Trend Analysis
The End of Emergency Flexibilities
The regulatory landscape for telemedicine is in flux. With the Public Health Emergency era federal waivers expected to end, and state laws increasingly diverging from these PHE era exceptions, the legal framework for telehealth and tele-prescribing is entering a period of rapid change and heightened complexity.
Providers must not only understand current rules but prepare for the post-pandemic regulatory landscape. What was permitted under emergency authority is not necessarily permitted going forward.
Current Federal Status
DEA Telehealth Prescribing Extension
Under the current DEA regulation extension, prescribers may continue to prescribe controlled substances via telemedicine (without an in-person evaluation) through December 31, 2025. What happens after that date remains subject to regulatory action and potential legislation.
Medicare Telehealth Flexibilities
In March 2025, Congress passed a Continuing Resolution that extended certain Medicare telehealth flexibilities until September 30, 2025, including:
- Waiving geographic restrictions
- Expanded eligible clinician types for telehealth
- Continued telehealth access in federally qualified and rural health centers
- Waiving certain in-person requirements for mental health visits
Following a government shutdown, H.R. 5371 temporarily reinstated several Medicare telehealth flexibilities through January 30, 2026. The situation remains fluid.
Ongoing Uncertainty
Key federal flexibilities with uncertain futures:
- DEA controlled substance prescribing via telemedicine
- Medicare geographic restrictions
- In-person requirements for certain services
- Audio-only telehealth coverage
State Licensing: Back to Basics
The Fundamental Rule
As states emerge from the COVID pandemic, they are reverting back to rules that require providers to be licensed in the state where they practice medicine—meaning the provider must be licensed in the state where a patient is physically located at the time of the visit.
This was always the underlying rule; pandemic-era waivers temporarily relaxed it in many states. Those waivers are largely gone.
Telemedicine Provider Requirements
Telemedicine providers must now hold active licenses in every state where they provide services, eliminating the previous gray areas that allowed some cross-border practice.
This means:
- License required in patient's state
- Compliance with that state's telemedicine regulations
- State-specific prescribing rules apply
- No exemptions based on where the provider is located
State-by-State Variation
Controlled Substance Prescribing Examples
New York: In May 2025, the New York State Department of Health finalized a rule governing the prescription of controlled substances through telemedicine. The rule requires an in-person medical evaluation prior to prescription of controlled substances, with certain exceptions.
New Hampshire: Adopted Senate Bill 252, authorizing licensed physicians, PAs, and APRNs to prescribe non-opioid and Schedule II through IV medication through telemedicine, removing the requirement for a prior in-person exam and instead requiring annual evaluation. Effective August 23, 2025.
Texas: Has taken a hybrid approach, permitting telehealth prescribing for mental health and chronic care management, but prohibiting the remote prescribing of certain Schedule II substances absent an in-person visit.
Payment Parity
As of November 2025:
- 23 states: Payment parity (require payers to reimburse telehealth at same rate as in-person)
- 5 states: Payment parity with caveats
- 22 states: No payment parity requirement
Payment parity affects the financial viability of telemedicine services in different markets.
The IMLC Solution—and Its Limits
What IMLC Provides
The Interstate Medical Licensure Compact (IMLC) streamlines the licensing process and makes it simpler for physicians providing telehealth services to hold licenses in multiple states.
With 44 participating jurisdictions, IMLC covers most of the country and significantly reduces the burden of multi-state licensing.
What IMLC Doesn't Solve
However, while the IMLC facilitates the licensing process across participating states, it does not eliminate the need for individual state licenses. You still need:
- A license in each state where patients are located
- Compliance with each state's regulations
- Separate renewals and CME compliance per state
And major states like California and New York remain outside the Compact.
Compliance Considerations
The Complexity Challenge
The post-pandemic landscape creates compliance challenges:
- Federal rules: Still in flux, may change
- State rules: 50+ different regulatory frameworks
- Payer rules: May differ from state and federal
- Controlled substances: Extra layer of complexity
Documentation Requirements
Telemedicine visits should document:
- Patient's physical location at time of visit
- Provider's license in that state
- Compliance with that state's telemedicine regulations
- Any required consents
In-Person Requirements
Track state-specific requirements for:
- Initial visits (some states require in-person first)
- Controlled substance prescribing
- Periodic in-person evaluations
- Specific conditions or treatments
What Providers Should Do
Immediate Actions
- Audit current licensing: Verify licenses in all states where you see patients
- Review state regulations: Understand requirements in each state
- Monitor federal developments: DEA rules particularly uncertain
- Document patient locations: Every visit
Operational Planning
- License expansion: Use IMLC for eligible states
- Credentialing coordination: Align payer enrollment with licensing
- Patient communication: Inform patients of service area limitations
- Workflow adjustment: Build location verification into intake
Controlled Substance Protocols
Given uncertainty about DEA telehealth prescribing:
- Review current prescribing practices
- Develop contingency plans
- Consider in-person visit requirements
- Document medical necessity thoroughly
Industry Trends
Telemedicine Is Here to Stay
Despite regulatory complexity, telemedicine has permanently changed healthcare delivery:
- Patient expectations for virtual access
- Provider adoption of telemedicine technology
- Payer coverage normalization
- Infrastructure investments made
Regulatory Stabilization Expected
Over time, expect:
- More states joining IMLC
- Federal telemedicine legislation (eventually)
- Greater uniformity in state approaches
- Clarity on controlled substance prescribing
Technology Adaptation
Technology platforms are adapting:
- License verification at visit time
- Geographic restriction enforcement
- State-specific compliance workflows
- Documentation automation
Conclusion
The post-pandemic telemedicine licensing landscape is complex and still evolving. Emergency-era flexibilities have largely expired, returning providers to the fundamental rule: you need a license in the state where your patient is located.
The IMLC eases multi-state licensing but doesn't eliminate it. State rules vary significantly, particularly for controlled substance prescribing. Federal rules—especially DEA telehealth prescribing authority—remain uncertain.
Successful telemedicine practice in 2026 requires treating licensing and compliance as core operational functions, not afterthoughts. Monitor regulations, maintain licenses in all service states, document carefully, and build flexibility into your practice model to adapt as rules continue to evolve.
Key Takeaways
- PHE flexibilities largely expired: Back to state license requirements
- DEA extension through December 2025: Future uncertain
- Medicare flexibilities temporary: Congress continues extensions
- State rules vary significantly: Especially for controlled substances
- IMLC helps but doesn't eliminate: Still need state-by-state compliance
- 23 states have payment parity: 22 states do not
References
[1]: CHG Healthcare - Telehealth Rules and Regulations: 2025 Healthcare Toolkit https://chghealthcare.com/blog/telehealth-rules-regulations
[2]: Telehealth.org - 2025 Quarterly Telemedicine Policy Timeline https://telehealth.org/blog/2025-quarterly-telemedicine-policy-timeline-a-review-and-expectations-of-laws-and-regulations/
[3]: Sheppard Health Law - Tracking Federal and State Updates to Pandemic Era Telehealth Exceptions https://www.sheppardhealthlaw.com/2025/08/articles/telehealth/telehealth-and-in-person-visits-tracking-federal-and-state-updates-to-pandemic-era-telehealth-exceptions/
[4]: Telehealth.HHS.gov - Licensing Across State Lines https://telehealth.hhs.gov/licensure/licensing-across-state-lines