<p>The COVID-19 pandemic accelerated the adoption of telehealth services, including at mental health treatment facilities (MHTFs). Policy changes at federal and state levels facilitated this transition by allowing qualified providers to offer telehealth services and expanding the settings where such services could be delivered and reimbursed. Despite these policy changes, there remains considerable variation in the use of telemental health among MHTFs. Our goal was to explore the underlying reasons for this variation. We conducted 16 qualitative interviews with administrators from MHTFs across the United States. Through thematic analysis, we identified several key factors influencing the adoption and expansion of telemental health services. Clinic transformation was a significant challenge for MHTFs transitioning to telehealth, particularly for those without prior experience. Staff buy-in and motivation were crucial factors affecting the willingness of clinicians to offer telehealth services, some expressing discomfort or skepticism about its efficacy. Financial considerations, such as revised reimbursement guidelines, also played a role in facilitating the implementation or expansion of telemental health. Additionally, the policy environment, including changes in reimbursement and HIPAA compliance requirements, influenced MHTFs’ ability to provide telehealth. Administrators shared that telemental health offers several benefits, including increased flexibility for patients and staff. However, they also noted challenges, including issues related to internet connectivity and concerns about the quality of care. Overall, this study highlights the complex interplay of factors shaping adoption of telemental health services in MHTFs and underscores the importance of addressing barriers to ensure equitable access to care.</p>