Telepractice is widening its reach across county and state lines—and that's raising lots of questions about licensure. Practitioners want to know the rules on whether they can provide services with a current state license, or whether they need to get new credentials in other states.
In many cases, the answers aren't straightforward. Legislation to regulate telepractice lags behind the growth of the technology. Still, 16 states and the District of Columbia have some form of policy, regulation, or statute on telepractice, and other states are working to develop their own policies.
To help speech-language pathologists and audiologists sort through the complexities, the Leader offers some answers to some of your most commonly asked questions about licensure portability.
Under a typical state law, if I'm an SLP wishing to provide telepractice services to a client in another state, would I have to obtain a license in that other state, in addition to the one I already have in my home state?
Although "site of services" has never been defined in any formal laws, current medical and legal practices indicate that it is the location of the client that determines the state in which the practitioner must be licensed. Under most laws, if that location is in a different state from the one where the practitioner is licensed to practice, then the practitioner needs to secure a license from the client's state. There might be exceptions if the state has exemption provisions within its licensure laws. Be aware, however, that many states don't yet have policies on telehealth.
Yet it's possible that a regulatory board receiving a complaint of a practitioner delivering telepractice services without a license in the client's state would fall back on the "operating without a license" penalty provision in every state law.
Alternatively, some states have consultation and licensure exemption provisions. For speech-language pathology and audiology, some states allow practitioners to work in another state without a license for up to 30 days in a calendar year. In this situation, the practitioner must hold a license from another state that has equivalent licensure requirements and must provide services in cooperation with an SLP or audiologist who is licensed in the state where the temporary practice will occur. Despite its existence in some states, this exemption remains largely untested in the telepractice delivery model.
How many states have telepractice regulations in place? How likely is it that others will follow?
Sixteen states and the District of Columbia have some form of policy, regulation, or statute on telepractice, a number that has been growing yearly. Judging from the number of inquiries we receive at ASHA about telepractice services and reimbursement—and the fact that we have a rapidly growing Special Interest Group on telepractice (18)—it is definitely catching on.
However, as is typical for any new form of service, the legal and regulatory requirements lag behind. Most state licensing boards do not have regulations in place. This regulatory gap can be a good thing and a bad thing. Although it is important for the state boards to protect the public from harm, if a board adopts poor regulatory wording, the evolution of this service is strangled. The results are raised barriers to practice, which decrease accessibility and prevent the professions from keeping up with advancements.
What is the impact on consumers, health care, and the practitioner if a full license is required in every state where service might be delivered?
The present state-based system of licensure certainly does not facilitate telepractice across state lines. Clients and practitioners suffer from a lack of access. For clients, access to services may be limited due to mobility, economic, and geographic constraints and provider shortages. For many providers, the state board licensing process is frustrating, administratively redundant, expensive, and time-consuming, and is seen as a major barrier to the provision of services and an impediment to workforce mobility. Alternative systems of licensure portability need to be examined and permitted to allow telepractitioners to serve clients wherever the need exists.
Are there alternative licensure portability efforts under way?
As the use of telepractice increases exponentially, pressure is building to change licensure. To date, five alternative models of licensure have been proposed with varying degrees of success:
- Mutual Recognition Compacts—similar to a driver's license model. A provider must have one full license in a state of residency, but can practice physically and/or electronically in another state that has entered into a legal agreement with the provider's home state. Created and promoted by the National Council of State Boards of Nursing, this model is used successfully by nurses in 24 states.
- Limited License—limited to the practice of telehealth across state lines. A provider must hold a full license in the home state and obtain this additional license for each outside state of remote practice. Originally created and promoted by the Federation of State Medical Boards, this license was adopted in nine states before it fell out of favor. Many practitioners saw the process as still too burdensome—because of paperwork and fees—and were concerned that this type of license designates telepractice as something other than just a new form of service delivery.
- Expedited License—streamlines the current state board licensure system using core standards and a uniform application. The system uses stored credential verification, forms pre-populated with individual data, and disciplinary history verified by national databanks. Qualified providers must have one full state license and can request that information be forwarded to multiple states where they want to practice. The Federation of State Medical Boards has been working on and promoting this strategy for physicians.
- National License—based on universal standard of practice and common criteria for each profession. This approach, not yet tried, can be administered at the state or national level.
- Federal License—health practitioners would be issued one license by the federal government. In this untried system, the government would establish and administer national standards, qualifications, and discipline for each profession and would pre-empt state laws.
It is also significant to note that in 2011, Congress passed the Service Members Telemedicine & e-Health Portability (STEP) Act. This law paves the way for Department of Defense civilian health care employees and contractors to serve military personnel regardless of geographic location, under a single license, and without the burden of acquiring additional state licenses.
Are there licensure portability efforts under way for telerehabilitation professionals,including SLPs and audiologists?
ASHA members and staff have been working with the American Telemedicine Association's Special Interest Group on Telerehabilitation to form an interdisciplinary working group on the subject of licensure portability. Representatives on this subcommittee include ASHA, the American Occupational Therapy Association, the American Physical Therapy Association, the National Council of State Boards of Examiners for Speech-Language Pathology and Audiology, the Federation of State Boards of Physical Therapy, the National Board for Certification in Occupational Therapy, and various professional practitioners.
In addition to educating key stakeholders, the group has, through a grant, begun measuring the areas of credentialing requirement agreement among the professions. The hope is to create key uniform elements—such as licensure forms, core requirements, and credential verification—that would make it easier to obtain a license from another state.
Where can ASHA members find out more about state board telepractice regulations?
ASHA maintains a list of existing state regulations, policies, and statutes. However, you should always check with a given state's licensure board before providing telepractice services there.
More information on telepractice, including ASHA's positions, necessary skills and knowledge, and professional requirements, is available on ASHA's telepractice website. This site also links to ASHA's suggested model licensure regulations for inter- and intra-state telepractice.