The landscape of virtual healthcare has entered a new and complex phase, where the rules governing patient access and provider reimbursement are no longer uniform across the board. In a significant move that underscores a growing divergence from federal guidelines, UnitedHealthcare announced on October 6, 2025, that it will continue its expanded Medicare Advantage (MA) telehealth coverage for certain in-home medical and mental health services through 2026. This decision highlights the autonomy that commercial MA plans possess to shape their benefit structures, creating a patchwork of policies that providers must navigate carefully. While this extension offers a lifeline for many patients who rely on virtual care, it also introduces a new layer of administrative challenges for behavioral health practices and other medical groups. The announcement is a clear signal that the one-size-fits-all approach to telehealth that characterized the public health emergency has given way to a more fragmented, payer-specific reality that demands proactive engagement from healthcare providers.
1. Understanding the Divergence in Telehealth Coverage
UnitedHealthcare’s decision to preserve some telehealth benefits for its Medicare Advantage members through 2026 marks a critical departure from the policies governing Original Medicare. As many of the temporary flexibilities established during the COVID-19 Federal Public Health Emergency lapsed on October 1, 2025, non-behavioral services under Original Medicare reverted to stricter geographic and originating-site restrictions. In contrast, UnitedHealthcare’s policy extension demonstrates how private MA carriers can use their flexibility to offer more generous benefits than the federal baseline. This creates a dual system where coverage for the same service can vary dramatically depending on whether a patient has Original Medicare or a private MA plan. However, this extension is not all-encompassing. In a move that tempers the positive news, the carrier also announced it is discontinuing coverage for most remote patient monitoring services starting in January 2026. This selective approach requires providers to scrutinize individual plan documents and stay vigilant about updates, as assuming uniformity across payers is no longer a viable strategy.
The broader implications of this trend extend far beyond a single carrier. As MA plans continue to enroll a significant portion of the Medicare-eligible population, their telehealth policies will increasingly shape the standard of care and access for millions of older adults. The divergence means that behavioral health clinicians and medical providers cannot rely solely on Centers for Medicare & Medicaid Services (CMS) guidance. Instead, they must engage directly with each commercial payer—including major carriers like Aetna, Humana, Cigna, and Anthem—to confirm their specific rules for in-home telehealth, audio-only visits, and out-of-network benefits. This shift places a substantial administrative burden on practices, which must now develop systems to track varying requirements for credentialing, billing, and documentation. The need for clear, written confirmation from payers has become paramount in order to prevent claim denials and ensure financial stability in an increasingly complex reimbursement environment that values specificity and meticulous record-keeping.
2. The Impact on Behavioral Health Practices
For behavioral health practices, UnitedHealthcare’s announcement is a double-edged sword, offering both opportunities for continuity of care and the potential for significant administrative hurdles. On one hand, the carrier’s decision to continue covering in-home telehealth visits, including services delivered by mental health and non-physician clinicians, provides a stable platform for treating patients with mobility issues, transportation barriers, or those living in remote areas. The continued acceptance of both audio-only and audio-video modalities, provided the services are on the approved CMS Medicare Telehealth List, is particularly crucial for maintaining access for patients who may lack the technology or digital literacy for video consultations. This commitment supports the ongoing integration of telehealth into routine mental healthcare, allowing practices to maintain established therapeutic relationships and outreach programs that have proven effective. It reinforces the value of virtual care as a core component of modern behavioral health delivery.
Conversely, the growing variation among MA plans complicates daily operations. A practice that serves patients from multiple MA carriers must now navigate a labyrinth of differing rules regarding network requirements, prior authorization, and reimbursement rates for telehealth services. The distinction between MA PPO, Group PPO, and PFFS products, for example, can determine whether an out-of-network telehealth visit is covered, partially covered, or denied entirely. This complexity necessitates a more sophisticated approach to patient intake and benefits verification, requiring staff to confirm not just the carrier but the specific plan type and its associated telehealth policies before a visit is scheduled. Without diligent, plan-level verification, practices risk an increase in claim denials, unexpected patient financial responsibility, and a heavier administrative workload to manage appeals and billing disputes. This new reality demands that practices invest in staff training and internal systems to manage this variability effectively.
3. Navigating Operational Complexities
Successfully adapting to the evolving telehealth landscape requires a deep understanding of key operational factors that can directly influence reimbursement. A provider’s network status has become more critical than ever, as coverage for telehealth services can differ significantly across various MA product types. For instance, an MA PPO plan may offer some level of out-of-network telehealth coverage, while an HMO or PFFS plan may not, leaving the patient responsible for the full cost of the visit. Practices must therefore implement a rigorous front-end process to verify each patient’s specific plan and its rules for virtual care. Furthermore, the eligibility of audio-only visits, while continued under some UHC policies, is not universal. Reimbursement is often contingent on the service being listed on the CMS Telehealth List and may require documentation justifying why a video modality was not used. This requires clinicians to be precise in their note-taking and for billing staff to be aware of which codes and circumstances permit audio-only reimbursement.
Beyond network status and modality, the fine print of credentialing and billing specificity can be the deciding factor between a paid claim and a denial. Providers must ensure their credentials are fully up-to-date with each MA plan and that claims are submitted with the correct place-of-service codes and telehealth modifiers that each specific payer requires. A simple coding error or a mismatch in the provider’s registered location versus the patient’s location can trigger an automatic rejection. Given these complexities, proactive communication with payer provider relations departments is essential. Rather than waiting for denials to occur, practices should initiate contact to ask targeted, code-level questions. Inquiries such as, “Are in-home telehealth visits reimbursable for my specific clinician type?” or “Do prior in-person visit requirements apply to telehealth services under this plan?” can provide the clarity needed to streamline workflows and reduce downstream payment issues, ensuring the financial health of the practice.
4. Proactive Steps for Medical Providers
To thrive in this fragmented payer environment, medical practices must adopt a strategic and proactive approach to managing their Medicare Advantage patient panels. The first step is to conduct a thorough analysis to map all MA plans currently represented in the practice’s patient base. This inventory serves as the foundation for a more targeted verification process. For each identified plan, the next crucial action is to confirm whether in-home telehealth is a covered benefit for the specific clinician types employed by the practice, as coverage can vary between physicians, psychologists, social workers, and other providers. This requires direct outreach to each payer, ideally seeking written confirmation of their policies to avoid ambiguity during claims disputes. This documentation becomes an invaluable internal resource for billing staff and clinicians alike, creating a reliable reference point for scheduling and treatment planning.
Once coverage is confirmed, practices must clarify the nuances of out-of-network rules, particularly for MA PPO products, which may offer some flexibility but often come with higher patient cost-sharing. This information should be integrated into updated intake scripts, empowering front-desk staff to have transparent conversations with patients about their plan type, potential out-of-pocket costs, and financial responsibilities before care is rendered. To close the loop, it is essential to establish an internal payer registry or tracking system for denials and policy carve-outs. This living document allows the practice to identify patterns, such as a specific MA plan consistently denying claims for a particular service code. This data-driven approach not only helps in appealing individual denials but also informs future contract negotiations and decisions about which MA plans the practice will continue to accept, ultimately protecting its operational and financial integrity.
5. Ensuring Accuracy in Documentation and Coding
In an environment where telehealth reimbursement is governed by payer-specific rules, meticulous documentation and precise coding have become non-negotiable for securing payment. Every telehealth encounter must be supported by clinical notes that are both comprehensive and compliant with the requirements of the patient’s specific MA plan. This includes explicitly stating the modality used for the visit—whether audio-video or audio-only—as this distinction often impacts reimbursement. It is also essential to document the patient’s location as “home” to satisfy the criteria for in-home telehealth benefits. For certain services or situations, particularly when an audio-only visit is conducted, the clinical rationale for choosing telehealth over an in-person visit may need to be clearly articulated in the patient’s record to justify medical necessity and preemptively address potential payer scrutiny.
Equally important is the verification that all service codes billed for telehealth encounters appear on the most current CMS Medicare Telehealth Services List. Billing for a code that is not on this list is a common reason for automatic claim denial. This verification step must be integrated into the workflow before a claim is submitted. To minimize errors and ensure consistency, a strong feedback loop between clinicians, professional coders, and billing vendors is critical. Clinicians must provide detailed notes, coders must translate those notes into accurate claims, and billers must be aware of the specific modifiers and submission guidelines for each MA plan. Regular internal audits and training sessions can help align all parties, reducing the frequency of correctable errors and improving the practice’s clean claim rate, which is fundamental to maintaining a healthy revenue cycle in the complex world of modern healthcare.
6. A Strategic Framework for Practice Leadership
For behavioral health leaders, operational readiness is the key determinant of whether a telehealth visit is ultimately paid or denied. The first strategic imperative was to update and maintain a dynamic list of all accepted insurance payers and conduct a detailed mapping of patient plan types. This foundational work enabled practices to understand their specific payer mix and identify the dominant MA plans within their patient population. Following this, leaders scheduled brief, targeted calls with provider relations representatives from their top payers. The goal of these meetings was not to renegotiate contracts but to seek clarification on telehealth policies, particularly concerning documentation requirements for audio-only visits and any nuances related to specific service codes. This direct engagement helped build relationships and establish clear channels for resolving future issues.
With this information in hand, the next phase involved translating payer guidance into internal action. Patient communication scripts were revised to include questions about specific MA plan types and to provide clear, upfront cost-sharing estimates. This transparency helped manage patient expectations and reduce billing-related frustrations. Internally, workflows were updated to ensure that clinicians and administrative staff followed the precise documentation standards required by each carrier. The most critical step in this strategic framework was the insistence on obtaining written policy confirmations from payers. These documents became an essential resource, providing a definitive reference point that could be used to contest improper denials and train staff. This proactive and systematic approach allowed practices to navigate the varied MA landscape with confidence, ensuring both continuity of care for patients and the financial stability of the organization.
