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The short answer for 2026
Behavioral health telehealth survived into 2026 on three separate legal tracks operators have to manage at the same time: a DEA controlled-substance flexibility good through December 31, 2026; Medicare telehealth extended through December 31, 2027; and state licensure rules that no federal action can preempt. None of them are interchangeable. None of them are stable.
The DEA and HHS extended pandemic-era prescribing a fourth time. The Fourth Temporary Rule is effective January 1, 2026 through December 31, 2026. Medicare telehealth lapsed during the October 2025 shutdown, was restored retroactively, then Congress extended it through December 31, 2027 in HR 7148, the Consolidated Appropriations Act, 2026, which President Trump signed on February 3, 2026.
If you operate a PHP (ASAM Level 2.5, outpatient), an IOP, or office-based opioid treatment in Florida, Texas, Arizona, or Tennessee, every one of those tracks touches your census, your billing, and your prescribing workflow.
What actually happened with the DEA in 2025
On November 15, 2024, DEA and HHS had already pushed pandemic-era telemedicine prescribing through December 31, 2025. Then the cliff arrived. DEA and HHS issued the Fourth Temporary Extension on December 30, 2025, and the rule amends portions of 21 CFR 1307.41 and 42 CFR 12.1 through December 31, 2026. DEA-registered practitioners can still prescribe Schedules II through V via telemedicine without an in-person evaluation. For now.
HHS framed the extension plainly, calling it a response to “the Administration’s commitment to patient-centered care, regulatory clarity, and public health, while avoiding unnecessary disruptions to treatment for millions of Americans.” Translation: another extension is not a permanent rule.
The Special Registration framework the DEA proposed in January 2025 remains unresolved. Two Final Rules also took effect December 31, 2025: one on buprenorphine via telemedicine encounter, and one for VA continuity of care. If you operate an OTP or an office-based opioid program, your clinical leadership should know which authority each prescription is being written under. DEA confirmed practitioners covered by one or both of the Two Final Rules may continue to utilize the flexibilities under the fourth temporary rule, which imposes fewer requirements.
Medicare telehealth: the shutdown that broke billing
October 1, 2025 was the day a lot of operators learned the hard way that retroactive is not the same as uninterrupted. Medicare telehealth flexibilities expired when the federal government shut down. CMS told Medicare Administrative Contractors to hold non-behavioral telehealth claims. Behavioral health claims kept moving because the in-person requirement waiver for tele-mental health sat on a different statutory track.
On November 10, 2025, the Continuing Appropriations Act, 2026 ended the 43-day government shutdown and reinstated Medicare telehealth waivers through January 30, 2026. Then Congress passed the longer fix. The American Medical Association confirmed that “Section 6209 extends Medicare telehealth flexibilities for two years, through Dec. 31, 2027” following the disruptive 43-day lapse. The full appropriations package included roughly $116.6 billion in discretionary funding for the Department of Health and Human Services, covering rural health, workforce, and behavioral health programs.
Inside client operations, our team saw held claims, refund obligations, payer-readiness meetings rescheduled twice, and finance leaders in Florida and Tennessee trying to reconcile two different effective dates against an October census. Operators who had standing UM and timely filing workflows recovered. Operators who treated telehealth billing as set-and-forget did not.
The licensure problem nobody at the federal level can fix
DEA flexibility and Medicare reimbursement are federal. State licensure is not. Telehealth providers generally must be licensed in the state where the patient is receiving care, and in the state where the provider is located. A Florida-licensed therapist treating a patient who drove home to Georgia is, at that moment, practicing in Georgia.
The behavioral health compacts have moved faster than most operators realize. The PSYPACT Commission welcomed Montana as the 43rd participating jurisdiction, effective October 1, 2025. The Counseling Compact is active in initial member states, and the Social Work Licensure Compact is in early implementation. These three compacts cover psychologists, licensed professional counselors, and social workers, the license types that drive most telebehavioral health volume.
The demand side is not subtle. HRSA data cited by County Health Rankings shows more than 122 million people lived in a Mental Health Professional Shortage Area as of December 2024, and Becker’s reported the number of designated mental health HPSAs rose from 6,418 to 6,807, with the covered population growing from roughly 122 million to 137 million. Operators in Arizona, Tennessee, and Texas who stand up multistate clinician panels through PSYPACT or counseling compact pathways are filling census faster than competitors still credentialing one state at a time.
One more piece operators forget: DEA extensions affect only federally-controlled substance prescribing rules. States maintain their own requirements, which may include stricter in-person visit rules for controlled substances. HHS noted the extension does not change existing requirements that prescriptions be issued for legitimate medical purposes, by licensed practitioners, and in compliance with federal and state law. A federal extension does not override a state board.
What we tell clients to do before the next deadline
The Medicare extension runs through December 31, 2027. The DEA extension runs through December 31, 2026. The Special Registration NPRM sits unresolved. Operators should build as if every deadline is real and every extension is temporary.
- Map prescribing authority by patient. If a buprenorphine patient is covered by the buprenorphine final rule, document it that way. If a Schedule II ADHD patient sits under the Fourth Temporary Rule, document that. Different authorities, different recordkeeping.
- Run a payer-readiness check on every Medicare telehealth claim from October 1, 2025 forward. If your MAC returned a claim with CARC 16 or RARC M77 during the lapse, it is payable and may be resubmitted. Identify any beneficiaries who paid out of pocket. Refund and rebill.
- Audit clinician licensure against patient location at the time of service, not at intake. If you operate in Florida and your snowbird census includes patients spending winters in three other states, your roster needs PSYPACT or compact privileges, not just a Florida license.
- Watch state controlled-substance rules separately from DEA. Some states have stricter in-person requirements. The federal extension does not preempt them.
- Treat utilization management documentation as if a SIU audit is coming. Telehealth claims are a known surveyor focus, and payers are escalating UM reviews on behavioral health telehealth volume. The Consolidated Appropriations Act also requires HHS to establish unique billing codes or modifiers when Medicare providers contract with third-party telehealth platforms, which will add another documentation lane in 2026 and 2027.
Telehealth access in 2026 was preserved by patchwork. Operators who built an operational backbone around the patchwork kept their census and their revenue. The ones who waited for a permanent rule are still waiting.
Frequently asked questions
Can behavioral health providers still prescribe controlled substances via telehealth in 2026?
Yes, through December 31, 2026, under the DEA and HHS Fourth Temporary Extension. The Federal Register notice published December 31, 2025 amends 21 CFR 1307.41 and 42 CFR 12.1 and allows DEA-registered practitioners to prescribe Schedules II through V via telemedicine without a prior in-person evaluation. Audio-only telemedicine remains permissible for FDA-approved Schedule III-V medications used in opioid use disorder maintenance and withdrawal. State law can still impose stricter in-person requirements, so check the patient’s state separately.
Were Medicare telehealth claims paid during the October 2025 government shutdown?
Behavioral and mental health telehealth claims continued to be processed because that in-person waiver sits on a separate statutory track. Other Medicare telehealth claims were held by Medicare Administrative Contractors starting October 1, 2025. The November 10, 2025 Continuing Appropriations Act ended the 43-day shutdown and reinstated the waivers through January 30, 2026. HR 7148, the Consolidated Appropriations Act, 2026, signed February 3, 2026, then extended Medicare telehealth flexibilities through December 31, 2027 via Section 6209.
Does a PSYPACT or Counseling Compact license replace state licensure for telebehavioral health?
It replaces the need for individual state licensure within participating jurisdictions for the specific profession. PSYPACT covers psychologists and, as of October 1, 2025, includes 43 participating jurisdictions with Montana as the most recent addition. The Counseling Compact and Social Work Licensure Compact are operational or in early implementation for LPCs and social workers. The licensed professional still follows the remote state’s scope of practice, and a telehealth encounter is treated as occurring where the patient is located.
What is the biggest operational risk for behavioral health operators relying on telehealth in 2026?
Treating the federal extensions as permanent. The DEA flexibility expires December 31, 2026, the Medicare extension expires December 31, 2027, and the DEA Special Registration framework remains unresolved. HR 7148 also introduced new requirements for unique billing codes or modifiers when Medicare providers use third-party telehealth platforms, which will add documentation obligations. Operators should map prescribing authority by patient, audit licensure against patient location at the time of service, and document telehealth claims as if a payer SIU audit is coming.
References
- Federal Register: Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications (Dec. 31, 2025)
- HHS Press Release: HHS & DEA Extend Telemedicine Flexibilities for Prescribing Controlled Medications Through 2026
- DEA Press Release: DEA Extends Telemedicine Flexibilities to Ensure Continued Access to Care (Dec. 31, 2025)
- American Medical Association: Feb. 6, 2026 National Advocacy Update (Section 6209, Medicare telehealth extension)
- AAPC: Congress Passes Spending Bill, Extends Telehealth Flexibilities
- National Law Review: Continuing Appropriations Act, 2026. Another Lifeline for Medicare Telehealth
- PSYPACT Commission News, October 2025 (Montana as 43rd jurisdiction)
- County Health Rankings, citing HRSA Bureau of Health Workforce: Mental Health Providers
- Becker’s Behavioral Health: Mental Healthcare Provider Gaps, by State (HRSA HPSA data)
- American Action Forum: Health Care Extenders. Key Provisions in the Consolidated Appropriations Act, 2026