After surging during the pandemic, many existing telehealth rules were set to expire on December 31, 2024, potentially leaving thousands of people with less access to needed care. But the Department of Health and Human Services and the Drug Enforcement Administration announced a one-year extension of some rules on November 15, 2024. This includes current prescribing rules for controlled substances via telehealth, without an initial in-person visit. 

Several other telehealth provisions slated to end on December 31, 2024, including many Medicare and hospital at-home services, were extended through March 31, 2025, in an eleventh hour continuing resolution (CR) that Congress passed on December 20, 2024. 

“Telehealth is here to stay. The challenge is figuring out what’s most effective for making those provisions permanent,” said LDI Senior Fellow Molly Candon, Assistant Professor in the Center for Mental Health, Department of Psychiatry, Perelman School of Medicine and in the Department of Health Care Management at Wharton. 

Telehealth rose dramatically during the COVID-19 pandemic, revolutionizing access as regulatory barriers were temporarily eased. The Centers for Medicare & Medicaid Services (CMS) enabled widespread use by allowing virtual visits across state lines, permitting audio-only care for certain conditions, and waiving in-person requirements for prescriptions. 

The rules were a boon to mental health and addiction care, and in areas as varied as transplantation coordination, remote monitoring of chronic conditions, physical therapy, and hospital post-discharge follow up.

Telehealth use has since fallen as in-person care has resumed, but it still remains higher than pre-pandemic levels.  

“There are individuals who will have the same or better experience with care via telehealth as they would in person,” said Candon, who has published research on using telehealth to help individuals seeking primary care who are at risk for suicide. “So, let’s ensure that those individuals can still access telehealth.” 

Even before a budget deal was reached, CMS eliminated the “Four Walls” rule, and will permit Medicare and Medicaid beneficiaries to receive telehealth from any location, including their home, through 2026. 

The continuing resolution extended through March includes most Medicare and Medicaid telehealth waivers that were set to expire on December 31, 2024. These include:

• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can serve as a distant site provider for non-behavioral/mental telehealth services.
• Telehealth services including physical and occupational therapy, emergency department visits, and nursing facility care.
• Any provider eligible to bill for Medicare-covered services can provide and bill for telehealth as a “distant site” telehealth provider and may conduct an initial telehealth visit regardless of whether they have previously treated the beneficiary.
• Waiver of an in-person visit requirement for behavioral health.
• Initial telehealth evaluations for controlled substances like buprenorphine, without prior in-person visits.

Notable exceptions to this extension include several payment-related issues—first-dollar coverage of telehealth services under high deductible health plans (HDHPs) and health savings accounts (HSAs)—as well as Medicare reimbursement for in-home cardiac and pulmonary rehabilitation services delivered by telehealth.

Several telehealth rules have also been made permanent, including: 

• Behavioral health services, including addiction care for Medicare beneficiaries.
• FQHCs and RHCs can serve as a distant site provider for behavioral/mental telehealth services.
• The elimination of geographic restrictions or originating site requirements for behavioral/mental telehealth services.
• Audio-only communication can be used for behavioral/mental telehealth services. 
• Rural Emergency Hospitals (REHs) are eligible as originating sites. 

State Licensure Still a Conundrum

One key issue surrounding telehealth use is the ability to care for individuals across state lines. During the pandemic, federal rules were lifted, allowing physicians to practice across state borders without acquiring separate state licenses. 

This dramatically increased telehealth’s reach and access to care for many individuals. But many waivers have already expired, and states are reverting to pre-pandemic licensure requirements. This change could further shrink telehealth’s reach, especially in underserved areas. 

“It makes no sense to have separate state licensure requirements when [people] might just cross the border for care,” said LDI Senior Fellow Marina Serper, Associate Professor of Medicine at Penn’s Perelman School of Medicine. 

Even for a specialty like liver transplantation, telehealth has many benefits—conducting pre-surgical education, evaluations, reviewing lab results, assessing and monitoring diet, and the person’s mental health, Serper said. 

LDI Senior Fellow Eric Bressman, Assistant Professor of Medicine at the Perelman School of Medicine, previously wrote about the need for a federal licensing approach that would allow physicians to practice across state lines. This approach would make telemedicine available to more people in the Pennsylvania-Delaware-New Jersey corridor, and in many others. 

“It’s really just having a flexible set of tools for [people to access care],” said Bressman. He led a 2022 study published in the Journal of General Internal Medicine showing that disparities in post-hospital discharge follow-up to primary care appointments narrowed when telehealth use was expanded. 

While Bressman doesn’t think this is likely to happen anytime soon on the federal level, he’s optimistic that more states will join medical licensure compacts, and allow reciprocal provision of care. 

“Broader reciprocity is the most promising pathway to having a system that makes sense where people can be licensed at the state level, but not be burdened too much with paperwork and rules to see individuals who happen to be either living in another state or just traveling to another state, which is often the case,” Bressman said. 

Telehealth offers unprecedented convenience but it’s not a panacea. Marginalized groups—such as people experiencing homelessness, residents of rural areas without broadband access, or those who lack computer literacy—remain underserved. 

For individuals who can access it, however, the advantages are undeniable. “For a lot of people who need care, it’s convenient,”  said LDI Senior Fellow Margaret Lowenstein, an Assistant Professor of Medicine and Research Director of the Penn Center for Addiction Medicine and Policy (CAMP). “For people who want their privacy, there’s more anonymity. Telehealth overcomes a number of barriers.” Lowenstein co-authored a 2022 LDI Issue Brief that noted expanded telehealth options for buprenorphine and greater flexibility in methadone prescribing increased treatment access and should be continued.

Requirements for an in-person visit before prescribing buprenorphine were waived during the COVID-19 pandemic, opening more opportunities to treat opioid addiction. “Given where we are in this public health crisis in our country, it really seems a shame to limit a really important tool we have for that,” Lowenstein said.

Lowenstein directs CareConnect, a telehealth bridge program with a toll-free number that she describes as a lifeline for certain individuals. “If you miss a day of buprenorphine, that can be life or death,” she said. 

There are many ways that things can go wrong as people try to stay in care. Some random barrier is enough to throw that off, Lowenstein said. In another co-authored study, published in 2021 in Harm Reduction Journal, Lowenstein and colleagues found telehealth enabled treatment for people with logistical and psychological barriers to in-person care. But access to and comfort with technology remained hurdles to expanding telehealth care.

She cited the case of one person who had arrived at a city clinic for a daily dose of buprenorphine, but learned the prescriber had already left. Without the CareConnect hotline, that person may have had to forgo needed medication, wait for hours in an emergency room, or hope to find another open clinic somewhere, perhaps without the resources to even travel across town.

Proposed legislation would make many of these temporary provisions permanent. The care allowed in the proposed bipartisan Telehealth Modernization Act is supported by most Medicare beneficiaries, and by many providers. It would make telehealth a standard adjunct to in-person care.  

Telehealth advocates said they would continue to work with the incoming Congress and new administration to strengthen and expand telehealth coverage. Congress may also reconsider the Telehealth Response for E-prescribing Addiction Therapy Services (TREATS) Act, which would expand e-prescribing of controlled substances. 

It’s not yet known whether the incoming Trump administration supports these measures, but during his previous term, telehealth rules were broadly expanded.

As Serper concluded, “there’s no one-size-fits-all, but I think we need to continue to work through this, continue to think of this as part of routine care. And it’s not for everything, but we need to think about how, and for whom, and under what circumstances.” 

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