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Providing Care Across State Lines

TelemedicineWhen telehealth services are provided, they are considered to be rendered at the physical location of the patient. Therefore, a clinician typically needs to be licensed in the patient’s state of jurisdiction. While this requirement was waived by many states during the COVID-19 public health emergency, such waivers and exemptions were mostly temporary. In order to continue practicing across state lines, allergists must understand current rules regarding cross-state licensing.

There is no national licensure at present. Medical licensure for MDs and DOs is under the jurisdiction of individual state medical boards. Physicians practicing in multiple states must adhere to a variety of state-specific medical practice regulations and there are annual license renewal fees for each state license. However, there is an expedited process for licensing board-certified physicians with no background issues in multiple states through the Interstate Medical Licensure Compact Commission, a branch of the Federation of State Medical Boards.

Expedited licensure process requires that a physician:
• Hold a full, unrestricted license in a member state
• Meet all nine qualifying requirements:
1. Graduated from an accredited medical school
2. Successfully completed ACGME- or AOA- accredited graduate medical education
3. Passed each component of the USMLE or COMLEX-USa in no more than 3 attempts
4. Holds a current specialty certification by the ABMS or AOABOS, aka Board Certified
5. Have no disciplinary actions against their medical license
6. Have no history of controlled substance actions against their medical license
7. Not be currently under investigation
8. Have no criminal history
9. Complete an FBI fingerprint-based background check

Approximately 80% of U.S. physicians meet the criteria for licensure through the Compact. As of September 2023, more than 72,000 licenses have been issued to US physicians through the IMLC. This compact has been approved in 39 states, Washington DC, and Guam thus far. Legislation is pending in other states as well.

However, the lack of license portability still remains a barrier. If a physician moves to a new state, they will need to establish full licensure in their new state of residence, designate it as their state of primary licensure (SPL), and apply to have that state provide a letter of qualification (LOQ) through which expedited licensure can be obtained in other states. If the state of primary licensure is not a member of the IMLC, this can pose an issue.

VA telehealth program, in a rule effective 6/11/2018 and posted in the Federal Register, enables VA practitioners to treat veterans no matter where the veteran or the doctor are located, effectively bypassing state licensure laws.

Ways to Provide Telemedicine Care Across State Lines
Providers who wish to practice in other states can apply for full licenses from those states if they prefer. However, state boards can also issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine. These types of special licenses allow practice under specified terms.

All state boards, plus the medical boards of the District of Columbia, Puerto Rico, and the Virgin Islands; require that physicians engaging in telemedicine are licensed in the state in which the patient is located, or are registered in the state, if they have a registry for interstate practice.
• Eight (8) states, plus the Virgin Islands, issue a special purpose license, telemedicine license or permit to practice telemedicine across state lines.
• Nine (9) states require physicians to register or receive a waiver if they wish to practice across state lines.
• Three (3) states, plus the District of Columbia, offer regional or proximal reciprocity for interstate practice.
• One (1) state allows pro bono interstate practice.
• Twenty-nine (29) states have licensure exceptions and/or consultation exceptions for services rendered across state lines.

Federation of State Medical Boards:  Telemedicine Policies – Board by Board Overview.

Texas has an Out-of-State Telemedicine License that limits practice to two types of service; (1) follow-up for a patient where the majority of care was rendered in another state, or (2) interpretation of diagnostic testing, but results must be reported to a fully licensed physician practicing in Texas.

Texas Medical Association:  Texas Laws and Regulations Relating to Telemedicine (white paper).

Outside of the IMLC, licensure by endorsement grants licenses to out-of-state providers whose states have equivalent standards. Some states allow providers from adjacent states to provide telehealth services in their state. In addition, some states have added exceptions to state licensure for health care providers in specific situations to help preserve continuity of care (for example, for patients who have already established care with a provider and then moved out of state).

State-by-state licensing guidelines are noted in this reference.

Interstate compacts as mentioned in the overview are available in 39 states at present.

This is a rapidly changing area and a number of states now have pending legislation regarding this matter.

These links are for research only. They are not endorsed by the American Academy of Allergy, Asthma & Immunology (AAAAI).