A permanent telehealth benefit with an in-person clock attached
Medicare’s July 2021 fee schedule proposal made home telehealth for mental health the first permanent post-pandemic benefit. Its conditions turned continuity of care into a records problem: where the patient is, how the visit happens, and when they were last seen in person.
Looking Back revisits one week at a time, from January 2020 to today, and asks what it meant for the banks, health systems and public agencies we serve. The series was written in 2026, with the benefit of hindsight, and each article says which week it looks back on.
The week
On July 13, 2021, CMS released its proposed Medicare Physician Fee Schedule for calendar year 2022. Among many provisions, it proposed how to implement a change Congress had made in the Consolidated Appropriations Act, 2021: removing the geographic restrictions on telehealth for the diagnosis, evaluation and treatment of mental health disorders, and allowing the patient’s home to serve as the originating site. As the law required, the proposal tied this to an in-person, non-telehealth visit within six months before the first telehealth mental health service, and CMS proposed further in-person visits every six months. It also proposed allowing audio-only care for mental health services to patients at home when the clinician could offer video but the patient could not use it or did not consent to it. Most other pandemic telehealth flexibilities remained tied to the public health emergency. CMS finalized these provisions in November 2021.
Before the pandemic, Medicare paid for telehealth only in narrow circumstances. The patient generally had to be in a rural area and at a clinical site such as a clinic or hospital, not at home. Emergency waivers in 2020 removed those limits temporarily, and every other telehealth flexibility in 2021 still had an expiry date attached to the public health emergency. Mental health was different. Congress had made home-based telehealth for mental health permanent in late 2020, and the July 2021 proposal set out how it would work.
For patients, the change was large. A Medicare beneficiary in a city could now see a therapist or psychiatrist from home, indefinitely. But the benefit arrived with conditions, and each condition depends on a fact the practice must record at every visit. Continuity of care for a patient now rested on three records: where the patient is, how the visit is delivered, and when the patient was last seen in person. A practice that cannot produce any one of them reliably risks denied claims, interrupted care, or both.
Where the patient is: location as a clinical and legal fact
The home could now serve as the originating site for mental health care. That made the patient’s location at the time of each visit a billable fact, not just a matter of convenience. It also made it a licensure fact. Medicare decides what it pays for; states decide who may practice. During the emergency, many states had relaxed licensure rules so clinicians could see patients across state lines. As those waivers ended through 2021, licensure followed the patient again. A psychiatrist treating a patient who had moved, was traveling or lived across a border needed a license in the state where the patient sat during that session.
Location also matters for safety. A clinician seeing a patient at home needs to know where that patient is in order to send help in a crisis. Good practice is to confirm the patient’s physical address and a local emergency contact at the start of each session, not once at registration.
The operational answer has two parts. One is a structured field in the visit record, completed by the clinician or check-in staff each time. The other is a rule in the scheduling system that compares the patient’s stated location with the clinician’s licensed states before the visit starts. Interstate compacts for psychologists and professional counselors offered partial relief, but coverage varied by state and profession, so the check could not be skipped.
How the visit is delivered: audio-only as an access decision
The proposal to allow audio-only mental health care recognized something the pandemic had made plain. Many older and lower-income patients lacked broadband, a suitable device or confidence with video. For some of them, a telephone call was the only workable form of virtual care. For a Medicare population, that group is large.
CMS attached conditions. The clinician had to be capable of video, and audio-only was allowed only when the patient could not use video or did not consent to it. That turns modality into a documented choice. The record should show that video was offered and why the visit took place by phone. Claims needed to carry the correct modifier to signal audio-only delivery.
The patient experience design follows from those rules. Outreach should offer video first and make it easy, with help for patients setting it up. The phone option should stay available without the patient having to argue for it. Scheduling templates should record the modality agreed for each patient, so that a patient who always uses the phone is not sent a video link they cannot open. For the patient, the best channel is the one that works on the day.
When the patient was last seen in person: a clock on every chart
The third condition was the most contested. The law required an in-person visit within six months before the first telehealth mental health service, and CMS proposed follow-up in-person visits every six months. In the final rule it settled on at least every 12 months, with exceptions where the clinician and patient agree the risks of an in-person visit outweigh the benefits and document why. The rationale was clinical oversight and program integrity. The objection was that it rebuilt part of the travel barrier telehealth had removed, especially for patients far from a clinic or unable to travel.
Whatever the policy merits, the condition created a running clock on every telehealth patient’s chart. A practice needs to know, for each patient, the date of the last qualifying in-person visit, by which clinician or practice, and when the next one is due. That information often sits in separate systems or separate organizations. Without a reliable report, practices face two bad outcomes: claims denied because the in-person visit lapsed, or patients brought in unnecessarily because nobody could confirm the date.
The fix is a registry. Flag each patient receiving telehealth mental health services, compute the due date for the next in-person visit, surface it to schedulers well ahead, and record any documented exception. The registry is cheap to build and expensive to lack. It also made practices ready for whatever date the requirement would finally bite, which, as it turned out, kept moving.
The three records share one design principle. Each condition attached to the benefit is a data element, captured at the visit, checked before the claim, and visible to the people who schedule care. Practices that treated them as such could offer patients a stable virtual service while Medicare policy shifted around it.
With hindsight
From 2026, mental health is where Medicare telehealth became most firmly embedded, and the in-person clock is the condition that never quite started. The public health emergency ended in May 2023, and Congress repeatedly extended the broader telehealth flexibilities in short increments, with a lapse during the federal government shutdown in October and November 2025. Each extension also postponed the in-person requirement for mental health. The Consolidated Appropriations Act, 2026, signed in February, extended the flexibilities through the end of 2027 and delayed the in-person requirement to January 1, 2028, so organizations should confirm the current dates. Audio-only care remained important for older and lower-income patients. Behavioral health has kept a far higher virtual share than most specialties. Practices that built location, modality and in-person tracking into their records in 2021 have absorbed each extension and lapse without disrupting patients.