For the better part of six years, behavioral health providers have operated under a set of rules that were never meant to last. The telehealth flexibilities first introduced during the COVID-19 pandemic—allowing clinicians to treat Medicare patients remotely, from their homes, without geographic restrictions or mandatory in-person visits—were emergency measures, designed for a crisis that has long since receded. Yet the crisis of access they addressed has not. And so Congress, unable or unwilling to make these provisions permanent, has chosen instead to extend them again: this time through the end of 2027.
The extension, passed in early 2026, was greeted with relief across the behavioral health industry. Providers exhaled. But beneath the gratitude lies a more uncomfortable truth: the country’s behavioral health infrastructure is now built atop a regulatory framework that could, in theory, vanish with a single act of congressional inaction. For providers in the ABA and substance use disorder spaces—where Medicaid, not Medicare, is the dominant payer—the implications are both different and, in some ways, more precarious than the headlines suggest.
The Numbers Behind the Dependency
The scale of the shift is difficult to overstate. Before the pandemic, just 2.1 percent of outpatient mental health services for fee-for-service Medicare beneficiaries were delivered via telehealth, according to a January 2026 study published in JAMA Network Open. By 2023, that figure had climbed to 43 percent. Medicare telehealth visits, which numbered roughly 840,000 in 2019, surged past 52 million during the pandemic’s peak. An 11 percent increase in spending on mental health services accompanied the shift. Telehealth, for millions of patients, is no longer an alternative to in-person care. It is care.
The data on fraud risk—one of the persistent objections to making telehealth permanent—has been similarly clear. A report from the HHS Office of Inspector General found that only 0.2 percent of providers billing for telehealth services during the pandemic’s first year posed a high risk to Medicare. The American Medical Association, in a December 2025 policy brief, argued that the absence of permanent legislation creates confusion for patients and providers alike and risks rolling back provisions such as allowing telehealth at home, lifting geographic restrictions, and expanding provider eligibility.
A Timeline of Near-Misses
The pattern of last-minute renewals has become a defining feature of telehealth policy. The flexibilities were originally tied to the public health emergency declaration, then to a series of continuing resolutions. In October 2025, when the federal government shut down, the flexibilities briefly lapsed. Medicare Administrative Contractors struggled to process telehealth claims submitted during the gap, holding or returning claims for non-behavioral telehealth services while approving those clearly tied to mental or behavioral health. HHS later reported a 24 percent drop in fee-for-service telemedicine visits during the disruption.
The new legislation extends several key provisions through December 31, 2027. Medicare patients can continue receiving telehealth services in their homes, with no geographic restrictions on originating sites. All eligible Medicare providers retain the ability to deliver telehealth services. Federally Qualified Health Centers and Rural Health Clinics can continue serving as distant-site providers. And the in-person visit requirement for behavioral health services remains waived. Some of these protections—for behavioral and mental health specifically—had already been made permanent, underscoring the unique position telehealth holds in psychiatric and psychological care. But for non-behavioral health telehealth, the extension remains the only barrier between the current system and a reversion to pre-pandemic restrictions.
A Parallel Cliff for Substance Use Disorder Providers
While Congress addressed the Medicare telehealth flexibilities, a separate but equally consequential set of rules remains in limbo. On December 31, 2025, the Drug Enforcement Administration, jointly with HHS, issued a fourth temporary extension of telemedicine flexibilities for the prescribing of controlled medications—including buprenorphine, methadone, and naltrexone—through the end of 2026. Under the extension, DEA-registered practitioners can continue prescribing Schedule II through V controlled substances via audio-video telehealth without an initial in-person evaluation. Audio-only telehealth remains permitted for Schedule III through V narcotic medications approved for opioid use disorder treatment.
The numbers suggest why the stakes are high. In 2024 alone, more than seven million prescriptions for controlled medications were issued via telemedicine without a prior in-person visit, according to data reviewed by federal agencies. Under the pre-pandemic Ryan Haight Act, an in-person medical evaluation was required before any controlled substance could be prescribed via telehealth. A return to those restrictions would force patients—many of whom live in areas with severe provider shortages, or who face transportation, work, or childcare barriers—to secure an in-person appointment before their treatment could begin or continue. For patients on buprenorphine, a disruption in access can mean a return to active use.
The DEA acknowledged in its Federal Register notice that the expiration of telehealth flexibilities without further regulation could disrupt patient care. A proposed special registration framework for permanent telehealth prescribing was introduced during the final days of the Biden administration in January 2025. Whether the current administration will move forward with it remains unclear. Kyle Zebley, CEO of the American Telemedicine Association and executive director of its advocacy arm ATA Action, called on Congress to preserve the flexibilities until a permanent policy is enacted, while the ATA and other stakeholders work toward that aim.
The ABA Blind Spot
For autism service providers, the telehealth conversation operates on a different axis. The Medicare extensions are largely irrelevant to ABA therapy, which is overwhelmingly delivered to children and funded by Medicaid or commercial insurance rather than Medicare. The DEA prescribing rules similarly have limited direct application, since ABA is a behavioral intervention, not a pharmacological one.
But telehealth has become an important delivery mechanism for several components of ABA care—parent training, caregiver coaching, supervision of Registered Behavior Technicians, and consultation between Board Certified Behavior Analysts and families. During the pandemic, many states issued emergency orders permitting these services to be delivered remotely. The question now is whether those state-level allowances will hold.
The answer varies dramatically by jurisdiction. Some states have codified telehealth flexibilities for ABA into permanent law. Others have allowed temporary orders to expire or have limited telehealth to specific service codes. In the current environment—with Medicaid budgets under severe pressure, states cutting ABA reimbursement rates, and federal funding for behavioral health shrinking—the risk is not that telehealth will be formally prohibited but that it will be quietly deprioritized, left off the list of covered modalities in rate-setting and prior-authorization frameworks. This is the gap that the national conversation about telehealth permanency tends to miss. The debate in Washington centers on Medicare and controlled substances. But for ABA providers, whose regulatory environment is shaped primarily by state Medicaid agencies and commercial payer contracts, the federal extensions are a signal, not a solution.
The Cost of Uncertainty
The practical consequences of governing by extension ripple through provider organizations in ways that are difficult to quantify but easy to observe. Providers building five- and ten-year strategic plans cannot confidently invest in telehealth infrastructure, hire remote clinicians, or expand into underserved geographies if the regulatory foundation might shift beneath them. Patients who have come to rely on virtual care—particularly the more than 120 million Americans living in mental health professional shortage areas, according to the Health Resources and Services Administration—cannot be assured that their treatment modality will survive the next congressional session.
Multiple bills before Congress represent the range of possible outcomes. Some would extend Medicare telehealth by a year or two; others would make the flexibilities permanent. None has advanced. At some point, Congress will have to decide whether telehealth is an emergency workaround or a permanent feature of American health care. For behavioral health providers—in ABA, SUD, and mental health alike—the answer has been obvious for years. The question is whether Washington will catch up before the next extension runs out.
