Medicare Telehealth Coverage Updates
(Nov. 10, 2025) The Centers for Medicare and Medicaid Services (CMS) issued updated guidance on Medicare telehealth coverage last week, just days before the announcement of a federal budget deal that will reportedly extend COVID-era telehealth flexibilities through Jan. 31, 2026.
As previously reported, the expanded telehealth coverage enacted during the pandemic expired on Sept. 30th, when Congress failed to reach a budget deal that included an extension of telehealth legislation. Restrictions on Medicare payment for many telehealth services, including those provided to beneficiaries in their homes and outside of rural areas, and hospice recertifications via telehealth, were restored. However, Medicare coverage for telehealth services for behavioral and mental health care, those for monthly end-stage renal disease (ESRD)-related clinical assessments, and those provided by applicable Medicare Shared Savings Program Accountable Care Organization (ACO) participants were not affected by the expiration.
In response, CMS has instructed the Medicare Administrative Contractors (MACs) to pay telehealth claims with dates of service on and after Oct. 1, 2025, when CMS can definitively confirm that the claims are for behavioral and mental health services or otherwise meet statutory requirements. CMS has identified these claims using a list of Healthcare Common Procedure Coding System (HCPCS) codes available here. CMS has also instructed the MACs to process Medicare telehealth claims with a place of service code 10 (patient’s home) that contains a diagnosis code in the F01.A0-F99 range, if the services were not performed by physical therapists (PTs), occupational therapists (OTs), speech language pathologists (SLPs), or audiologists.
However, due to systems limitations, CMS is holding a subset of telehealth claims, including those submitted by clinicians in certain ACOs and those that cannot be identified as pertaining to behavioral and mental health services. To resolve this subset of claims and improve cash flow for practitioners, claims that were submitted on or before Nov. 10, 2025 with dates of service on or after Oct. 1, 2025 will be returned to providers. For professional claims, claims will be returned with the following messages: CARC 16 and RARC M77. Practitioners may resubmit returned claims that meet the statutory requirements.
Recent activity in Congress to resolve the federal budget impasse may make this guidance short-lived. On Nov. 9th, the Senate announced a deal to fund government programs through Jan. 30, 2026, which included an extension of Medicare telehealth flexibilities for the same period. LeadingAge NY and LeadingAge National will keep members posted on the progress of the budget deal.
More information is available on CMS's All Fee-For-Service Providers webpage.
Contact: Karen Lipson, klipson@leadingageny.org