Mental and Behavioral Health
On September 9, 2024, the White House announced the issuing of final rules filed jointly by the Department of Labor, Department of Health and Human Services, and Internal Revenue Service implementing parts of the Mental Health Parity and Addiction Equity Act of 2008.
Summary of Major Provisions
Emphasizes that the law requires no higher restrictions on access to mental health /substance use disorder care compared to medical/surgical care.
Plans cannot issue non-quantitative treatment limitations (NQTLs) for mental health/substance use disorder treatments that are more restrictive than those for medical/surgical treatments. These include:
Prior authorization requirements,
Standards related to network composition,
Methodologies to determine out-of-network reimbursement rates,
Plans must evaluate their provider networks to ensure their compliance with the law, including metrics such as how often prior authorization is required and denied for mental health/substance use disorder services.
Plans cannot use discriminatory information, evidence, or standards that are designed to disfavor access to mental health/substance use disorder care when setting NQTLs.
Optional compliance with the law will be phased out for non-federal government health plans; compliance will now be required.
Next Steps
The rules will take effect for group health plans for plan years starting January 1, 2025. Individual health insurance coverage plans are required to comply with the rules starting January 1, 2026.
Clinicians should be aware of changes to their patients’ health plan network composition and new opportunities for mental health/substance use disorder treatment that may soon be available for patients. Clinicians can inform their patients of these new policies and how their access to care may change.
Opposition to the final rules is also expected from insurers, among others. Should a legal challenge be raised against the rules, it may argue that the agencies do not have statutory authority to issue the rules, potentially citing the overturn of ‘Chevron Doctrine’ in the Supreme Court’s 2024 decision in Loper Bright Enterprises v. Raimondo. CTeL will track and relay any legal developments in the implementation of these final rules.
CTeL is Committed to Ensuring Network Adequacy and Access to Critical Healthcare
One of the most profound benefits of telehealth and other digital health technologies is to help bridge the gaps in access to high-quality healthcare. Telehealth technology cannot do this alone – all patients must be able to connect with clinicians in an affordable and timely manner. CTeL members, staff, and partners will continue to work with policymakers at the federal and state levels to ensure that high-quality and equitable care is available to all.
Federal Guidelines for Opioid Treatment Programs
The Substance Abuse and Mental Health Services Administration published an updated edition of its Federal Guidelines for Opioid Treatment Programs.
The new publication expands on best practices for telehealth, including:
The Substance Abuse and Mental Health Services Administration (SAMHSA) recently released an updated edition of the Federal Guidelines for Opioid Treatment Programs (OTPs), introducing new measures to enhance access to treatment and integrate telehealth into care for opioid use disorder (OUD). Key updates include:
Telehealth for MOUD: The guidelines now permit the use of telehealth to prescribe and manage medications for opioid use disorder (MOUD), including buprenorphine and methadone. These measures address gaps in care by allowing OTPs to initiate treatment remotely without requiring an in-person physical evaluation.
Patient Admission Flexibility: Admission processes for OTPs have been revised to accommodate telehealth technologies, including audio-only platforms. These changes aim to increase accessibility for patients in rural or underserved areas and reduce barriers to treatment.
Scope of Practice Expansion: The definition of practitioners eligible to prescribe and dispense MOUD has been broadened to include non-physician professionals, such as nurse practitioners and physician assistants, expanding the workforce available to meet demand.
Increased Take-Home Flexibility: Flexibilities initially implemented during the COVID-19 pandemic, such as take-home methadone doses, have been made permanent, offering patients greater autonomy while ensuring continuity of care.
Stigma Reduction and Patient-Centered Language: The new guidelines incorporate harm reduction principles, including offering fentanyl test strips and HIV/STI testing, and prioritize language that respects patient autonomy.
Improved Compliance Processes: SAMHSA has streamlined accreditation and compliance for OTPs, allowing electronic documentation and corrective action timelines to ensure uninterrupted service delivery
CTeL remains committed to advocating for telehealth as a vital tool in addressing the opioid crisis. By bridging gaps in access, telehealth not only improves admission rates but also increases treatment retention and outcomes. We urge the Department of Health and Human Services (HHS) and the Drug Enforcement Administration (DEA) to continue supporting telehealth innovations as essential to combating the opioid epidemic.
For more details, you can review the complete guidelines on SAMHSA's official site or relevant healthcare policy publications.
DEA and Prescribing Laws
The Ryan Haight Act: The Ryan Haight Online Pharmacy Consumer Protection Act was enacted in 2008 to reign in rogue internet pharmacies by regulating online prescriptions. The Act requires practitioners to conduct an in-person medical evaluation before prescribing controlled substances. This requirement had a dampening effect on legitimate healthcare practitioners who practice via telehealth. The law does allow for seven telemedicine-specific exceptions, but they are highly technical and do not apply to all practitioners. One of the exceptions, creating a special registration through the DEA, has not yet been implemented.
DEA Extends Prescribing Waivers to EOY 2025
The DEA, in collaboration with the Department of Health and Human Services (HHS), has issued a third extension of telemedicine prescribing flexibilities, allowing healthcare providers to continue prescribing controlled substances via telehealth without an in-person evaluation through December 31, 2025. This measure builds on earlier temporary rules established during the COVID-19 Public Health Emergency (PHE), aimed at maintaining access to care for patients needing Schedule II-V medications, such as those managing chronic pain, mental health issues, or opioid addiction.
The extension provides additional time for regulators to finalize long-term telehealth policies while addressing public health needs and mitigating risks of misuse or diversion. This decision acknowledges the transformative role telemedicine has played in improving access to care, particularly for rural, underserved, and mobility-limited populations. It also offers healthcare providers and systems an adjustment period to prepare for anticipated compliance requirements in the evolving telehealth regulatory framework.
This extension underscores the DEA’s commitment to balancing healthcare access with the need for appropriate safeguards against controlled substance misuse, while aiming to provide a seamless transition once permanent policies are enacted.
For more information on the third-extension, click here.
Privacy and Security
Telehealth platforms must comply with HIPAA and HITECH Act standards to protect patient information.
Providers should implement end-to-end encryption and conduct periodic audits of technology systems.
A Business Associate Agreement (BAA) is required for third-party platforms handling patient data.
Standards of Care
The care provided via telehealth must meet the same clinical standards as in-person services. Providers should:
Adapt session workflows to address challenges unique to virtual settings.
Ensure readiness to manage crises remotely, including protocols for emergency interventions.
Prescribing Controlled Substances
Under the DEA’s extended telehealth flexibilities (valid through December 31, 2025), prescribing Schedule II-V medications without an in-person exam is permissible under specific conditions.
Providers must adhere to state-specific requirements and the DEA’s forthcoming permanent guidelines to ensure compliance.
Medicare and Medicaid Regulations
For reimbursement:
Services must be on CMS’s Medicare Telehealth Services List.
Providers must use the appropriate billing codes and modifiers, especially for mental health services provided via telehealth.
Medicaid rules vary by state, so consulting the state Medicaid office is essential.
State-Specific Regulations
States may impose unique requirements, such as:
Training for telehealth personnel.
Mandated data collection on telehealth efficacy.
Additional reporting for mental health crises handled virtually.
Digital Mental Health Treatment (DMHT) Devices
CMS is exploring reimbursement pathways for FDA-cleared DMHT devices, such as apps for depression or anxiety management, when used alongside traditional therapy.
Supervision Requirements
Licensed practitioners supervising provisionally licensed counselors or social workers may need to adapt to state-specific tele-supervision guidelines.
Ongoing Monitoring and Documentation
Stay informed about evolving telehealth regulations, including federal and state policy updates.
Maintain meticulous documentation of sessions, informed consent, and the use of digital tools for transparency and billing purposes.
Proactive Compliance Steps
Consult Legal Experts: Regularly engage with legal advisors to navigate complex telehealth regulations.
Invest in Training: Equip staff with knowledge on privacy laws, reimbursement policies, and emerging technologies.
Stay Updated: Subscribe to updates from CMS, the DEA, and professional organizations like the CTeL, CCHP, APA, and ATA.
By integrating these best practices, mental health providers can confidently and compliantly deliver care in the virtual space while staying prepared for regulatory shifts.
Ensuring Compliance in Virtual Mental and Behavioral Health Care
For mental health providers operating in the virtual care space, understanding and adhering to federal and state-specific regulations is critical to maintaining compliance and delivering quality care. Below is a detailed overview of key considerations:
Licensing Requirements
State Licensure: Providers must hold an active license in the state where the patient is physically located during the telehealth session.
Telehealth-Specific Licenses: Some states offer expedited or telehealth-specific licensing to facilitate out-of-state practice.
Regional Practices: In areas like the District of Columbia, Maryland, and Virginia, reciprocity agreements allow practice across the region with a license from one jurisdiction.
Interstate Compacts
The Interstate Medical Licensure Compact (IMLC) and the Psychology Interjurisdictional Compact (PSYPACT) allow streamlined licensing for physicians and psychologists, respectively, across participating states.
Counselors and social workers may benefit from evolving licensure agreements, but individual state rules still apply.
Informed Consent
Providers must document informed consent before initiating services. This includes detailing:
Limitations of virtual care (e.g., inability to address emergencies in person).
Technology risks, such as confidentiality breaches.
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