On July 16, 2024, at the Health Resources and Services Administration (HRSA) National Telehealth Conference, a new investment into the multi-state social work licensure compact was announced. The $2.5 million HRSA investment will support the launch of the social work compact while also building upon HRSA’s ongoing work on other licensure compacts to improve access to primary care and behavioral health services. The initiative is part of the Licensure Portability Grant Program, which seeks to support state licensure board partnerships to promote the development and implementation of state laws that make telehealth more accessible.
As mentioned in the HRSA press release on the latest investment, generally state licensure compacts give states an opportunity to collaborate on a common approach to licensing providers to allow them to practice across state lines without having to apply for a license in each state. Note that some compacts work a bit differently, for instance the Interstate Medical Licensure Compact (IMLC) focuses more on streamlining and expediting licensure approval with each state. Since telehealth is generally considered rendered at the location of the patient, as noted on the U.S. Department of Health and Human Services (HHS) licensure compacts page, the common compact approach seeks to ensure the licensure boards in both the provider state and patient state can maintain oversight and jurisdiction over the care being provided. In addition, the investments into an interstate approach allow the federal government to engage on the issue of licensure, which is primarily a function of state governments.
While licensure portability issues aren’t specific to telehealth (or healthcare), as telehealth use has increased and become more recognized as an important way to address access issues, a focus on licensure policy and ways to reduce cross-state barriers to care have also increased. CCHP has begun to categorize out-of-state telehealth provider policies into three areas:
- Limited Licensure Exceptions
- Telehealth License/Registration Processes
- Interstate Licensure Compacts
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Out-of-State Telehealth Provider Policies
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The Council of State Governments National Center for Interstate Compacts provides a number of compact resources and also assists in their development. According to the Center’s Occupational Licensure Compacts page, licensure compacts are specific to different licensees and created through a stakeholder process that establishes uniform standards for a particular profession, taking into account different state practice acts and licensure processes while also ensuring the states can communicate relevant data about their licensees. Once a compact is established, states can join by passing the uniform provisions through their legislative process. The compact becomes active when a certain number of states have legislatively enacted the compact’s uniform language. For instance, since the Social Work Licensure Compact has now been enacted in more than seven states as of this year (now at a total of 22), it is now considered active. Nevertheless, as mentioned on the Social Work Compact website, upon activation of the compact, an implementation process must then begin prior to the compact being able to issue multistate licenses. In addition, the language adopted in each state must be the same in order for a state to officially participate and the compact to be enforceable – the National Center for Interstate Compacts reviews legislation to ensure consistency. This legislative language requirement is often a reason behind some states hesitancy to become compact members, because if they choose to participate in the compact, they are limited in amending the compact language to meet any particular policy goals. In addition, compacts are each governed by an administrative entity or commission, which typically consists of delegates made up of member states, meaning some authority is then delegated to the interstate agency rather than lying completely within a state. Nevertheless, compact membership does not change a state’s authority within its own borders and compacts also seek to preserve each state’s practice act and initial licensure process, with multistate licensees still required to abide by the laws of the state where both the provider and the patient are located. Most state legislatures have endorsed the concept of compact membership, with only 5 jurisdictions (as of the writing of this newsletter) currently not a member of any compact (Alaska, California, Massachusetts, New York, and Puerto Rico).
The number of compacts is continuing to increase as well. According to the Council of State Governments National Center for Interstate Compacts, there are 15 professions with available occupational licensure compacts and two with licensure compacts in development. At this time, CCHP is tracking 12 of those compacts on its state compact pages:
- Advanced Practice Registered Nurses Compact
- Audiology and Speech-Language Pathology Interstate Compact
- Counseling Compact
- Dietitian Compact
- Emergency Medical Services Personnel Licensure Interstate Compact
- Interstate Medical Licensure Compact
- Nurses Licensure Compact
- Occupational Therapy Licensure Compact
- Physician Assistant Licensure Compact
- Physical Therapy Compact
- Psychology Interjurisdictional Compact
- Social Work Licensure Compact
The other compacts referenced but not tracked currently by CCHP include ones for cosmetologists, teachers, dentists, school psychologists, and massage therapists. Some compacts are relatively new, such as the Dietitian Licensure Compact, which is still under development along with the School Psychologists Compact, while others have been established for many years. The IMLC for example, discusses its creation on its website, highlighting how state medical boards began working together in 2013 to create the compact process and model legislation, with it becoming operational in 2017. In addition, as mentioned in the latest HRSA compacts press release, since HRSA began investing in licensure compacts, the IMLC as well as the Psychology Interjurisdictional Compact (PSYPACT) have each grown to include 40 states, Washington D.C., and one territory. State membership has also rapidly grown over the past few years for the Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC), which now has been enacted into law in over 30 states. According to the ASLP-IC website, the ASLP-IC Commission began establishing its rules and bylaws to implement the compact in 2022, with the process of operationalizing the compact expected to take close to two years. Upon integrating member states into the compact’s data system, compact privileges to practice will become available, with ASLP-IC anticipating the ability to accept applications by late 2024 – early 2025. The Counseling Compact has followed a similar trajectory of quick growth, with nearly 40 states passing the compact language and applications for compact privileges to practice anticipated to open in 2025, according to their website.
Once a state joins a compact, and the compact becomes fully operational, licensees in compact member states can then apply for a multistate license to practice in other member states. However, the structure of each compact, application process, fees, and privileges provided varies, and some are not yet active or operational. Please see each specific compact website for the most up-to-date implementation and license issuing status, state participation maps, and other related requirements. Despite variances across compacts, as interest grows around providing and receiving care via telehealth across state lines, interstate licensure compacts will continue to be an important policy area to watch, as they provide one of the most popular, consistent, and well-established processes available to implement allowances for out-of-state telehealth providers.
For more information on HRSA’s compact investments, please view the latest press release and Licensure Portability Grant Program website. For more information on state licensure policies, please review CCHP’s Cross-State Licensing page and Licensure Compacts page, as well as CCHP’s recent write-up on Out-of-State Telehealth Provider Policies.
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