1. SLP Cross Licensure in the Age of COVID
The COVID-19 pandemic has been a game-changer in the world of telehealth and remote speech therapy, by dramatically increasing the number of providers and recipients across the country.
Accompanying this meteoric growth has been the increasing challenge of implementing digital health solutions, particularly telehealth, within the patchwork setup of both federal and various state regulations. These often confusing and at times contradictory regulations have made it difficult for providers and telehealth vendors to offer solutions at a large scale, in particular across state lines.
In the current state of public emergency, both the federal government and various state governments are recognizing the need to ease prior restrictions and expand telehealth availability to help patients receive care at home; this helps limit the spread of COVID-19 by further enabling social distancing and freeing up providers’ brick-and-mortar hospitals and clinics to treat COVID-19 patients.
The need is clear, as is the desire by all parties to jump in and offer telehealth visits. The new challenge has become understanding how state requirements fit with daily updates to federal law.
2. The Status Quo
Traditionally, licensing laws for mental health care disciplines in the United States have been intentionally defined and regulated by the authority of individual states to allow licensing boards to operate independently. Consequently, definitions for the scope of practice for each discipline, and the regulation of the professional requirements, are often quite different between boards across states.
Another reason for the state-specific laws involves states’ territorial agendas: the desire to protect the livelihood of local professionals, especially in sparsely populated states, from being overrun by practitioners from other states.
Given that most of these licensing laws were written in the 1950s, they don’t reflect the dramatic changes allowing people to travel easily between states and countries, nor the revolution of the internet.
It is obvious to almost all practitioners and experts alike that many state licensing laws are still archaic and do not match 21st-century digital realities. While most states address telehealth issues, some states have yet to address the issue of cross-border licensing.
3. Fully Grasping the Complexity
When it comes to telemental health, telepsychology, e-counseling or teletherapy, the overarching question is, where does the psychotherapy or counseling take place? Does it take place where the client is, where the therapist is, in both places, in cyberspace, or in all three places?
Old definitions of the location of treatment are not suitable to modern digital and Internet-based treatments. This question gets additionally complicated when considering what is now becoming the prevalent practice of cross-jurisdictional clinical work.
A basic thing that a practitioner needs to understand is that, when a clinician is physically located in a state different from his/her client, the jurisdiction over the therapeutic relationship falls on both states.
It is therefore important for mental health professionals to fully understand and comply with the regulations of both states. Given the variability in state laws, this can get quite complex.
For example, if a psychotherapist is licensed in state A and treats a client who is present in state B (also known as the foreign or host state), s/he might not be violating state A’s licensing laws but may be violating state B’s licensing laws (if they have laws that are relevant to the issue).
Some states, for example, openly allow clinicians licensed outside of their borders to offer telehealth to clients in their jurisdiction; other states restrict and regulate this, and some states prohibit it altogether.
The issues of inter-jurisdictional – across the state or country boundaries (across states’ lines) can be summed up as follows:
- whether a psychologist in State A can treat a patient who is in State B via telehealth if the practitioner is licensed only in State A but not in State B;
- a psychologist who is temporarily in State B, without a license there, can treat the patient back home in State A via telehealth;
- whether, when neither psychologist nor client is physically in State A, where the practitioner has a license, treatment via telehealth can take place.
- This topic also covers international issues such as whether a European or South American counselor can treat a patient in the US, where the counselor or psychotherapist is not licensed.
- Or visa versa, whether a US licensed counselor can treat a patient in China or another country without being licensed there.
4. Solutions
Cross-State Pacts
But recent changes like the creation of The Psychology Interjurisdictional Compact (PSYPACT), and the fact that many national associations are currently working to develop a cross-state practice model, are encouraging. Until things become clearer and more regulated, the question becomes how to apply telehealth issues across state lines to the existing traditional regulations.
The SLP equivalent is the ASLP-IC. ASLP-IC 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.
The Audiology & Speech-Language Pathology Interstate Compact (ASLP-IC) facilitates the interstate practice of audiology and speech-language pathology while maintaining public protection.
Current Status of ASLP-IC: ASLP-IC will become operational when ten states have enacted ASLP-IC legislation. The interactive state map lists the current ASLP-IC member states and other states proposing to join the ASLP-IC.
Privilege to Practice: Once ten states enact ASLP-IC, licensed audiologists and speech-language pathologists will be able to apply for a privilege to practice in-person and through telehealth in ASLP-IC states.
The ASLP-IC offers several benefits to the public:
- Improves continuity of care
- Improves portability for military spouses
- Improves access to audiology and speech-language pathology providers
- Increases choice of audiology and speech-language pathology providers
- Facilitates alternate delivery methods (Telehealth)
- Simplifies/speeds up the current process
- Addresses portability & barriers to access
- The practice of audiology and speech-language pathology occurs in the state where the patient/client is located at the time of the patient/client encounter
Contacting Licensure Boards
It is strongly suggested that mental health professionals consult their licensure boards for guidance to practice outside their state, as well as contact other jurisdictions’ licensing boards (where the client resides) regarding the possible need for a temporary license and to understand the laws and regulations addressing these issues.
When it comes to the question of “residence vs. presence” of a client in a state other than the state of the practitioner, one should know that, as soon as a client is simply present on the ground of a different jurisdiction, not necessarily as a resident, the client falls under the responsibility of that state’s licensing board.
It means therefore that the board of the foreign state decides if the clinician complies with their laws, regulations, and rules when working with a person within their jurisdiction.
A primary question that arises is whether it is legal or ethical to violate state B’s (the foreign state’s) laws and regulations, where the practitioner does not have a license, if they have such rules for inter-state clinical work.
The secondary question is how likely it is that state B would pursue the therapist who resides in state A, or file for his/her extradition from state A. So far, it is not very likely that state A will spend time, efforts, resources, and thousands of dollars to try extraditing a therapist from state A so that it can bring him/her to justice in state B (and then spend more money in court costs).
That being said, therapists need to be mindful of potential penalties for the unlawful practice of telehealth. If State B discovers that a practitioner is offering services in their jurisdiction without appropriate authorization, they might be able to bring penalties against the practitioner, which could include reprimand, fines, charges of criminal behavior, or, while unlikely, even incarceration.
Temporary Licensing Provisions and Reciprocity Arrangements
Some states have temporary licensing provisions; some have reciprocity arrangements for psychologists. At present, SLPs don’t have a national license or any reciprocity arrangement whereby a clinician who is licensed in one jurisdiction may be automatically eligible to practice under that license in other jurisdictions.
However, Nursing has an arrangement that allows nurses licensed in one jurisdiction to practice in another jurisdiction under his or her one license. This interstate compact has been agreed to by approximately 24 states. While such a nurse may practice in one state using the other state’s license, the nurse is responsible to be knowledgeable of and to follow all relevant laws and regulations in the state where he or she is practicing.
Similar arrangements have been instituted for medics and EMTs who may need to cross state lines in their line of duty. Regretfully, such an arrangement is not available for mental health professionals, yet.
5. Becoming Informed will Save You a Big Headache
As a result of this kind of complexity and confusion, most mental-health practitioners who practice a form of telehealth, such as calling one’s client, are guessing about what is required of them and if, practicing across state lines at times, they are not following the proper regulations.
The average professional’s knowledge and understanding of telehealth issues is still quite limited. A study from 2018 involving psychologists who were asked about their attitude toward online services revealed that 42 percent of participants either believed that practicing online is not regulated by their licensing boards or they didn’t know if it was. (For information about the survey click here.)
There are a variety of issues that mental health professionals need to understand to properly and legally practice in other jurisdictions, such as:
- What are the regulations and laws of each state regarding the practice of telemental health, and where can one find them?
- Which states are more open to cross-jurisdictional practice?
- How does one get a temporary license in other states?
- How should a mental health practitioner document their practice to meet different requirements in different states?
- What types of documentation are required for behavioral practice in different states?
- How does a practitioner’s malpractice insurance carrier protect them if the case involves illegal practice?
6.The Bottom Line
As is so often the case, regarding the tricky cross licensure challenge for SLPs, knowledge is power. The more that you learn about this dynamic and evolving situation, the better you will be legally protected, and the more you will be liberated to practice across state lines.
This blog is a basic yet essential outline of a most timely and critical issue that will bear directly on your profession and income. It’s now time for you to “take the bull by the horns” and answer the questions most relevant to your particular situation. Success will not only be yours but the children’s that you serve as well. They are depending on you.
