Medicare’s In-Person Visit Rule for Telehealth: A Barrier in Search of a Problem
The Big Picture: Telehealth Is Working - So Why Mess With It? 🤨
TL;DR…
Medicare’s in-person visit rule for telehealth blocks access for the seniors who need it most. There’s no clinical reason for it - studies show telehealth works just as well as in-person care. This rule will shrink provider availability, increase costs, and force some patients to go without care. Congress needs to eliminate it for good.
Intro
Imagine you’re an 80-year-old Medicare beneficiary living in a rural town. You have major depressive disorder, panic disorder, or maybe PTSD. The nearest psychiatrist is a two-hour drive away, and you don’t drive anymore. Maybe you rely on a home health aide for daily tasks, or maybe just getting dressed and out the door feels overwhelming and causes a panic attack. During COVID, telehealth became your lifeline. Therapy sessions from your living room. A psychiatrist checking in over video. Maybe even a phone call when WiFi failed you.
Now imagine that Medicare (really, CMS) decides you have to physically show up at an office every year just to keep receiving care. And if you can’t? Well, too bad - no more virtual mental health visits for you.
That scenario is exactly what will happen if Medicare’s in-person visit rule for behavioral telehealth goes back into effect. It was set to re-activate in 2021, and has been delayed multiple times (for good reason!). If it takes effect, Medicare beneficiaries will have to see their mental health clinician in person within 6 months of the first virtual visit, and at least once every year thereafter to continue using their Medicare benefits for tele-mental health services.
Here’s the problem: This rule solves a problem that doesn’t exist while creating real, harmful barriers to care.
Oh, and before anyone asks - yes, this impacts our companies because we work in telehealth. One of us is a clinical leader at a fully virtual healthcare company 🖥️, the other at a hybrid model 🏥. We both serve Medicare patients directly and see firsthand how this policy would disrupt access to care. But this isn’t just about business - this is about patients, plain and simple.
How This Rule Will Harm Medicare Beneficiaries
1. It Blocks Access for Patients Who Need Telehealth the Most 😡
One of telehealth’s biggest wins has been expanding access for rural, disabled, and mobility-limited patients - precisely the Americans who struggle the most to get to in-person visits.
During the pandemic, while this rule was waived, Medicare telehealth use skyrocketed. By 2021, 35% of behavioral health specialist visits for Medicare beneficiaries occurred via telehealth. And for good reason:
Seniors in small towns got connected to specialists without putting up with hours-long round-trips.
Nursing home residents received care without having to disrupt their routine and be transported to a clinic.
Homebound patients with depression or anxiety could get help without the stress of leaving their house.
This in-person requirement inactivation wipes out these gains by forcing Medicare beneficiaries to travel, even when it’s unnecessary or outright impossible. And let’s be clear: If you’re a Medicare beneficiary who is homebound or disabled or live in a mental healthcare desert, this is a telehealth vs. no-care situation.
2. There’s No Medical Justification for This Rule 🤷♂️
Let’s talk about the actual clinical evidence - because there’s a lot of it.
Study after study has shown that behavioral health outcomes via telehealth are just as good as in-person care:
A large 2022 study in rural clinics found that patients with depression and anxiety had equal symptom improvement whether they received treatment via telehealth or in person.
Research on opioid use disorder (OUD) treatment in Medicare found that patients receiving telehealth care were less likely to relapse or overdose than those who ONLY had in-person visits.
Even audio-only therapy (phone calls) has been shown to be effective for many patients. Seniors without broadband? They’ve benefited dramatically from audio-based mental health care.
So what’s the argument for requiring in-person visits for Medicare beneficiaries? There isn’t one. There’s no data showing that patients who prefer telehealth-only visits have worse outcomes. There is no evidence that in-person visits “improve” care for patients who prefer virtual-only care. And there is substantial evidence that meeting patients where they are, and delivering care in the modality they prefer (in-person only, hybrid, or telehealth-only) improves outcomes, plain and simple. There is no reason this mandate should exist (aside from outdated thinking about how medicine has to be delivered): we should follow our patients’ guide when making these treatment decisions (as clinically appropriate).
3. It Worsens the Mental Health Workforce Crisis ⏳
We are in the middle of a mental health clinician shortage - and it’s only getting worse. The Health Resources & Services Administration (HRSA) estimates that by 2030, the U.S. will be short 250,000 mental health providers.
Telehealth has helped ease this strain by expanding clinician reach - allowing psychiatric clinicians and therapists to see more patients without location being a barrier. But forcing periodic in-person visits for all Meidcare patients? This disrupts care models that have been working.
Many telehealth-first providers serving Medicare patients don’t have physical offices. If required to see patients in person, they might have to stop serving Medicare patients altogether.
Psychiatrists and therapists will spend time on redundant in-person check-ins instead of seeing new patients. While we battle the clinician shortage, forcing the clinicians we do have into administrative visits is a terrible idea.
Patients who were finally able to access mental health care via telehealth may be left without any care at all.
If our goal as a society is to increase access to mental health care, this rule does the exact opposite.
The Economic Reality: This Rule Costs More in the Long Run 💰
One of the biggest fears about telehealth expansion is that it will drive up Medicare costs. Critics argue that if care is too convenient, people will overuse it, and Medicare spending will spike. The Government Accountability Office (GAO) and Congressional Budget Office (CBO) have raised concerns about telehealth overuse - but the data tells a different story.
What actually happens when we remove barriers to telehealth?
Emergency room (ER) visits for psychiatric crises decrease. Untreated psychiatric disease costs the American healthcare system billions each year, and improving access to routine care helps prevent the crises that disproportionately drive these costs.
Patients are more likely to follow up after hospitalization. A study found that Medicare beneficiaries with serious and persistent psychiatric illness in high-telehealth areas were 6.5% more likely to have a follow-up visit after psychiatric hospitalization. That means better continuity of care, fewer relapses, and improved quality of life.
Preventive care saves money. When patients can access therapy and psychiatric care, they’re less likely to end up needing expensive inpatient or emergency care down the road.
The bottom line? Reintroducing barriers will increase Medicare costs in the long run.
What Needs to Happen: Policy Solutions 🏛️
Congress has already delayed this rule multiple times, but a delay isn’t enough - it needs to be eliminated entirely.
✅ Remove the in-person requirement permanently. Bills like the Telemental Health Care Access Act aim to strike the rule altogether. Congress should act now to ensure Medicare beneficiaries don’t lose access to care.
✅ Keep telehealth flexibilities in place. The pandemic demonstrated that policies like home-based telehealth visits and audio-only therapy work. They should be made permanent.
✅ Invest in broadband and digital literacy for seniors. If policymakers want to improve telehealth access, they should focus on expanding internet access - not forcing unnecessary in-person visits.
✅ Continue monitoring telehealth outcomes. Instead of arbitrary mandates, Medicare should track real data: how telehealth patients fare over time, hospitalization rates, adherence to care plans, and total cost of care - to ensure quality without unnecessary hurdles.
The Bottom Line: This Rule Solves Nothing and Hurts the People Who Need Telehealth the Most
At a time when mental health care access is more critical than ever, Medicare’s in-person rule is an outdated, unnecessary barrier that will harm patients, strain clinicians, and drive up costs - all without improving care.
America’s seniors should be able to access mental health care in a way that works for them. Telehealth works. The data is there. The patient demand is there. The clinician support is there.
It’s time to stop delaying and permanently remove this rule. The last thing we need in healthcare right now is a barrier in search of a problem.
Two Questions:
💬 What do you think? Is Medicare’s in-person rule a necessary safeguard or an outdated barrier to care? Who stands to lose the most if it takes effect?
🔎 What are we missing? Beyond access and cost, what ripple effects could this rule have on the future of mental health care?
✌🏽 A + A
To read more about our vision for the Stack, check out our intro post here.
Another point to dig into - WHY does CMS want to restrict telehealth in Medicare? There must be some rationale or interest they have in restricting telehealth payment. If we understand what that reservation is, then lobbying & public comment efforts could be more effective.
By succumbing to the allure of tele therapy our profession is ignoring what we have learnt as a specialty over decades. That much is communicated by seeing a person in their entirety and not just a close up of a pimple on their face as they sit before a screen, TD ridden hands and legs flailing unseen. To see a patient in person once or twice a year is the very least we should expect. While you may say some treatment is better than no treatment , I would argue in psychiatry , with the perils and risks of unnecessary polypharmacy that in fact in many instances , no treatment causes less harm than some tele treatment. Just look at how many unnecessary BZDs and stimulants are prescribed over tele and you’ll see the damage our profession is causing to humankind.