Eight weeks ago, a large share of American physicians had never billed for a video visit, and many had never conducted one. Telehealth existed, but it lived at the margins of the health system — a convenience feature for a narrow set of use cases, hemmed in by reimbursement rules that made it impractical for most patients and practices to use routinely. Then, within a matter of weeks in March 2020, that changed. Waiting rooms emptied as patients avoided in-person care for fear of exposure to the novel coronavirus, and federal regulators tore down, almost overnight, many of the rules that had kept telehealth sidelined. What followed was less a gradual rollout than a scramble: clinics standing up video platforms in days, regulators issuing guidance in real time, and patients and providers learning a new mode of care while the pandemic was still accelerating.

This is a look at how that scramble unfolded through the first half of 2020 — the regulatory changes that made it possible, what the early utilization data shows, the operational reality inside practices, and the open questions about which changes are temporary emergency accommodations and which represent a lasting shift in care delivery.

Why Telehealth Was Marginal Before 2020

To understand why the current moment feels so abrupt, it helps to recall how constrained telehealth was under pre-pandemic Medicare rules. Traditional Medicare telehealth coverage was largely limited to beneficiaries in rural areas, and even then only if the patient traveled to an approved “originating site” — typically a clinic, not their own home. That reflected telehealth’s original purpose: extending specialist access to rural and underserved areas, not serving as a general substitute for an office visit. Commercial payers and state Medicaid programs varied widely in what they covered, and many states required a prior in-person visit before a telehealth relationship could be billed at all. Telehealth technology had existed in usable form for years, but the payment and regulatory architecture around it had not caught up.

The CMS 1135 Waiver and Medicare’s Emergency Telehealth Expansion

The turning point was the invocation of Section 1135 waiver authority. Under the Social Security Act, the HHS Secretary can waive or modify certain Medicare, Medicaid, and CHIP requirements during a declared public health emergency and presidentially declared disaster. HHS declared a COVID-19 public health emergency effective January 27, 2020, and the national emergency declaration followed on March 13, 2020, which unlocked broader 1135 waiver authority.

What the Waiver Actually Changed

Using that authority, along with provisions in the Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS made several specific changes to Medicare telehealth rules effective for services starting March 6, 2020, for the duration of the public health emergency:

  • Originating site restrictions dropped. Medicare began paying for telehealth visits regardless of beneficiary location, including the patient’s own home — eliminating the old rural-only, clinic-only originating site requirement.
  • Broader provider eligibility. A wider range of practitioner types — physicians, nurse practitioners, physician assistants, nurse midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, and registered dietitians — were authorized to bill Medicare for telehealth.
  • Prior relationship requirement relaxed. HHS announced it would not audit for a prior patient-practitioner relationship on claims submitted during the emergency, effectively allowing new-patient telehealth visits.
  • Payment parity. CMS said it would pay for the newly expanded Medicare telehealth services at the same rate as comparable in-person visits, removing a major financial disincentive to offering video care.
  • Cost-sharing flexibility. The HHS Office of Inspector General said it would allow providers to reduce or waive Medicare beneficiary cost-sharing for telehealth visits without violating fraud and abuse rules.

Source: CMS, Medicare Telemedicine Health Care Provider Fact Sheet.

HIPAA Enforcement Discretion Removed a Major Technology Barrier

A parallel but equally consequential change came from the HHS Office for Civil Rights (OCR). On March 17, 2020, OCR issued a Notification of Enforcement Discretion stating it would not impose HIPAA penalties on covered health care providers for good-faith use of everyday communication apps — including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, and Skype — to deliver telehealth during the emergency, regardless of whether the visit was COVID-19-related. OCR drew a line at public-facing video products such as Facebook Live, Twitch, and TikTok, which should not be used for telehealth. This mattered practically: before the notice, many clinicians assumed they needed a signed business associate agreement with a dedicated telehealth vendor before seeing a single patient by video — a procurement process that could take weeks a fast-moving emergency did not allow. Source: HHS, Notification of Enforcement Discretion for Telehealth Remote Communications.

It is worth being precise about what these are: temporary waivers and enforcement postures tied to the declared public health emergency, not permanent statutory changes. Several underlying restrictions — particularly the Medicare originating-site and geographic limits — are set in statute, so a durable fix would require an act of Congress rather than continued agency discretion. That distinction is central to the “what sticks” question this article closes with.

How Much Did Utilization Actually Spike?

Regulatory permission is only useful if patients and providers actually use it, and the early utilization data suggests they did.

The CDC’s Early National Picture

One clear early national data point comes from a CDC analysis published in the Morbidity and Mortality Weekly Report (MMWR), drawing on de-identified data from four large U.S. telehealth providers. Looking at telehealth encounters during the first quarter of 2020 compared with the same period in 2019, CDC researchers found approximately 1,629,000 telehealth encounters in Q1 2020 versus roughly 1,084,000 in Q1 2019 — an overall increase of about 50%. The growth was not steady; it concentrated in a sharp late-March spike. During surveillance week 13 of 2020 (the last week of March), telehealth visits were up 154% compared with the same week the prior year. Notably, most of that early surge was not, strictly speaking, coronavirus-related: most telehealth encounters during the analysis period addressed non-COVID health concerns, though the share coded as COVID-related rose sharply within the final three surveillance weeks of March, from about 5.5% to roughly 16.2%. In other words, the initial wave looks less like “people substituting video visits for coronavirus screening” and more like “people substituting video visits for the ordinary care they would otherwise have delayed or sought in person.” Source: CDC, MMWR, “Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020”.

Reading the Numbers with Appropriate Caution

A few caveats are worth flagging for anyone citing these figures. First, the CDC analysis draws on data from a set of large commercial telehealth providers, not a comprehensive census of every telehealth encounter in the country — it is directionally reliable but not a precise national total. Second, “telehealth” is not used consistently across data sources; some studies count only live video, others fold in telephone-only encounters, remote monitoring, or asynchronous e-visits, which makes cross-study comparisons unreliable unless the definition is stated. Third, figures from spring 2020 were captured in the most acute and unrepresentative phase of the pandemic — widespread stay-at-home orders, deferred elective care, and acute fear of exposure — so they should be read as a snapshot of an extraordinary moment rather than a stable new baseline, and any single early data point deserves to be treated as provisional.

The Operational Scramble Inside Practices and Health Systems

Behind the aggregate numbers was a chaotic operational period for many provider organizations. Practices that had no telehealth program at all were, within days, expected to have one.

Standing Up Technology Under Pressure

For organizations without an existing telehealth platform, the enforcement discretion around communication tools meant the fastest path was often the least sophisticated one: clinicians conducting visits over consumer video-calling apps from personal devices, scheduled through ad hoc phone calls rather than integrated systems. Larger health systems with existing electronic health record (EHR) vendor relationships activated embedded video-visit modules that had previously seen limited use, but even there, capacity constraints emerged quickly as demand outstripped what systems had been provisioned to handle. Reports throughout this period described vendors managing demand surges, and IT teams rapidly training clinical staff who had never conducted a video visit, often with no formal workflow for triage or a failed connection mid-visit.

Workflow and Billing Complexity

Beyond the technology, practices faced a fast-moving billing landscape. CMS and commercial payers updated coding and reimbursement guidance on a rolling basis through March and April, so billing staff had to track which telehealth codes were payable, at what rate, under which payer, and for which provider type — guidance that in some cases changed within the same month it was issued. Documentation also had to adapt: physical examination, historically a core component of the visit note, is impossible or severely limited over video, forcing clinicians to lean on patient-reported symptoms, visual inspection through the camera, and sometimes patient-owned devices (thermometers, pulse oximeters, blood pressure cuffs) to fill gaps an in-person exam would normally close.

Which Specialties Adapted Fastest

Not every visit translates equally well to video. Behavioral health and psychiatry, primary care follow-ups, chronic disease check-ins, and certain dermatology follow-ups (aided by patient-submitted photos) adapted relatively quickly, since much of the clinical value in those encounters comes from conversation and observation rather than hands-on examination. Specialties built around physical examination, procedures, or imaging — orthopedics, most surgical specialties, and much of women’s health — had a harder adaptation, often using telehealth only for initial triage or post-procedure follow-up while preserving in-person visits for anything requiring hands-on assessment.

Open Questions: Equity, Access, and What Sticks

Even amid enthusiasm about telehealth’s rapid rise, several open questions are already visible in mid-2020, and deserve to be stated plainly rather than glossed over.

The Access Gap Telehealth Can Widen as Easily as It Closes

Telehealth’s promise has always rested partly on an assumption: that removing the need to travel to a clinic expands access, particularly for rural and underserved patients. But that promise depends on the patient having a reliable broadband connection and a video-capable device, or at minimum a phone line for audio-only visits (which several payers, including Medicare in some circumstances, moved to reimburse given how many patients lack video capability). Broadband access is not evenly distributed: estimates from this period put the share of rural Americans lacking access to fixed high-speed broadband at roughly 22%, a far higher rate than in urban areas, and worse still on tribal lands. So the population telehealth was originally designed to help — rural patients with limited specialist access — is disproportionately the same population least likely to have the connectivity it requires. Older adults, lower-income patients who rely solely on smartphones, and patients with limited digital literacy face compounding versions of the same barrier. Whether the 2020 boom narrows or widens existing health disparities is genuinely unresolved, and depends heavily on policy choices — audio-only reimbursement, digital literacy support, subsidized broadband and devices — still being worked out.

Temporary Emergency Measure or Durable Policy Change?

The single biggest open question hanging over telehealth in mid-2020 is durability. Nearly everything described above — the originating-site waiver, expanded provider eligibility, payment parity, and HIPAA enforcement discretion — is explicitly tied to the declared COVID-19 public health emergency and could lapse when it ends, unless Congress changes the underlying Medicare statute or CMS finalizes separate permanent rulemaking. Provider organizations that have made real capital and staffing investments over the past two months are, in effect, betting on what happens after the emergency declaration is lifted. Payment parity in particular is a flashpoint: insurers and CMS have generally paid telehealth visits at the same rate as in-person visits during the emergency, but whether that continues once the crisis rationale for it is no longer the primary justification is an open question.

Quality and Clinical Outcomes Data Is Still Thin

Finally, much of the current conversation is about access and volume, not yet outcomes. Rigorous, peer-reviewed comparative data on clinical outcomes for video versus in-person visits, across the range of conditions now managed by telehealth, is still limited, partly because the volume is itself so new. Questions about diagnostic accuracy without a physical exam, medication management safety over video, and appropriate triage criteria for escalating a telehealth visit to in-person or emergency care remain active areas needing real study before the health system can confidently say which categories of care telehealth handles as well as in-person visits — and which it does not.

Frequently Asked Questions

What is the CMS Section 1135 waiver and how did it affect telehealth?

Section 1135 waiver authority lets the HHS Secretary temporarily modify Medicare, Medicaid, and CHIP requirements during a declared public health emergency. For COVID-19, CMS used it to drop Medicare’s originating-site and geographic restrictions, letting beneficiaries receive telehealth visits from home rather than only at approved rural facilities, starting with services on or after March 6, 2020.

Did Medicare pay telehealth visits at the same rate as in-person visits during the pandemic?

Yes. CMS said it would reimburse the newly expanded set of Medicare telehealth services at rates equivalent to comparable in-person, office-based visits for the duration of the public health emergency. This “payment parity” removed a major financial disincentive that had discouraged many practices from offering video visits before 2020.

Could providers use apps like Zoom or FaceTime for telehealth without violating HIPAA?

During the public health emergency, yes. HHS’s Office for Civil Rights announced on March 17, 2020 that it would exercise enforcement discretion and not penalize providers for good-faith use of everyday video apps, including FaceTime, Zoom, Skype, and Google Hangouts, for telehealth. Public-facing platforms like Facebook Live and TikTok were explicitly excluded from this discretion.

How much did telehealth use actually increase in 2020?

A CDC analysis found telehealth encounters rose about 50% in Q1 2020 versus Q1 2019, with a peak of 154% year-over-year growth in the last week of March 2020. These figures come from a set of large commercial telehealth providers, not a full national census, and should be read as directional evidence of a sharp, concentrated surge rather than a precise total.

Will the 2020 telehealth expansion become permanent?

That was still unresolved as of mid-2020. Most of the changes — including Medicare’s relaxed originating-site rules and HIPAA enforcement discretion — are tied explicitly to the declared public health emergency. Several of the underlying restrictions exist in statute, meaning a lasting change would likely require congressional action rather than continued agency waivers alone.

Does telehealth expansion help or hurt healthcare access equity?

It could do either, depending on implementation. Telehealth removes travel barriers, helping rural and mobility-limited patients, but it requires reliable broadband and a compatible device — both less available in many of the same rural, low-income, and older populations that stand to benefit most. Roughly 22% of rural Americans lacked high-speed broadband during this period, versus a far smaller share of urban residents.