The Telemedicine Cliff Is Back: What Behavioral Health Programs Should Do Before December 31

Behavioral health programs have until the end of the day on December 31, 2026 to prepare for a federal rule whose text has not been made public. That is when DEA’s current telemedicine prescribing flexibilities expire. On August 25, DEA sent its final special registration rule to the White House for review. The last extension was published on December 31, 2025, the day the previous one was due to lapse.

As the December 31 deadline approaches, the safe plan is not to guess which outcome arrives. It is to be ready for all three.

Where things stand

The waiver runs through December 31, 2026, and its permanent replacement has not been published. Under the Ryan Haight Act, a practitioner generally must evaluate a patient in person before prescribing a controlled substance remotely. Since March 2020, DEA has waived that requirement for Schedule II–V medications, and it has extended the waiver four times. The permanent fix is a special registration for telemedicine prescribers. Congress called for one in 2008 and set a 2019 deadline for final rules. DEA proposed a framework in January 2025, and the final rule reached OMB’s review office (OIRA) on August 25, 2026.

OIRA reviews often conclude within 90 days, although reviews can vary in length and timelines are not guaranteed. The text under review is not public. No one outside government knows whether it tracks the proposal, or whether it arrives before the waiver expires. One piece is already permanent. The buprenorphine telemedicine rule took effect December 31, 2025. It allows audio-only prescribing for opioid use disorder for up to six calendar months, with a documented PDMP review and a pharmacist identity check, before an in-person evaluation or another exception is required.

Why behavioral health is exposed

Behavioral health is directly exposed. ADHD stimulants are Schedule II, benzodiazepines are Schedule IV, and buprenorphine is Schedule III. All three are routine in telepsychiatry and telehealth addiction treatment. The volume is large. DEA’s rule cites one stakeholder analysis of 2024 data from 258 organizations: roughly 16 percent of 44.6 million controlled-substance prescriptions were issued without a prior in-person evaluation. Your organization’s share may differ, but you should know it.

The Medicare lapse offers a preview. When Medicare’s telehealth flexibilities ended on September 30, 2025, fee-for-service telemedicine visits fell 24 percent in 17 days. DEA’s rule treats that drop as a warning about what a prescribing cliff does to access.

Plan for three outcomes

Each outcome demands different preparation, and none is certain. A workable special registration would require prescribers to register and meet new recordkeeping and security requirements. Another temporary extension has happened four times, but it has also arrived on deadline day. If neither arrives, on January 1, 2027, the pre-pandemic in-person requirement returns, subject to the statutory exceptions and the buprenorphine rule.

What to do now

Start with a patient-level registry. Everything else depends on it. Record, for every patient receiving a controlled substance through telehealth: prescriber, drug and schedule, first prescription date, and whether the prescriber has ever evaluated the patient in person. Sort patients into three groups: in-person evaluation on file, buprenorphine for opioid use disorder, and everyone else. Book in-person visits for everyone else first. Alert scheduling staff now, draft patient notices and prescriber scripts, and name one owner to check OMB’s review page and the Federal Register weekly through year-end.

The bottom line

The risk is not that the rule will be strict. The risk is learning the answer on the last day. If the flexibilities lapsed on January 1, how many of your patients would need an in-person visit? If you cannot answer that today, that is your first task. Because the final special registration rule has not been published, organizations should monitor DEA, OIRA, and state regulatory developments for updates. The Ryan Haight Act, PDMP query duties and corresponding-responsibility rules behind this checklist are covered in Chapter 25 of Behavioral Health Quality & Compliance (Port Hudson Press).