The Latest in Licensure: Out-of-State Telehealth Provider Policies

Provider licensure exceptions particular to the use of telehealth across state lines continues to be a popular issue area for those reaching out to CCHP for technical assistance. Questions are received from providers and patients alike, and often providers ask for a list of specific states that currently allow out-of-state providers to deliver care via telehealth to in-state patients for their specific profession. In this week’s write up, we would like to drill down on this area of telehealth policy in the hopes of painting a clearer picture.
 
Telehealth is considered rendered at the location of the patient and generally speaking individual states will require providers delivering care within their borders to have a license or some type of in-state approval. While limited licensure exemptions do exist, they vary widely (both between states and different professions), therefore there unfortunately is not a simple list that will clearly convey the complexities inherent to practicing telehealth across state lines. Nevertheless, at the bottom of this newsletter, CCHP has attempted to organize out-of-state telehealth provider policies by state into two main areas as a starting point in understanding the primary types of licensure policies that may allow out-of-state telehealth provider practice, in addition to Licensure Compacts: 

Based on the latest updates to CCHP’s Policy Finder as of June 25, 2024, CCHP has compiled lists showing the states that fall into these policy areas at the bottom of this write-up.
 
LIMITED LICENSURE EXCEPTIONS

Limited exceptions to full in-state licensure are the most popular way for states to allow an out-of-state provider to deliver telehealth services to their residents (besides interstate licensure compacts), however they are often very narrow and limited to specific circumstances and provider types. For instance, even if CCHP included a state within the below limited licensure exception list, it is still possible that the exception doesn’t apply to all provider types or patients. One common exception found throughout some state licensure requirements doesn’t actually apply directly to patients at all, rather it only exempts providers consulting with other providers that may not be licensed in the same state (i.e. New Jersey). Other exceptions often focus around continuity of care allowances, such as licensure exceptions for already established provider-patient relationships like in South Carolina, Virginia, and Washington. Exceptions also may be allowed for infrequent interactions, such as telehealth services occurring less than 10 days a year or involving less than 10 patients a year, as is the case of Alabama, or in instances of emergency, such as in the District of Columbia. Additionally, there are exceptions specific to specialized care, such as mental health services (Colorado, for example) or treatment related to life-threatening diseases. For instance, California has historically been one of the states with the least allowances for out-of-state providers, only having an exception for provider consultations until last year, when the state adopted an allowance for out-of-state physicians treating patients with life-threatening diseases.
 
In total, 29 states currently have limited licensure exceptions. However, they vary widely and must be reviewed carefully to ensure applicability and compliance. In addition, 9 states have adopted both limited licensure exceptions in addition to a telehealth registration process, therefore those states will appear in both lists below, with a notation that they fall under each.
 
TELEHEALTH LICENSE/REGISTRATION PROCESS

Overall, 21 states currently have some kind of telehealth registration process, including Arizona and Florida, though the term “registration process” may go by a different name and requirements do vary. Whether called a telemedicine license, registration, certification, permit or waiver, these policies are also often specific to certain providers and have varying requirements and fees similar to the licensure process. Generally, registration processes seek to ensure board oversight and jurisdiction over out-of-state providers operating in the state, while including additional limitations on their practice, such as prohibiting them from opening an office and providing in-person care in the state.
 
CAN'T FORGET COMPACTS

Compacts are also a very popular way for states to adopt exceptions to full in-state licensure for purposes of out-of-state telehealth providers. In fact, as of the date of this newsletter, only 5 jurisdictions are not a current member of any compact that CCHP is tracking. In addition, of the 12 jurisdictions with neither limited licensure exceptions nor registration processes, 9 are members of at least one compact. CCHP is currently tracking twelve compacts:

Each compact structure varies and is specific to different provider types, but generally compacts seek to allow providers to meet only one approval process (through the Compact) to participate in multiple states (Compact member states). Note that the Interstate Medical Licensure Compact (IMLC), in particular, operates a bit differently from the others, in that it focuses more on streamlining and expediting licensure approval with each state. Regardless of structure, compacts are also a key component to out-of-state telehealth provider policies. Some states, however, may have more hesitation than others in becoming members due to the fact that the same statutory language used to legislatively enact a compact must be adopted across each member state, limiting the ability for specific states to amend compact language to meet their particular policy goals. For more information on which states participate in which compacts, view CCHP’s licensure compacts page.
 
LIMITATIONS TO THE LIMITATIONS

Even if a state is listed as having a limited licensure exception or registration process, given the nuances of such policies and the presence of additional policies that may apply to the care (such policies related to consent and/or prescribing), it is always best for providers to check with both the appropriate board in their state and the state the patient will be located in at the time of the visit to ensure full compliance. It is also important to note that compliance with state licensure and practice requirements doesn’t necessarily ensure insurer coverage of services provided. Payer policies for out-of-state providers also vary widely and may include additional locational limitations. CCHP tracks Medicaid policies for out-of-state providers, and as it pertains to Medicare, there is generally just a requirement to comply with state laws. When it comes to private payers, providers should check always with individual private payers directly, as their rules vary more widely.
 
Licensure By the Numbers (as of 6/25/24)