Gaining medical licensure in multiple states and practicing across state lines has been a regulatory burden for providers for years, but it's become an especially important issue during the COVID-19 pandemic because of the rapid rise of telehealth.
Like everything with healthcare, adopting telehealth isn’t as simple as installing Zoom on your office laptop: One of the key issues is licensure. In theory, telehealth could connect any physician with any patient, regardless of location. But state licensure rules generally prevent such direct access, requiring physicians and other providers to be licensed in the state(s) where their patients are physically located.
Here, we'll dive into some of the rules surrounding licensure and telehealth, including:
- How they can vary depending on location
- The latest ways states are making it easier for physicians to practice telehealth across state lines
- Special considerations for physicians who want to practice interstate telehealth
- How technology can help healthcare organizations stay on top of licensure needs
The telemedicine rules are always changing
Before telehealth, state licensure was straightforward. Physicians and other healthcare providers needed to be licensed in the state or states where they practiced medicine. Where they practiced was limited by simple geography.
Although telehealth has the potential to erase those limits—such as opening healthcare visits from far-off specialists for patients in rural or underserved areas—many states' licensure rules haven't caught up with advances in technology and require physicians to hold individually obtained licenses in each state where they practice. Moreover, every state has different rules about telehealth licensure, and those rules are always changing.
The pandemic has hastened many of the changes. Because of their public health emergencies, many states lifted or eased interstate licensure rules, temporarily waiving practice restrictions or providing easier avenues for interstate licensure. Some states’ waivers are still in place (with upcoming expiration dates), while some have already expired, like ones in Arkansas.
Some states have extended their waivers, like Massachusetts, which has allowed out-of-state physicians to apply for an Emergency Temporary License during its state of emergency. In February 2022, Massachusetts's Board of Registration in Medicine said that those Emergency Temporary Licenses are now valid until June 30, 2022.
Other states, though, have made those once-temporary changes permanent. Arizona now allows healthcare providers licensed in other states to provide telehealth services into Arizona under certain conditions.
In addition, a few states allowed telehealth license portability even before the pandemic. In Florida, for instance, telehealth license portability has been allowed since 2019. There, out-of-state healthcare practitioners can perform telehealth services for patients in Florida if they meet eligibility requirements and register with the department of health.
It's no wonder, then, that two years into the pandemic, many healthcare providers are still confused about what their licenses allow them to do when it comes to telehealth. Yet if healthcare providers are going to fully benefit from the opportunities that expanded telehealth access could provide, they need to understand the licensure rules and possible pitfalls related to this providing this new form of care.
A state-by-state patchwork and licensure compacts
There are several reasons why state licensure for telehealth is so strict. Proponents of the current state-based licensure system say that it's important for patient safety that they can license, monitor, and discipline physicians in their own state.
In addition, many physicians and state medical boards want to protect the medical practices in their states. In fact, some states even specify that out-of-state physicians who do obtain telehealth licenses can't open a physical practice there.
Yet the pandemic and ongoing healthcare provider shortages across the country have shown the need for expanding telehealth practices to physicians in other states.
As of January 19, 2022, 19 states and four territories have adopted either long-term or permanent interstate telemedicine allowances, mostly because of the pandemic, according to the Federation of State Medical Boards, which tracks and updates information about how each U.S. state and territory is modifying its telehealth requirements.
But even among states that grant interstate licensure for telehealth in some way, no two seem to have the same rules or processes in place, so it's critically important for providers to understand the specific laws governing the states where they practice or wish to practice, including rules about telehealth.
Healthcare providers should also be aware of licensing compacts that exist between states, which make it easier for physicians to apply for and receive licenses in different states.
The biggest, and perhaps the most important of these interstate compacts, is the Interstate Medical Licensure Compact Commission (IMLCC), an agreement among 34 participating states, plus the District of Columbia and Guam, to streamline and expedite the licensing process for physicians who live in those states and want to be licensed in another. Physicians who meet certain eligibility criteria must complete "just one application within the Compact, receiving separate licenses from each state in which they intend to practice," the IMLCC says.
The IMLCC now has 36 member jurisdictions, and physicians can apply for licenses in participating states. The compact added its latest member, New Jersey, on January 10, 2022, and also said at that time that legislation was also pending to add Missouri, Indiana, and North Carolina.
The Center for Connected Health Policy tracks the IMLCC, as well as five other compacts:
- The Nurse Licensure Compact
- The Physical Therapy Compact
- The Psychology Interjurisdictional Compact
- The Audiology and Speech-Language Pathology Interstate Compact
- The EMS Compact
Another interstate compact, The Counseling Compact, is in development and will take effect once 10 states join.
Common pitfalls and things to consider
Even states that have allowances or waivers regarding interstate telehealth practice and licensure have rules that vary, not to mention exceptions and contingencies about what's allowed and what's not when it comes to telehealth.
Before diving into multistate licensure and expanding the scope of their telehealth practice, healthcare providers should understand some common pitfalls and other quirks and complications of the system:
- Having an established a physician-patient relationship/face-to-face encounters: Although all states allow providers to establish a relationship with a new patient via telehealth, some have stricter rules about it than others, such as requiring the patient to be at a medical facility (rather than their home or another location) when having the visit, according to the American Medical Association. When it comes to interstate telehealth practices, those rules can be even trickier. For instance, Hawaii allows patients and physicians to establish a new relationship via telehealth, but only if providers are licensed there. In Mississippi, on the other hand, out-of-state physicians can only use telemedicine to treat patients in Mississippi if they have a pre-existing doctor-patient relationship.
- Controlled substance prescribing: The pandemic temporarily waived many states' prohibitions against providing controlled substance prescriptions via telehealth, but a physician practicing telehealth across state lines may face additional restrictions. For instance, Alaska SB 241 allows a licensed healthcare provider in good standing in another jurisdiction to provide services via telemedicine to Alaska patients during a declared state of emergency, except for prescribing controlled substances.
- Consultative services only: Some states allow out-of-state physicians in certain circumstances to practice telehealth, but on a consultative basis. For instance, in Maine, out-of-state physicians can provide consultative services via telehealth if those services are requested by another provider and only if the out-of-state doctor meets other requirements, such as registering to practice medicine in Maine and doesn’t plan to open an office or see patients in person there. In New Hampshire, out-of-state physicians who only provide telehealth on a consultative basis don’t need to be licensed there.
- Telehealth-specific licensure: Some states—such as Georgia, New Mexico, and Tennessee—allow out-of-state physicians to apply specifically for telehealth licensure if they're already licensed in another state. Each of these states has its own qualifications and requirements for telehealth-specific licensure, and some are more stringent than others. For example, Texas requires out-of-state telehealth license recipients to pass the Texas Medical Jurisprudence Examination, among other conditions.
- Temporarily active: Physicians who are allowed to practice telemedicine across state lines because of pandemic-related emergency waivers should keep in mind that their telehealth licenses are likely only temporary. One example of this is in New Jersey, where waivers allow healthcare providers licensed in other states to obtain temporary licensure there. That temporary licensure period was extended in January 2022 but is set to expire on June 30. Similarly, Connecticut also extended its waivers, but its public health commissioner strongly recommended that out-of-state providers apply for a permanent Connecticut license in the meantime "to help ensure that the care they are providing does not abruptly stop once the temporary order expires and the practitioner’s authority to practice in Connecticut ends." This actually happened when Johns Hopkins Medicine in Maryland had to quickly cancel more than 1,000 telehealth appointments for Virginia residents, according to Kaiser Health News. Patients abruptly losing healthcare access in this way has been called falling off the "telehealth cliff."
- It takes time: Healthcare providers should be aware that if they are applying for licenses in multiple states, the turnaround time can be long. According to the AMA, physicians should anticipate at least 60 days between when they submit their application and when they're granted their license. Each state also has specific licensure requirements, so physicians should be aware of those as well and plan accordingly, especially if they're operating with a temporary telehealth license that's set to expire but want to keep seeing their patients without gaps in care. State medical boards also require physicians to renew their licenses periodically, which can be burdensome, too, especially for those with licenses in multiple states.
Technology can do the hard work
Unless your organization has spare time and resources to parse charts from state medical boards, follow meandering legislative actions, and translate government statutes, you'll need technology to track the complex and changing licensure rules and regulations for physicians and other providers, especially because many telehealth waivers are set to expire in early 2022.
Provider organizations can use symplr's provider data management solutions for telemedicine, which provide end-to-end tools like symplr Provider, a provider data management system and credentialing software that has functionalities like automating checks for expired or suspended medical licenses.
Similarly, symplr Directory offers provider directory software with functionalities like maintaining data profiles for every credentialed and referring provider. In addition, a robust provider search functionality can match patients with the most optimal providers by location, among other variables, which is especially important for organizations like multistate health systems when it comes to licensure.
The genie's out of the bottle
Even before the COVID-19 pandemic, states and payers were slowly making it easier for healthcare providers to treat patients via telehealth. But the public health emergency blew telehealth access open, from allowing providers to treat patients across state lines via telehealth to reimbursing providers for in-person visits and telemedicine at the same rate.
Although many patients are seeing their healthcare providers in person again, the telehealth genie is out of the bottle. Even now, telemedicine remains the easiest and most convenient way for many patients and providers to connect.
When it comes to telehealth licensure, states truly have been at the helm. At the federal level, pandemic-related telehealth licensure exceptions have been extremely narrow in scope. For instance, under the Public Readiness and Preparedness (PREP) Act, healthcare providers have been allowed to order and administer "covered countermeasures" across state lines via telehealth as long as they're licensed to do so in any one state. In other words, the PREP Act allowed interstate telemedicine only for specified COVID-19-related care.
Also limited in scope is the newly introduced Telehealth Extension and Evaluation Act which would establish a two-year extension for certain pandemic-related telehealth waivers for Medicare beneficiaries. The legislation would aim to evaluate virtual care's effectiveness and give patients more time to avoid falling off the "telehealth cliff."
That's why healthcare providers need to pay closest attention to the rules at the state level. Only by tracking and understanding licensure rules in the state where they practice—and states where they might want to provide telehealth—can physicians and healthcare organizations stay ahead and be at the forefront of the virtual healthcare revolution.
