Can a Therapist Do Telehealth Across State Lines? Navigating Licensure, Ethics, and Risk Management

Mental health care is shifting rapidly, with telehealth gaining popularity as a mode of service delivery. As clients move more frequently and seek care across state lines, therapists face a complex web of licensure requirements, ethical concerns, and risk management strategies.

While telehealth offers undeniable convenience and accessibility, practicing across state lines involves more than just starting a video call. Each state enforces its own rules and regulations for mental health care, and noncompliance can have serious consequences.

This article explains the core principles of interstate practice, the basic licensure knowledge every therapist needs, and the steps to widen your telehealth reach while reducing risk. Whether you're a seasoned telehealth provider or new to this growing field, knowing the details of practicing across state lines helps you provide safe, effective, and compliant care.

Licensure Basics and Jurisdictional Authority

For practicing telehealth across state lines, the "place-of-service" rule is the most important concept. This rule states that the laws and regulations of the state where the client is physically present during service govern mental health care practice, not those of the therapist's state.

Licensure requirements and practice scopes can vary significantly among mental health professions like psychologists, social workers, counselors, and marriage and family therapists. Each has its own set of rules and regulations governing interstate practice, so therapists must understand the specific requirements for their respective license type.

When considering interstate practice, therapists should be aware of pathways to licensure mobility, such as reciprocity, endorsement, and temporary practice permissions. Reciprocity allows a therapist licensed in one state to obtain a license in another state without meeting all new licensure requirements. Endorsement requires the therapist to meet the new state's full licensure requirements to practice in that state. Temporary practice permissions may enable a therapist to offer services in another state for a limited time without obtaining a full license.

Interstate Compacts and Provisional Pathways

Interstate compacts are changing how telehealth practice works for mental health professionals. The Psychology Interjurisdictional Compact (PSYPACT) allows licensed psychologists to provide telepsychology services across state lines in participating states. To join PSYPACT, psychologists must:

• Meet eligibility criteria: Have an active license in a PSYPACT state and no disciplinary actions.
• Submit an application: Complete the PSYPACT application and pay the necessary fees.
• Adhere to compact rules: Follow all PSYPACT regulations, including limits on in-person services.

Similar compacts are starting to appear for other mental health professions:

• Counselors: The Counseling Compact (CC) is currently in development to enable interstate practice for licensed professional counselors.
• Social Workers: The Council of State Governments (CSG), in collaboration with the Department of Defense (DoD) and the Association of Social Work Boards (ASWB), is working to develop a new interstate compact.
• Marriage and Family Therapists: The American Association for Marriage and Family Therapy (AAMFT) is in the early stages of discussing a potential MFT compact.

Beyond compacts, some states offer temporary or emergency practice permissions for out-of-state providers. These permissions may be granted in situations such as:

• Disaster response: States may waive licensure requirements for mental health professionals helping with disaster relief efforts.
• Short-term practice: Certain states allow temporary practice for a limited number of days per year without needing a full license.

As telehealth services keep expanding, interstate compacts and provisional practice pathways will become more important for enabling therapists to provide care across state lines while ensuring public protection and maintaining professional standards.

Legal and Ethical Considerations Beyond Licensure

Licensure is just one piece of the complicated puzzle when providing telehealth services across state lines. Therapists must also handle a variety of legal and ethical considerations that can vary significantly from state to state:

• Duty to report: All states have mandatory reporting laws for suspected child abuse or neglect, but the specifics of these laws can differ. Some states require reporting of elder abuse or domestic violence, while others do not. Therapists must learn about the reporting requirements in each state where they practice.
• Involuntary commitment: The criteria and procedures for involuntary psychiatric hospitalization can also vary by state. Some states allow telehealth providers to initiate involuntary commitment, while others require an in-person evaluation. Knowing the local laws and resources is important for managing high-risk clients across state lines.

Malpractice coverage is another significant consideration. Many malpractice insurance policies have specific provisions or exclusions related to telehealth, particularly when practicing in multiple states. Therapists should carefully review their policy language and consult with their insurance provider to ensure adequate coverage for interstate telehealth services.

Informed consent is a fundamental aspect of ethical practice, and telehealth across state lines adds an extra layer of complexity. In addition to discussing the standard risks and benefits of treatment, therapists must also address:

• Physical location: Clients should disclose their physical location at the start of each session, as this determines the applicable laws and regulations.
• Emergency procedures: Therapists must have a clear plan for handling emergencies or crises when the client is in another state, including resources local to the client and their emergency contacts.
• Jurisdictional limits: Clients should be aware of any limitations on the therapist's ability to provide services due to licensing or other legal restrictions.

Navigating the legal and ethical landscape of interstate telehealth can feel overwhelming, but it is necessary for providing safe, effective, and compliant care. Consulting with colleagues, professional organizations, and legal experts can help therapists stay informed and proactive in managing these complex issues.

Technology, Privacy, and Record-Keeping Across State Lines

Telehealth technology presents new challenges for protecting client privacy and maintaining secure records when working across state lines. Therapists need to ensure their telehealth platform and practices are HIPAA-compliant while also adhering to any additional state privacy regulations, such as mental health parity laws or specific requirements for adolescent consent.

To safeguard client data during interstate telehealth, consider these best practices:

• Choose a HIPAA-compliant telehealth platform: Select a software provider that offers end-to-end encryption, secure data storage, and strong access controls. Confirm their compliance through a Business Associate Agreement (BAA).
• Implement strong authentication and access controls: Use multi-factor authentication (MFA) to prevent unauthorized access to client records. Restrict data access based on staff roles and maintain detailed audit logs.
• Encrypt data in transit and at rest: Ensure all client information is encrypted during video calls, messaging, and file transfers using strong standards. Use secure storage solutions that encrypt data at rest.

When handling client records across state lines, therapists must also consider the secure storage of data and any state-specific requirements for data hosting locations. Some states may require client records to be stored within their borders or have specific data retention policies. Research the regulations in each state where you practice to ensure compliance.

Interstate telehealth also complicates the process of responding to subpoenas or court orders related to client records. When a subpoena originates from another state, therapists must navigate the legal requirements of both jurisdictions. Consult with an attorney familiar with mental health law and interstate practice to develop a plan for managing out-of-state record requests.

Focusing on client privacy and secure record-keeping is vital for therapists providing telehealth services across state lines. Implementing strong technical safeguards, understanding state-specific requirements, and seeking legal guidance when needed can help protect both clients and therapists in this rapidly evolving practice area.

Workflow Integration and Risk-Reduction Strategies

Bringing interstate telehealth into your practice workflow requires careful planning and attention to risk management. Start each session by asking for the client's physical location and noting it in the progress note. This keeps you in compliance with telehealth record keeping requirements. 

Setting up clear crisis-response protocols is important when working with clients across state lines. These protocols should include:

• Local emergency contacts: Keep a list of emergency services, crisis hotlines, and trusted contacts in the client's area.
• Escalation procedures: Develop a plan for assessing risk, contacting local resources, and involving emergency services when necessary.
• Documentation: Record all crisis-related actions, including dates, times, and parties contacted.

To comply with licensure requirements in various jurisdictions, establish a system for periodically reviewing your license status, renewal deadlines, and continuing education requirements in each state where you practice. This might involve:

• Calendar reminders: Set up automated reminders for license renewals, compact privileges, and state-specific continuing education deadlines.
• Dedicated tracking spreadsheet: Use a spreadsheet to monitor licensure information, renewal dates, and continuing education progress across states.
• Continuing education plan: Identify courses and providers that meet the requirements for each state and maintain a schedule for completing them.

These risk-reduction strategies can help make your interstate telehealth practice more efficient while ensuring you meet state regulations and ethical standards. Regularly review and update your protocols as laws and best practices change to maintain a safe, effective, and sustainable telehealth practice.

Practical Steps for Expanding Your Telehealth Reach

To grow your telehealth practice across state lines, you need careful planning and strategic decision-making. Begin by assessing the demand for your services in various states and identifying target areas where you want to practice. Consider factors such as:

• Population demographics: Look for states with a high concentration of your ideal clients, such as specific age groups, cultural backgrounds, or clinical needs.
• Licensure requirements: Research the licensure process, reciprocity agreements, and interstate compacts for your profession in each target state.
• Reimbursement landscape: Investigate insurance credentialing, parity laws, and reimbursement rates for telehealth services in each state.

After identifying your target states, create a budget and timeline for obtaining additional licensure. Factor in the costs of:

• Application fees: Each state will have its own fees for initial licensure and renewal.
• Jurisprudence exams: Many states require passing a state-specific law and ethics exam.
• Background checks: You may need to submit fingerprints and undergo a criminal background check.
• Continuing education: Keep track of the unique continuing education requirements for each state license.

Allocate enough time in your schedule to complete the licensure process, which can take several months. Develop a system for tracking deadlines, renewal dates, and continuing education progress across multiple states.

Connecting with colleagues and experts who have experience with interstate telehealth can provide valuable guidance and support. Consider:

• Joining professional organizations: Many national and state professional associations have resources and networks focused on telehealth and interstate practice.
• Participating in online communities: Connect with other therapists navigating interstate telehealth through social media groups, listservs, and forums.
• Seeking consultation: Work with a consultant who has expertise in interstate practice to review your cases, protocols, and compliance strategies.

Staying Current: Resources and Continuing Education

The changing nature of interstate telehealth requires therapists to stay informed about regulatory changes, ethical guidelines, and best practices. Keeping an eye on updates from state licensing boards, professional associations, and federal agencies helps maintain compliance and provide effective care.

Key resources for staying updated include:

• State Licensing Boards: Regularly visit your state licensing board's website for updates on telehealth regulations, licensure requirements, and disciplinary actions. Many boards offer email newsletters or social media updates for your convenience.
• Professional Associations: National and state professional associations, such as the American Psychological Association (APA), the National Association of Social Workers (NASW), and the American Counseling Association (ACA), provide resources on interstate telehealth practice, including webinars, articles, and policy updates.
• Federal Agencies: Stay informed about federal telehealth policies and reimbursement changes by following updates from the Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS), and the Health Resources and Services Administration (HRSA).

To ensure timely compliance with interstate telehealth regulations, set calendar reminders for important deadlines, such as:

• License renewals: Keep track of license expiration dates for each state where you practice, and plan ahead for renewal requirements, such as continuing education or jurisprudence exams.
• Compact privileges: If you participate in interstate compacts like PSYPACT, set reminders for renewing your compact privileges and completing any necessary training or attestations.
• Legislative changes: Monitor legislative sessions in the states where you practice, and set reminders to review any new telehealth laws or regulations that may affect your practice.

Engaging in continuing education (CE) helps therapists stay updated with the latest research, best practices, and ethical standards related to interstate telehealth. Look for specialized CE courses that cover topics such as:

• Legal and ethical considerations: Courses that explore the unique legal and ethical challenges of practicing across state lines, including licensure requirements, informed consent, and privacy regulations.
• Technology and security: Training on selecting and using HIPAA-compliant telehealth platforms, implementing security best practices, and troubleshooting technical issues.
• Cultural competence: Courses that address cultural considerations in telehealth, such as working with diverse populations, navigating language barriers, and adapting interventions for different cultural contexts.

Staying informed about interstate telehealth is an ongoing process that requires effort and continuous learning. Relying on trusted resources, setting reminders for important updates, and participating in targeted continuing education can help therapists manage the complexities of practicing across state lines while providing high-quality, compliant care to their clients.

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