As December 31, 2024 quickly approaches, those in the telehealth community, as well as those who receive services via telehealth, may begin to wonder if the federal waivers regarding Medicare telehealth policies will again be extended, or if they will come to an end once the clock hits midnight. As of the writing of this newsletter, no one is absolutely certain what will happen in the coming weeks. Just after the Presidential election in early November, there were some indications that the waiver deadline may pass without any Congressional action taken to extend the waivers, as talk on Capitol Hill seemed to indicate a desire to wait until the new Congress was installed in 2025 before any major policy decisions were made. However, in recent weeks there have been rumors that an extension might be passed before the December 31 deadline. At this time these are only rumors and by no means is there a guarantee that we will see an extension to the waivers. Additionally, along with the possible extension rumor as a whole, there is also the possibility that any forthcoming extension could be limited to a short period of time, even potentially lasting only a few months, or have other conditions attached. Therefore, we currently find ourselves not being entirely certain what exactly will happen as the year comes to a close. Nevertheless, there is certainly a bit more hope than there was just a few weeks ago.
If we were to assume that the waiver deadline does come to pass as a result of Congress not taking additional action to extend it, what will happen next? The simple answer to that question is: Medicare policies will revert back to the permanent telehealth requirements in statutes and regulations. These permanent policies do differ significantly in comparison to what has been allowed during the waiver period. Many may ask what will the impact of reverting back to Medicare permanent telehealth policies be, as they have only experienced or utilized telehealth during the waiver period. To help answer that question, the Center for Connected Health Policy (CCHP) has compiled below some of the most common inquiries received from providers, organizations and patients regarding the potential end of the Medicare telehealth waivers.
If the Waivers do expire on 12/31/24, will telehealth become unavailable?
No. The Medicare telehealth waivers do not impact the ability of a practitioner to utilize technology to provide a health care service. What the Medicare waivers currently do is expand the potential to use telehealth to provide a service under the Medicare program so that Medicare will cover and reimburse the provider who delivers that service. Therefore, if the waivers end, you can still access services via telehealth, but your provider may no longer be able to offer those services via telehealth because they will no longer be reimbursed by Medicare. However, if your health care is covered by a payer other than Medicare, for example through private health insurance at work or through your state Medicaid program, the end of the waivers may not directly impact you. Could your insurance carrier potentially change their policies to match what Medicare covers for telehealth? Yes, but there are still other rules they would have to follow, meaning that there will not be an immediate change to your coverage starting January 1, 2025, as there would be for Medicare enrollees should the waivers expire.
As a Medicare patient, if the waivers expire will I lose all access to services via telehealth? As a provider with Medicare patients, will I lose all ability to use telehealth to treat my Medicare patients?
It depends. Without the waivers in place, the coverage and reimbursement policies for telehealth in Medicare become narrower. Certain geographic/site conditions will need to be met to make Medicare coverage and reimbursement possible. For example, under the telehealth waivers any eligible service can take place in the home. Without the waivers, the only services that are eligible to take place in the home are those for end stage renal disease, mental health services when a co-occurring opioid use disorder is being treated, or mental health services where certain conditions are met.
Under permanent Medicare telehealth policy, a geographic requirement must be met before a telehealth service can be covered and reimbursed. Specifically, the patient at the time of the telehealth interaction must be located in an area that is designated as a rural health professional shortage area (HPSA); a county that is not included in a Metropolitan Statistical Area (MSA) or an entity participating in a federal telehealth demonstration project. There are also limited exceptions to this geographic rule, such as services related to the treatment for stroke. In general, however, under permanent Medicare telehealth policy, patients will need to be located in certain rural areas, as well as within certain types of health care settings, in order to be eligible for telehealth services. Therefore, with these requirements back in place in the absence of the waivers, the ability for telehealth to be provided and still be paid by Medicare shrinks. To determine if an address qualifies as an originating site under CMS’ definition of a rural HPSA to meet the returning geographic/site requirements, you can use the Medicare Telehealth Payment Eligibility Analyzer Tool.
If I meet the location requirements, can I still get telehealth services as a Medicare enrollee from my provider if the waivers expire? If my patient meets the location requirements, does a provider still qualify to be reimbursed by Medicare if the service is provided via telehealth?
This is another question where the answer is another “it depends.” The permanent telehealth policies in federal law limit the types of providers who are eligible for reimbursement from Medicare if they use telehealth to provide those services. On that list of eligible telehealth providers are:
- Physicians
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- Nurse-midwives
- Clinical nurse specialists (CNSs)
- Certified registered nurse anesthetists
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- Clinical psychologists (CPs) and clinical social workers (CSWs)
- Registered dietitians or nutrition professionals
- Marriage and Family Therapists and Counselors
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Two additional things to note:
- The above list of Medicare eligible providers is limited to specific health care professionals only and is missing the inclusion of other professionals who have recently been able to provide services via telehealth and be reimbursed by Medicare during this waiver period, such as physical and occupational therapists and speech language pathologists. Consequently, if the waivers are not extended and you have been receiving telehealth delivered services from or providing services as a physical therapist, for example, or as one of the providers who are not on the permanent eligible provider list, it will no longer be covered by Medicare
- To expand this list of eligible providers to include more healthcare professionals would require Congress passing legislation, as this specific limitation is in federal law.
I don’t receive services from a specialist, but I do get primary care services from a federally qualified health center (FQHC) or a rural health clinic (RHC), does this mean I can’t use telehealth anymore if the waivers have expired? Can FQHCs and RHCs continue to provide services via telehealth and get reimbursed by Medicare?
If the Medicare waivers expire on December 31, 2024 and you receive services from an FQHC or an RHC via telehealth, that facility will still be able to continue to provide your services via telehealth and Medicare will continue to pay for them.
You might now be wondering how that is possible especially since within the previous question the answer stated that an act of Congress was necessary to change the list of eligible providers. As noted previously, the permanent eligible provider list relates only to individual health care professionals. FQHCs and RHCs are treated as an organization when billing, not as an individual provider. In the 2025 Physician Fee Schedule (PFS), the Centers for Medicare and Medicaid Services (CMS) explained that since the federal law applied to which health care professional was eligible to provide services via telehealth in the Medicare program, that rule did not apply to organizations like an FQHC and RHC. Therefore, within the 2025 PFS, CMS extended for one year the ability of an FQHC or RHC to continue to provide services via telehealth and have Medicare reimburse for it. To learn more about the 2025 PFS, you can download a copy of CCHP’s CY 2025 PFS fact sheet on the policies CMS finalized last month.
Will the ability to provide/receive services via audio-only in Medicare continue without the waivers?
Under federal law, the telehealth services covered by Medicare are those delivered via a “telecommunication system”, but the enacting legislation did not define what exactly that means. By implementing the statute via regulations, CMS created a definition for the term and added the word “interactive” before it. Subsequently, the 2025 PFS expanded the definition of what an “interactive telecommunication system” means to permanently include the use of audio-only in the home for any eligible telehealth service if certain conditions are met. While this may appear to mean you can receive more services via audio-only, the reality is that because of the certain conditions that need to be met, it in fact is much narrower than it may appear at first glance. For example, one of the conditions is the requirement that the patient is located in their home at the time of the audio-only interaction. However, as noted earlier, under permanent Medicare telehealth policies, only certain services can take place in the home, in addition to needing to meet other additional requirements for delivering services via telehealth (i.e. the location of the patient and provider type described in previous questions must also be met). Therefore, if no other policies are changed, the expanded definition of “interactive telecommunication system” only allows a limited set of services to take place via audio-only. See the audio-only section in CCHP’s 2025 PFS fact sheet and page 139 of the PFS for more information.
It is also important to note that there are communication technology-based service (CTBS) codes that may also apply in some instances, which are not subject to the telehealth statutory requirements and billing rules – more information on CTBS can be found starting on page 11 of the CCHP Medicare Telehealth Billing Guide. Lastly, in regard to CPT codes 99441-99443 – for Medicare purposes, according to the 2025 Medicare Physician Fee Schedule (PFS), the 99441-99443 codes are planned to be returned to bundled status in 2025 – see page 240 of the PFS: CPT codes 99441, 99442, and 99443, each are [currently] assigned provisional status on the Medicare telehealth services list and would return to bundled status when the telehealth flexibilities expire on December 31, 2024.
Will tele-behavioral health visits require periodic in-person visits in order to be reimbursed under Medicare if the waivers expire?
The in-person requirements specific to behavioral health that are set to go into effect upon expiration of the federal waivers are actually part of a permanent policy that sought to expand access to telehealth in the event of this return to pre-existing geographic/site limitations. Meaning that for behavioral health, the geographic/site requirements would no longer have to be met in order to receive Medicare coverage, if certain conditions such as prior and subsequent in-person visits with the telehealth provider are met. Therefore, without an additional waiver extension, there would be two Medicare coverage tracks available for behavioral health via telehealth in 2025 – one that requires providers to meet the geographic/site requirements and the other that requires providers to instead meet the in-person requirements.
However, the prior in-person visit requirement placed on FQHCs and RHCs for utilizing telehealth to provide mental health visits will continue to be waived through 2025. CMS delayed the activation of this requirement for FQHCs and RHCs to January 1, 2026. One may ask how can CMS delay the in-person requirement for FQHCs and RHCs but not for everyone else? The answer is that the prior in-person visit requirement for everyone else is in federal law and would require Congress to change it. When the telehealth waivers were passed by Congress, they also included a delay of the prior in-person visit requirement until the end of 2024. However, the prior in-person visit requirement on FQHCs and RHCS has its origin in regulations promulgated by CMS in the 2022 PFS, rather than federal law. Therefore, CMS is able to act on the FQHC/RHC prior in-person requirement for mental health without waiting for Congressional action.
How does the end of the waivers impact licensure requirements?
If the Medicare waivers come to an end, it will not impact licensure, as the federal waivers are specific to Medicare reimbursement. Licensure requirements are in the jurisdiction of each individual state and are separate from reimbursement policies. Essentially, if you are providing services, even via technology, to a patient located within a respective state’s border, you typically will need to be licensed by the state where the patient is located. There are some narrow exceptions and other means to meet this requirement that vary by state, such as having a state telehealth registration process or having a state participate in a licensure compact, however, it is always important to highlight that licensure policies will vary from state-to-state. For more information, please visit the CCHP Policy Finder to review a specific state’s licensure rules.
What about prescribing and telehealth if the waivers end?
The Medicare waivers do not impact the federal waiver that is in place for the prescribing of controlled substances via telehealth. The Drug Enforcement Administration (DEA) is the administering agency of that particular waiver, and in early November the DEA extended the prescribing waiver for telehealth for an additional one-year, to December 31, 2025. State rules regarding telehealth and prescribing may still apply, for more information please visit the CCHP Policy Finder to review a specific state’s online prescribing rules.
There are so many exceptions to keep track of, how do I know which specific policies apply to me?
There is still the possibility that an extension of the federal Medicare waivers will occur, in which case the above-mentioned permanent policy scenarios may not come into play until later into 2025 or further out. There is also the possibility that at some point Congress may act to change some of the permanent Medicare telehealth policies to something else. At this point it is unclear which policies will be in play starting January 1, 2025, and unfortunately, we may not know what the policy landscape will look like as it pertains to the use of telehealth until the very last minute. No matter what happens, CCHP will be here to continue to provide clarity and understanding to our readers. You can continue to track developments through CCHP’s newsletters and through our website.
Additionally, you can join CCHP for our next webinar on January 9, 2025 where we will review what the current Medicare telehealth policy environment looks like at that time. This webinar will be held jointly with the National Consortium of Telehealth Resource Centers. REGISTRATION is free, but space is limited.
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