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CMS Change to Telehealth Coverage
- Kristi Stovall
- Oct 7
- 2 min read
Updated: Oct 27
Telehealth Coverage Just Changed: What Providers Need to Know After October 1
🚨 October 24 Update: CMS Lifts Some Telehealth & Claims Holds — But Not All
CMS has instructed Medicare Administrative Contractors (MACs) to resume processing claims for certain services that had been placed on hold after the October 1 legislative expirations.
Claims for the following are now being paid:
Medicare Physician Fee Schedule services
Ground ambulance transport
Federally Qualified Health Center (FQHC) services
Telehealth services definitively for behavioral and mental health
However, CMS is still holding:
Telehealth claims for services not clearly classified as behavioral/mental health
Acute Hospital Care at Home claims
Important for ACOs: CMS reconfirmed that only “applicable ACOs” — those in two-sided risk arrangements with prospective alignment — continue to receive extended telehealth flexibilities. This applies only to qualifying claims and does not override current limitations on non-behavioral telehealth services.
(original post)
On October 1, 2025, several COVID-era Medicare telehealth coverage flexibilities expired, marking a major shift for providers nationwide. While the guidance issued by CMS may seem procedural, the operational impact—especially for practices outside certain ACO models—is significant and immediate.
Why Claims Are Temporarily On Hold
Due to the government shutdown, CMS has directed Medicare Administrative Contractors (MACs) to temporarily hold some claims (up to 10 business days). This is standard protocol when Congress fails to extend specific legislative provisions on time.
You can still submit claims—but they won’t be paid out until the hold is lifted.
CMS expects minimal impact, as most Medicare payments already operate on a 14-day payment cycle.
Still, billing teams should monitor cash flow and stay updated in case Congress retroactively extends flexibilities.
What’s Changing for Telehealth Coverage
Without Congressional action, the following telehealth flexibilities expired October 1:
Geographic restrictions are back: Medicare telehealth is only reimbursable for patients in rural or designated originating sites.
In-home telehealth for most services is no longer reimbursed, except for behavioral and mental health.
Hospice re-certifications now require in-person visits.
Certain providers (PTs, OTs, SLPs, audiologists) are no longer eligible for telehealth reimbursement.
ABNs (Advance Beneficiary Notices) are recommended when offering services that may not be covered.
Are ACOs Exempt? Only Some.
Yes—but only if your ACO meets specific criteria.
According to CMS’s Shared Savings Program guidance, only “applicable ACOs” retain telehealth flexibility. To qualify, an ACO must be:
In a two-sided (downside-risk) financial arrangement
Using prospective patient attribution
In these cases, providers may still deliver Medicare telehealth services without geographic or site-of-service restrictions. No special action is needed—it’s automatic through 2025.
If your ACO is upside-only or uses retrospective alignment, these exemptions do not apply.
What Providers Should Do Now
Clarify your ACO model: Are you in an “applicable” ACO? If not, plan accordingly.
Update patient messaging: Let patients know which services may no longer be covered.
Review your claims strategy: Consider holding potentially non-payable claims or attaching ABNs.
Prepare for financial impacts: Assess how claim holds and service limitations may affect revenue.
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