Thanks, Brad. It is my honor today to introduce my colleague and friend, Mei Wa Kwong. Mei has over two decades of experience in state and federal policy work. Mei is the executive director for the Center for Connected Health Policy, or CCHP, which is the federally designated national telehealth policy resource center. 

Mei has written numerous policy briefs. She's crafted state legislation and led several coalition efforts on a variety of issues. Mei has published articles on telehealth policy and is recognized as an expert in her field, and has been consulted by state and federal lawmakers on telehealth legislation and policy. Mei is a graduate of George Washington University Law School. And without further ado, I'm going to hand it over to her. 

Thank you, Nikki, and thank you also to Harborview and the Northwest Regional telehealth Research Center for having me, again, speaking to you guys. I really enjoy working with them in this partnership and feel very honored that they've asked me again to present at the beginning of the year, the telehealth policy environment, what's going on with it. 

For those who don't know me, I am an attorney. So I'm going to put another disclaimer here again. So this is my own disclaimer, which is very similar. It's like any information that I provide today is not to be considered legal advice. It is strictly for informational purposes. CCHP recommends that you consult with legal counsel if you are interested in a formal legal opinion. And also know if I happen to mention a company, or show a picture or a product, or mention a product, neither I nor CCHP has any type of relationship or affiliation with such company. 

A little bit of background about CCHP if you're not familiar with us. We were actually established in 2009 as a program underneath the Public Health Institute to be a California telehealth policy organization. An opportunity to become the federally designated national telehealth policy resource center became available in 2012 through funding from HRSA. And CCHP applied for it back then. We got it, and we've actually been serving in that capacity ever since. So over a decade acting as the national telehealth policy resource center. 

Actually, our funding just got renewed in the middle of last year towards the end of the summer. So if the funding holds steady, we'll be able to do this for a couple more years with you guys. We also, at CCHP, work with a variety of other funders and partners on a state and federal level, and we also act as the administrator for the National Consortium of Telehealth Resource Centers. 

So just really briefly, I wanted to talk about the National Consortium of Telehealth Resource Centers. Both CCHP and the Northwest Regional Telehealth Resource Centers are a part of this national consortium. And what it is it's made up of the 14 telehealth resource centers who received that funding from HRSA to provide technical assistance on telehealth. Basically, any of your questions regarding telehealth. 

There are 12 regional resource centers that cover specific states. They are all fabulous. They are all knowledgeable. And I always say, if you have a question around telehealth, reach out to your regional telehealth resource centers first because not only are they the most knowledgeable folks around or some of the most knowledgeable folks around telehealth from everything from policy, to technology, to where do I begin? What should I do if I want to try to provide mental health? What should I do about prescribing? They can help you through those questions. 

And because we all receive federal funding, most of what we do is free. So I say, what have you got to lose? Reach out to your regional telehealth resource centers with your questions. And then if they can't answer a technology or policy question, they send it on to the National Center, CCHP's policy, and the technology centers based out of Alaska. 

But we all work very collaboratively together, which is why we formed this national consortium, is to really be more efficient in the resources we put out, but also in our communications with each other and with you. So again, if you have telehealth questions, definitely-- excuse me. Definitely reach out to your regional telehealth resource center first to get those questions answered. Excuse me. My apologies there. 

Really quickly, for today's agenda, my brief for speaking today was to talk about the developments around telehealth policy, what's going on with it. So this is how I've broken it up-- the current status of what's going on with the Medicare telehealth waivers and what's going on with the DEA on prescribing, and then other important federal developments that have happened recently that I think can impact some if not all of you in some way. And then just a really brief overview of what's going on with the states and what they're doing around telehealth policy. 

So really quickly, federal developments and what's going on. We're going to take first the telehealth waivers in Medicare. This slide should not be a surprise to many of you. This is the really high level overview of the current Medicare telehealth policy evolution. And where it started from before the pandemic pre-COVID was it was pretty restrictive. 

It had a lot of requirements that people had to meet in order for those services that are delivered via telehealth to qualify to be covered and reimbursed by Medicare. Things such as the patient had to be in a rural area, which was very specifically defined, and they also had to be in some type of specific site, like a doctor's office, or a hospital, or clinic. Only certain providers can provide services via telehealth or Medicare would cover that. So very narrow, very restrictive, and also, more importantly, embedded in federal law. 

So when the pandemic hit, CMS as an administrative agency was very limited in what they could do. So it was a situation where it actually required an act of Congress. So Congress had to step in and say, OK, we've got this public health emergency here. Telehealth would be a great tool, but it's restricted by current federal law. 

So Congress had to come in, institute a lot of waivers through legislation that had to be passed and then signed by the president. And that was how we got these waivers during the pandemic. So it wasn't necessarily CMS was acting to create the waivers because they couldn't because so many of those restrictions were in federal law. So you had Congress come in and institute the waivers. 

Now, over the years, through the pandemic and also post-COVID, we've had a series of extensions to the majority of those waivers, the bigger ones. And again, that's had to take place through congressional legislation, again, because those things were embedded in federal law. So it really takes Congress to act in order to extend those waivers there. 

The current situation is, and with the last waiver, is that those waivers have been extended to January 30, 2026. So basically the end of this month. Now, right now, there is discussion not only on extending the telehealth waivers, but a lot of other things as well too. And the reason why the telehealth waivers are lumped into all these other discussions is because the telehealth waivers in those legislations that created the waivers and to extend them have been in bigger federal bills, usually an appropriation bill. 

So when you start talking budget, and money, and everything, that's usually a larger discussion than this small piece of policy around telehealth. So there's all this discussion around a bunch of these other things. And telehealth waivers have just been caught up into it because their presence has always been in these bills. 

So that's why we haven't seen, oh, this is an easy issue to be addressed because everybody is supportive of telehealth and they are for the most part. It's a very bipartisan issue. But because the policy has been embedded over the last couple of years in these larger bills, it's stalled as congressional members deal with these other questions in these other bills. 

So all that to say is I don't really have any news for you on the waivers. And our current information is that they are set to expire on January 30. Now, I was back in Washington, DC, at the American Telemedicine Conference back in the second week of December. So what I'm about to say is information I got at that conference. Keep in mind that's about a month ago. It's about four weeks ago. 

And the policy landscape and the policy environment can shift very rapidly. So I'm not quite sure if this is holding true anymore what I heard back in mid-December. So keep that in mind. Take this all with a grain of salt. But at least what I heard back in mid-December, as far as telehealth waivers is, again, it's very bipartisan. It's essentially noncontroversial. 

They are aware that they need to do something, but the big other policy issues are acting as the hurdle. And one of the biggest hurdles was or is the ACA subsidies. And the sense that I got is if congressional members can get over that hurdle of deciding what to do around the ACA subsidies, then they can decide about all the other issues that they need to work on. And things can move very quickly after that. 

Now, where the ACA subsidies questions is is that I think it was just last week, the House actually passed a bill that would extend the subsidies by three years, but the Senate rejected that bill. So they're back to the starting board. But at least there was a little bit of movement. There was discussion there on that. And the question now is are they going to be able to resolve that issue before the 30th and then they can get to these other issues, or is that going to drag on a little longer? I don't know. I don't have any new information on that. But at least back in December, the feeling was is they wanted to get over the hurdle about the ACA subsidies and then they can talk about all these other things. 

The other thing I heard-- again, take it over grain of salt. This was a couple of weeks ago. People were given even odds on if we're going to have another shutdown. 50% of the people I talked to said, oh, no, there's not going to be a shutdown. And then the other 50% said, no, I think we're going to have another shutdown. So that was a couple of weeks ago. They cancel each other out. Nobody quite knows where it's going to go at that point. But that was the other thing that was floating around. 

And then the only other thing that I have to share with what I heard is that as far as the length of the waivers, while nothing was written in stone or written down, the discussion was that the telehealth waiver extension, what they were talking about was likely another two-year extension. So not like what we've had the last two times, like a couple of months, but a longer extension of two years. 

So that's all the information I got for you in regards to the Medicare telehealth waiver. So what does that mean if we face another shutdown and they expire? Well, if that happens, the telehealth waivers expire, but we're also in another shutdown here. And while the shutdown in last year, the October and November shutdown, was by no means fun or anything, it did give us insight, at least, on how CMS might handle the situation of, oh, the waivers expired. What happens now? 

And essentially what they can't do is say like, well, we're not going to apply things. Things do revert back to the original telehealth policies, which are law, which is very restrictive. So none of this should really be a surprise to you. But I know when the shutdown first happened last time, there was a little confusion on some of the policies. 

And then it took CMS maybe about a week or two to clarify them. So they're in a better spot if-- I'm not saying we're going to have a shutdown. And hopefully, we can avoid it. But if a shutdown does happen, we're in a little bit better spot, at least as far as knowing what the policies are going to be going into it, because we do have that experience from 2025. 

So what happens? Just really briefly, if the waivers expire, again, you're going to have restrictions on patient location, both geographically and where they are. The home only becomes eligible as originating site if you are providing services for end stage renal disease, or substance use disorder, or substance use disorder with a co-occurring mental health condition that's being treated. 

Mental health can take place in the home without that substance use disorder treatment. But you would need to meet an in-person visit requirement. Now, that in-person visit requirement, we'll get to that in a little bit more detail. That's the third item down here. There are some nuances to that policy as well too. And then the other thing for location is that for acute stroke, the geographic limitation also would not apply. 

Your limited list of eligible providers, right now It's basically anybody can provide the services. So that includes OTs, and PTs, and speech language pathologists, FQHCs and RHCs. Most of those expanded list of eligible providers would not be eligible anymore. Exceptions are federally qualified health centers and rural health clinics. 

And this is due to the fact that there is a regulatory change that was made by CMS over the last couple of years, in that, FQHCs and RHCs can continue to provide mental health services via telecommunications technologies. That was a permanent policy, but CMS also instituted a temporary policy to allow them to provide medical services through telecommunications technologies through the end of 2026. So FQHCs and RHCs will still be able to do that. I know that gets very confusing for people. People are like, why if you said it takes an act of Congress to change things? It's because of what I just called it. 

FQHCs and RHCs. If the waivers expire, their ability to provide services via telehealth expires as well because that's underneath the waivers. However, in regulations with CMS, FQHCs and RHCs can provide medical services via telecommunications technologies through the end of 2026. Mental health services via telecommunications technology, permanent policy. Does not expire. 

So what's the difference you ask? It's basically a terminology difference. So the policy that expires with the waivers are telehealth policy. This regulatory policies for FQHCs and RHCs is telecommunications technologies policies. And it is something that CMS created and that they have control over and that we saw during the last shutdown that was in place, that FQHCs and RHCs can do this. That was something that they put in place through the 2025 physician fee schedule. And for 2026, they've added on an additional year, again, probably just in case there was another shutdown. 

In a lot of ways, it didn't matter eventually in the end, because when the last shutdown was resolved, they did retroactive policies. But know that there's not going to be that potential gap there for FQHCs and RHCs. And this was reconfirmed by CMS in their Medicare learning network newsletter, their fact sheet, which I have here on the slide. And I think you all get copies of the slides too. So I do have everything hyperlinked, which was just a shoot in December of 2025. So you'll have that reaffirmed in there by CMS. 

Now the other thing that is tricky is the prior in-person visit for mental health services, which is only required if you are trying to avoid or if you don't meet those geographic or site location requirements. So if your patient is at, let's say, an FQHC or a hospital and eligible originating site underneath permanent policy and that location of that site meets the geographic requirement, you're fine. 

You don't need to meet this in-person visit requirement. It's only when you are not meeting the geographic requirement or they're not in an eligible type of facility when that telehealth interaction takes place. So if that happens, you can still do it, but you need to have the prior in-person visit. And what that says is that it needs to be a service that Medicare reimbursed for or would have reimbursed for, and it needs to take place six months before the telehealth services start. 

Now, this is also a situation where it was a little fuzzy during the last shutdown when the waivers temporarily expired of how CMS would start counting, like, well, six months before, does that mean that it needs to have taken a place already if I'm already seeing the patient via telehealth and we've never had an in-person contact? Or does the clock start ticking the first day of when the waivers expire? 

And CMS did clarify, say, if you establish that relationship via telehealth during the waiver period, you're fine. Your grandfathered in. The clock does not start ticking on you. It is only for newly established patients where we are going to require that. So if things expire on January 31, the waivers expired, and you've already have patients that you've seen via telehealth, but you've never had that in-person visit, they're not going to require you to meet that six-month requirement. But if you see somebody new after the waivers expired, you are technically then required to have that prior in-person visit. 

Now, there's also a follow-up 12-month visit after you began the telehealth services. That's the one that was not really clarified by CMS and what they were expecting out of that. And I think that's simply because they didn't expect the shutdown to go on for another 12 months. So again, you have the question of, well, when does your clock start ticking for that 12-month visit? Again, when you first started seeing the patient, or does it start taking the first day of the waivers? It hasn't been clarified. 

My guess is that CMS probably-- if we face another waiver expiration gap period again, my guess is that CMS is not going to really say when the clock is going to start ticking because, again, probably in their minds, they're just going to grandfather in the folks that have already been doing this during the waiver period and also the expectation of, well, surely something's going to get resolved before 12 months for any new patient. 

And then probably the expectation of even we have this gap here, whatever they finally resolve this, they'll probably do what they did last time. Congress is what I mean by they. And they'll retroactively reapply things. So it's going to be a moot point anyway. So that would be my thinking. I mean, I'm not 100% guaranteeing it, but I think the reason why they never really were explicit on how you meet that 12-month requirement is because, A, they were thinking this isn't going to be a 12-month lapse here. 

And also they're probably going to apply it retroactively. So it's going to be a wash anyway. But that's just my thinking on that. But it is a question that was out there of like, well, that one was never really quite clarified like the prior six-month in-person visit. So I just wanted to make you aware of that. 

And then audio only as a modality, it is going to be just limited in gunnery permanent policy to mental health services with some caveats. There's some additional requirements you need to meet. There's basically the patient saying they want services via audio only or they're not able to use video maybe because of limited connectivity there. 

So what does this mean, impact on behavioral health if it expires? We just kind of went over that a little bit there. It's the geographic and site restrictions don't really impact if you meet all these caveats that are there or these exceptions that were put on there. So that's all that slide is. It's just written down what I just talked about there. 

The other thing that would be important for you guys is prescribing of controlled substances via telehealth. Now I can give you a little bit better news around this. So this is a little bit more concrete on what's going on here. Just for our background, this is, again, a high level overview of the evolution of what's happened. 

So for those who are not familiar, when you use telehealth to control substance, again, that's embedded in federal law and how you can do that. It was put into federal law and piece of legislation called the Ryan Haight Act. So sometimes you'll hear people say in connection with telehealth and prescribing controlled substances the Ryan Haight Act. That's what they mean. It's because that piece of legislation was what put it in federal law. 

Basically what it says in federal law is you can use telehealth to prescribe a controlled substance, but only in these limited circumstances. And those limited circumstances are if there was a prior in-person exam by the telehealth provider before they start using telehealth to prescribe or if the patient is physically with a provider or in a facility that's DEA-registered during the time of telehealth interaction. So very narrow, very specific. 

One of the other exceptions is when a public health emergency is declared. And that's why it kicked in during the COVID pandemic, a public health emergency was declared, the exception kicked in, which also means why Congress didn't need to do anything. It was already baked into federal law. So it's the administering agency that has control over this, and that's the DEA. So you never have Congress really doing anything to step in and sort this, where you had with the Medicare waivers. We did not have to wait for Congress to do this. You had the agency able to make decisions. 

And it's been a bit of a journey here with the DEA. Initially, when the public health emergency was going to be declared over, they had said, well, we'll just extend the waivers for a couple of months and then we'll go into permanent policy. That was not met with much enthusiasm by folks. So we've had a series of extensions also from the DEA on these waivers as well. 

And towards the end of last year, just when it was about to expire, the DEA extended their waivers for another year. So yes, the official confirmation came at the last minute, literally at the last minute. December 31, 2025 was when it appeared in the Federal Register, but we had known about a month and a half, two months before that the DEA was going to extend an additional year. It just took a little bit of time to go through the process. 

So, I mean, a little bit props to the DEA for keeping on top of that and making sure that there isn't a gap or anything in there where there could be confusion. So prescribing controlled substances that waiver for telehealth is extended for another year. It is going to at least be good through December 31, 2026. So that was a good development to see at the end of the year. 

A couple other things. It was towards the end of the year. There was actually quite a bit of activity. I mean, maybe not the most hoped for with the Medicare waivers, but there was actually quite a bit of activity related to telehealth. So another thing that happened was AI executive order. It's called ensuring a national policy framework for artificial intelligence. 

There has been some debate over who should really set the AI policy. Because right now, if you look at it, there really isn't a lot of specific AI policy out there. It's been developing over the last couple of years, but nothing really major or overarching. And you've really had the states pushing forward with that and developing it as opposed to the federal government, which, depending on who you talk to, could be a good or a bad thing. 

The concern is that you've got 50 states in the District of Columbia, 51 different jurisdictions doing their own thing on it there. So the concern is that you might be creating this patchwork quilt of different policies that maybe they conflict with each other or they require different things, similar to telehealth as it developed with their own state policies. It was all very different. So you can have people who might be wanting to operate in multiple states, having to do different things just because of how they created their policy. 

So the president issued this executive order on December 11 saying that trying to bring a bit more overarching cohesiveness, I think, on AI policy and its development. These are only a couple of things I pulled from the executive order. There's a couple other things in there, and I have the link where you can go read it. 

But two things that I thought were interesting is that one-- and we're happening fairly quickly because they had deadlines on them, there would be creation of AI litigation task force, which essentially means that the Department of Justice would be looking at state laws regarding artificial intelligence and see if they have been shaped or written to impede development of AI and then a group to do that evaluation of looking at those AI state laws. 

I'm not quite sure where they are. I do have linked on the AI litigation task force a press release from the DOJ regarding the establishment of it. That's dated January 9. I don't know if they publicly made available who's on there or maybe they won't even because it might just be different attorneys in the Department of Justice. 

But they said, we're working on this right now. The evaluation of state AI laws, I think they got 90 days to do that. So they have a little bit more time. So we haven't seen anything regarding that as well either. But just to make you aware of that is out there-- and I'll circle back around to it when we get to the state level stuff as well because a couple of potentially interesting things there as well. 

The other thing to make you aware of is CMS access model. This is really around chronic care. I can see some mental health application to this, but it is focused more on chronic care. But I did want to make you aware about this. It is a new payment model or a new model underneath original Medicare, which is what the waivers impact. So remember those Medicare telehealth waivers impact fee for service or original Medicare. They don't impact Medicare Advantage. 

So this is a new model, a CMS announced that they were doing. They have released the application for it. They have to be submitted by April 1. And then the first round of folks will begin July 1 starting their model. And then it's a rolling application after that. But the first group are expected to start July 1. So that is something if it piques your interest, or somebody in your organization should interest, you might want to check out as well too. 

And then the other thing that I want to touch upon is the rural health transformation program. Really quickly, last year when HR1, which is The Big Beautiful Bill, was approved, in that bill was $50 billion over five years that would go to states to basically improve health for rural residents. It had a very aggressive timeline on when applications had to be submitted. 

So the NOFO for that came out in mid-September and it had to be a state. States had to have their applications in by November 5. And then CMS said we're going to award this basically at the end of the year. And they did. On December 29, they announced who they were awarding, and all 50 states were awarded funding. 

District of Columbia and the territories were not eligible for this funding. So it was the 50 states. So basically, again, the application timeline was very ambitious. So is the rollout of this. Funds are supposed to go to states this month. They may have already been rolling that out. And states need to meet certain milestones pretty quickly. So they need to roll it out as well too. 

I bring this up is that every state has gotten funding. Every state is going to have to push out this funding and show results. This, again, presents an opportunity for you possibly to get involved in this work and to really reach out. I would advise you to really reach out to whoever is overseeing this for your state and try to be involved in it if this is something that you feel would be beneficial for you or your organization to be involved in. It's going to move quickly. So if you have not already done that, start doing that now. 

Also, whoever administers it for the state, it's going to vary. So a lot of states have it running through their health and human services department or the equivalent of that. Others have it running through rural health offices. So it's going to vary depending on what state you're in. But I really recommend that-- this is something that you should check out because not only could there be potential funding for some work that you're doing, but this funding can change some of the policies and some of the landscape of how telehealth is being used in your state as well too. So just a heads-up that this may be something you might want to be involved in. 

Additionally, on the federal level, there are four currently forecasted grant opportunities related to telehealth. The NOFOs are not out yet. They're just forecasted. My understanding is that they hope to have them available out there by mid-February. And then give people two months to apply. But those are something that you can just check out. Just go to grants.gov and type in telehealth and they'll pop up. That's the actual search link there on there that I use. So can go ahead and just click on that as well too. 

Now state policies. Really quickly here. I know I've been talking a long time. My apologies. I said I don't have much news for you, but actually, it turns out I did. State policies, why it's important focusing on this? New year means a lot of new sessions being a lot of new legislation coming out. It is early days, so I don't have quite a sense of what the big trends are going to be. 

I mean, I have a sense, but that could shift as more legislation is introduced. But really what we're looking at is, first off, those Medicare waivers expiring, really not going to impact the states. I mean, unless the state has something tied to those Medicare waivers, which very, very few do, if any, if they expire, they're not going to really impact Medicaid, or private payers, or whatever it's going on in your state. 

That's not related to the Medicare funding there. So don't worry about that if that's the spear that you operate in. And the majority of states have already settled on their temporary policies, what they're doing with them. There's a handful that have extended deadlines as well for their pandemic policies. It's just a couple of states. Most of the states have already said, this is what we're doing, and they haven't really changed it. 

But what to look out for over the next year as far as state legislation, licensure, that's always going to be a big issue. Right now, the biggest thing seems to be joining a compact. And there's always seems to be a new compact out there. I think the latest one is sports trainers compact. So that's going to be, probably, again, a very popular type of piece of legislation introduced on the state level. Does not mean that a state may not introduce something a little bit different like, oh, we're going to make exceptions in these cases. A patient provider relationship was already established or something like that in another state. 

These other two bullets, I'll circle back around to the AI one in a second. But for the other one, this is what I was referring to, the rural health transformation policy. I've looked at a couple of application, and they had mentioned that there's the possibility that they would need to do some policy changes in order to make what they want to do under the rural health transformation program more effective. That's why I said it's important that you probably get involved in some way or at least track what's going on with this rural health transformation funding that's coming in your state. Because they may have how to do some policy changes, they either directly involve telehealth or may not involve telehealth. 

The latter, what I mean, may not directly involve telehealth, is there may be an old policy that they have to change to accommodate telehealth, such as, oh, there was this policy that they had where you had to be in person for these services. And now we know we can use telehealth then, so you don't really require in-person. That happens a lot with some state policies around group treatment because, in the past group sessions, people are required to be there. They said, oh, you need to be there in-person, because that was how a group session happened. 

But with the advent of technology, you can now do that over telehealth. But some of that old policy has just stuck around where it's had in its language in-person. So that's just an example of where they may need to change it to accommodate what technology can do nowadays. But it's not specific of we're changing it to say put the word telehealth in there. So that's what I mean by it may or may not directly involve telehealth in the verbiage that they're using to change the policy there. 

But of the state applications that I did more than just a cursory look at, there were-- practically all of them. And granted, they were not all 50 state applications. They were just a handful. But they did mention that they may need to do policy changes. So again, keep your eye on that real health transformation because there may be a policy change that impacts you in other ways. 

And then for AI legislation, we talked about the executive order. States are still continuing, though, with doing their own AI legislation. And where this could be interesting is that that order in some ways was broad, but it was also specific, in that, it was talking about impeding the development of AI technology in some way. But there's been at least one bill that was passed last year, but I can see more of this where it didn't necessarily involve the development of AI, but it talked about how a provider uses AI. 

And this is the wellness and oversight for psychological resources act in Illinois. And it passed in 2025, signed into law by the governor. And it prohibits anyone from using AI to provide mental health therapeutic decision-making while allowing to use AI for administrative and supplementary support services for licensed behavioral health professionals. And that's the link to the press release and everything. So it wasn't saying that, oh, well, AI developers, you need to do X, Y, and Z. It was telling a practitioner, this is what you need to do if you are going to plan to use AI. And this is what happens if you use AI. 

So would this fall underneath the executive order? I don't know because this is more about scope of practice for a health care professional as opposed to AI development. And I don't think the executive order was meant to touch something like scope of practice for practitioners. So this sets up an interesting scenario going into future. It's like, is this going to be swept up by that AI task force as, no, you were supposed to do this? 

Because you can argue it's a different discussion here. This is not about the AI development, and it is about the use by a health practitioner and how they perform their services. So I just want to put that on your radar. And that could be of an interesting policy discussion going into to 2026 here. And that is it. Some contact information for CCHP, our website, where you can also find our 50-state policy finder, our newsletter, and then our info TA email if you have a specific question. So I'll turn it back over to Cara before we get to Q&A. 

Excellent. Thank you, Mei. Great job. So much information. We have a lot of questions so I'm going to get started quickly. Can you speak to what is required for behavioral health service provider to provide services across state lines? 

So first off, your biggest thing is going to be about licensure. So if you are doing it across state lines, depending on what state you are looking at, you're going to need to look at your licensure requirements. Essentially, most states would say you need to be licensed in our state. There are some exceptions. Again, I briefly mentioned it. 

Some states may have exceptions such as, well, if you've already have a patient provider relationship established with the patient and they're only here temporarily, they're passing through or something, we're not going to require a license for you. Highly specific things. So it is going to depend on what states you're talking about. Now that's your legal requirement of what the states have around licensure. Your payment requirement is going to depend on your payer. 

For the most part, you won't have issues necessarily with Medicaid or Medicare in a lot of cases. I can't say the same about private insurers. I don't know what their policies might be because they all vary. But it's two things that you need to consider-- one, to be legal. And that's usually around licensure. And the other is if you want to get paid it's going to depend on what the patient's coverage is. I mean, if it's out-of-pocket, then you don't really need to worry about that, if the patient pays you out-of-pocket. But if they're covered by some insurance, you're going to have to worry about what their policies are. 

So that leads right into the next question is, do the telehealth laws apply to commercial insurance or private therapy practice for private pay clients? 

So I'm not quite sure what you mean by telehealth laws. So for the most part, every state has some telehealth private insurance policy on their books-- for the most part. However, they vary widely in exactly what they say and how detailed they get. So essentially, what a lot of states have, if you're talking about private insurance, is that they would have policies that range from if you are a private insurer, you must cover the telehealth delivered the services the same way you would have had you covered it in-person and you need to pay the same amount. Highly specific. Really insures parity between in-person and telehealth-delivered services. 

But then you have at the other end of the spectrum, states that say you can cover telehealth if you want to. So very vague and broad and leaving it up to them to do things. And then you got everybody else falling in the middle of it. So you need to, again, it's going to depend on what state the patient's insurance covers. So if you're seeing a patient that's in another state, it's not your state law that's going to be covering it if their insurance is not underneath that state law. So that's the other thing you need to keep in mind. 

And we have the different policies-- I mean, at least the statutes. Again, private insurance, for the most part, a lot of them are not open to sharing what their telehealth policies are. So it's a little hard to find the details on there. But at least on the CCH policy finder, we have what's in statute and regulation. So you can check that out for a state that you're interested in. 

OK, great. Thanks. Yeah, these are tough. Would they ever change the law rather than extending the waivers? 

That's been talked about. So I would say that's a little bit of a long shot right now-- at least right now. There was a little bit of movement on that as far as discussion was concerned towards the end of last year. But I don't think congressional members are there yet of like, hey. you know what? Whatever bill we pass to address the appropriations and budget and everything like that, let's just put in there this change to the telehealth stuff. So yeah, I don't think in this round. Maybe in two years they might do that. I don't think in this round. 

The one thing that I can see getting changed first is actually that prior in-person visit for mental health because a lot of congressional members don't like that. They're confused by it. And it's like, oh, you all passed it, I mean. But in talking with them privately, I think some of them were not quite fully cognizant of what that meant when they passed it a couple years ago. So that one is pretty unpopular. 

So I can see that being one of the permanent policies that gets changed quicker than the whole let's eliminate the geographic restriction, the problem with the other permanent policy is about the geographic restriction and home eligible site is a lot of policymakers are worried about fraud. And they figure like, well, if we change that, we're going to open up the floodgates to fraud. And I keep telling them, it's like, you did that during the pandemic and you didn't really see it happen. 

Or they're worried there's going to be overuse. Everybody's going to rush to and do. And it's like, again, it didn't really happen with the pandemic. It actually dropped after the pandemic, and you still had the policies in place. So that concern may not actually come to fruition there. But I would say, no, probably in this round, we're not going to see them do a permanent policy change. And the one that I give the best odds to be changed first is probably that prior in-person visit for a mental health service. 

OK, well, and this next question has to do with that, is must the in-person visit be by the same provider who continues with telehealth, or would another provider and ample coordination of care be sufficient to meet the in-person requirement? 

So this question came up. So I did, basically, this webinar for the National Consortium yesterday. And this question came up. And I wasn't quite certain. I knew there was an exception for the 12-month visit. But for the six-month prior in-person visit, I wasn't sure. I did look this up yesterday. And you can, but it needs to be somebody in the same subspecialty and in the same group that's doing that visit. 

So if you are a psychiatrist and then you expect the person's primary care visit to cover that, that's not going to work. They need to be in the same subspecialty and they need to be in the same group for that to apply for it to not be the actual telehealth provider. I don't have it in this slide deck, but I did create a slide for when that question came up. And that is like on the consortium slide deck. I'll send that slide to Cara so she can include it in the slide deck as well too. 

That'd be great. We have time for just one or two more here. So when you refer to rural health clinics, is that recognizing free medical clinics? We are not federally qualified health centers. 

It is probably however the feds define it underneath that rural health clinic. And I'll be honest with you, I'm not sure if a free clinic actually falls underneath that definition. 

OK, and then does this mean that we are required to see new clients in-person for six months before starting telehealth? 

Not for six months. You just had to have had one visit no sooner than six months before. So if you saw them a month before, that also counts too. But it's not like you need to see them multiple times. You just need to have had one service. It's a service that would have been covered by Medicare if they had Medicare at the time or was covered by Medicare. And it doesn't have to be a mental health services. CMS just says it just needs to be something that Medicare paid for or would have paid for and you saw them in-person when you did that. 

OK, and then last one. This should be a quick one. Are these policies or changes only for Medicare or do they include changes for Medicaid as well? 

So the Medicare waivers are just for Medicare fee for service. It does not impact Medicare Advantage directly. So for those who don't know, Medicare Advantage, their requirement where telehealth is concerned, that the telehealth fee for service policies is their base. They can do more if they want. And also the waivers doesn't necessarily impact. If they were already doing more and they can say like, well, we can do that because that's within their power to do that. So these telehealth waivers only impact Medicare fee for service. 

Excellent. So we didn't get to a lot of the questions in the Q&A. But that being said, email in the slides that you're going to get is the email for CCHP, which is the National Telehealth Resource Center that Mei runs. And if you send your questions that didn't get answered either in the Q&A or the chat, or you've come up with new ones, send them to her at that email address and they'll get back to you. So thank you, Mei, very much and for everybody that attended today. Have a healthy and safe weekend. 

Or send them to Nikki's northwest telehealth resource center. They're equally smart too. 

And we can get them to Mei too. Thanks, Mei. 

All right, have a great day. Thank you. 

Take care, everybody.