One of the most prominent barriers to virtual care are the antiquated state licensure laws that limit the ability of health care providers to see patients across state lines. State lines create artificial barriers to the delivery of care – complicating access for patients and creating additional burden on clinicians. These lines sometimes split major urban areas and hamper the ability of telemedicine providers to fill in gaps in the delivery system and provide high value care directly to consumers in rural or underserved areas. Current efforts to expand interstate licensure have been insufficient to meet the needs of patients and the clinicians seeking to better serve them.
Health care professionals are prohibited from treating patients in states where they are not licensed, but the state-by-state licensing processes are burdensome and expensive. Uniform national standards across clinical practice areas are in place, but there is wide variation in state licensing processes. In the case of physician licensure, all states require postgraduate training, proof of successful completion of all three steps of the U.S. Medical Licensing Examination, and training verification forms. However, some states add additional unique requirements for medical licensure such as background checks, fingerprinting, completing continuing medical education requirements, providing additional documents such as birth certificates, or even character witnesses. Another barrier is the expense. Licenses in a single state can cost upwards of $1,000, and application fees on top of licensing fees can add up.
Impact of COVID-19 on Licensure
COVID-19 has exposed the barriers posed by the fragmentation of state practice act laws and regulations. The ability for licensed, credentialed health care professionals to provide patient care across state lines via telehealth during the pandemic helped maintain continuity of care, promoted patient choice, helped address workforce shortages, and improved care coordination. Telehealth also helped improve patient access to primary and specialty care, boosted patient and caregiver engagement, reduced missed appointments, and improved post-operative care.
At the outset of the pandemic, the federal government took action at the start of the pandemic to address care across state lines. CMS temporarily waived requirements that out-of-state Medicare practitioners be licensed in the state where they are providing services when they are licensed in another state. CMS also released guidance stating that state Medicaid agencies could use Section 1135 waiver authority to permit providers located out of state to provide care to another state’s Medicaid enrollee impacted by the COVID-19 emergency.
Governors across the country also took action to address licensure laws to ensure access to care. These licensure flexibilities provided health care practitioners more flexibility to treat patients in other states when there were pressing needs or specialized expertise not available where they lived. Our experience during the pandemic has provided an unprecedented opportunity for patients, providers, and policymakers to explore the impact of cross-state care. We have seen it benefit the delivery of health care in many ways, but most notably through new avenues for patient access to care.
As state emergency declarations enacted at the start of COVID-19, including licensure and telehealth flexibilities, began to expire, providers had to go back to cumbersome and expensive state-by-state licensing requirements if they wanted to continue to help patients in other states. Without a glidepath or permanent policy measures to adjust to these changes, patients have to either travel long distances to see a provider in person or cancel appointments, which creates a barrier to accessing convenient care and to continuity of care.
Alliance Advocacy Highlights
The Alliance has championed a number of initiatives to address this issue and advocate for more flexibility to provide care via telehealth across state lines. See below for our advocacy on this issue. Please contact Casey Osgood Landry at email@example.com if you have any questions about this topic.
- TELEmedicine for MEDicare (TELE-MED) Act – First introduced in 2013 (H.R. 3077) by Reps. Nunes (R- CA) and Pallone (D-NJ) and later reintroduced in 2015 by Reps. Nunes and Pallone and Sens. Hirono (D-HI) and Ernst (R- IA) (H.R. 3081/S. 1778). This bill would have permitted certain Medicare providers to provide telemedicine services to a Medicare beneficiary who is in a different state from the one in which the provider is licensed or authorized to provide health care services. The licensing or authorizing state has jurisdiction to enforce its licensure or other legal authorization requirements with regard to such a provision of service.
- Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act – First introduced in 2020 by Reps. Latta (R-OH) and Dingell (D-MI) and Sens. Murphy (D-CT) and Blunt (R-MO) (H.R. 8283/S. 4421), and later reintroduced by same co-sponsors in 2021 (H.R. 708/S. 168). This bill would temporarily authorize the interstate provision of in person and telehealth services. This authorization would apply during, and for at least 180 days after, the COVID 19 public health emergency. Subject to scope of practice and other requirements, a health care professional may provide health services in any U.S. jurisdiction based on that individual’s authorization to practice in any one state or territory. The bill also provides certain related powers to health care professional regulatory bodies, such as medical boards. Specifically, regulatory bodies may investigate and take disciplinary actions against a professional who provides services pursuant to this bill to a patient in that body’s jurisdiction.
- Accelerating Kids’ Access to Care Act – Introduced by Sens. Grassley (R-IA) and Bennet (D-CO) and Reps. Clark (D-MA) and Herrera Beutler (R-WA) in May 2021 (S. 1544/H.R. 3089). This bill would streamline enrollment under the Medicaid program of certain providers across state lines. The bill requires state Medicaid programs to establish a process through which qualifying out-of-state providers may enroll as participating providers without undergoing additional screening requirements.
- Compacts, Access and Responsible Expansion (CARE) for Mental Health Professionals Act – Introduced by Rep. Neguse (D-CO) in November 2021 (H.R. 6076) and Sen. King (I-ME) in April 2022 (S. 4058). This bill would reform medical licensure to expand interstate access to mental health resources. The bill would require HHS to establish the Mental Health Licensure Portability Program to award grants to eligible entities for projects to: incentivize counselors to practice in states that have entered into interstate compacts for the purpose of expanding the workforce of credentialed mental health professionals; and Develop, operate or maintain interstate compact commissions authorized to effectuate the provisions of interstate compacts entered into by such states.
- Telehealth Treatment and Technology (3T) Act – Introduced by Reps. Cawthorn (R-NC) and Gosar (R-AZ) in March 2022 (H.R. 7097). This bill would facilitate the provision of telehealth services through interstate recognition of health care professionals’ licenses.
Other Notable Action
Senate Finance Committee: Medicaid Interstate Licensure Provision Included in the Youth Mental Health Discussion Draft (6/15) – Senate Finance Committee Chair Wyden (D-OR), Ranking Member Crapo (R-ID), Senator Carper (D-DE) and Senator Cassidy (R-LA) released the second draft section of the Committee’s mental health package. This portion focuses on youth mental health care policies as part of the Committee’s ongoing work to improve mental health. The draft includes language that would simplify the process for eligible out-of-state providers to enroll as a participating provider in state Medicaid or CHIP plans without additional screening requirements, among other provisions.
Inside Telehealth: Senate Finance Telehealth Draft Requires CMS Continue to Embrace Interstate Compacts (6/3) – In the recently released Senate Finance’s draft telehealth-mental health bill, the bill provides a vague paragraph on interstate licensing. A Senate staffer clarified the language on interstate licensing in the Senate Finance’s draft telehealth-mental health bill. The staffer clarified that Section 8 of bill requires that CMS regularly update its current coverage guidance to make it clear Medicare covers tele-mental health services when a practitioner participates in a state that is part of an interstate licensure compact and the beneficiary is also located in a state that recognizes the compact.
Strategy to Address the National Mental Health Crisis (March 2022) – On March 1, 2022, President Biden announced his strategy to address the national mental health crisis during his first State of the Union. This strategy will strengthen system capacity, connect more Americans to care, and create a continuum of support to transform our health and social services infrastructure to address mental health holistically and equitably. As part of this strategy, President Biden included a goal to expand access to tele- and virtual mental health care options. This includes that the Administration will work with Congress to ensure coverage of tele-behavioral health across health plans, and support appropriate delivery of telemedicine across state lines, to maintain continuity of access
Inside Telehealth: Biden Administration Pursues Interstate Licensing for Behavioral Practitioners (5/2) – The White House is exploring multiple pathways to address barriers to interstate licensing for mental health practitioners, which includes plans the Administration could enact on its own and others that would be in conjunction with Congress. The Administration is considering removing interstate licensing barriers for decentralized clinical trials, among other strategies. Although interstate licensing has recently caught the attention of federal legislators with the rapid expansion of telehealth, Congress is limited in what it can do to remove licensing barriers for practitioners because state licensing boards have primary jurisdiction over the issue. Increased interstate licensing would make specialized care more accessible to a wider population, like behavioral health care, especially for patients in rural and underserved areas.
JAMA Health Forum: Receipt of Out-of-State Telemedicine Visits Among Medicare Beneficiaries During the COVID-19 Pandemic (9/16/22) – This study focused on how out-of-state telemedicine was used during the COVID-19 pandemic, examining telemedicine visits in the first half of 2021 (Jan – June) among patients with traditional Medicare coverage. Key findings from the study include:
- Of the 8,392,092 patients with a telehealth visit, 422,547 patients (5 percent) had one or more out-of-state telemedicine visits.
- In 62.6 percent of all out-of-state visits, a prior in-person visit occurred between the same patient and clinician between March 2019 and the visit, showing that out-of-state telemedicine visits were largely used for continuity of care purposes with an existing provider-patient relationship.
- These visits were most common among those who lived near a border (57.2 percent of out-of-state visits).
- Visits were largely for primary care and mental health treatment (64.3 percent of out-of-state visits).
- People in rural communities were more likely to receive out-of-state telemedicine care (33.8 percent vs 21 percent).
- There was high out-of-state telemedicine use for cancer care (9.8 percent of all telemedicine visits for cancer care).
Health Affairs: Interstate Telehealth Use By Medicare Beneficiaries Before And After COVID-19 Licensure Waivers, 2017–20 (6/6/22) – A study by the University of Michigan analyzed trends in interstate telehealth use by Medicare beneficiaries during 2017-2020, which covered the period both directly before and during the first year of the pandemic. The study found that the number of out-of-state telehealth services from the first quarter to the fourth quarter of 2020 increased by 572 percent, and that a higher percentage of out-of-state telehealth users lived in rural areas (28 percent). Additionally, 64 percent of out-of-state telehealth visits occurred between a patient and clinician in a bordering state. The study also found that most out-of-state telehealth use was for established patient care, suggesting the majority of out-of-state telehealth is used for continuity of care rather than acquisition of new patients.
Inside Telehealth: Cardiology, Family Physician Leaders: Continue Audio-Only Telehealth, Care Across State Lines (6/16) – During a recent FiscalNote webinar, leaders at the American College of Cardiology, and Alliance Advisory Board Member American Academy of Family Physicians (AAFP), expressed support for the federal government and states making pandemic-era allowances for telehealth across state lines and audio-only services permanent beyond the COVID-19 public health emergency. Members of the American College of Cardiology are invested in making sure patients with chronic heart conditions can see their regular provider via telehealth while traveling or spending part of their time in another state.
Inside TeleHealth: Medical Boards to Vote Saturday on New Telemedicine Policy (4/29) – The Federation of State Medical Boards is set to vote on its first update in nearly a decade to guidance on the appropriate use of telemedicine in the practice of medicine. The updated document contained sections related to licensure exceptions, standards of care, patient privacy, and health equity, among others. The Alliance for Connected Care submitted comments in response to the draft document in February, recommending that the FSMB consider broadening the circumstances in which it recommends interstate licensure for telehealth treatment.
Pharmacy Times: The Challenge of Multistate Pharmacy Licensure in the Telehealth Era (4/27) – Telehealth use expanded in pharmacies during the pandemic, however, pharmacy personnel face challenges when implementing these services, beginning with regulatory requirements affecting their ability to provide telehealth. Challenges for pharmacy personnel who wish to fully use telehealth to serve patients in multiple states include obtaining licenses to practice in each of these states. Acute shortages of pharmacists and pharmacy technicians in certain geographic regions and across areas of practice can be exacerbated by licensure requirements for such professionals. The American Society of Health-Systems Pharmacists (ASHP) has developed a series of policies that support the harmonization of laws and regulations impacting pharmacy practice across states and enhances the ability of pharmacists to practice in multiple states.
MedTech Intelligence: Telemedicine Moved Forward During the Pandemic. Our Policies and Regulations Need to Catch Up (4/22) – Outdated policies and regulations threaten to bring progress to a standstill, restrict vital telehealth access to millions of Americans, and exacerbate health inequities. All 50 states and the District of Columbia, as well as CMS, waived state licensure requirements so physicians could treat patients virtually across state lines during the pandemic. These flexibilities opened up a wave of record-breaking new investments in digital health technology, providing patients with new options in telehealth services and remote-monitoring solutions. However, according to a tracker by the Alliance for Connected Care, only 23 states still have those licensure waivers in place, and the future remains unclear for expanded telehealth benefit coverage and loosened prescription regulations. Permanently eliminating geographic and financial barriers to telemedicine is essential to reducing the health care access gap, providing consumers with greater choice in their medical care, and encouraging continued innovation in the digital health space.
Politico Pro: Telehealth growing pains (4/20) – The telehealth industry faces some uncertainty as more states end waivers allowing care across state lines. As many states’ emergency regulations permitting such care wind down and the patchwork system of state rules becomes patchier, millions of patients are losing expanded access to telehealth. The Alliance for Connected Care has proposed a voluntary national system, similar to the driver’s license system, that would enable states to recognize each other’s licenses. Patient advocates, public health officials and telehealth and provider groups are pushing for utilization of telehealth across state lines.
Politico Pro: Millions set to lose telehealth access across state lines as waivers wind down (4/19) – Millions of patients are losing expanded access to telehealth across state lines as many states’ pandemic emergency declarations wind down, prompting patient advocates, public health officials and telehealth and provider groups to call on states and Congress for a fix. According to data from the Alliance for Connected Care, states could see expanded access lapse in the second half of the year, with flexibilities intact for 15 states, down from 24 in early March. Access to virtual care across state lines, which patients increasingly took advantage of during the pandemic, is overwhelmingly popular among patients and providers. National data on the rise of care across state lines is sparse, but one in five providers say they provided care across state lines amid the pandemic, according to a recent Morning Consult poll conducted on behalf of the Alliance for Connected Care.
Featured Advocacy: Letter to Governors on Care Across State Lines
On November 1, 2021, more than 230 organizations sent a letter to all 50 state governors urging them to maintain and expand licensure flexibilities enacted at the start of the pandemic for the duration of the federal public health emergency, to better address patient needs during the ongoing pandemic. The letter was convened by the Alliance for Connected Care, ALS Association, and National Organization for Rare Disorders (NORD), and includes a diverse mix of signers ranging from patient advocacy organizations, hospitals and health systems, academic medical centers, higher education, digital health companies, health information management associations, and many more.