicare’s telehealth policies.
• Make Practice and Workflow Adjustments
  • If a provider loses telehealth eligibility, a transition plan should be developed for affected patients to ensure continuity of care. Identify in-person service alternatives for patients who can no longer receive telehealth visits and consider transportation resources or referrals to facilities where in-person care is accessible.
• Prepare Patient, Provider and Staff Communication and Education
  • Notify patients in advance about potential changes to telehealth eligibility so they can prepare accordingly. 
  • Ensure providers and schedulers understand the new requirements.
  • Plan for multiple distribution channels (e.g., email, patient portals, office signage, website updates).

Bookmark this page and check back each Monday for the latest updates!