Key Takeaways
- Behavioral health dominates telehealth volume. Trilliant Health’s 2026 Behavioral Health Report found that the share of telehealth volume attributed to behavioral health rose from 18.4 percent in 2018 to 65.6 percent in 2024, even as overall telehealth volume plateaued.
- Controlled-substance prescribing flexibilities extended through 2026. On December 30, 2025, the DEA and HHS issued a Fourth Temporary Extension permitting DEA-registered practitioners to prescribe Schedule II-V controlled substances via telemedicine without a prior in-person visit through December 31, 2026.
- Strong evidence for telehealth in medication management and MAT. A 2022 Veterans Affairs cohort study published in the Journal of General Internal Medicine found that telehealth utilization during buprenorphine treatment for opioid use disorder was associated with a 52 percent lower risk of treatment discontinuation for SUD and a 54 percent lower risk for mental health, compared with in-person care only.
- Mixed or weaker evidence for serious mental illness and crisis care. A 2024 Veterans Affairs retrospective study of 138 facilities found that individuals with serious mental illness show lower engagement with telehealth and are less likely to use video-based services, with implications for psychotherapy continuity and crisis response.
Behavioral health was supposed to be one of the first parts of medicine to revert to in-person care once the pandemic emergency lifted. Five years later, the opposite has happened. Behavioral health is now the most reliably virtual specialty in American medicine, the only major category where telehealth has functioned as a substitute for in-person care rather than a complement to it. The question facing clinicians, payors, and regulators in 2026 is no longer whether telepsychiatry will persist; it has. The question is which parts of it work, which parts do not, and what the still-temporary regulatory scaffolding will look like once the DEA finalizes the rules that have governed controlled-substance prescribing since 2020.
The headline data make the durability hard to dispute. Trilliant Health’s 2026 Behavioral Health Report found that behavioral health accounted for 65.6 percent of all telehealth volume in 2024, up from 18.4 percent in 2018. Total telehealth visits across all specialties have declined 32 percent since their 2020 peak, but behavioral health’s share of what remains has grown. The American Hospital Association’s analysis of the same data noted that behavioral health represented 67 percent of telehealth encounters in 2024 among commercially insured patients, and that all other specialties combined accounted for fewer than 20 million telehealth visits, against behavioral health’s roughly 40 million. The broader demand-side picture in Acuity’s coverage of the Trilliant report tracks the same dynamic: behavioral health visit volume crossed primary care visit volume in 2024, the first year that distinction has held.
The DEA telehealth flexibilities are now in their fourth one-year extension
The regulatory scaffolding supporting virtual psychiatry was built for an emergency that has been over for several years. The COVID-19 telemedicine flexibilities for prescribing controlled substances were originally issued in March 2020, suspending the in-person evaluation requirement that the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 had imposed on remote prescribing. The flexibilities have been extended four times: through December 31, 2024; through December 31, 2025; and most recently through December 31, 2026, in a Fourth Temporary Extension that the DEA and HHS jointly issued on December 30, 2025.
The mechanics matter for clinicians. Under the Fourth Temporary Extension, a DEA-registered practitioner may prescribe a Schedule II-V controlled substance via telemedicine to a patient without conducting an in-person medical evaluation, provided the prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice and the encounter uses two-way, real-time audio-visual technology. For prescriptions to treat a mental health disorder, audio-only telemedicine is permitted if the patient is not capable of, or does not consent to, video. The audio-only carve-out also applies to FDA-approved Schedule III-V narcotic controlled substances for maintenance or withdrawal management of opioid use disorder, the regulatory pathway that has kept telehealth buprenorphine initiation viable.
Federal data suggest the flexibilities are now load-bearing. In 2024, more than 7 million prescriptions for controlled medications were issued via telemedicine without a prior in-person visit, according to HHS. The Department also noted a 24 percent drop in fee-for-service telemedicine visits following the lapse of Medicare telehealth flexibilities in September 2025, an outcome that has shaped how policymakers describe the cost of letting the flexibilities expire. The DEA’s rationale for the fourth extension cited prevention of a “telemedicine cliff” and the need to finalize permanent regulations, including a proposed Special Registration for Telemedicine that has not advanced beyond the 2025 proposed-rule stage.
What the Trump administration will do with the proposed special registration framework remains unsettled. The DEA received over 6,000 public comments on the January 2025 proposed rule, many requesting clarity on operational and administrative requirements that stakeholders said could limit patient access. The fourth extension gives the agency another year to issue final regulations and to provide an implementation runway for providers and pharmacies. The practical effect for psychiatry, addiction medicine, and primary care prescribers is that the regulatory regime governing virtual controlled-substance prescribing will remain “temporary” through the end of 2026, with no firm date for permanence. Acuity has covered the parallel two-year telehealth flexibility extension for ABA and SUD providers, where the same governance-by-extension pattern is creating planning challenges for operators.
Medication management and buprenorphine care are where the evidence is strongest
The strongest empirical case for virtual psychiatry is in medication management and medications for opioid use disorder. The research base has grown steadily since the pandemic began, and the findings are unusually consistent across study designs. A retrospective cohort study within the Veterans Health Administration by Vakkalanka and colleagues, published in the Journal of General Internal Medicine in 2022 and covering veterans treated for OUD between 2008 and 2017, found that telehealth utilization during buprenorphine treatment was associated with lower risk of treatment discontinuation than in-person care alone. The study reported adjusted hazard ratios of 0.48 (95 percent CI: 0.37 to 0.62) for substance use disorder treatment retention and 0.46 (95 percent CI: 0.33 to 0.65) for mental health retention among telehealth-only patients compared with in-person-only patients. A 2024 follow-on study by the same group, published in Telemedicine and e-Health and covering 2012 through 2022 data, extended these findings into the post-pandemic period.
Commercial-payor data tell a similar story. A study using deidentified insurance claims for 23,565 adult buprenorphine initiators between March 2020 and November 2021, published in the Journal of General Internal Medicine in 2024, found that 14.1 percent initiated treatment via telehealth, and that telehealth-initiated treatment was associated with reduced opioid overdose rates and improved patient engagement after propensity-score matching. A 2025 study published in the Journal of Addiction Medicine examining a Philadelphia telehealth bridge clinic, CareConnect, found that the program served 1,023 patients between 2021 and 2023, with 74 percent enrolled in Medicaid, providing real-world evidence that telehealth-initiated buprenorphine can reach Medicaid-dependent and underserved populations.
The mechanism is not mysterious. Buprenorphine maintenance does not require physical examination at each visit; it requires consistent engagement, regular medication checks, and the ability to identify and respond to early signs of return-to-use. Telehealth removes transportation, scheduling, and stigma barriers that disproportionately affect the populations most likely to drop out of treatment. A 2024 qualitative study in the Journal of General Internal Medicine, surveying patients and clinicians on buprenorphine across phone, video, and in-person modalities, found that patients valued the privacy and flexibility of telehealth, particularly when facing housing instability or stigma, while clinicians cited reduced nonverbal feedback as a complication for risk assessment. The recurring conclusion across studies is that hybrid models, combining telehealth access with periodic in-person contact when clinically indicated, outperform either modality alone.
The same pattern holds in routine psychiatric medication management. Trilliant Health’s 2026 report noted that the proportion of telehealth volume attributed to behavioral health is plateauing rather than retreating, suggesting that the modality has settled into a stable role rather than aging out. The report also found that prescription-only treatment is becoming more common, with the share of patients receiving medication alone (rather than therapy plus medication) rising nearly two percentage points between 2018 and 2024. Stimulant prescription volume grew 53 percent over the same period; antipsychotic volume grew 45 percent. The patterns of telehealth use for ADHD, depression, and anxiety medication management track with the wider shift toward what Acuity has previously documented as a reimbursement system that pays reliably for CBT and medications while leaving newer evidence-based interventions undercompensated.
Serious mental illness and crisis intervention are where telepsychiatry struggles
The evidence for telehealth in serious mental illness is materially weaker, and the populations are harder to reach virtually. A 2024 retrospective observational study of Veterans Affairs administrative data across 138 facilities, published in JMIR Mental Health, examined the impacts of telehealth adoption on quality-of-care metrics for patients with serious mental illness from January 2021 through December 2022. The authors found that individuals with primary or co-occurring serious mental illness, defined as psychotic-spectrum disorders or bipolar disorder, show lower engagement with telehealth and are less likely to use video-based services than other diagnostic groups.
The pattern is consistent across the literature. A multicenter Spanish study examining 270 outpatient mental health users during the first COVID-19 wave found that teletherapy adoption among patients with serious mental illness was limited and that its efficacy as a primary therapeutic modality (rather than a complement to in-person treatment) is not clearly established. A systematic review of randomized controlled trials examining telehealth for severe mental illness management noted methodological limitations across studies, including small sample sizes, lack of control groups, short follow-up periods, and selection bias toward patients and clinicians with more favorable attitudes toward virtual care.
A 2024 study commissioned by the HHS Office of the Assistant Secretary for Planning and Evaluation surveyed providers, patients, and caregivers on the optimal balance of telehealth and in-person care for adults with serious mental illness and children with serious emotional disturbance. The conclusion was nuanced: telehealth was credited with maintaining access during the pandemic, often allowing patients to reach mental health care more quickly than in person, but providers and clients valued the flexibility to make session-by-session choices about appropriateness. Before the public health emergency, telehealth had been used primarily for mild-to-moderate conditions; SMI and SED populations were historically excluded from telehealth research and treatment, and most evidence-based interventions for complex mental health conditions were designed to be delivered in person.
Crisis intervention is the other locus of acute concern. The clinical literature on telehealth-delivered crisis response remains thin, and the regulatory structure that funds and coordinates crisis services in most states assumes in-person mobile crisis teams, 988 hotline operations, or co-located crisis stabilization units rather than purely virtual response. The 988 Suicide and Crisis Lifeline, launched in July 2022, has expanded national capacity for telephone and text-based crisis triage, but escalation to mobile response, hospitalization, or other interventions still depends on geographically anchored services. For patients in acute psychiatric crisis, the modality that telehealth most reliably substitutes for is the in-person medication visit, not the in-person evaluation that resolves a crisis or the in-person follow-up that prevents recurrence.
Medicare telehealth coverage in 2026: behavioral health flexibilities are permanent, the rest are not
The federal coverage picture is more settled for behavioral health than for the rest of telehealth. Medicare’s in-home behavioral health telehealth coverage is permanent under the Consolidated Appropriations Act of 2021, and audio-only behavioral health telehealth, FQHC and RHC distant-site coverage for behavioral health, and the elimination of geographic restrictions for behavioral health telehealth are all permanent as well. The Consolidated Appropriations Act of 2026, passed in February 2026, extended the broader (non-behavioral-health) Medicare telehealth flexibilities through December 31, 2027, including the 6-month in-person visit waiver for behavioral telehealth, which had been scheduled to take effect after January 30, 2026 under the prior continuing resolution.
Audio-only behavioral health visits in the home are permanent under Medicare, provided the clinician is technically capable of video and the patient cannot or does not consent. Virtual supervision by teaching physicians became permanent on January 1, 2026 under the CY 2026 Medicare Physician Fee Schedule final rule. The Drug Enforcement Administration’s controlled-substance prescribing flexibilities run separately through December 31, 2026. The result, as the American Psychiatric Association summarized in its January 2026 update for members, is that behavioral health clinicians serving Medicare patients have permanent coverage for video, audio-only, and in-home telehealth, while other non-behavioral-health telehealth flexibilities (and the DEA controlled-substance pathway) sit on different statutory clocks running through December 31, 2026 and December 31, 2027.
Commercial coverage has generally followed Medicare’s lead but remains heterogeneous. Most large commercial plans have made behavioral health telehealth coverage permanent and have aligned in-person and virtual reimbursement rates, but Acuity has documented payer-by-payer variation in Medicaid managed care behavioral health practices that affects how telehealth gets coded, authorized, and paid in practice. State Medicaid programs have moved unevenly. Most states cover telehealth for behavioral health services delivered to a patient at home, but coverage of audio-only visits, the originating-site flexibility, and the cross-state licensure question have not been standardized.
Where states are pulling back on behavioral health telehealth
At the state level, the policy direction for telehealth in behavioral health is not uniformly expansive. A small but consequential set of state Medicaid programs has begun restricting telehealth delivery for specific behavioral health services where in-person interaction is judged clinically necessary. Indiana Medicaid’s Bulletin BT202627, issued February 26, 2026, eliminated the use of the synchronous telemedicine modifier for ABA codes 97151, 97152, 97153, 97154, and 0373T, a change effective April 1, 2026 that Acuity has covered in detail. North Carolina Medicaid’s draft Clinical Coverage Policy 8F, presented in April 2026, would bar telehealth for ABA behavioral assessments and individual or group treatment sessions, and would limit supervisory sessions to no more than 10 percent telehealth, an example of how the same modality that has expanded mental health access is being restricted for autism services where direct observation is considered essential.
The state-level pullback on autism therapy telehealth illustrates a tension that runs through the broader policy debate. The clinical evidence supporting telehealth varies by service line, patient acuity, and condition. Medication management for ADHD, anxiety, and depression performs well virtually; behavioral assessment and direct ABA service delivery for young children with significant aggression or self-injury performs less well. The federal regulatory structure, which is largely uniform across condition categories, does not yet reflect those differences in fine-grained way. The state structures are beginning to.
What still has not been solved: licensure, equity gaps, and the audio-only question
Three structural issues are still constraining what telepsychiatry can deliver. The first is interstate licensure. The Interstate Medical Licensure Compact has streamlined cross-state practice for physicians, and PSYPACT, the Psychology Interjurisdictional Compact, allows licensed psychologists to practice telepsychology across 40-plus participating states. There is no comparable compact for licensed clinical social workers, professional counselors, or marriage and family therapists in widespread effect, which means that a patient who moves across state lines (a not-uncommon event for college students, military families, and rural residents) may lose access to their established therapist for reasons unrelated to clinical appropriateness.
The second is the equity gap in video versus audio-only utilization. The RAND Connected Care Accelerator Initiative’s final 2024 report on California community health centers found that patients whose preferred language was English represented 80.1 percent of behavioral health video visits but only 66.6 percent of behavioral health patients overall, an indicator that video telehealth is reaching English-speaking patients more readily than patients who prefer other languages. The audio-only modality has been important for reaching older adults, patients with limited broadband, and non-English speakers, and the long-term federal posture on audio-only reimbursement will shape who can access virtual psychiatry under what payor.
The third is the long-term federal policy on controlled-substance prescribing. The fourth temporary extension expires December 31, 2026. If a permanent rule has not been finalized by then, providers will face either a fifth extension or the reinstatement of the Ryan Haight in-person evaluation requirement, which would disrupt the buprenorphine, stimulant, and benzodiazepine prescribing pathways that millions of patients now depend on. The DEA’s Special Registration for Telemedicine proposal is one possible permanent answer, but the operational, security, and reporting requirements in the January 2025 proposed rule generated significant pushback from stakeholders. The administration’s posture on whether to finalize, amend, or replace the proposed framework is one of the most important unanswered questions for behavioral health in 2026.
Telehealth in psychiatry is no longer the experiment it was five years ago. It is the modality through which roughly two-thirds of all telehealth volume in the United States now flows, the principal mechanism through which buprenorphine treatment is reaching Medicaid-dependent populations, and the structural reason behavioral health visits exceeded primary care visits for the first time in 2024. The Consolidated Appropriations Act of 2026 extended the broader telehealth flexibilities through December 31, 2027, leaving the DEA controlled-substance pathway (December 31, 2026) as the most immediate federal expiration point that would force operational change for psychiatric prescribers. The clinical case for virtual psychiatry has settled. The federal regulatory framework has more headroom than it did a year ago, but its long-term shape (particularly the controlled-substance pathway) is still unresolved. Acuity’s continuing regulatory coverage tracks each of the decisions that will determine what the field looks like in 2027 and beyond.
Frequently Asked Questions
Has telehealth become a permanent part of psychiatric care after the pandemic?
For most behavioral health services, yes. Trilliant Health’s 2026 Behavioral Health Report found that behavioral health accounted for 65.6 percent of all telehealth volume in 2024, up from 18.4 percent in 2018, even as overall telehealth volume declined 32 percent from its 2020 peak. Medicare made in-home behavioral health telehealth permanent under the Consolidated Appropriations Act of 2021, and the Consolidated Appropriations Act of 2026 (passed February 2026) extended the broader non-behavioral-health telehealth flexibilities through December 31, 2027. Most commercial plans have followed suit. The DEA controlled-substance prescribing flexibilities are on a separate clock, running through December 31, 2026.
Can psychiatrists still prescribe controlled substances via telehealth in 2026?
Yes, through December 31, 2026. On December 30, 2025, the DEA and HHS jointly issued a Fourth Temporary Extension of the COVID-19 telemedicine flexibilities, permitting DEA-registered practitioners to prescribe Schedule II-V controlled substances via telemedicine without conducting a prior in-person medical evaluation, provided certain conditions are met. The extension preserves audio-video prescribing for all DEA-registered providers and audio-only prescribing for mental health and FDA-approved opioid use disorder maintenance and withdrawal management.
What does the evidence say about telehealth for opioid use disorder treatment?
The evidence is strong and consistent. A 2022 Veterans Health Administration retrospective cohort study by Vakkalanka and colleagues, published in the Journal of General Internal Medicine, found that telehealth utilization during buprenorphine treatment was associated with lower discontinuation risk, with adjusted hazard ratios of 0.48 for SUD retention and 0.46 for mental health retention among telehealth-only patients compared with in-person-only patients (cohort: 2008 to 2017). A separate 2024 commercial-claims study of 23,565 buprenorphine initiators found that telehealth initiation was associated with reduced opioid overdose rates and improved patient engagement after propensity-score matching.
Where does telehealth in psychiatry fall short?
The literature consistently identifies two weak areas: serious mental illness and crisis intervention. A 2024 Veterans Affairs retrospective study of 138 facilities, published in JMIR Mental Health, found that individuals with primary or co-occurring serious mental illness, including psychotic-spectrum disorders and bipolar disorder, show lower engagement with telehealth and are less likely to use video-based services. Crisis intervention services still depend largely on in-person mobile teams, 988-line escalation pathways, and crisis stabilization facilities; the evidence base for purely virtual crisis response remains thin.
What share of telehealth visits are now behavioral health?
Roughly two-thirds. Trilliant Health’s 2026 Behavioral Health Report put the share at 65.6 percent in 2024, while the American Hospital Association cited 67 percent of commercially insured telehealth encounters. Behavioral health visit volume crossed primary care visit volume in 2024 for the first time, reaching 66.4 million total visits compared to 62.8 million primary care visits, per Trilliant.
Are state Medicaid programs restricting behavioral health telehealth?
A small but growing set of states is restricting telehealth for specific behavioral health services where in-person delivery is judged clinically necessary, even as mental health telehealth more broadly continues to expand. Indiana Medicaid eliminated the synchronous telemedicine modifier for several ABA codes effective April 1, 2026. North Carolina Medicaid’s draft Clinical Coverage Policy 8F would bar telehealth for ABA behavioral assessments and treatment sessions and limit supervisory sessions to no more than 10 percent telehealth. Acuity’s coverage of the Indiana bulletin and related state Medicaid ABA policy actions track these developments.
