Telehealth Policy Changes During and After COVID-19

The COVID-19 pandemic triggered the most sweeping regulatory transformation in telehealth's history — compressing a decade of cautious policy evolution into roughly twelve weeks. What changed in March 2020, how much of it survived, and what the current landscape looks like are questions that touch every patient, provider, and payer in the American healthcare system. The answers are neither simple nor settled.

Definition and scope

The policy changes that arrived with the pandemic were not incremental tweaks. They were structural breaks — formal declarations, emergency waivers, and statutory modifications that suspended rules which had governed telehealth policy and regulation for years.

The legal architecture centered on Section 1135 of the Social Security Act, which authorizes the Secretary of Health and Human Services to waive or modify Medicare and Medicaid requirements during a declared public health emergency (PHE). When the PHE was declared in January 2020, CMS used that authority with unusual breadth. The result was a set of temporary permissions that collectively redefined who could deliver telehealth, where patients could receive it, and how providers could be paid for it.

The PHE formally ended on May 11, 2023 — a date that had been extended 13 consecutive times since the original declaration (HHS.gov). But "ended" is doing a lot of work in that sentence. Through the Consolidated Appropriations Act of 2023 and subsequent legislation, Congress extended the most consequential telehealth flexibilities through December 31, 2024, and subsequent appropriations have continued certain provisions further still.

How it works

The pandemic-era waivers operated on three distinct mechanisms, each affecting a different layer of the regulatory stack:

1. Geographic restrictions lifted. Before March 2020, Medicare reimbursed telehealth only when the patient was located in a rural Health Professional Shortage Area and traveled to an approved "originating site" such as a clinic or hospital. The waivers eliminated both requirements — patients could receive services from home, anywhere in the country.

2. Provider type expansion. CMS expanded the list of eligible distant-site providers to include physical therapists, occupational therapists, speech-language pathologists, and audiologists. Federally Qualified Health Centers and Rural Health Clinics became eligible to serve as distant sites for the first time.

3. Prescribing rules relaxed. The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 had required an in-person evaluation before controlled substances could be prescribed via telemedicine. The DEA issued blanket exceptions under the PHE — a change that generated significant policy debate, particularly around buprenorphine prescribing for opioid use disorder. The DEA's subsequent proposed rules on post-PHE prescribing have undergone multiple comment periods and revisions. The telehealth prescribing rules page covers that thread in detail.

Audio-only visits — phone calls without video — received special attention. CMS added telephone E/M codes to the covered services list, a recognition that broadband access is not universal. That tension between digital access and equity remains unresolved, as explored in telehealth and the digital divide.

Common scenarios

The policy shifts played out differently depending on setting and specialty. Three patterns emerged most clearly:

Medicare beneficiaries and mental health. Mental health telehealth for Medicare beneficiaries had been especially restricted pre-pandemic. The waivers opened the door; Congress then formalized expanded mental health telehealth coverage in the Consolidated Appropriations Act of 2023, which added a provision requiring an in-person visit within 6 months of initiating mental health services and annually thereafter — a compromise that preserved expanded access while restoring some physical presence requirements.

Chronic disease management. Patients managing diabetes, hypertension, and heart failure made extensive use of remote patient monitoring services that CMS had reimbursed since 2019 but which saw accelerated adoption under the waivers. Utilization of RPM codes grew sharply through 2021 and 2022 according to CMS claims data.

Rural and federally qualified health centers. Providers serving rural populations saw telehealth for rural communities shift from a regulatory obstacle course to a reimbursable standard of care, at least temporarily. The question of whether Medicare telehealth coverage rules will permanently accommodate rural patients without geographic restrictions remains contingent on Congressional action.

Decision boundaries

Not everything changed, and not everything that changed stayed changed. The clearest way to map the current landscape is by distinguishing four categories:

Permanently codified. Congress permanently allowed Medicare to cover telehealth for mental health services (with the in-person visit requirement), federally qualified health centers as distant sites, and audio-only visits for certain behavioral health services.

Extended but not permanent. The geographic and originating site flexibilities for most Medicare telehealth services have been extended repeatedly through appropriations legislation. Each extension has a sunset date requiring Congressional action to renew — a cycle that creates planning uncertainty for health systems and patients alike.

Under active rulemaking. Controlled substance prescribing via telemedicine remains in regulatory limbo. The DEA has proposed a "telemedicine prescribing" registration framework that would create a new pathway separate from the PHE blanket exceptions, but final rules had not been published as of the most recent Congressional Research Service analysis of the topic.

Returned to pre-pandemic rules. Some HIPAA enforcement flexibilities — specifically around the use of non-HIPAA-compliant communication platforms — ended with the PHE. Telehealth HIPAA compliance requirements reverted to their full pre-pandemic standards in May 2023.

The contrast between pre-2020 telehealth policy and the framework that emerged afterward is most visible in telehealth statistics and utilization data: telehealth visits as a share of all outpatient visits went from roughly 1% before the pandemic to peaks above 30% in April 2020, according to McKinsey & Company's 2021 analysis. The policy architecture built to sustain even a fraction of that volume is still being assembled, piece by piece, appropriations bill by appropriations bill.