Table of Contents
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The short answer
Telehealth access for behavioral health in 2025 survived, but barely, and on three separate legal tracks that operators have to manage at the same time. The DEA telemedicine flexibility for controlled-substance prescribing was extended a fourth time through December 31, 2026. Medicare telehealth lapsed during the October 2025 government shutdown, was restored retroactively through January 30, 2026, and then extended through December 31, 2027. State licensure rules are still the bottleneck most operators underestimate.
If you run 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 affects your census, your billing, and your prescribing workflow. None of them are interchangeable.
What actually happened with the DEA in 2025
On November 19, 2024, the DEA and SAMHSA had already extended pandemic-era telemedicine prescribing through December 31, 2025. Then the December 31, 2025 cliff arrived. DEA, jointly with HHS, issued a Fourth Temporary Rule that amends 21 CFR 1307.41 and 42 CFR 12.1 through December 31, 2026. DEA-registered practitioners can still prescribe Schedules II–V via telemedicine without an in-person evaluation, for now.
The volume matters. In 2024, more than 7 million prescriptions for controlled medications were issued via telemedicine without a prior in-person visit. For SUD and psychiatric programs, that is not a rounding error. That is the prescribing backbone.
DEA Assistant Administrator Cheri Oz of the Diversion Control Division framed the agency’s position plainly: “DEA supports telehealth access for patients who need medication, but not at the expense of public safety.” Translation: another extension is not a permanent rule, and the Special Registration framework the DEA proposed in January 2025 (which drew over 6,475 comments) is still 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 office-based opioid program, your clinical leadership should know which authority each prescription is being written under. The Fourth Temporary Rule imposes fewer requirements than the two final rules, and practitioners may continue under it for now.
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 was on a different statutory track.
On November 12, 2025, the continuing resolution restored the flexibilities retroactively through January 30, 2026. CMS confirmed the extension applies retroactively and that claims returned during the lapse with CARC 16 or RARC M77 are now payable and may be resubmitted. CMS also told practitioners to identify Medicare beneficiaries who paid out of pocket during the lapse, submit the claims, and refund the overpayments.
Then the longer fix arrived. On February 3, 2026, Congress passed the Labor, HHS appropriations bill including a two-year extension of the Medicare telehealth flexibilities through December 31, 2027. The cost of this episode was real and measurable. Federal agencies cited a 24 percent drop in fee-for-service telemedicine visits following the lapse of Medicare telehealth flexibilities in September 2025.
What we saw inside client operations: held claims, refund obligations, payer-readiness meetings rescheduled twice, and finance teams 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 care providers typically must be licensed in the state where the patient is receiving care, as well as the state in which 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. PSYPACT now includes 43 participating jurisdictions, with Montana becoming an active member in October 2025 and the PSYPACT Commission updating its rulebook on November 18, 2025. The Counseling Compact is active in initial member states, and the Social Work Licensure Compact is in early implementation. These compacts cover psychologists, licensed professional counselors, and social workers, the three license types that drive most telebehavioral health volume.
The demand side is not subtle. As of 2024, approximately 123 million Americans lived in a community recognized as a Mental Health Professional Shortage Area. Operators in Arizona, Tennessee, and Texas who set up multistate clinician panels through PSYPACT or counseling compact pathways are filling census faster than competitors still credentialing one state at a time. Operators who ignore the compact map are leaving referrals on the table.
One more piece operators forget: DEA extensions affect only federally-controlled substance prescribing rules. States maintain their own requirements, which may include stricter requirements for in-person visits prior to the prescribing of controlled substances. 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 is unresolved. That is not a stable regulatory environment. Build operations as if every deadline is real and every extension is temporary.
- Map your 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 is covered 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, it is payable. 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.
Telehealth access in 2025 was preserved by patchwork. Operators who built 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 Rule published December 31, 2025. The rule amends 21 CFR 1307.41 and 42 CFR 12.1 and lets DEA-registered practitioners prescribe Schedules II–V via telemedicine without a prior in-person evaluation. 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. Other Medicare telehealth claims were held by MACs starting October 1, 2025. The November 12, 2025 continuing resolution restored flexibilities retroactively through January 30, 2026, and CMS confirmed held claims with CARC 16 or RARC M77 are now payable and may be resubmitted. The February 2026 appropriations bill then extended Medicare telehealth flexibilities through December 31, 2027.
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 now includes 43 participating jurisdictions; the Counseling Compact and Social Work Licensure Compact are operational or in early implementation for LPCs and social workers. The licensed profession still must follow 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 is unresolved after over 6,475 public comments. 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 (December 31, 2025)
- DEA Press Release: DEA Extends Telemedicine Flexibilities to Ensure Continued Access to Care
- HHS Press Release: HHS & DEA Extend Telemedicine Flexibilities for Prescribing Controlled Medications Through 2026
- Telehealth.HHS.gov: Federal Telehealth Policy Updates
- K&L Gates: Congress Extends Medicare Telehealth Flexibilities Through January 30, 2026
- ASCO: Medicare Telehealth Flexibilities and CMS Operations During Government Shutdown
- Telehealth.org: Telehealth Licensure 2025–2026: Cross-State Practice and Compacts
- National Governors Association: Understanding Behavioral Health Licensure Compacts
- RCPA: DEA Releases Fourth Temporary Extension of Telemedicine Flexibilities