If you own an outpatient behavioral health practice in 2026, you are running two businesses under one tax ID. One of them happens in a room. The other happens on a screen. They look identical on your profit and loss statement, and a buyer will not treat them as the same asset.

That gap is about to get sharper. The federal rules that let clinicians prescribe controlled medications to patients they have never met in person are scheduled to lapse on December 31, 2026. That is 114 days from the date of this article. Nothing about the schedule is hidden. It is written into a published federal rule, and any buyer with a healthcare attorney will find it in an afternoon.

This article is about what that date does to the price of a behavioral health practice, which parts of your revenue are exposed to it, which parts are not, and the four questions a serious buyer is going to ask you about your virtual visits. Every number below is drawn from a federal primary source and linked so you can check it.

What actually expires on December 31, 2026

The Drug Enforcement Administration, jointly with the Substance Abuse and Mental Health Services Administration, issued the Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications, published in the Federal Register on December 31, 2025 at 90 FR 61301. The rule states its own life span in a single line: effective January 1, 2026 through December 31, 2026.

The underlying law is older than the pandemic. Under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, a prescribing practitioner may remotely prescribe a controlled substance only after conducting at least one in-person medical evaluation of that patient, subject to a short list of statutory exceptions. The temporary flexibilities set that requirement aside. They authorize practitioners to prescribe Schedule II through V controlled medications through audio and video telemedicine encounters, and they allow buprenorphine approved for the maintenance and withdrawal management treatment of opioid use disorder to be prescribed through audio-only encounters.

There is a permanent framework on the table. DEA published Special Registrations for Telemedicine and Limited State Telemedicine Registrations on January 17, 2025 at 90 FR 6541. As of the date of this article it is still a proposed rule. A search of the Federal Register under the governing regulatory identification number, RIN 1117-AB40, returns the proposal and the four temporary extensions, and no final special registration rule.

So there are three live possibilities heading into the end of the year. DEA finalizes a special registration framework. DEA issues a fifth temporary extension. Or the flexibilities lapse and the Ryan Haight in-person requirement returns for new patient relationships. We are not going to predict which. What matters for a seller is that a buyer underwriting your practice in the fourth quarter of 2026 has to price all three, and uncertainty gets priced as risk.

How much of the industry is actually exposed

Telehealth is no longer a segment of behavioral health. It is close to the whole field. The federal facility census makes that plain.

In the 2024 National Substance Use and Mental Health Services Survey annual detailed tables published by SAMHSA, 12,825 of the 15,953 substance use treatment facilities in the country, or 80.4 percent, reported telemedicine and telehealth as a clinical approach they use frequently (Table SU19). On the mental health side, 11,190 of 14,091 facilities, or 79.4 percent, offer telehealth therapy (Tables MH14a and MH14b). Among outpatient mental health facilities specifically, the figure is 89.1 percent, and among certified community behavioral health clinics it is 92.8 percent.

Read those numbers carefully, because the distinction they hide is the entire valuation question. Offering telehealth therapy is not the same as prescribing a controlled substance over video. A talk therapy practice with a fully virtual schedule has essentially no exposure to the December 31 date. A psychiatric medication management practice with a virtual panel of stimulant or buprenorphine patients has a great deal of it. Two practices with identical revenue and identical margins can sit on opposite sides of that line, and buyers know it.

How many patients are actually being treated this way

The demand side is just as concentrated. SAMHSA published the 2025 National Survey on Drug Use and Health national report in July 2026. Among people aged 12 or older, 7.6 million received substance use treatment in the past year. Of those, 4.4 million received it in an outpatient setting and 3.6 million received it through telehealth.

The mental health figures are closer still. Among adults who had a past year major depressive episode, 47.6 percent, or 9.4 million people, received mental health treatment in an outpatient setting, and 44.7 percent, or 8.8 million people, received it through telehealth. Among adolescents aged 12 to 17, 20.3 percent received outpatient treatment and 13.0 percent received treatment through telehealth.

For a seller, that is the good news and the bad news in one line. The virtual channel is not a pandemic artifact that patients are abandoning. It is roughly co-equal with the office visit. That durability is real and it supports value. It also means the regulatory exposure is not confined to a corner of your practice.

Why a buyer prices a virtual visit differently from an office visit

Buyers in this market are not sentimental about modality. They are pricing four things, and telehealth changes all four.

• Durability of the revenue. Revenue that exists because of a rule with a published expiration date is not underwritten the same way as revenue that exists because of a lease and a waiting room. The discount is not always large, but it is applied.
• Transferability. A physical clinic transfers with the entity. A virtual panel transfers only if the clinicians transfer, the payer contracts transfer, and the prescribing authority survives the change of ownership.
• Geography. A virtual practice can serve patients in states where the buyer has no licensure footprint. That is either a growth story or a compliance liability, depending entirely on which clinicians hold which state licenses.
• Operating leverage. Virtual delivery removes real estate from the cost stack and raises clinician utilization. That is genuine margin, and it is the reason telehealth-heavy practices often show better earnings than their in-person peers.

The mistake owners make is assuming those four cancel out. They do not. The margin benefit shows up in this year’s earnings. The durability and transferability questions show up in the multiple, in the purchase price allocation, and in how much of the price is held back in an escrow or an earnout. You can have an excellent year and still be offered a structure you do not like.

The four telehealth questions a buyer will ask, and the one that decides the deal

If you take nothing else from this article, take this list. These are the four data points a prepared buyer asks for, and most owners cannot answer any of them from their practice management system without a week of work.

1. What share of your encounters over the trailing twelve months were delivered virtually, month by month? Not an average. A monthly series, because the trend line tells the buyer whether virtual delivery is your growth engine or your ceiling.
2. What share of those virtual encounters involved a controlled substance prescription? This separates the exposed revenue from the unexposed revenue. In most therapy-led practices the answer is close to zero, which is worth knowing and worth proving.
3. Of the patients receiving controlled substances through virtual visits, how many have had at least one in-person evaluation with the prescribing clinician? This is the question that decides the deal, and it is explained below.
4. Which states do your patients sit in, and which of your clinicians hold a license in each of those states? A single state where the answer is unclear can hold up a closing for weeks.

Why question three is the one that matters

Read the Ryan Haight structure again, as the DEA rule itself describes it. The in-person evaluation requirement attaches to the practitioner and patient relationship. Once a practitioner has conducted at least one in-person medical evaluation of a particular patient, the specific remote prescribing requirements of the Ryan Haight Act no longer apply to that specific relationship, and the practitioner may continue prescribing remotely to that patient. That is the DEA’s own description of the statute, set out in the December 31, 2025 rule linked above.

The commercial consequence is direct. A practice whose virtual controlled substance patients have all been seen in person at least once by their prescriber is materially less exposed to a lapse than a practice built on never seeing anyone. Same specialty. Same revenue. Different risk profile, and a buyer’s counsel will find that difference in diligence whether or not you raise it.

If you can produce that number and it is favorable, produce it early. It is one of the few pieces of diligence data that reliably moves a behavioral health negotiation in the seller’s direction. If you cannot produce it, that is the single most valuable thing you can go build before you go to market. None of this is legal advice, and the specific application to your practice belongs with your healthcare counsel, but the question is coming either way.

Where this sits next to the licensure question

Telehealth exposure is a second layer on top of a problem we have written about before. In Selling a Behavioral Health Practice in 2026: Why Licensure and Credentialing Decide Your Valuation we walked through what happens to state licenses, accreditations and payer credentialing at a change of ownership. That article is about whether the asset survives the transfer at all.

This one is about something narrower and more current: whether the way you deliver care today is still legal in the same form after December 31, 2026, and how a buyer discounts the possibility that it is not. The two stack. A practice with a clean license stack and a heavily virtual controlled substance panel is not a clean deal. A practice with a messy license stack and a purely in-person model is not a clean deal either. Buyers price both layers, separately.

What the behavioral health market looks like right now

The backdrop is a growing, fragmented and increasingly expensive sector. The Bureau of Labor Statistics Quarterly Census of Employment and Wages counts 18,875 private establishments in outpatient mental health and substance abuse centers (NAICS 62142) for 2025, up 1,319 locations or 7.5 percent from 2024. Employment in those establishments averaged 327,366, up 4.9 percent, and the average weekly wage was 1,141 dollars, up 3.4 percent.

More current national data from the BLS Current Employment Statistics program for the same industry shows 337,400 employees as of July 2026 on a preliminary basis, with average hourly earnings of 32.81 dollars.

Three things follow from that for an owner thinking about an exit. Establishment growth of 7.5 percent in a single year is faster than the sector’s employment growth, which means the average new site is small. Fragmentation like that is what consolidators buy. Wage growth running ahead of three percent a year means your clinician cost line is going to keep climbing, and a buyer will model that forward rather than accept your trailing margin. And an industry adding locations this quickly is not short of supply, which puts the burden on your practice to be differentiated on something other than existing.

We are deliberately not quoting a valuation multiple here. There is no primary federal source for behavioral health transaction multiples, and a number without a source is worse than no number. What we will say is what we tell owners directly: the range in this sector is wide, it is driven far more by payer mix, clinician retention and regulatory cleanliness than by size alone, and anyone quoting you a single multiple over the phone has not looked at your practice.

What to do in the next 90 days

Whether or not you intend to sell in 2027, the work below is worth doing before the December date arrives, because it is far harder to reconstruct afterwards.

1. Build the modality report. Twelve months of encounters, split in-person against virtual, by month, by clinician, by payer. If your system cannot produce it, that itself is a diligence finding.
2. Flag the controlled substance encounters. Within the virtual set, isolate the encounters that resulted in a controlled substance prescription. This is the exposed revenue, and it is usually much smaller than owners fear.
3. Answer question three. For that exposed group, determine how many patients have had an in-person evaluation with the prescribing clinician at any point. Have your counsel confirm how the rule applies to your model before you put the number in front of a buyer.
4. Map the license grid. A simple table: clinicians down the side, states across the top, license status and expiration in the cells. Buyers ask for this in some form in every deal and almost nobody has it ready.
5. Get your state law answered in writing. State telehealth and prescribing rules are independent of the federal ones and in several states they are stricter. A written answer from counsel for your own state is worth more than any article, including this one.
6. Do not restructure your clinical model to chase a rule. Buyers can tell the difference between a practice that operates a certain way and a practice that was rearranged ninety days before going to market. The second one invites more diligence, not less.

What does not change either way

It is worth being clear about the limits of this story, because the commentary around telehealth deadlines tends toward the apocalyptic.

• Therapy delivered virtually is not affected by the DEA date. Counseling, psychotherapy, group work and assessment do not involve a controlled substance prescription.
• Existing practitioner and patient relationships where an in-person evaluation has already occurred are, per the DEA’s own description of the statute, outside the specific Ryan Haight remote prescribing requirements.
• Demand is not the issue. The NSDUH figures above describe millions of people receiving care through this channel, and nothing about a prescribing rule reduces the number of people who need treatment.
• Buyer appetite for behavioral health has not evaporated. What has changed is that buyers now ask sharper questions, and the owners who can answer them get better terms.

What we are seeing in the market

Our current behavioral health inventory is a fair snapshot of what buyers are looking at in this sector: a California intensive outpatient and outpatient license, a pediatric ABA practice in Colorado, and an established pediatric therapy clinic in northern Illinois. You can see how we work in this sector on our behavioral health advisory page.

If you are twelve to twenty-four months from an exit, the prepare for your exit section of our seller learning center covers the broader readiness work this article sits inside. If you want a confidential read on where your practice stands, including the telehealth exposure question, contact us. Vallexa Advisors works on a success fee basis, so the first conversation costs you nothing but an hour.

Frequently asked questions

Sources

• Drug Enforcement Administration and Substance Abuse and Mental Health Services Administration, Fourth Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications, 90 FR 61301, December 31, 2025.
• Drug Enforcement Administration, Special Registrations for Telemedicine and Limited State Telemedicine Registrations, proposed rule, 90 FR 6541, January 17, 2025. RIN 1117-AB40, not finalized as of publication.
• SAMHSA, National Substance Use and Mental Health Services Survey 2024, Annual Detailed Tables, Tables SU19, MH14a and MH14b.
• SAMHSA, Key Substance Use and Mental Health Indicators in the United States: Results from the 2025 National Survey on Drug Use and Health, July 2026, Figures 78 and 82 and the associated detailed tables.
• U.S. Bureau of Labor Statistics, Quarterly Census of Employment and Wages, NAICS 62142, private ownership, 2025 and 2024 annual averages.
• U.S. Bureau of Labor Statistics, Current Employment Statistics, series CES6562142001 and CES6562142003, July 2026 preliminary.

This article is general information about market and regulatory conditions and is not legal, tax or investment advice. Regulatory status described here is current as of September 8, 2026. Confirm the application of any federal or state rule to your practice with your own counsel.