If you see Medicare clients via telehealth, the question is still looming: will Medicare resume the requirement to have an in-person visit prior to being seen via telehealth?
On October 1, 2025, the answer will once more be yes – unless Congress acts. Since the start of COVID in 2020, this drama plays out every year (or more often), causing anxiety among therapists and clients. Will Medicare extend the waiver they put in place during the COVID days that allows clients to be seen via telehealth without first having an in-person visit? If they extend the waiver yet again, postponing a decision, how long will the extension last this time? Will they ever come to their senses and make telehealth without face-to-face evaluation permanent?
It’s been like the old TV soap operas: tune in tomorrow!
Now, once again, legislation has been introduced that would permanently remove the Medicare in-person visit requirement. It’s called the Telemental Health Care Access Act of 2025. Click here to read the press release from Doris Matsui (D-CA) and her fellow sponsors in the House and Senate.
Before you get your hopes up or make practice-altering decisions: so far, this is just a bill. It still has to pass both houses of Congress and receive presidential approval. But in the current volatile climate of unprecedented political upheaval and a new war, it’s going to be hard for any piece of legislation right now, however important it is to mental health professionals and our clients, to compete with “The Big Beautiful Bill” for everyone’s attention. The outcome of THAT mammoth piece of legislation is likely to have an influence on our field that goes far beyond whether Medicare clients can be seen via telehealth without having first had a face-to-face visit.
What are the in-person visit rules?
If the waiver expires without Rep. Matsui’s bill becoming law, Medicare’s coverage rules for telehealth revert to:
- The client must be treated or evaluated on an in-person basis within the 6 months prior to the first telehealth session.
- At least one follow-up in-person visit every 365 days thereafter.
But…as always, there are exceptions.
If a client begins treatment and is seen via telehealth prior to the expiration of the waiver on September 30, 2025, they wouldn’t be required to have an in-person visit after October 1 before having telehealth again just because the waiver expired. However, going forward, they would still be required to have at least one face-to-face visit every year.
And, whether or not a client was already in treatment before September 30, the in-person visit requirement can also be waived on a case-by-case basis if
…the physician or practitioner and patient agree that the risks and burdens outweigh the benefits associated with furnishing the in-person item or service, and the practitioner documents the reasons for this decision in the patient’s medical record.
Center for Connected Health Policy, February 4 2025 (emphasis on documentation is mine)
Does this apply to Medicare Advantage?
Medicare coverage, rules, and reimbursement rates are always a matter of law and are set by Congress. Typically, they apply to commercial Medicare “Advantage” plans as well as Original Medicare.
What makes “Advantage” plans so difficult, though, is understanding all the Medicare rules on top of the confusion and lack of clarity that always seems to accompany dealing with commercial insurance companies. It’s a double whammy, because insurance payers do have some flexibility in how they structure their Medicare “Advantage” products.
If you’re stumped by Medicare, Medicare Advantage, billing issues, or any other insurance conundrum, I’m always available to help. My 4-hour All Things Medicare webinar is also a great resource to ensure that lack of knowledge of the rules doesn’t turn into your next big clawback.
