The National Association of Rural Health Clinics’ 2025 Policy Survey found that 66% of over 1,200 RHCs actively use telehealth for medical visits. Yet billing these services remains complicated by payment disparities and policy gaps. Each state’s Medicaid program sets different rules for RHC distant site eligibility and AIR payment structures. Non-behavioral telehealth flexibility expired September 30, 2025, while mental health coverage stays permanent.
This guide addresses RHC telehealth billing requirements across Medicare and Medicaid programs. You’ll find current federal policies, state-level Medicaid variations, AIR payment structures, and the codes needed to submit claims correctly. The focus stays practical: how to bill telehealth encounters and receive proper reimbursement under each program.
Federal Medicare rules create a uniform billing framework for all 5,600+ Rural Health Clinics nationwide. An RHC in Montana follows identical federal guidelines as one in Georgia. The complexity arises from how these rules divide into permanent mental health coverage versus expired non-behavioral flexibilities, each with distinct payment methodologies.
Congress made RHC telehealth billing for behavioral health permanent in the 2022 Medicare Physician Fee Schedule. These services now generate the same AIR (All-Inclusive Rate) payment as in-person mental health encounters, eliminating the payment disparity that plagued earlier temporary policies.
RHCs receive their facility-specific AIR for mental health visits delivered through interactive telecommunications. This includes psychiatric evaluations, psychotherapy, substance use disorder counseling, and crisis intervention services. The patient’s location doesn’t matter; services to patients at home qualify for full AIR payment.
Billing requirements for mental health telehealth:
| Component | Requirement | Notes |
|---|---|---|
| Billing Codes | G0469 (new patient), G0470 (established patient) | Standard mental health visit codes |
| Payment Rate | Full AIR | Matches in-person encounter rate |
| Modifiers | 95 for video, FQ for audio-only | Required to identify modality |
| Patient Location | Any location including home | No geographic restrictions |
| Audio-Only | Permanently allowed | When patient unable/unwilling to use video |
| Coverage Status | Permanent | No expiration date |
Mental health RHC telehealth billing services currently have no in-person visit mandate. Starting January 1, 2026, Medicare requires one face-to-face visit within six months before initiating telehealth mental health services, then annually thereafter. This requirement applies only to beneficiaries receiving care in their homes, not to patients at clinical sites.
The distant site authorization for non-behavioral telehealth expired September 30, 2025. RHCs lost the ability to bill Medicare when providing general medical services via telehealth to patients outside qualifying facilities. This expiration affects routine primary care visits, chronic disease management, follow-up appointments, and specialty consultations delivered remotely.
Pre-expiration payment structure:
| Code | Service Type | Payment Amount | Administrative Burden | Status |
|---|---|---|---|---|
| G2025 | Non-behavioral telehealth | ~$97 per visit | Must segregate costs on cost report | Expired Sept 30, 2025 |
| Standard AIR | In-person encounter | $180-$250 typical range | Normal encounter reporting | Active |
Without congressional action, RHCs revert to pre-pandemic restrictions. Patients must physically present at qualifying originating sites, practitioner offices, hospitals, Critical Access Hospitals, other RHCs, skilled nursing facilities, or dialysis centers, located in rural areas or Health Professional Shortage Areas. The patient connects via telecommunications to the distant site provider during this facility-based encounter.
| Code | Description | Payment | Eligibility |
|---|---|---|---|
| Q3014 | Originating site facility fee | $28.64 | When patient physically at RHC for telehealth connection |
RHCs can bill Q3014 when serving as the originating site where the patient receives telehealth services from a distant provider. This fee compensates for facility use and telecommunications equipment but doesn’t replace lost distant site revenue.
CMS extended the payment methodology, anticipating legislative action, though the originating site flexibilities already expired on October 1, 2025. The G2025 code remains valid through December 31, 2025, but only applies if Congress restores distant site authorization.
Medicare Administrative Contractors apply minor locality-based adjustments (typically ±5-15%) to account for regional cost variations. These adjustments affect both AIR calculations and the G2025 rate but don’t change the underlying coverage rules or coding requirements.
Medicaid functions as 51 separate programs, one per state plus the District of Columbia, each establishing its own telehealth framework within federal guidelines. Unlike Medicare’s nationwide uniformity, Medicaid telehealth billing for RHCs varies drastically depending on your state’s specific regulations.
State telehealth policies have stabilized following the pandemic’s emergency flexibilities. The Center for Connected Health Policy’s Fall 2025 data reveals the following nationwide patterns:
| Policy Area | States + DC |
|---|---|
| Explicitly allow RHCs as distant site providers | 40 states + DC |
| Provide facility fee for originating site services | 35 states |
| Cover live video telehealth | 50 states + DC + Puerto Rico |
| Cover audio-only services | 46 states + DC |
| Cover remote patient monitoring | 41 states |
| Cover store-and-forward | 40 states |
| Cover all four modalities | 32 states |
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These numbers reflect explicit state Medicaid documentation. States without clear RHC telehealth policies may still reimburse services under general provider telehealth provisions, but payment certainty varies considerably.
State Medicaid programs determine whether RHCs qualify as distant site providers, originating site providers, or both. Some states explicitly list RHCs in their telehealth-eligible provider categories. Others apply general provider eligibility rules without mentioning RHCs specifically, creating ambiguity about reimbursement rights.
The distinction matters significantly. Distant site designation allows RHCs to deliver telehealth services and bill their AIR. Originating site designation permits facility fee billing when patients physically present at the RHC connect to remote providers. States like Mississippi authorize both roles simultaneously, while others restrict RHCs to originating site status only.
States choose which telehealth delivery methods qualify for Medicaid reimbursement:
Coverage decisions extend beyond modalities to service types. Some states limit RHC telehealth to behavioral health services. Others allow comprehensive primary care delivery through telecommunications. States also specify acceptable patient locations, homes, schools, community centers, or facility-based sites only.
Most state Medicaid programs pay RHCs using the All-Inclusive Rate methodology for telehealth encounters, mirroring in-person visit reimbursement. This payment parity ensures RHCs receive adequate compensation for remote care delivery. However, some states employ Alternative Payment Methodologies.
Facility fee availability represents another state-level decision. When RHCs serve as originating sites, 35 states reimburse an additional facility fee compensating for space, equipment, and staff time. The fee typically doesn’t apply when patients receive care at home or other non-clinical locations.
Instead of listing all 50 states separately, we’ve organized them by their telehealth coverage patterns.
These 32 states cover live video, audio-only, store-and-forward, AND remote patient monitoring for RHCs:
| States | RHC as Distant Site | AIR Payment | Facility Fee |
|---|---|---|---|
| Alaska, Arizona, California, Colorado, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Ohio, Oregon, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin | Yes (except CA, IL, MA, NJ, OR) | Yes - AIR | Yes (except CA, IL, MA, OR) |
| States | RHC as Distant Site | RHC NOT Distant Site | AIR Payment | Facility Fee |
|---|---|---|---|---|
| Arkansas, Florida, Georgia, Indiana, Kansas, Montana, Nebraska, Nevada, New Jersey, New Mexico, Tennessee | Arkansas, Georgia, Indiana, Kansas, Montana, Nebraska, Nevada | Florida, New Jersey, New Mexico, Tennessee | Yes - AIR | Yes |
| States | RHC as Distant Site | RHC NOT Distant Site | AIR Payment | Facility Fee |
|---|---|---|---|---|
| Alabama, Connecticut, District of Columbia, Louisiana, Mississippi, Oklahoma, Wyoming | Alabama, Connecticut, DC, Mississippi | Louisiana, Oklahoma, Wyoming | Yes - AIR | Yes |
| State | Coverage | RHC as Distant Site | AIR Payment | Facility Fee |
|---|---|---|---|---|
| Idaho | Video + Audio | No | Yes - AIR | Yes |
| Rhode Island | Video only | No | Yes - AIR | Yes |
Most states apply standard telehealth policies, but some have implemented distinct requirements affecting Rural Health Clinics.
New York released a dedicated Telehealth Provider Manual consolidating all fee-for-service policies. The manual clarifies RHC billing procedures, eligible services, modifiers, and documentation requirements. New York also added eVisit reimbursement for patient-initiated virtual check-ins and clarified doula service eligibility through telehealth delivery.
Texas allows Q3014 facility fee billing, but multiple facility fees for the same patient on the same day require a signed provider letter documenting that the patient suffered an injury requiring additional distant site diagnosis or treatment. Without this documentation, the second facility fee will be denied. Texas also expanded RHC eligibility for ESRD telemonitoring services.
Mississippi recognizes RHCs as both originating and distant site providers simultaneously. When your clinic provides both roles in a single encounter, a patient at one RHC location connecting to your provider at another site, you can bill both the distant site AIR and the originating site facility fee when services are “appropriately provided by the same organization.”
Montana prohibits telehealth when originating and distant sites are “located within the same facility or community.” The state doesn’t define “community,” creating ambiguity for multi-site RHCs. Verify with Montana Medicaid whether your clinic configuration qualifies before submitting distant site claims to avoid denials.
Indiana permits RHC telehealth billing only when services qualify as both valid RHC encounters and covered telehealth services. Bill encounters codes T1015 or D9999 with appropriate POS codes (02 or 10) and modifiers (93 or 95). Payment occurs at AIR for the encounter code; additional procedure codes document services but don’t generate a separate payment.
Nebraska requires distant sites to bill with POS code 02 (telehealth not in the patient’s home) or code 10 (telehealth in the patient’s home). Reimbursement matches face-to-face service rates regardless of location. Documentation requirements mirror in-person visit standards without a reduction for the remote delivery method.
South Dakota expanded eligible originating sites to include inpatient hospitals and hospital-based renal dialysis centers. This change increases referral opportunities for RHCs serving as distant site providers to patients receiving inpatient or dialysis care, particularly benefiting clinics offering specialty consultation services.
Medicare permanently covers RHC telehealth billing for behavioral health at full AIR, while non-behavioral distant site flexibility expired September 30, 2025. Without legislative action, medical telehealth reverts to originating site billing only. Forty states plus DC authorize RHCs as distant site providers for Medicaid, though modality coverage and payment structures vary significantly by jurisdiction.
Verify your state’s Medicaid policies using the comparison tables above and confirm current requirements directly with your state fiscal intermediary. The National Association of Rural Health Clinics tracks policy updates at NARHC.org, while the Center for Connected Health Policy offers searchable state-specific details for ongoing reference.
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