CMS TELEMENTAL HEALTH UPDATE

Here are the key points of the clarification concerning telemental health care claims in Medicare:

1. In-Person Visit Requirements for Telemental Health
The most significant clarification revolves around the statutory requirement for an in-person visit:

New Patients (Starting on or after October 1, 2025): The mental health provider must have conducted an in-person, non-telehealth visit within the 6 months prior to the initial mental health telehealth service.

Established Patients (Began services on or before September 30, 2025): These patients are exempt from the 6-month prior in-person visit requirement. They are only required to comply with the ongoing annual in-person visit requirement (at least once every 12 months).

2. Ongoing Annual In-Person Visit Exception
Annual Visit Requirement: After the initial in-person visit (for new patients), established patients must have an in-person visit at least once every 12 months.

Exception: CMS allows a limited exception to the annual requirement if both the provider and patient determine the risks or burdens of an in-person visit outweigh the potential benefits. This decision must be documented in the patient’s medical record.

Note: While Medicare’s policies often influence the private market and set a national benchmark, the rules for private insurers are primarily
determined by state law and private contract and market practice.

3. Claims Processing and Holds
Claims Lifted: Following the October 2025 guidance (and a subsequent legislative action), CMS instructed Medicare Administrative Contractors (MACs) to lift the temporary claims hold and process claims with dates of service on or after October 1, 2025, for telehealth claims that CMS can confirm are definitively for behavioral and mental health services.

4. Audio-Only Telehealth
Continuation: Audio-only telehealth is still generally covered for mental and behavioral health services furnished to patients in their homes, provided the distant site practitioner is technically capable of using an audio-video system but the patient is unable to or declines to use video.

Duration: Current legislation (as of late 2025) extends some telehealth flexibilities, including audio-only for behavioral health in the home, through January 30, 2026.

5. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs)
Delayed In-Person Requirement: For behavioral health services furnished by RHCs and FQHCs where the patient is present virtually, the in-person visit requirement is delayed until at least January 1, 2026.

The key takeaway is that telemental health services continue to have broader coverage flexibilities than non-behavioral health services, particularly regarding the patient’s location (the patient’s home is a permanent originating site) and modality (audio-only is allowed).

However, the new and clarified in-person visit requirements for patients receiving services in their homes are now in effect, with a distinction made for established patients (pre-October 1, 2025) and a limited exception for the annual visit.

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