The Telehealth Policy Cliff: Preparing for October 1, 2025

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Introduction

Without Congressional action, key telehealth flexibilities that were first put in place during the COVID-19 pandemic will expire on September 30, 2025. These extensions were tied to the federal continuing resolution.  With ongoing political uncertainty and many competing priorities in Congress, there’s a real risk that lawmakers may not act in time – creating a “telehealth policy cliff” that would roll back policy gains.

What does this mean? If the cliff isn’t addressed,

• Providers would no longer be reimbursed for telehealth visits delivered to Medicare beneficiaries in their homes.  Pre-pandemic rural and facility restrictions would return.
• Critical programs like Hospital at Home could face major disruption.
• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) would no longer be able to serve as distant site providers for most telehealth services after December 2025.
• While the DEA extended flexibilities for prescribing controlled substances via telehealth until December 2025, providers may struggle to sustain telehealth-based care if reimbursement disappears. 

September is approaching quickly!  Yet unlike earlier policy cliffs, many providers and organizations are showing signs of “boy who cried wolf” fatigue—hesitant to mobilize as strongly this time because previous deadlines were extended at the last minute. The risk, however, is real.  In this post, we’ll break down the specific telehealth flexibilities at stake, examine their impact on clinical practice, and provide actionable checklists for contingency planning and communication. 

Even if Congress acts again, having a clear communication strategy now will help staff and patients understand and navigate potential changes—so you aren’t caught unprepared should this deadline hold.

Table of Contents:

1. The Return of Physical and Geographic Locations
2. The End of the Hospital at Home Waiver
3. Implications on Prescribing Controlled Substances
4. Implications on Provider Eligibility
5. Implications for FQHCs and RHCs
6. Implications for Telemental Health Services

The Return of Physical and Geographic Location and Modality Requirements

Read more about the impact of the cliff on:   

• Eligible Telehealth Services (Including Audio-Only Services) 
• Eligible Locations for Telehealth Services

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 September 30, 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 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 the expiration.  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 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 September 30, 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 September 30, 2025 and beyond.  

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

Implications on Prescribing of Controlled Substances

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.

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 Meaningful Changes 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, Derek Maltz. 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 II controlled 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)

Implications for Provider Eligibility

Read more about the impact on Eligible Telehealth Providers.

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 September 30, 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.  In the transition plan, consider identifying and communicating the follow to affected patients who can no longer receive telehealth visits:
    • Available locations for in-person visits and instructions for scheduling
    • Transportation services/resources
    • Referral options to other facilities/providers if in-person visits to your location(s) are not feasible
• 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).

Implications for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)

Read more about the impact on FQHCs and RHCs.

Implications of Expiring Telehealth Waivers:

• After September 20, 2025 (without Congressional action):
  • Medicare’s pre-pandemic geographic, originating site and modality restrictions will return for most telehealth services.  In practice, this means
    • Audio-only will no longer be broadly covered, except:
      • When the patient is in their home AND the distant site provider has the capability to use live video but the patient cannot or does not wish to use it.
    • Home as the originating site will only remain for:
      • Treatment for a substance use disorder and co-occurring mental health conditions
      • Mental/behavioral health services (if all in-person visit requirements are met)  
      • End-stage renal disease (ESRD) home dialysis services
    • All other telehealth visits must take place at eligible facilities in approved geographic locations.
• After December 31, 2025 (without Congressional action):
  • FQHCs and RHCs lose their status as eligible distant site telehealth providers for medical visits
    • CMS extended FQHC/RHC authority to provide these services using the G2025 billing code.  This provides parity with the Physician Fee Schedule (PFS) rate through December 31, 2025.  In the 2026 PFS, CMS has proposed another one-year extension (through 2026), but this has not yet been finalized.
  • FQHCs and RHCs may continue to provide mental health visits via live video or audio-only under CMS’s permanent definition
    • Reimbursement would be at the PPS/AIR rate.
    • Beginning January 1, 2026, FQHCs and RHCs must meet the prior and subsequent in-person visit requirements for home-based mental health visits, unless the patient and provider document that the risks outweigh the benefits.  (please note:  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).

Contingency Planning and Communications Checklist

• Review services currently provided under telehealth waivers:
  • Identify all telehealth services and determine whether they remain eligible after September 30, 2025.
  • Identify telehealth services that will expire December 31, 2025 for long-term planning. 
  • Review geographic restrictions based on FQHC/RHC location.
  • Review provider/practitioner schedule and staffing needs to implement adjusted patient/client schedules. 
• Make Practice, Workflow, and Reimbursement Adjustments:
  • Adjust clinic schedules to accommodate shifts in appointment needs.
  • Adjust the workflow for scheduling telehealth appointments to accommodate changes in service types (e.g. in-person if required).
  • Plan for reimbursement changes that impact operations.
  • Prepare for alternative appointment options to share with patients/clients.
  • If applicable, understand transportation options available in your area to aid in accommodating shifts to in-person visits. 
• 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/practitioners, schedulers, support staff, and billing department understand the new requirements.
  • Plan for multiple distribution channels (e.g., email, patient portals, office signage, website updates).

Implications for Telemental Health Services

Read more about the impact on Telehealth & Medicare Mental Health Services.

Implications of Expiring Telehealth Waivers (without Congressional action):

• Beginning October 1, 2025, patients must have received a Medicare covered/Medicare eligible service mental health 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.
  • CMS has 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.   
  • The in-person service must be a Medicare-billable visit so that it is accurately recorded in CMS’s claims processing system.
• Exceptions to the in-person requirement include:
  • Patients located in a rural area and in an eligible originating site as defined under permanent law. 
  • 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.  

Because this requirement has yet to be implemented, CMS has not issued any guidance.  Therefore, CMS may provide additional clarification as the deadline approaches.  

Contingency Planning and Communications Checklist

• While awaiting more detailed guidance from CMS, organizations should:
  • Assess the Impact on Your Patients
    • Identify how many and which patients would fall under the in-person requirement
    • Flag those who may qualify for exceptions
  • Identify In-Person Care Capacity
    • Assess whether your organization has the capacity to schedule and complete in-person visits for all impacted patients every 12 months
    • Map geographic areas where impacted patients live to identify travel burden “hot spots”.
  • Brainstorm Options with Your Team
    • Explore ways to integrate in-person visits into care plans without disrupting continuity
    • If additional in-person capacity is needed:
      • Evaluate staffing models, extended hours or shared provider arrangements
      • Strengthen or create referral networks based on where your patients are located
  • Prepare Patient, Provider and Staff Communications
    • Draft clear and proactive notices explaining upcoming requirements and possilble changes
    • Consider using an Advance Beneficiary Notice of Non-coverage (ABN) when appropriate to alert patients of potential financial liability – and give them the option of cotinuing telehealth on a self-pay basis.
    • Ensure providers, schedulers and front-line staff understand the new rules and exceptions
    • Plan for multiple communication channels (e.g., email, patient portals, office signage, website updates).
    • Document and Track Exceptions
      • Develop a standardized workflow for documenting when patients meet exception criteria
      • Train staff and providers on how to record this in the medical record so that decisions are defensible in the event of an audit
    • Monitor CMS Updates Closely
      • Because this requirement has not yet been implemented, CMS may still issue clarifications – such as whether existing patients will be grandfathered in for the 6-month prior requirement, when the 12-month requirement begins, how to document travel burden risks and benefits, or whether group practices can flex further on the “colleague” provision
      • Assign responsibility for monitoring and disseminating updates within your organization

Bookmark this page and check back regularly for the latest updates!