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Is It Legal to Practice Across State Lines with Online Therapy, Telemental Health & Telebehavioral Health?

by | Oct 30, 2018 | 73 comments

licensing lawsIs it OK for licensed clinicians to go over state lines for a few clients/patients? What if the treatment is just for a few sessions? What if the client/patient is just visiting out-of-state family for a few days?

Onlookers scratch their heads and wonder why licensed professionals simply can’t practice everywhere with their professional licenses. The disconcerting fact is that an act of Congress would be needed to override our current state-based system for health care professionals to practice nationally. (Given the current political climate, such an act is not likely.)

This article will outline the basics related to interjurisdictional practice (practicing over state and international borders) before answering the question of whether it is legal to practice over state lines.

State Licensing Boards Intentionally Operate Independently

Licensing laws in the United States have traditionally been based on the authority of individual states. They frequently defined the scope of practice for their discipline differently. They then regulated how professionals could qualify for professional practice based on specific requirements for training, reporting, and documentation. Licensing laws for most healthcare disciplines were not only written differently across states but being written in the 1950s. They often still reflect the world prior to the dramatic rise of interstate travel or the rapid advancement of communication technologies. The primary concern of regulators was the protection of their citizens.

Bad Apples and Interjurisdictional Practice

State licensing boards faced local issues with keeping “bad apples” out of practice in their states. Now, with the advent of technology, states have even more reason to be concerned that a “bad apple” will harm their citizens. In fact, with a few simple clicks of a mouse, a “bad apple” from anywhere on the planet may:

  • Practice outside the accepted and legally defined scope of their respective specialties
  • Provide services for which they are ill-trained or in which they cannot exhibit clinical competence
  • Give their respective professions a bad reputation
  • Present an intentional danger to harm the public

Clinicians Are Too Often Unaware of the Rules Related to Practicing over State Lines

However, not all clinicians practicing over state lines are “bad apples.” Many well-intentioned clinicians are unknowingly practicing over state lines without being aware of their requirements. These issues only recently became relevant, leaving many professionals at a deficit if educated prior to just recently. In fact, the vast majority of graduate and medical schools do not yet offer dedicated classes to telehealth. (I and my writing team are now writing the first interprofessional textbook for graduate students to cover telebehavioral health competencies. To review a chapter, send a note here).

Problems with the average professional’s lack of knowledge related to telehealth are still prevalent. In a recent study of psychologists who responded to a survey regarding their online services and related attitudes, only 80 percent thought that it is ethical to practice online.  Twenty percent either were not sure or thought that it is unethical to practice online. On the flip side, only 58 percent of respondents reported that current state laws have bearing on their online activities. In other words, 42 percent either didn’t know or thought that practicing online is unregulated by their respective licensing boards (Glueckauf, Maheu, Drude, Nelson, 2018).1

Turf Wars

Protecting turf was another strong motivator for licensing boards to develop state-specific laws. Initially, some sparsely-populated states do not want to be over-run with professionals from other states, depriving local practitioners of their livelihoods. This factor is still prevalent in some states, where state laws require a foreign practitioner to be physically located in the state where a client/patient is being served. In different states, the opposite can also be true. For example, in one state, a non-resident, out-of-state professional visiting for the winter is not allowed to deliver care to their “home state” where they are licensed to practice without passing the “visited” state’s licensing exam.

Licensing Laws Differ Within States, Too

Unfortunately, turf wars still exist not only across states but also between disciplines. Professional groups within a state can include addiction, behavior analysts, behavioral nurse practitioners, counseling, marriage and family therapists, psychiatrists, psychiatric nurses, psychologists, and social workers. Even today, laws for different professional disciplines can differ within states because they are ruled by groups of professionals from different disciplines.  Regulators from these disciplines then are tasked to decide rules for their own disciplines. The regulations developed by one regulatory board may differ sharply from another board’s regulations within the same state.

The Problem is Conflicting Board Positions Regarding Basic, Non-Technology Mediated Practice

The issue is not just whether or not telehealth is allowed. The conflict of basic definitions and regulations within a single state creates confusion and misinformation for within-state as well as out-of-state professionals involved in education, training, and practice. For example, in 2015, the composite board in Georgia required social workers, marriage and family therapists, and counselors to take a minimum of 6 hours of professional training to practice any form of telehealth, including telephone service delivery. Psychologists in the same state are not required to take any specialized training in telehealth.

A psychologist then may very well be uninformed of the basic rules required as practitioners of telehealth, as reflected in the above-cited survey by Glueckauf. If that psychologist is working in a value-based model, his or her expectations of colleagues from other disciplines are likely to be uninformed. The same is true to a psychologist supervisor working with a social work supervisee.

Issues in question are not only related to interjurisdictional practice but other issues regulated differently by different boards, such as informed consent; privacy and security; screening and triage; documentation including intakes and intake forms, progress notes, termination processes and notes, mandated reporting, and referrals; and managing fees, continuity of care, and handling emergencies. Involvement with the client’s/patient’s local community resources is also required by many states. Of course, HIPAA requirements for staff training, risk analyses, and written policies including business associate agreements also should be in place when trying to comply with different state requirements.

Clinical Issues Are Also Important in Legal Telepractice

Clinical issues also may need careful consideration and ample documentation, such as hygiene checks, mental status exams, and gait analyses when conducted online through the telephone, video, text messaging, or other devices that claim to invite the clinician to operate in a platform that is the “digital equivalent for in-person care.” Consumer welfare of the most vulnerable people who seek behavioral care ultimately must be considered. Choosing one’s client/patient population wisely and knowing how to compensate for the lack of physcial presence are the key.

More Than Meets the Eye… Interjurisdictional Telehealth Model Acts

Critics argue that this current system is archaic, contradictory, and confusing. They complain that licensing laws have not yet evolved to reflect 21st Century practice. However, an obvious truth is that many very bright and capable professionals serve regulatory boards. They are not asleep at the wheel. They understand that their licensees want to expand their practices over state lines, keep down their overhead costs, and enjoy the many benefits of working from home.

Rather than coming up with a national law to allow professionals to practice over state lines, several professional groups have developed “model acts” for individual states to consider for their respective regulations. Adoption of such models acts is now currently underway in a number of professions, including medicine, nursing, and psychology.

Most Clinicians Practicing Over State Lines Are Practicing Illegally

The disturbing fact is that many professionals are simply guessing at their telepractice requirements. Most clinicians practicing over state lines are practicing illegally if not properly licensed or registered in the client’s/patient’s location at the time of the contact (not the client/patient’s state of residence). These clinicians may very well be good practitioners. They probably are not considering their ethics classes, where they probably learned that practice in a new area requires professional training, not guesswork. As untrained professionals, they not only are practicing unethically, but they may be unaware of the many ways in which they can harm consumers. They also are not aware of how they themselves can be harmed by what they don’t know. Other practitioners may be needlessly staying away from telepractice altogether.

What to do?

The real problem is that most professionals practicing over state lines do not know how to get appropriately licensed or registered, which states are more or less receptive than others, and how to document their telepractices to meet different state requirements. They haven’t thought about:

  • How the definition of the therapeutic relationship differs from state-to-state, potentially making disengagement from an unsuitable client/patients “abandonment”
  • How to handle emergencies such as suicide or homicide threats, child or elder abuse
  • How to handle the client/patient who presents with an issue such as intoxication that prohibits the delivery of legitimate treatment, or psychosis, or mania
  • How to be in compliance with myriad state requirements
  • How different states require different types of documentation for behavioral practice
  • How federal laws can conflict with state laws, and which to choose
  • How their malpractice insurance carrier might refuse to protect them for problems that arise with their illegal practices
  • How to give appropriate local referrals for seriously disordered individuals who do not comply with treatment
  • How to find and recruit local community support for complex cases
  • How many online employers leave the licensed professional holding 100 percent of the liability

To make matters worse, many clinicians don’t know whom to ask, whom to believe, or where to get verifiable facts. They have followed their errant colleagues, who too, are very excited about telepractice, but who haven’t gotten the basic training needed to know how to comply with all mandates.

Unbeknownst to most clinicians whose state boards are still mute on the topic is the fact that telepractice is legal everywhere if the clinician knows how to comply with all federal and local laws. Furthermore, it is 100 percent legal to practice over state lines when the professional is properly licensed or registered in the foreign state (or country) and in full compliance with all laws. Professional training is often needed to understand how to comply.

 

1 Glueckauf, Robert L.; Maheu, Marlene M.; Drude, Kenneth P.; Wells, Brittny A.; Wang, Yuxia; Gustafson, David J.; Nelson, Eve-Lynn . Survey of psychologists’ telebehavioral health practices: Technology use, ethical issues, and training needs. Professional Psychology: Research and Practice, Vol 49(3), Jun 2018, 205-219

What Are Your Thoughts?

Please leave your comments below.

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73 Comments

  1. Dr.Robert Heller

    Is it really worth the effort to find out and comply with the rules, laws and ethics of each state you may be working with, the insurance carrier, the particluar requirments and documentation etc. if you are only going to possibly work with a few clients ?

  2. Steven Griggs

    If a client has legal residence in my state and I work with that person, in person, in my office for six months, then goes to school in another state (but still has residence in my state), is it legal to continue working with him with video counseling, using a HIPAA-compliant platform (VSee)?

  3. Ginny Winn

    It seems all states need to get together to discuss solutions to collaboratively define the problems and come up with solutions. It’s a process that has to begin in order to open legal access to existing and prospective clients.

  4. Marlene Maheu, Ph. D.

    Ginny,

    I agree – and some disciplines have regulatory associations that have done this. Others are in the process, and yet others haven’t even begun.
    Marlene

  5. Marlene Maheu, Ph. D.

    Steve,

    Disappointingly, no, a licensed professional cannot legally treat a student who is going to school in a different state without engaging with a few simple but costly and time-intensive activities first. These will be outlined in the upcoming webinar for professionals who want to know how to be compliant with the legal, ethical and malpractice risk management issues involved. It makes no sense in the big picture, but such is the case nonetheless. This is the webinar link.

  6. Marlene Maheu, Ph. D.

    Yes, even most regulators would agree that it takes effort to develop a legal telepractice, but just like with in-person practice, the number of clients with whom you violate the law isn’t the issue in their eyes. Your practices are either legal or illegal according to state statute and regulatory code.
    We at TBHI encourage you to get the facts before you decide to comply or not. Participating in a webinar is easy enough. We at TBHI make all webinars available on-demand after the fact, so you can listen to them anytime, anywhere, with any device. See our past webinars here for yet more telepractice-related topics.

  7. K A

    Hi, thank you (from the patient’s perspective) for helping to move this conversation forward. I wonder if you know of patient resources for people who are trying to work with a therapist remotely – in my case, I am actually trying to see a therapist with another person while we live in different states (family/relationship counseling). That is, one of us would go in person and the other would participate remotely. We could establish care while both in-person, potentially, then continue while in different states.

  8. Marlene Maheu, Ph. D.

    KA,

    You are asking a very important question. This SAMHSA-sponsored webinar recording might be helpful to you as a telehealth client/patient: https://telehealth.org/blog/tbhi-samhsa-telebehavioral-health-consumer-webinar/

    As for the legalities of the arrangement you proposed, your clinician may need to be careful about treating you as a couple if one of you travels over state lines. Establishing care in-person is most likely not to be relevant once one of you travels over state lines. Unless your couple’s therapist is licensed wherever you travel, a legal violation may very well be occurring.

    The situation may be manageable but private consultation is warranted for your therapist to make sure this arrangement is being properly arranged, notated and coded if you are getting insurance reimbursement. Several factors are involved and discussing them in a public blog is not appropriate. Such private clinician telehealth consultation is available here at TBHI.

    Lastly, I commend you for seeking relevant information as a consumer! Finding and implementing more relevant information can only maximize the chances of success.

  9. Marlene Maheu, Ph. D.

    Ginny,

    You make a very good point. A lot is happening behind the scenes, though.

    Many legislators are already working on interjurisdictional practice at the state level. It may also interest you to know that regulators within states are approaching this legislative change by working within their disciplines. For example, physicians work within the Federation of State Medical Boards (FSMB); psychologists work within their regulatory association, called the Association of State and Provincial Psychology Boards (ASPPB). Social workers work within ASWB, counselors through AASCB, etc.

    If you’d like to see more rapid advancement, consider sending your relevant national association a letter describing your credentials and why you’d like to see them focus more quickly on interjurisdictional practice. We at TBHI developed a recording on how to think about and what to put into such a letter a few years ago, but it is still 100% relevant today. Ask for it by sending us an email. We’ll be happy to share it with you through our training center for FREE as a community service.

    Lastly, we at TBHI have also tried to advance the cause by offering free training to a number of regulators. Some regulators have consulted with us to quickly get up to speed on the literature and advancements in other states.

  10. Shoshana Katz

    What about when a psychologist goes away to a state in which she is not licensed, and would like to use Telemental Health back home, in the state she is licensed, with established patients?

  11. Marlene Maheu, Ph. D.

    Shoshana,

    Yours is a common question that confuses many people. The answer depends on the state. Most states will allow their licensed practitioners to be on other soil when serving the state’s citizens, but some won’t. Florida is an example of a state that won’t allow out-of-state residents to go to their state and serve out-of-Florida clients/patients while they (the clinician) is in Florida. Bottom line – always check with your discipline’s board where you are geographically located as well as the board of the state that your client/patient is at the time of the contact.

    BTW, for psychologists, ASPPB’s PsyPact will help eliminate some of this serious barrier to care. The ASPP explains, “Psychology Interjurisdictional Compact (PSYPACT)
    Approved in February 2015 by the ASPPB Board of Directors, the Psychology Interjurisdictional Compact (PSYPACT) has been created to facilitate telehealth and temporary in-person, face-to-face practice of psychology across jurisdictional boundaries. PSYPACT is an interstate compact, which is an agreement between states to enact legislation and enter into a contract for a specific, limited purpose or address a particular policy issue.”

    I would encourage you to write a letter to your board if they have not yet adopted this model act. Cast your vote by asking them to review and accept the PsyPact Model Act.

  12. L. Gross

    Can a psychiatrist licensed in Florida treat a patient living in Colorado over the phone?

  13. Kelly Z.

    Can a psychologist who is licensed in Texas, but working in South Carolina do a restoration on a patient who is charged with crimes in Alaska? He’ll be coming to SC for the process….

  14. Marlene Maheu, Ph. D.

    Dear L.
    Most licensed healthcare professionals must be licensed in the location of the patient at the time of the contact. You may want to check with your local licensing board to know which rules apply to you.

    Marlene

  15. Krish Kar

    This is a question for the licensing boards involved. When issues are this complex, I suggest that you go straight to the boards, put it in writing and ask for written replies.

  16. Shontina Floyd

    Hi, does the same telemental health laws apply to talking with families who live out of state for a current client in your state? Including getting the families to help coordinate care with permission from client.

  17. Sharon Finn, MA, LPC

    Would it be considered illegal to provide Telehealth/Mental Health services with a license issued by my state of residence if the entity I am practicing in affiliation with is in the same state as the client, and the services would be billed under the entity’s group NPI?

  18. Marlene Maheu, Ph. D.

    Sharon,

    You are right to ask questions about your service delivery and billing. As I have stated in all posts about licensing, your best source of information about your licensure is your licensing board.

    Although I am not an attorney, what I have learned as a psychologist is that if you are practicing out of your own state of licensure, most states will consider that illegal. Depending on the state and your profession, that type of practice can incur remarkably stiff penalties if you are discovered. The solution may be relatively easy, though. If you are dealing with only one state in addition to your own, you might want to consider asking the distant state about “registration”, whereby you can simply explain why you want to practice in their state and get permission to treat individuals that you must identify by name. Your second and more thorough option is to consider getting licensed in that distant state. Most state exams are pretty easy, in that they only require knowledge of local state laws (jurisprudence exam).

    The fact that you are practicing under an entity that bills with a company group NPI will not protect you from your licensing responsibilities. Your employer may tell you that you are fine doing it their way, but the truth is, they are not responsible to your licensing board — only you are. In fact, ethical rules generally state that if your employer asks you to do something illegal, your obligation is to inform them of your ethical requirements and ask them to change their policy. For guidance, explain your situation to the ethical board at your national professional association and ask for guidance. They will give you a list of things to consider and you can share that list with your employer.

    If you think you may need legal advice to disentangle yourself from past complications, you may want to hire an attorney to clarify. You may want to go to the CTEL.ORG website and look at their list of recommended legal resourse. Two of the three listed have been foundational in the building of TBHI, BTW: Joeseph McMenamin and Rene Quashie. I recommend any of the professionals listed on the CTEL.ORG page, as they have been in the field for over a decade and understand telehealth law. You may want to contact each of them to ask about their individual pricing.

    I wish you all the best and applaud you for asking these questions. Again, your board is your best source of information about their requirements.
    Marlene

  19. Elsa Willis

    I am licensed as an LPC in Idaho. I am also licensed as a Psychologist in Peru ( license does not have to renew, never expires.) Could I do telemental health from Peru to clients in Idaho?

  20. Sheila Weaver LCSW

    Hello,
    When working with a couple and you have one spouse in your office in a state you are legally licensed to practice as a clinical social worker but the other spouse is active duty military and stationed in Korea is it out of jurisdiction? Military bases are federal and one can practice with any state license with a federal posting. Is it legal to see one half of the couple in your office while using telehealth to engage with the other spouse?

  21. Greg Dowty

    How do these restrictions apply to federal statutes regarding protected interstate commerce where only an imminent risk to citizens (within or outside jurisdiction) is considered legitimate cause to deny said commerce? Are states federally culpable when they assume (through unmitigated hubris) that licensed practitioners in other states are a more present danger than their own? And, has this premise been tested in federal courts? Another issue is client rights. Without being able to document danger to clients outside of anecdotal or philosophical standards, states are denying clients to seek services they want from specific providers. While issues such as suicide and violence may fit the definition of inherent and imminent risk… do states not have the responsibility to make reasonable and evidence-based restrictions rather than obliterate interstate commerce altogether?

  22. Jourdan

    Hello,

    Is it illegal for an LCSW to work with a patient in another state if they are private pay? Or provide therapeutic tips and skills under the umbrella of Life Coaching to said patient?

  23. Marlene Maheu, Ph. D.

    Jourdon,

    Good question. We get this one a lot. If you are a licensed professional, payment options or calling yourself a coach is not relevant. You are still held to the strictures of your license when working as a licensed professional. All laws always apply. Now in the time of COVID-19, you may want to listen to our free program, outlined on this COVID-19 Telehealth Best Practices webinar on-demand.

  24. Charles Tullis

    It has been my understanding having spoke with every board in the US that if I am legally licensed I can conduct tele therapy in another state on a military installation with a soldier on that post because the state where the post is has no jurisdiction regarding what is taking place om the post. Is this correct? Therefore, I would not need to be licensed in both states.

    Thanks,
    Charles

  25. Julie

    What are the steps if just realized client lived in different state and 2 telehealth sessions provided? As you stated in article an agency was unaware but personal training found the regulations on own and contacted clients immediately. What are the requirements such as stop billing of provided services, and should state boards be contacted, etc?

  26. Marlene Maheu, Ph. D.

    Julie, Kudos for having the professionalism for asking about how to proceed. You might want to start by contacting the attorney service associated with your malpractice insurance. Upon your attorney’s advice, consider asking for an opinion from the ethics department in your state or national professional association. You should get a detailed list of instructions that you will need to weigh in light of the specific clients who have entrusted you with their care. Best wishes.

  27. OnCallMD

    Thanks for the blog. It is very much important that the doctor’s need to upload their license to render their service in a particular state/country to gain the trust of the patient.

  28. Ginger Schwartz, PsyD

    This is a slight variation on the question from January 2019: I am currently a permanent resident of California and have a California psychology license. If I were to relocate and become a permanent resident of Hawaii but maintain my California license, would I be able to continue doing therapy (telehealth) with my California clients who would be in the same state as my license?

  29. Marlene Maheu, Ph. D.

    Ginger, my understanding is that yes, you may. But as with all jurisdictional questions, I must encourage you to write directly to all involved licensing boards and ask them in email. Only they know their rules. Things are changing so quickly that I do not want to pretend to know everything about all licensing boards at all times. (Ask them and don’t trust anyone else’s to tell you their stance. Only your board(s) know for sure.)

  30. Marlene Maheu, Ph. D.

    Thank you for the comment. I hadn’t previously heard of a doctor sending/showing a copy of their license to the client/patient. However, now that you mention it, I can see how that would instill confidence in the provider of any type. Actually, a copy of the license might also be something that a clinician posts in a video waiting room, where PDFs and images are frequently uploaded for clients/patients to see while they wait for the provider to appear on video. Some video platforms don’t have waiting rooms, but many do these days.

    Thanks again for sharing!

  31. Deanna Moody

    I live in Oklahoma 30 miles from the Texas border. I am not looking for a telecommunications therapist but one I can drive to their office and see in person. Never telecommunications. Are licensed Texas therapists able to see me in Person if I live in Oklahoma?? If not, Could you tell me what type of therapist I am able to see in the state of Texas. I am much better located to see a therapist in Texas than to to try to drive to the nearest accommodating therapist in Oklahoma. Please respond and thank you.

  32. Jillian Denman

    Good afternoon,
    I have a question regarding telehealth across state lines. Due to COVID many college campuses are closed and college counseling centers have gone remote. Many of these students have returned home to different states. If a counselor was seeing a client prior to going remote due to COVID and the student is now temporarily (but undetermined time) in another state, can counseling continue?
    Thanks!

  33. Marlene Maheu, Ph. D.

    Jillian,
    Right now, the vast majority of states have announced that it is ok to enter their state without a license. you just need to check with the licensing board for your profession in all the other states involved. If they are among the states that allow foreign professionals, you probably will just need to complete a 1-2 page affidavit to let that board know that you are entering their state because of COVID. Submitting this documentation is quick and easy, usually does not incur a fee, and highly advised to make sure that your malpractice insurance will cover you if something goes wrong.

  34. Marlene Maheu, Ph. D.

    Ginger, My understanding is that yes, if you are licensed in California, you can serve California citizens from anywhere you choose to be. But just to be sure, please write to the Board and ask them for confirmation in writing.

  35. Marlene Maheu, Ph. D.

    Julie, Kudos for learning about the rules and asking questions early on. Most state boards will probably just ask you to complete an affidavit to get registered during COVID. So it probably isn’t a problem right now. But yes, checking the Board’s website may put your mind at ease. If you contact them, be sure to do it in email so as to create a document trail that is time-stamped. As for the payer, contacting them is important too. They might very well ask you to continue taking care of the client/patient and pay you for it.

  36. Marlene Maheu, Ph. D.

    Charles, You are right about licensing rules being much more lenient when working with military personnel. If you have spoken to representatives of every board in the US and they approve, then you have done your homework. Save those documents. The only other thing that you may want to do is let your malpractice carrier know what you are doing and get their approval in writing.

  37. Marlene Maheu, Ph. D.

    Greg, If you don’t like our current state of affairs regarding inter-jurisdictional law, you are not alone. Most regulators will agree that the laws are outdated and don’t make sense anymore. Nonetheless, the law is the law. We can expect much more change because of CIVID. Meanwhile, write to your board and ask them to change the rules.

  38. Marlene Maheu, Ph. D.

    Sheila,
    I can see why the situation you describe can seem complicated. A consutlation may be needed to get all the details regarding your profession, the state law involved and whether you are officially approved to offer services to military personnel. Best solution that I can recommend is to write to your board and ask for their decision in writing, and call your malpractice carrier to check with their attorney. Until you get an answer, know that during COVID, enforcement is relaxed so you probably are going to be ok. Document your rationales and use the phrase “beneficence over malfeasance” – meaning that if you are breaking the law, your rationale is that you are doing more good than bad.

  39. Marlene Maheu, Ph. D.

    Hello Elsa, Your question is best answered by your Idaho licensing board. Send them an email to get a quicker response. Just off the cuff, not knowing your board, I can say that most US boards would not have a problem with you seeing someone in their state if you are a licensee in that state.

  40. Felicia McParland

    I have a similar question. Due to COVID, I am currently not working in my office so I see all clients online. If a client goes on vacation out of state and still wants to meet online for their weekly session is that okay?
    What about if there were no pandemic, can we meet via Telehealth while they’re on vacation? If not, do they have to miss their appointment, pay out of pocket, or do I have to call that state’s board for permission/instructions to be able to?
    Thank you in advance!

  41. Marlene Maheu, Ph. D.

    Felicia,

    To practice legally over state lines, licensed professionals in the United States have to inform all involved boards in writing for your particular profession at all times. To my knowledge, there are no exceptions to those rules, but if anyone here knows of one, please comment. It is easy enough to go to the board’s website in a foreign state and either contact them by email or look around to see if you can find their position statement about licensed professionals working in their state with a foreign license.

    During COVID, you do that by going to the board for your profession in whatever state and look for an “affidavit” to sign. The vast majority of states now have approved this simple registration process during the emergency.

    After COVID, no one but the states know for sure, but I suspect that the registration process will revert back to being as it was until a significant amount of work is done. The states are literally all over the map with their requirements, and resolving their differences has not been easy despite the best efforts of many groups over several decades of telehealth activism by many parties.

  42. Lindsey Nolan

    I have a question going the opposite direction of many here! Due to COVID I have switched to telehealth in GA and my husband may be getting a job opportunity in Ohio. If we move to Ohio, can I continue seeing my Georgia clients from Ohio? Keeping in mind my LPC license is for Georgia, where my clients reside. I see policies on only serving clients within your licensed state, but not anything stating that the clinician must also be in that state. Any help appreciated!

  43. Patricia

    I work for a psychiatrist in Michigan. I am trying to determine if he can use telepsychiatry across state and international lines if we don’t bill to insurance but bill the patient as self pay. I am finding that it may have to do with malpractice insurance and licensing regulations rather than just an insurance issue. I can’t find any specific information on it though. He has had several international requests for service, but we can’t find if they can be treated via telepsychiatry or if they do, in fact, have to be seen in person regardless of whether or not insurance is involved. Any information you have would be very valuable. Thank you.

  44. Marlene Maheu, Ph. D.

    Patricia, The problem with inter-jurisdictional practice is licensure and malpractice coverage and not payment. Even practitioners who do all work pro bono are subject to licensing laws and cannot practice over state lines. To learn how to practice over state lines legally, take this on-demand 1-hour program: How to Legally Practice Over State Lines: https://telehealth.org/webinar/legally-practice-over-state-lines/ That program also covers international practice. During COVID of course, many states have waived rules. You have to go to the Center for Connected Health policy website to see their list of COVID legal waivers and other changes.

  45. J

    I am a CA licensed Psychologist and work primarily with University students. Due to the pandemic many of my long term clients are considering temporarily moving back home to be with family in other states or in one case to another country (though client is a US citizen). Is it possible for me to continue teleheath sessions with these established clients during these temporary moves? I would not be taking new clients from other states, just hoping to continue with existing ones while they temporarily relocate. Please advise

  46. Marlene Maheu, Ph. D.

    Hello J, It may be best for you to check with your licensing board. They are the only ones who can tell you exactly what to do in your circumstance. Everyone else would be guessing. You may want to take the free webinar being offered here for details: https://telehealth.org/covid

  47. Michael

    Dear Dr. Maheu,

    I am pleased to take a course of yours if you cover this directly, but I have yet to get information from my licensing Board (in California) on this issue. I am licensed in both California and Louisiana. If I am overseas in Europe in the summer (in a country that does not regulate the practice of psychotherapy), can I see my clients via teletherapy in the two states in which I am duly licensed (assuming all other ethical and legal requirements are met and my malpractice carrier is notified). They have already said it’s fine with them (the insurance carrier), depending on whether my state board agrees. Problem is that I cannot get any response from them. Thanks, in advance, for any guidance.

  48. K

    I am a client receiving remote therapy in IL. If I attended an online counseling session while visiting my family in WI, then can I get sued by my insurance company for being unaware of the legalities of interstate therapy? I had notified her beforehand and wished to cancel the session for that week but was not able to because of her insistence. Please advise.

  49. Marlene Maheu, Ph. D.

    K, As a patient, you are not legally responsible for what a clinician does. And violating inter-jurisdictional law rarely results in clinician’s getting sued. The issue usually only comes up when other, more egregious issues are investigated. I hope this helps.

  50. Coco Owen

    Hi Ginger,
    I have exactly the same question about seeing CA telehealth clients while I am in Hawaii. I have emailed the Hawaii board to ask if they have any policy on that, but haven’t received a reply yet (10/28/20).

    Coco Owen, PhD

  51. Marlene Maheu, Ph. D.

    Michael, We have two courses that may interest you. They can be found in replies to others here in this thread. If you have specific questions about your particular circumstance and want immediate answers, you can register for private consultation here: https://telehealth.org/fees. I have helped thousands of professionals find the right answers to inter-jurisdictional questions by showing you exactly where to find your answers. I am not an attorney and do not/cannot offer legal advice. However, the path to these answers is well-worn and I certainly can help you get the answers you need.

  52. Genette Stanton

    As an LPC, if you go on vacation out of the country, but your client is still in Texas where you are licensed, can you see that client through teletherapy?

  53. Marlene Maheu, Ph. D.

    Genette,

    Thank you for your inquiry. Your first step is to contact your licensing board to see what they will allow you to do with the license they have issued to you. The next is to consider whether you are seeking reimbursement from a third party. If so, they may have rules associated with your being out of the country. The third step is to contact your malpractice carrier to be sure they will cover you while out of the country as well.

    We have received so many inquiries about this topic that we have scheduled a 1-hour webinar to answer all your questions and give you 1 CME or CE for attending. it will be recorded so if you cannot make the lives event, you still can learn the info that we present, as well as learn from attendee questions. If then, you want to understand more about licensure and what you can do to practice legally over state lines, I encourage you to attend our upcoming 1-hour webinar Legally Practice Over State Lines. See details HERE.

  54. Lidia H. Glennon

    This is an extraordinary post that is loaded up with so numerous valuable pieces. Much obliged to you for being so itemized on blog.

  55. Patrick

    Hello, as I consider pursuing my MSW I am doing so with the idea that as a LCSW in a given state I will (in some states) be able to travel and conduct telehealth sessions with clients residing in my state of licensure. Do you think this is feasible, and if you believe there will be a national licensure in the future which may relax some interstate commerce laws?

  56. LV

    I am about to take a travel nursing job. I will probably be changing locations every 3 months or so, and obviously finding a new therapist/meds management that often does not make sense. But if telepsych is based the state I am located, will I have to?

  57. Marlene

    If your provider is licensed in the state where you are physically located, you should be good to go. BUT, it would be wise for you to ask your provider to contact their licensing board and that of any other states to which you might travel to see if anything has changed with regard to working with you as you move about. And just know that laws are in flux. Your provider can simply send an email to make the inquiry and have a record of the response for the relevant licensing board.

    If you don’t like a board’s decision, you have the right as a citizen to contact them and ask them to change their regulations. The more requests they get, the more they will be forced to consider a change. If you want to understand more about licensure and what you can do to practice legally over state lines, I encourage you to attend our upcoming 1-hour webinar Legally Practice Over State Lines. See details HERE.

  58. KBD

    My established client needed to abruptly move to another state. Am I legally allowed to provide services to them via telephone/telehealth until the client can establish care?

  59. Felice

    Does anyone know if the use of the term “coach” can apply to other disciplines outside of psychology? I am an occupational therapist hoping to provide pro bono services outside of state lines.

  60. Marlene

    Felice,

    Much to the dismay of many therapists who have paid for coaching training, calling yourself a coach to go over state lines is usually illegal. Most licensing boards would frown upon giving a license to a licensed professional to practice, only to have them disregard all the issues they are mandated to address by calling themselves something different to go over state lines. A number of licensing boards have asked me to consult with them board as they ramp up for telehealth, and this issue always comes up as a common misunderstanding, largely perpetuated by some coaching training programs that have been a bit vague about the real issues. In 100% of the consults, board members have agreed with my pubically-stated position on this. (If you are in doubt, contact your board and ask in writing, then please come back and let us all know what they said.)

    You may also want to put yourself in the shoes of a judge who has to rule in a case involving a licensed professional who chose to call themselves another title to evade the strictures of their license. This infraction is a felony in some states, carries monetary as well a jail time for some fines. Lastly, consider the malpractice carrier, who will most likely weigh in on the side of not paying your benefits if you get sued for practicing in a state without a license, regardless of what you call yourself. Most malpractice policies have a clause that states that they will not be obligated to pay your benefits if you are found to have been “practicing illegally” or other policies say “practicing with criminal intent.”

    I’ve also consulted with a number of professionals who have decided that they can make more $$ by giving up their licensure to practice over state lines. Even that decision can be complicated, in that if you ever were forced to stand in front of a judge, the judge would most certainly have been given evidence of your prior licensure. In that case, it could very well be decided that you intentionally gave up your licensure to “avoid the strictures” of that license, thereby incurring an even harsher penalty if one gets awarded. The harsher penalty could be justified because you have proven at some point in time that you are competent enough to have passed a state licensing exam. You therefore should know better than to practice in another state without a license.

    The system has us coming and going. That’s why licensure is such a big issue in telehealth. Otherwise, everyone would simply call themselves what they want to do as they please. Now I realize that my response to your innocently posed question is probably more than you bargained for, but I want you to know that your original question is a very common one. Again, I think the coaching training programs could have done a much better job educating licensed professionals about what they can and cannot do. From what I hear, most of them are now finally giving their Leaners the right information, but thousands of other pros are still going on information they perhaps were given 10-20 years ago.

    I could go on (and usually do at every opportunity), but if you want to understand more about licensure and what you can do to practice legally over state lines, I encourage you to attend our upcoming 1-hour webinar Legally Practice Over State Lines. See details HERE.

  61. Marlene

    KBD, your licensing board is the only one to trust with questions about your legal obligations. I encourage you to go straight to the source and avoid asking other professionals. Many may have an opinion, but only your board can tell you for sure in these rapidly changing times. Put your inquiry in writing via email. Best of luck to you.

  62. Marlene

    LV, Thank you for your question. Many states have signed the Nurse Compact to share licensure across state lines. Look it up. It has been around for decades and was initially set up by one of the national nursing associations, the NCSBN. I interviewed the chair of that committee years ago. It is real and still exists today. See details HERE.

    If you want to go to a state that is not in the compact, ask that association for guidance. They will know how to direct you. I would not trust other people with such a serious matter. Best wishes to you in your travels.

  63. Marlene

    Thank you for your appreciation, Lidia!

  64. Telana

    How is it in the best interest of the client for the provider unable to speak with their client when they are on vacation? This is almost saying you are unable to leave because you are under orders? I understand if there was an emergency ‘crisis’ then the provider would have to direct the client to find support or already had found a place to direct client. This is like leaving your client hanging out to dry?

  65. Marlene

    Telana, I agree with you 100%. Unfortunately, our lawmakers have not been adequately informed of the needs that we see with the populations that we serve. That is what we repeatedly encourage readers here in this blog learn to write to their legislators, name the specific bill they want to be addressed, give a case example of how a change will be helpful (omit any PHI), and send it to all officials who can help. That requires a little legwork on everyone’s part, but without it, these types of laws will stand, and we have no one but ourselves to blame. If you see this message, and you see how we at TBHI take our valuable time to create this forum, draw attention to these issues, and then explain how to take action, we hope to pass on the message. Please do the same in your circles. Each and every one of us can help. State and national associations also help with these efforts, but many of us no longer join such groups. That is unfortunate because as a large group that can speak for a profession, they have more power. That’s why we always encourage our readers to join their associations and pay their fees. Either way, every one of us can help. Please pass on the message however you can.

  66. Salubritas

    Thanks for getting me back into the reading again. I really enjoyed the stuff you shared in the form of blogs. Keep writing.

  67. John

    Dr. Maheu,

    Thank you for this article and this site. I am confused by the legalities posed here. The scenario’s laid out in the comments seem to be with practitioners providing services to clients with residency in a different state than their license. But what is acceptable if the client has residency in the state the practitioner is licensed but is temporarily on vacation out of state or possibly out of country?

    The scenario of the practitioner licensed in state A, but living in state B, while providing services to a client in state A was deemed acceptable. I see the vacation scenario as no different, a practitioner resides in state A, has license in state A and client has residency in state A but is temporarily on vacation in state B.

    If this is not acceptable this poses a major problem. There is no means of verifying a clients current physical location. The practitioner could ask, but the client could lie. This seems to be a serious problem for practitioners trying to provide teleservices if their legality is completely dependent on the clients honesty.

  68. Marlene

    John,

    It seems that you may be under the impression that licensing laws are rational. They are not. 🙂

    I often organized panels for various national professional assocaitions, including the American Psychological Association. One of my frequent panel speakers was the CEO of ASPPB, the regualtory association where licensing board members attended. He would call his talks something like, “The irrational, contradictory and antiquated licensing laws…” where he explained why telehealth faced so many regualtory barriers at the time.

    He has since retired, and ASPPB received over a million dollars of grant money to develop PSYPACT, but the truth is that more states have chosen to NOT opt in the PSYPACT than have. Adoption is increasing now because of COVID, so I will continue to be optomistic about psychology. As for the other behavioral professions, it is steep climb. Your best bet is to write to your board, explain why you want/need regualtory change, give examples from your caseload as to why people would beneift (omit identifying information) and keep at it. You may want to keep reading some of our blog posts about licensure. You will see that a lot of people have been working diligently for many years to get us where we are now.

    As I’ve said dozens of times in this blog, be the pebble in the shoe of your regulators. Polite, respectiful but persistent. Join your colleages in your state and national associations an advoate for change. Without our getting invovled, this will take much longer than if we each take 20-30 minutes to advocate by writing letters.

  69. RF

    As a patient desiring care, I am beyond confused by all of this.

    I recently registered for help with an online service that matches you to a counselor. My first counselor was based in Ohio. I switched to someone else but she said she couldn’t work with me because she is in Tennessee. I am in NY. I wonder now if the services provided by these companies are legal. Do they just leave it to individual counselors to know the ethical bounds?

    I understand laws may be complicated and varied across states. I’ve read through the comments here and it’s clear this is a maze of confusion depending on the scenario

    I’m wondering: Has anyone compiled a simple spreadsheet (it may not be that simple) that lists the states and these various scenarios and charts them with simple Yes/No or other relevant information?

    This would be a helpful starting point to identify the big places to focus in seeking legislative change.

    Mental health is so overlooked and access to quality care is already so challenging. This is yet another barrier we don’t need.

  70. Karen Elizabeth

    I’ve seen many questions about working with clients who are in another state where the therapist is not licensed. I’m trying my best to find guidance about a therapist who moves to a new state but wants to continue seeing only clients in the state where they are licensed using telehealth. I’m an LMHC in Massachusetts. My family may be moving to Tennessee where I believe I do not meet current requirements to get licensed. (My original counseling license was issued over 20 years ago; regulations have changed a lot since then.) Any recommendations where I can find out if regulations allow me to live in TN but see clients in MA where I am licensed? I can’t find anything in the regulations that says I can’t, but was told in a Telehealth Webinar that therapists should be licensed in both the state where they are AND the state where the client is. I’ve been unable to locate the rule/regulation to confirm that.

  71. Marlene

    Karen, I am sorry to see that you’ve taken a telehealth webinar that confused you rather than answer your question. I trust that webinar was not taken here at Telehealth.org… Regardless, the one point that we always make in our training is never to trust anyone’s opinion about what you should do to meet your board’s requirements. That is especially true about our competitor’s training. There are many overnight “experts” in telehealth these days. Buyer beware.

    The one and only source to trust about your board’s requirements is your board. The same is true for the board for your profession in Tennessee. We encourage you to avoid calling or checking websites. Things are moving quickly right now. Some board websites are out of date when compared to written responses being given to professionals’ written inquiries to get telehealth-related answers.

    Write to both boards, yours in Massachusetts and that for your profession in Tennessee. Explain your predicament, and ask them how to proceed. Send these informational requests to them via mail to get the quickest possible responses. Please let us know what you learn. And good luck. You might be pleasantly surprised at how far many boards have come, particularly in the rural states where the need for our services is high right now.

  72. Marlene

    RF, Thank you for your inquiry. And yes, state laws are listed on this federally-funded websiteCenter for Connected Health Policy, but it may be a bit complex to decipher. The work we do here at Telehealth.org is to help behavioral professionals make sense of such resources and apply them to their practices. It is much complex than many of us can easily absorb. As for business owners, they have a responsibility to obnly offer apprropriate services to consumers, but there is no legal oversight from what we can see. The only thing I can say is consumer beware – which is not right. Consumers should be protected, but that simply isn’t happening. I ask my colleagues to comment if they have additional thoughts or resources to share.

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