Cross-State Licensure Laws for Telehealth Evolve During Pandemic
Abstract
Physicians practicing telehealth must keep up with a dizzying array of state laws for cross-state licensure during the pandemic. Thirty-three states and D.C. have now joined a multi-state compact to expedite physician licensure.
State regulations governing the provision of telehealth across state lines have been in a state of flux during the COVID-19 pandemic. To avoid uncertainty, an increasing number of physicians are obtaining multiple state licenses through an expedited process.
“When it comes to interstate licensure rules as well as reimbursement for physicians using telehealth, the landscape is still shifting, and states are all on different timetables,” Mei Wa Kwong, J.D., executive director of the Center for Connected Health Policy (CCHP), a federally funded nonprofit providing telehealth policy research, education, and technical assistance, told Psychiatric News. “Some states have made permanent changes to their interstate licensure laws; others tied them to declarations of public health emergency, which for some states have expired; and some enacted temporary changes in procedures during the pandemic. It is very difficult for clinicians to navigate.”
According to CCHP, telehealth services are generally considered to be rendered at the physical location of the patient, so to avoid practicing without a license or jeopardizing malpractice insurance, physicians should verify the location of their patients at the start of each telehealth session. Kwong said complying with the rules can pose challenges when patients become more transient, such as young people moving back in with their parents during the pandemic. “It’s a tricky path for clinicians to navigate, especially if they suddenly have patients in three states that all do things differently.”
Many States Retained Licensure Waivers
Although the details vary widely, as of press time, a number of states retained some form of waiver of licensure requirements for out-of-state physicians who are providing telehealth services including Arizona, Colorado, Delaware, Idaho, Indiana, Iowa, Louisiana, Michigan, Minnesota, Mississippi, Nevada, New Mexico, North Carolina, Oregon, Pennsylvania, Texas, Utah, Washington, West Virginia, Wisconsin, and Wyoming, according to the Federation of State Medical Boards (FSMB), which maintains the most detailed database on the subject. Of those, 14 states plus four U.S. territories have opted to allow long-term or permanent cross-state licensure waivers for clinicians engaged in telehealth. Virtually all the waivers require physicians to be licensed in their state of residence and in good standing with no complaints against their medical license.
“It’s imperative that physicians keep up with the status of these rules,” Lisa A. Robin, chief advocacy officer for the FSMB, told Psychiatric News. One trend she is seeing is that more states are starting to carve out exceptions to licensure rules only to allow cross-state physicians to treat established patients via telehealth for continuity of care. Ultimately, psychiatrists may be the most impacted by these changes: “It is anticipated that the majority of telehealth is going to be in the field of mental health going forward,” she added.
Arizona’s HB 2454 permanently allows physicians licensed out of state to provide telehealth to Arizona patients, but they must register; Florida has a similar law. Delaware’s HB 348, signed into law last July, permanently allows only those out-of-state physicians who are providing mental health care to serve state residents using telehealth without a Delaware license. Alabama requires out-of-state clinicians to apply for a “special purpose license” to engage in telehealth. Colorado allows out-of-state physicians to provide “occasional” telehealth services to residents.
Meanwhile, Texas allows physicians to apply for a special telemedicine licensure, but it is limited to follow-up care or interpretation of diagnostic testing. Washington permits clinicians licensed out of state to provide telehealth care, but only for “infrequent or episodic” follow up. Connecticut’s changes may be the most confusing: An executive order expired that had temporarily permitted out-of-state physicians to treat Connecticut residents, and while its Public Act 21-9 authorized an extension, no such order was put in place.
Ultimately, Kwong recommends that clinicians who are frustrated with the complexity of current telehealth rules consider contacting officials. “Speak to your representatives at the state and federal levels because they are the ones who really hold the keys to all of this. [Clinicians] are the folks they want to hear from, if you want to move the needle on this.”
Route to Multistate Licensure
An increasing number of physicians are bypassing the uncertainty of shifting state regulations by obtaining licenses through the Interstate Medical Licensure Compact Commission (IMLCC), which issued nearly 27,000 licenses through 2021, more than triple the 8,200 through pre-pandemic 2019.
“Physicians who use telehealth as their delivery model of care find this to be a much easier way to obtain licensure in multiple states,” Marschall Smith, the IMLCC’s executive director, told Psychiatric News. The goal of the IMLCC is to increase access to health care, particularly for patients in underserved and rural areas.
Regionalism is another reason for obtaining licenses through the IMLCC—for example, physicians who live close to a state border, want to maintain a practice in more than one state, or have patients who move between states. It is also popular among locum tenens physicians, or physicians working in short-term positions.
While it can take up to three to four months to obtain a state medical license using the traditional route, Smith said that physicians in good standing who hold a license from an IMLCC member state can obtain additional licenses in seven to 10 days. The licenses are full and unrestricted; on average, physicians obtain licenses from three states. Physicians must meet a list of criteria, for which about 80% of physicians qualify, Smith said.
“The reason we’re able to obtain licenses so quickly is we leverage a physician’s existing license from the physician’s home state. Those states verify from primary sources all the information on the application, including a fingerprint-based background check, the medical school transcripts, all the national practitioner databank information, the DEA web page entries. … So there’s a lot of vetting that goes on by that one state, which then issues a letter of qualification, allowing all the other IMLCC member states, in turn, to issue a medical license without doing the vetting.”
The IMLCC is controlled and governed by member states; each state’s legislature must pass legislation for a state to join. There are now 29 member states that can issue licenses; physicians who join can also obtain a license to practice in Vermont and Oklahoma through the compact. Another four states (Delaware, Ohio, Pennsylvania, and Texas) and Washington, D.C., are in the process of joining. Physicians using the compact pay the IMLCC $700 for the first year and $25 for annual renewals (in addition to the typical state licensing fees). ■
