When HHS and DEA announced the fourth extension of telemedicine prescribing flexibilities on January 1, 2026, the news landed without much surprise in behavioral health circles. Clinicians had seen this before, each extension arriving just before the prior one lapsed.
By now, the pattern is its own kind of evidence. Telehealth prescribing has been operating at scale for five years. In 2024 alone, more than 7 million prescriptions for controlled medications were issued via telemedicine without a prior in-person visit — 16% of all controlled substance prescriptions that year. That volume reflects a delivery modality that has been tested, scrutinized, and extended four times over, not because policymakers keep running out of time, but because it works.
The current extension runs through December 31, 2026, and gives DEA and HHS the runway to finalize permanent regulations, including the proposed Special Registration for Telemedicine. Behavioral health providers have spent five years waiting to see if this model would hold. It has. The work now is building care delivery around the permanence that is coming.
Who This Protects and Why It Matters
Parents of a child with ADHD who has been stable on a stimulant for two years aren’t typically the ones following telehealth policy debates. What they do know is that sometime around Thanksgiving, their child’s psychiatrist’s office starts fielding calls about whether prescriptions will still be valid in January. That uncertainty alone — before any policy actually changes — is enough to send families scrambling for alternatives, many of which aren’t the best solution.
This is the reality that controlled substance prescribing parities protect. The medications at the center of this conversation — stimulants, benzodiazepines, gabapentin — are not optional for the patients who rely on them. Disrupted access sets back treatment, sometimes significantly.
The patients most exposed when these flexibilities lapse are also the ones least equipped to absorb the disruption. Rural patients, people with disabilities, and those without reliable transportation built their care around telehealth because in-person access was never realistic to begin with. For them, a policy gap is not an inconvenience.
Getting someone back into treatment after they have stepped away is far harder than keeping them engaged. That is the cost that never shows up in a regulatory filing.
What Good Permanent Policy Looks Like
The Ryan Haight Act was signed in 2008 to address online pharmacies dispensing controlled substances without valid prescriptions. The in-person visit requirement it established made sense in that context. What has never made clinical sense is applying that same requirement to a psychiatrist who has been treating a patient for two years and wants to refill a medication that is working.
Permanent policy needs to make that distinction. The providers who should concern regulators are not the ones carefully documenting every prescribing decision and maintaining ongoing therapeutic relationships via telehealth. Separating legitimate prescribers from bad actors is the core challenge the Special Registration for Telemedicine is designed to solve, and solving it well means building standards around clinical accountability rather than visit modality.
Reimbursement is the other side of this. Telehealth prescribing parity does not mean much if payers can quietly reduce reimbursement for virtual visits. Permanent prescribing policy and sustainable reimbursement reform need to move together, or providers will find themselves with legal clarity but no financial model to support it.
What Providers Can Do Right Now
Providers have a full calendar year of operational clarity. The rules are documented, extended, and publicly available. Use it.
Treat the patient in front of you. Document the clinical rationale, the patient’s treatment history, and the basis for each prescribing decision. Evaluate whether your current telehealth infrastructure is built for the long term. These are not complicated directives, but they are the ones that matter most right now.
Some health systems are already operating from that posture. Bernard Jones, vice president for behavioral health at Mass General Brigham, has been direct about the ongoing uncertainty his organization faces, while remaining equally direct that virtual care’s value to behavioral health patients is not in question. That is the right way to think about building care infrastructure that will outlast any single extension.
The Future Belongs to Location-Agnostic Care
Five years of extensions have produced something that no single policy decision could have delivered on its own: proof, at scale, that behavioral health care delivered via telehealth produces outcomes worth protecting. The regulatory conversation has been slow to reflect that, but it is catching up.
The trajectory is clear. As permanent prescribing policy takes shape and reimbursement models mature, the mechanism of care will become increasingly incidental. Whether a patient sees their psychiatrist in an office or from their car will matter less than whether they show up consistently, stay engaged, and get the medication and support they need. That is what good behavioral health care has always looked like.
The systems and providers building toward that model now, rather than waiting for every regulatory question to be answered, will define what this field looks like in five years. The “tele” in telehealth is already fading as a meaningful distinction. What remains is the care.
Dr. Tom Milam serves as Chief Medical Officer at Iris Telehealth and President of Iris Medical Group – guiding their team of providers in telemedicine and industry best practices. He received his undergraduate degree from WVU in Anthropology, where he graduated summa cum laude and Phi Beta Kappa. He went on to earn his Master of Divinity Degree from Yale, where he was a Yale’s Associate Scholar, followed by receiving his Doctorate of Medicine (MD) from the University of Virginia. His residency training in psychiatry took place at Duke and UVA. Dr. Milam has practiced in North Carolina, Virginia, and New Zealand and is an Associate Professor of Psychiatry and Behavioral Medicine at the Virginia Tech Carilion School of Medicine and Research Institute in Roanoke, VA. For more information, email [email protected].
