Telehealth Policy Changes During and After COVID-19

The COVID-19 public health emergency triggered the most sweeping expansion of telehealth policy in United States history, dismantling regulatory barriers that had constrained remote care delivery for decades. This page covers the specific federal and state policy changes enacted between 2020 and the post-emergency period, the mechanisms through which those changes operated, the clinical and administrative scenarios they affected, and the boundary conditions that determine which flexibilities have become permanent versus which remain temporary or expired. Understanding this policy landscape is foundational to interpreting the current telehealth regulatory framework in the United States.

Definition and scope

Telehealth policy changes during the COVID-19 era refer to a discrete body of federal waivers, statutory amendments, regulatory guidance documents, and state-level executive orders that collectively altered how remote healthcare services were authorized, reimbursed, and regulated. The triggering mechanism at the federal level was the declaration of a Public Health Emergency (PHE) under Section 319 of the Public Health Service Act, first issued by the U.S. Department of Health and Human Services (HHS) on January 31, 2020, and renewed 13 consecutive times before expiring on May 11, 2023 (HHS PHE Declaration Archive).

The scope of changes encompassed four distinct policy domains:

1. Medicare coverage expansion — geographic and site-of-service restrictions were waived under Section 1135 of the Social Security Act, allowing beneficiaries to receive telehealth services from their homes rather than only from designated rural originating sites.
2. Controlled substance prescribing — the Drug Enforcement Administration (DEA) Ryan Haight Act requirement for an in-person evaluation prior to prescribing Schedule II–V controlled substances was suspended through telemedicine exceptions.
3. HIPAA enforcement discretion — the HHS Office for Civil Rights (OCR) announced it would exercise enforcement discretion for good-faith telehealth use of non-HIPAA-compliant communications platforms, documented in the March 2020 OCR Notification of Enforcement Discretion.
4. State licensure reciprocity — more than 30 states enacted emergency orders permitting out-of-state clinicians to practice via telehealth without obtaining a full in-state license.

For a fuller taxonomy of service modalities affected, see synchronous vs. asynchronous telehealth and store-and-forward telehealth.

How it works

The federal waiver mechanism operated through a layered authority structure. CMS (Centers for Medicare & Medicaid Services) issued blanket waivers under Section 1135 that took effect retroactively to March 1, 2020. These waivers suspended specific Medicare conditions of participation and expanded the list of covered telehealth services from approximately 100 pre-pandemic codes to more than 250 services by 2021 (CMS Telehealth Information).

The process through which individual flexibilities transitioned from emergency to permanent status followed a structured legislative pathway:

1. PHE-linked waiver period — flexibilities were operative only while the PHE remained active unless separately legislated.
2. Consolidated Appropriations Act extensions — Congress extended a defined subset of Medicare telehealth flexibilities through December 31, 2024, and then through September 30, 2025, via the Consolidated Appropriations Act, 2024 (Public Law 118-42).
3. Permanent statutory change — a narrower set of provisions, including audio-only telehealth coverage for mental health services under Medicare, were made permanent through the Consolidated Appropriations Act, 2021.
4. DEA rulemaking — the DEA proposed a Special Registration framework in 2023 to replace the PHE-based controlled substance prescribing exception, with final rules pending as of the 2024 fiscal year. Details are covered under DEA telemedicine prescribing regulations.
5. State-level rollback or codification — each state independently determined whether emergency licensure reciprocity and coverage mandates became permanent law or expired with the state PHE declaration.

HIPAA enforcement discretion ended on May 11, 2023, coinciding with the federal PHE expiration, meaning providers must use only HIPAA-compliant platforms for telehealth encounters. Full compliance requirements are detailed at telehealth HIPAA compliance requirements.

Common scenarios

Medicare beneficiary in a non-rural area receiving primary care via video visit — Pre-pandemic, this encounter would not have qualified for Medicare reimbursement under the originating site rules. During the PHE, the home became a qualifying originating site. Through Congressional extensions, this flexibility remained operative for Medicare FFS beneficiaries beyond May 2023.

Psychiatrist prescribing a controlled substance without a prior in-person visit — The PHE exception to the Ryan Haight Act permitted this practice. Post-PHE, DEA issued a series of temporary rules extending the exception in 90-day increments while finalizing a permanent Special Registration rule. Clinicians operating in this space must track DEA Federal Register notices directly. See controlled substances telehealth prescribing for current rule status.

Out-of-state clinician treating patients in a new state — During the PHE, emergency licensure waivers in over 30 states permitted this. Post-PHE, interstate practice reverts to the standard licensure framework unless the clinician holds a compact license through the Interstate Medical Licensure Compact or the state independently enacted permanent reciprocity legislation.

Audio-only mental health encounter under Medicare — Made permanently reimbursable for mental health services under the Consolidated Appropriations Act, 2021, provided the beneficiary is unable to use video technology and the clinician documents that limitation. This represents one of the clearest permanent policy gains from the pandemic period.

Federally Qualified Health Center (FQHC) billing for telehealth — FQHCs were temporarily authorized to serve as distant sites for Medicare telehealth billing during the PHE. This flexibility has been extended through September 30, 2025 under current appropriations legislation. Background on FQHC telehealth operations is available at federally qualified health center telehealth.

Decision boundaries

The critical analytical distinction in post-COVID telehealth policy is between PHE-dependent flexibilities, legislatively extended flexibilities, and permanently codified changes. These three categories carry fundamentally different compliance implications.

A second boundary concerns service type. Not all telehealth modalities received uniform treatment. Remote patient monitoring billing codes were separately addressed through CMS final rules independent of PHE waivers, making their reimbursement framework more stable than video-visit originating site rules. Store-and-forward telehealth remains largely excluded from Medicare coverage except in Alaska and Hawaii under permanent statute.

A third boundary involves payer type. Medicare and Medicaid flexibilities are governed by distinct statutory authorities. Medicaid telehealth policy is state-administered within federal parameters, meaning post-PHE Medicaid coverage varies across all 50 states and the District of Columbia. Telehealth Medicaid coverage by state documents this variation. Private insurer obligations are governed by state parity laws, which 43 states and the District of Columbia had enacted in some form as of 2023 (National Conference of State Legislatures Telehealth Policy).

Safety and quality framing also shifts across this boundary. The Joint Commission and URAC both maintain accreditation standards for telehealth programs that apply regardless of PHE status. Accreditation requirements are not subject to waiver and continued without interruption throughout the pandemic period and after.

References

• HHS Public Health Emergency Declarations Archive
• CMS Telehealth Information Center
• HHS OCR Notification of Enforcement Discretion for Telehealth (March 2020)
• Consolidated Appropriations Act, 2024 — Public Law 118-42
• DEA Telemedicine Regulations and the Ryan Haight Act — Federal Register
• National Conference of State Legislatures — Telehealth Policy
• CARES Act — Public Law 116-136
• [The Joint Commission — Telehealth Accreditation](https://www.jointcommission