State Expansion of Telehealth and Licensing Waivers

During the public health emergency, all 50 states and the District of Columbia used emergency authority to waive some aspect(s) of state licensure requirements to facilitate patients getting care. This has provided an unprecedented opportunity for patients, providers, and policymakers to explore the impact of cross-state care. This has benefited the delivery of health care in many ways, but perhaps most notably, it has opened up many new avenues for patient choice and access to care.

As states begin to lift their COVID-19 emergency waivers or let them expire, many of the telehealth and licensure flexibilities enacted at the start of the pandemic to ensure continuity and access to care for patients are also expiring. As such, the Alliance has created a chart outlining which states have lifted their COVID-19 emergency waivers, and how this has impacted telehealth and licensing flexibilities in each state. This document will be updated regularly, and can be found below.

Key Highlights

As of November 8, 2021:

  • 27 states and D.C. have ended their emergency declarations.
  • 23 states continue to have emergency declarations in place.
    • States with declarations in place include: AZ, CA, CT, DE, HI, ID, IL, IN, IA, KY, LA, MS, MO, NC, NV, NM, RI, TN, TX, UT, WA, WV, WY.
    • Of these 23 states, 19 states still have licensure flexibilities in place. Licensure flexibilities have expired in CT, MS, NM, and TN despite emergency declarations still in place.
    • Alabama, Arkansas, Delaware and New York issued new state emergency declarations that include state licensure flexibilities.
  • Other state licensure-related updates:
    • AZ and FL allow out-of-state providers to register with the state to practice telemedicine in the state, per state law.
    • CT passed a bill that will allow out-of-state providers to provide telehealth services to patients in CT through June 30, 2023. This bill authorizes the Commissioner of Public Health to issue an order allowing an out of state licensed physician or PA to provide services via telehealth without obtaining a CT license through this date, however no order is currently in place.
    • MD waivers for out-of-state providers expired August 15, 2021. The state’s emergency declaration was lifted July 1, 2021.
    • VT pandemic-related waivers, including allowing health care professionals licensed in other jurisdiction to practice in the state as a volunteer member of the Medical Reserve Corps or part of a staff of a licensed facility/FQHC, will be extended through March 31, 2022 per SB 117. The state’s emergency declaration was lifted on June 15, 2021.
    • WV passed a bill to allow health care practitioners licensed and in good standing in another jurisdiction to pay a fee to become registered with the appropriate medical board and become an interstate telehealth practitioner in the state.
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CMS Approved 1135 Waivers

Under a disaster or emergency declaration and a public health emergency, the HHS Secretary is authorized to take additional actions to provide programmatic flexibility in Medicare, Medicaid and the Children’s Health Insurance Program through section 1135 waivers. The Secretary may issue blanket waivers, or may approve state specific waivers. Waivers end no later than the termination of the emergency period. CMS released a checklist for states to aid in the development of 1135 waivers requests.

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

Several states requested flexibility to incent greater use of telehealth through Medicaid Section 1135 Waivers during the pandemic. For example:

  • IL, LA, NC, and WA requested CMS to allow providers to use non-HIPAA compliant telehealth modes from platforms like Facetime, WhatsApp, and Skype to facilitate visits.
  • CA requested flexibility to make it easier for providers to care for people in their own homes by allowing telehealth and virtual/telephonic communications for covered State plan benefits, a Waiver of face-to-face encounters for FQHCs and Rural Health Clinics, and Reimbursement of virtual communication and e-consults for certain providers.
  • MD requested flexibility so that Medicaid and Managed care enrollees could use telephones to receive care if they did not have an appropriate device.
  • SD requested flexibility to allow Medicaid to pay for the same telehealth services that Medicare has been granted authority to pay for, including services furnished while a patient is at home.

As of April 2020, CMS had approved 53 state waivers.  A full list of the approved 1135 waivers (last updated April 23, 2020) can be found here.