Telehealth’s three policy clocks all ran down in December, so virtual care needed an annual cycle
After the 2025 fee schedule, a Medicare virtual visit still depended on CMS rulemaking, a congressional extension and a DEA rule. What had looked like a post-emergency transition was a standing condition, with all three clocks converging at year-end, best run as a yearly cycle.
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 November 1, 2024, the Centers for Medicare & Medicaid Services released the final calendar year 2025 Medicare physician fee schedule. On telehealth, CMS permanently allowed audio-only communication for services delivered to patients at home when the practitioner can offer video but the patient cannot use it or does not consent. It extended virtual direct supervision through 2025, and made it permanent for a narrow set of lower-risk services. It also let practitioners deliver telehealth from home through 2025 without listing a home address on enrollment. The broader flexibilities that let beneficiaries receive most telehealth at home, regardless of geography, rested on statute and were due to expire on December 31, 2024. Separately, the DEA’s temporary rule allowing controlled substances to be prescribed by telemedicine without a prior in-person visit was also due to expire at the end of 2024. Two weeks later, DEA and HHS extended it through 2025.
Earlier articles in this series followed telehealth through 90-day emergency renewals and the first permanent mental health benefit. They also covered the end of the emergency in 2023, when flexibilities began expiring on separate schedules set by different authorities. That last stage was treated as a transition. By late 2024 it was clearly something else. The emergency was long over. Yet whether a given virtual visit could happen, and be paid, still depended on three authorities acting on three schedules, and all three had settled into a pattern of running down in December.
CMS controls what it can change by regulation in the annual fee schedule: how services are defined, how clinicians supervise, and enrollment details. Congress controls what the statute restricts: where the patient may be, which practitioners may bill and the in-person visit requirement for mental health. The DEA, with HHS, controls whether controlled substances can be prescribed without an in-person visit. Every Medicare telehealth dependency falls under exactly one of these three, and each affects a different group of patients. Medicare Advantage and commercial payer policies add variation, but the three public clocks set the floor. Treating them as a recurring annual cycle, with a calendar and an owner, was the change in mindset the 2025 fee schedule called for.
The CMS clock: annual and mostly clinician-facing
Fee schedule changes arrive once a year, with a proposed rule in summer and a final rule around November 1. That cadence is predictable, and the November 2024 changes mostly concerned how clinicians work. Virtual direct supervision lets a supervising practitioner be present by real-time audio and video. Staffing models for infusion, remote patient monitoring and some outpatient services had been built on it since 2020. Clinicians working from home could keep their home address off public enrollment records, a safety concern for many.
For patients, these changes are mostly invisible unless they fail. The planning task is internal: an inventory of which workflows rely on each CMS flexibility, its end date and the staffing change needed if it lapses. Because the CMS clock is annual, that inventory can be reviewed each summer when the proposed rule appears, well ahead of the January effective date.
The congressional clock: short, late and patient-facing
The statutory flexibilities are the ones patients feel. If they lapse, most Medicare beneficiaries outside rural areas could no longer receive many services at home by telehealth. Physical and occupational therapists, speech-language pathologists and audiologists would lose their ability to bill for telehealth. The in-person visit requirement for mental health telehealth would take effect. Congress had renewed these flexibilities in short increments, usually near the deadline and often inside larger spending bills.
The same clock governed the Acute Hospital Care at Home waiver, which lets hospitals treat selected inpatients at home. Its statutory extension also ran to the end of 2024. A health system with a hospital-at-home program faced a sharper version of the telehealth problem: if the waiver lapsed, patients already admitted at home would need a plan, and new admissions would stop. Census planning for the last weeks of each extension period, with a defined path back to a bed in the building, is the contingency that matters.
This clock calls for patient-level planning. Scheduling systems can flag appointments that fall after a deadline, by service type and patient location. Patient messages can be drafted for each outcome. In-person capacity can be reserved for conversions. Patients who rely on audio-only care, often older or without reliable broadband, need particular attention, because the permanent CMS change on audio-only does not by itself restore home eligibility if the statutory flexibilities lapse. On the billing side, claims systems need configurations ready for both outcomes and a rule for holding claims when coverage on the date of service is uncertain.
The DEA clock: narrow but highest-stakes
The third clock affects a smaller group with the most to lose: patients receiving controlled substances through telemedicine, including buprenorphine for opioid use disorder and stimulants for ADHD. Without the temporary rule, many would need an in-person visit before a prescription could be issued or renewed. For patients in treatment for addiction, an interruption is a clinical risk, not an inconvenience.
The DEA rule applies across payers, so it is not a Medicare question. Health systems needed a registry of patients receiving controlled substances via telemedicine, with the date of each patient’s last in-person visit, so they could prioritize in-person appointments if the extension failed. They also needed to track state rules, which can be stricter than federal ones, and the DEA’s pending permanent framework, including a proposed special registration for telemedicine.
The three clocks interact at year-end, when the fee schedule takes effect, congressional deadlines cluster and DEA extensions have tended to arrive. That is also when staff are on leave. A single policy owner, with a calendar of every telehealth-related expiry by authority and a pre-agreed trigger for each contingency, prevents the last-week scramble. Messages to patients, clinicians and billing staff can then go out in the right order: billing first, clinicians next so they can advise patients, and patients a week or two before any change.
With hindsight
All three clocks kept running. Congress extended the statutory flexibilities in December 2024 and again in March 2025, each time for months rather than years. They lapsed when the federal government shut down on October 1, 2025, and some visits were converted, rescheduled or held for billing until legislation restored them in November. A later article in this series covers the longer extension that followed a further lapse in early 2026. The DEA clock behaved similarly: the extension through 2025 was followed in early 2026 by a fourth temporary extension through the end of 2026, while the permanent special registration framework remained unfinished. CMS continued to make incremental changes within its authority in later fee schedules. Organizations that had mapped services and patients to the governing authority could see which group each lapse touched and act on that group alone.