Please support Telehealth.org’s ability to deliver helpful news, opinions, and analyses by turning off your ad blocker.
A silver lining to the COVID-19 pandemic has been the permission given to health care providers to render medical services and telemedicine across state lines. Several states as well as the Centers for Medicaid and Medicare Services (CMS) temporarily waived requirements for licensure in the state where the patient is located. (See here for more information.) With the tremendous expansion of telehealth due to the pandemic, maintaining and continuing growth of service delivery via telehealth will necessitate permanent changes in the law.
State Control of Licensing Across State Lines
Traditionally, beginning in the 1800s and growing substantially in the 1950s, states have had the authority to license healthcare professionals. States have a vested interest in maintaining that authority because it allows them to exert control over the quality of care given to their citizens by setting standards including the passing of a licensing exam. They respond to citizen complaints and increasingly in some states, coordinate efforts with other professional boards in the same state. States also have been responsible for keeping out “bad apples,” shouldering the cost of providing disciplinary action and following up with corrective interventions when needed.
As noted by Dr. Ateev Mehrotra of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston and two colleagues, Alok Nimgaonkar, B.A., and Barak Richman, J.D., Ph.D., in an article in the New England Journal of Medicine, Telemedicine and Medical Licensure— Potential Paths for Reform, maintaining the expanded use of telehealth post-pandemic will require permanent rather than the temporary licensure reform that now exists due to COVID-19. Per Dr. Mehrota et al, “… the growth of large national and regional health systems and the increased use of telemedicine have expanded the scope of healthcare markets and telemedicine across state lines.” A similar movement to reduce the barriers to telehealth practice across state lines is evident in many professions beyond medicine.
These same issues are of relevance to all healthcare professionals, including psychologists, social workers, counselors, MFTs, behavior analysts, speech therapists, occupational therapists, physical therapists, nurses, and nurse practitioners to name a few. For more an earlier summary of COVID’s impact on interjurisdictional issues in other professions, see Telehealth.org’s
Interjurisdictional Telehealth Legislative Action
The issue of interjurisdictional practice across state and international borders is such a hot topic in telehealth that it is front-and-center in several legislative bills currently being argued at both the state and federal levels.
For current updates regarding telehealth legislative actions related to practicing telehealth across state lines, see these Telehealth.org articles:
You may also want to consider registering for one or more no-cost subscriptions to Telehealth.org’s no-cost, telehealth-industry newsletters to be sent to you weekly by clicking here.
A Federal License to Practice Telemedicine and Telepsychology Across State Lines
The federal government has the power to enact laws to prevent practices that limit interstate commerce. Another option would be to have the federal government set up a second, parallel licensing route which would allow healthcare professionals to be licensed to practice nationally, across state lines, in addition to being licensed by their state. However, this could complicate states’ ability to provide disciplinary action when needed.
Physicians: The Interstate Licensure Compact
A seemingly viable solution to physician interstate licensing is the Interstate Medical Licensure Compact introduced by the Federation of State Medical Boards (FSMB). It is an agreement that has grown to include 28 states and Guam that facilitates the acquisition of additional state licenses. It, however, has not been widely used, with only 0.4% of physicians in the participating states utilizing it. One proposed suggestion is for the federal government to pass legislation to encourage the remaining states to join the compact – a move that would lessen administrative burdens and fees for physicians, as well as provide improved advertising. For more information see here.
Psychologists: The Psychology PSYPACT
For psychologists, the Association of State and Provincial Psychology Boards (AASPB) has made significant inroads with legalizing interjurisdictional practice for psychologists with PsyPACT. See this Telehealth.org article for more information about PsyPACT:
Nurses: The Enhanced Nurse Licensure Compact
The enhanced Nurse Licensure Compact (NLC) allows for registered nurses (RNs) and licensed practical/vocational nurses (LPN/VNs) to have a multi-state license, with the privilege to practice in their home state and other NLC states. With 25 member states in the NLC, nurses in member states are allowed to practice telehealth across the country without having to obtain additional licenses. For details of the NLC, see this summary.
Counselors: Licensed Mental Health Counselor Portability Intiviatives
Counselor interjurisdictional initiates have been led by the American Mental Health Counselor Association (AMCHA) Interstate Portability Task Force. They have published a position paper on portability to identify their view of the best features of several portability proposals that have recently developed. Details can be found here on the AMCHA website.
Using Medicare to Lead By Example
It doesn’t seem likely that states would willingly give up their control of the licensing process. Dr. Mehrotra proposes an option in which the federal government could “encourage reciprocity under which states automatically recognize an out-of-state license” by instituting the change in the Medicare program, as is already the case in the VA health system (see here). Following that lead, states would potentially adopt state legislation regarding reciprocity, which would also benefit patients with private payers and other types of insurance.
The pandemic has led to the tremendous expansion in the availability of healthcare via telehealth to millions of Americans, in part by removing federal and state licensure restrictions. Those temporary changes to telemedicine across state lines need to be made permanent in order for telehealth to continue to expand and to be a viable way to improve the quality and availability of healthcare for all Americans.
Telehealth: How to Legally and Ethically Practice Over State Lines & International Borders
Practicing telehealth across state lines or international borders? Operate legally & ethically 100% of the time.
Please share your thoughts in the comment box below.
I appreciate these updates as I have been confused by what I can and cannot do as a Licensed Marriage and Family Therapist regarding providing services across state lines. I am wondering if anyone has feedback in a case where I am providing services in a role that does not require me to have a license (i.e., general case management, Employee Assistance Program, etc.), yet I do, in fact, have a license. Am I still bound to state mandates, even if I am providing more general services that are not license-related?
I suggest that you only get your information from the licensing boards involved. There are many “wannabee” authorities who will share their “opinions” with you regarding your specific licensure questions, but we at TBHI want to help you get facts. While we offer training for professionals interested in how the system works and what is likely to change in the short term, (see How to Legally Practice Over State Lines and International Boarders at https://blog.telehealth.org/telehealth-across-state-lines) someone asking your question really needs to talk directly to the boards involved.
Many boards are in rapid flux right now, so our suggestion is that you get the boards to put their requirements in writing regarding what you can and cannot do today. Only they are fully informed. Please take the time to search this blog and read our answers to other people regarding this licensure issue and you will see why we are taking this stance – and have been correct in doing so for the last 28 years.
This is misleading. Therapists can only practice in the state they are licensed and where their clients reside.
Thank you for your comment. Let me tell you about TBHI. We have studied, lectured and written about telehealth interjurisdictional practice for 28 years. We have been paid by a number of licensing boards who have asked us to help them better understand the telehealth literature and trends. I can then, without a doubt tell you that if you want to work out of your state, you should consult your board and that of the state you wish to serve.
Right now for COVID, more than 43 boards are allowing an affidavit to be signed to be allowed to practice in a foreign state. An affidavit is a simple statement that you can complete online. It allows licensed professionals from other states can serve citizens in foreign states during the Public Health Emergency (PHE). Where your client resides is irrelevant.
The law for more professions in most states makes it very clear that the licensure requirement follows the client or patient, so we must be licensed where they are. It follows the client or patient, much like a driver’s license, in that if you have an accident in a foreign state, the local law presides. You will need to appear before a local judge if a serious infraction is involved. Similarly for telehealth then, we need to be licensed where the client or patient is located at the time of the contact, regardless of where they reside. If they live in Texas and are now in New Jersey, and we see them when they are in New Jersey, we need to be licensed, registered, or have signed and submitted an affidavit in New Jersey to legally see them.
I hope that clarifies any ambiguity. Let me know if it doesn’t.
It’s clear that state licensing is increasingly absurd. Why can’t a mental health counselor from one state practice in another? Clinically, it makes no difference. Laws and rules may vary in some minor respects, but this doesn’t justify the fragmentation between states. Can you imagine visiting, say, Oregon and not being allowed to drive a car there because your driver’s license is from, say, Pennsylvania?
Jerry, The colors are just part of the image and do not signify anything of importance. You may want to note that TBHI is an interprofessional telehealth training site. As such, we do not only address any single profession as most telehealth issues are generic across professions. Licensure is a moderate but not complete exception. Only a few professions have made strides toward shared or reciprocal licensure, as described with FSMB physician, ASPPB psychologist, and nurse licensure compacts mentioned in this article. BTW, NLC is a shared program, supported by a large number of nursing-related groups.
One other distinction may be helpful. The FSMB physician compact is a reciprocal model, where physician documents can be easily shared across states by the compact organization, which collects a fee. Psychology and nursing have a shared licensure model, whereby approval into the ASPPB and Program allows actual practice in other compact states.
Covid-19 has proven to be a much needed catalyst and a turning point in mental health care.
Ironically, professionals claiming to believe in change were forced
to open their minds to online treatment and reciprocity between states in order to survive. Some of them, older adults, including myself had to learn new skills.
What is being done to arm long time providers with facts to reduce fears created by their peers and the organizations that they believe they must agree with to protect them?
How can we create more
awareness about the modern and forward thinking needs of the future, specifically, for licensed clinical social workers?
How can we help to grow a strong lobby for the freedom to provide needed mental health services across state lines?
Julie Lyons, LICSW
Licensed in RI
Currently in California
Serving clients across the globe
Julie, Thank you for your question. We have discussed this issue of advocacy in several other blog posts here at TBHI. You may want to look at this article regarding telehealth advocacy related to Post-pandemic reimbursement Telehealth Reimbursement: What to Expect Post-Public Health Emergency (PHE) Similarly, we can write to our legislators and ask them to support the bills relevant to interjurisdictional practice currently up for discussion at both the federal and state levels. See COVID-19 Telehealth Licensure Across State Lines – Bill Reintroduced
I am in the process of moving our home right now and cannot take the time to do the interactive training. I’d
appreciate knowing the status of Washington state.
Toni, In general, WA is more progressive than other states. It passed a law last year that took effect this year, requiring that the vast majority of professionals regulated by licnesure take a mandated 3 hours of professional telehealth training. We at TBHI were at the forefront of offering this training, with thousands of professionals taking one or more of our telehealth training programs listed in our training catalog here. For details, see this TBHI blog post: Washington Telemedicine Law Requires Training for Healthcare Providers Practicing Telemedicine, Senate Bill 6061 As for specific interjurisdictional laws, licensure differs by profession within a state. To know what your profession allows, you need to contact your profession’s licensing board in Washington. (Get your answer in writing by sending them an email rather than calling them.)
Great update, super important for us physician/telemedicine providers and leaders to stay informed.
Thank you for your comment, Carla.
Question: Does this apply to Tele-Mental Health with psychotherapists or is this limited to physicians? I’m a licensed clinical social worker. Thank you!
The newly invigorated focus on licensure barriers to telehealth applies to all licensed healthcare professionals practicing telehealth.
I’ve been practicing outpatient psychotherapy only in California, where I’m licensed, and only with clients who legally live here. Is it legal to see patients who live out of state at this time? Where is there an article that sums all this up?
Steve, Thank you for the question. There is so much confusion about this issue that stay tuned, I will write a more complete blog post about it in the next few weeks. Thank you for inspiring me.
Meanwhile, in short, to practice in another state during the Public Health Emergency (PHE), in most states, all you have to do is fill out a COVID “affidavit” for your profession by going to your profession’s licensing board in the state you want to enter. Different states call it different things, but for example, if you want to practice in WA state as a psychologist, go to this board of psychology link and scroll down to the Psychologist Temporary Permit Application (PDF)
Can you please tell me if this also is true for mental health care workers, like psychologists, psychiatrists, and other clinical mental health therapists, like LMSW’s?
Abby, Yes, these same issues are of relevance to psychologists, psychiatrists, and other clinical mental health therapists, such LMSWs, counselors, occupational therapists, speech therapists, nurses, physical therapists, and all other healthcare professionals.
What are the states and for what license(s)?
This notification of potential changes appears to be relevant only to medical providers, but not to mental health clinicians and therapists.
Can you please inform of any changes that may expand reciprocity to licensed mental health clinicians (notably, LPC’s and LPCC’s)?
Vicki, to clarify the confusion, I added info about the article being of relevance to all licensed healthcare professionals. Please see added comments in the article — and thank you for asking your question.
Yes as a trauma therapy practice owner the demands for service continues to be at extreme levels . We are receiving requests for service for many states. This type of legislation will help provide critical mental health services with no walls.
The biggest barrier to telehealth is inconsistency of payment policies, and arbitrary fees by medicare and private carriers. Medicare and private carriers should have “an electronic services rider” attached to medicare and private carriers where in: Pay is based on the providers BILLED CHARGES for an electronic service (phone, fax, email, zoom, facetime etc. etc.) wherein the carrier (Medicare or private carrier) pay 50% of the billed charges with the patient responsible for the other 50% up to an annual electronic benefit limit of $1000.00. Again, this should be based on physician billed charges not some arbitrary fees by the carrier. This would encourage doctors to actually make themselves available readily for providing electronic services, and with the patient co-pay would limit excessive utilization by the patient ant excessive charged fees by the doctor.
Tom, The article does not say that counselors and MFTs have the same training. Not sure what you read, but as a psychologist, I can tell you for sure that psychological training is quite a bit more extensive. However, counselors and MFTs certainly have enough skills to offer professional assistance to people in need without supervision from a psychologist or any other professional. Hundreds of thousands of them do so weekly here in the US. We at TBHI support the bill that would allow their services to reimbursed when delivered to seniors and others in need.
This notice only mentions medical practice. Does this also cover behavioral health/psychotherapy?
Margaret, Thank you for your comment. The notice is true of the other professions.