PSYPACT- Practicing Over State Lines May 2024.pptx

Navigating
PSYPACT:
Your Guide
to
Interstate
Practice

Mariann Burnetti-Atwell, PsyD
• Chief Executive Officer for the Association
of State and Provincial Psychology Boards,
the founding group behind PSYPACT.
• She has been touring the country training
psychologists in the basic of PSYPACT for
several years.
• She sits on the PSYPACT Commission as
the Ex-Officio Member, but does not
represent the Commission or the opinions
of the Commission.

Marlene M. Maheu, PhD
Published five peer-reviewed telehealth textbooks,
60+ book chapters and journal articles, and 1250+
blog posts found at blog.telehealth.org.
Developed 72+ hours of evidence-based and
competency-based telehealth training at
Telehealth.org, trained more than 86k professionals
in telehealth since 1994.
• Founder & CEO of Telehealth.org
• Founder & CEO of the Coalition for Technology
in Behavioral Science (CTiBS) & Founder of
the Journal for Technology in Behavioral
Science
• Chair of the first Committee for Telebehavioral
Health Competencies
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And you? Please introduce
yourself to our group with:
1. Your City, State
2. Your Specialty …
3. If you have ever taken any
of our training.

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Suggestion
Make a Telehealth To-Do List
• Focus on “to-dos”
• Group then prioritize your activities.
• Review weekly with colleagues if you
can.
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Disclaimer & Disclosure
Our efforts are focused on educating rather than
deliver legal or psychological advice. We are not
attorneys. We and our organizations disclaim
responsibility, that is, we cannot and will not take
responsibility for your choices based on our broad
overview of relevant issues.
Please proceed with caution and seek the advice of
an experience telehealth attorney before taking any
questionable action or if you have any questions.
DISCLOSURE: we have no conflicts of interest with
parties mentioned in this presentation.
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Audio-Only Mode
• You are free to leave after our
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• What is your #1, most burning
legal or ethical question about
working over state lines with
PSYPACT?
• Please type your response into the
chat box.

Maximize Your Learning
• Please turn on your camera.
• Ask questions in chat box as they occur
to you rather than waiting.
• We will stay up to 10 minutes after the
meeting to answer as many of your
questions as possible. First come, first
served.
• You are free to leave after 60 minutes
for post-test content will have been
covered.
• Ask family & friends to stay away. 
• Mute your phone. Lock your door.

Learning Objectives
• Participants will explain the responsibilities of
PSYPACT practitioners in ensuring compliance with
state laws and ethical standards.
• Participants will describe how to assess ethical
considerations, including confidentiality and
informed consent when practicing across state
lines under PSYPACT.
• Participants will describe where to access resources
and support for maintaining ethical and legal
compliance into their practice as PSYPACT
practitioners.
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When Practicing Telehealth, All In-Person,
Local, Legal & Ethical Rules Apply

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Regulations for
Practicing Over
State Lines Are
Made by State
Licensing
Boards
• Not the federal
government
• Not professional
associations
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Who to ask about
licensure?
State Boards Are Your Only
Only 100% Reliable Source
• No exceptions.
• Not one.
• None.

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State laws and
regulations override
all other contributing
factors when it
comes to practicing
over state lines.
This is even true
with national
emergencies.

Which State Boards Are
Involved with Practicing
Over State Lines?
Licensing boards for your
profession or different professional
boards for supervisees from other
professions may assert jurisdiction.
• The board in your state(s) of
licensure.
• The licensing board in the
patient’s or client’s location at
time of contact.
• Boards in both geographic
areas.

Typically, healthcare providers must be licensed in the state where
the client or patient is located at the time of the telehealth
interaction.
• Patient centered care – care follows the client or patient
• PSYPACT facilitates the ability for providers to practice in multiple
states. However, several responsibilities remain for the individual
practitioner to navigate.
• The bulk of today’s program will outline those responsibilities.
• This outline is not necessarily comprehensive.
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All ethical codes start by requiring
adherence to all relevant laws.
• Therefore, all ethical standards
are built on the foundational
framework established by law.
What is relationship
between law & ethics?
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1. State Licensing Requirements (PSYPACT)
2. Definition of Practice – Standard of Care
3. Emergency Service Management
4. Establishing a “Professional Relationship”
5. Privacy & Confidentiality
6. Informed Consent
7. Continuity of Care
8. Mandated Abuse Reporting
9. Mandated Duty to Warn (Protect, Tarasoff)
10. Mandated Practitioner Reporting
11.Prescribing Policies
22 Regulations & Issues that Can Differ
Across States
18

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12. Reimbursement Regulations
13. Clinical Documentation Requirements
14. Ownership of Patient Records
15. Cross-State Emergency Licensing Exceptions
16. Supervision, Telesupervision & Documentation
17. Continuing Education Requirements
18. Malpractice Liability Insurance Policy Laws
19. Professional Liability (Malpractice) Coverage
20. Cultural, Diversity & Linguistic Accommodations
21. Definitions of Telehealth
22. Registration for # of Days or Miles
22 Regulations & Issues that Can Differ
Across States
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Types of Behavioral Regulatory
Boards in the US
1. Addictions
2. Behavior Analysis
3. Counseling
4. Marriage & Family Therapy
5. Nursing
6. Nurse Practice
7. Psychology
8. Psychiatry
9. Psychoanalysis
10.School Psychology
11.Social Work
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1. Regulatory Boards.
• States can differ widely and operate
unchallenged as little “fiefdoms.”
• States have many regulatory boards.
• Boards are made of a few people who
interpret state law for their profession.
• Board interpretations of state law can
differ widely from state to state.
• Regulations can also differ widely from
one board to the next in the same state.
Regulations & Issues that Can Differ
Across States
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• These outside boards can dominate in
language, which can lead to contradictions.
• Some state have composite boards with
multiple professions under the psychology
board (behavior analysts &
psychoanalysts). Regulatory language can
be confusing to out-of-state professionals.
• Example: New Jersey refers to telehealth
services by counselors and psychologists
as “telemedicine,” even though New Jersey
psychologists and counselors are
prohibited from practicing “medicine.”
Across States
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Some regulations may lack internal
consistency. Language in one part of the
code can contradict another part of the
same code.
• Some states have adopted the APA
ethics code as law (California), which
can be problematic as the ethics code
was written to guide thinking through
dilemmas - and not written to be law.
Across States
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1. Boards Define the Standard of Care – A
Standard of Care outlines the level and type
of care that a reasonably competent and
skilled healthcare professional, with a
similar background and in the same
community, would have provided under
similar circumstances.
• Can vary, with some states providing
detailed guidelines on what is expected of
telehealth providers. Other states say little or
nothing about telehealth, leaving the
practitioner to guess at how to operate.
Across States
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Some boards require that you “register” with
their board when licensed from out of state, but
do not routinely confirm receipt of forms when
filed through the board website (Georgia).
You cannot be sure if you are legally
registered without repeatedly writing to
inquire about status.
• Weeks or months can pass with
communications unacknowledged.
• Best to always communicate by email
with time stamps, if email address is
provided.
• Others answer inquiries in just a few days.
• Some boards have members who are not
psychologists (Colorado).
Across States
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https://psypact.site-ym.com/page/PracticeUnderPSYPACT
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2. Boards Define the Standard of Care –
Outlines the level and type of care is to be
delivered by a reasonably competent and
skilled healthcare professional, with a
similar background and in the same
community, under similar circumstances.
Regulations vary, with some states providing
detailed guidelines for expectations of
telehealth providers. Other states say little or
nothing about telehealth, leaving practitioners
to guess at how to conduct themselves.
Across States
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3. Establishing a “Professional
Relationship” – States may differ on
definitions for when a provider-patient
relationship exists.
Depending on the state, such a relationship
can be established with:
• Any contact
• Intake protocol
• Signing informed consent document.
Across States
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• States typically have a “definition
of practice.” That definition
explains what licensees are
expected to do.
• States are in flux with regards to
telehealth.
• Regulations can change quickly
as regulators get more
sophisticated about telehealth
practice.
Who decides when healthcare
professionals are engaged in
a “professional relationship?”

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4. Privacy & Confidentiality
• Patient privacy as defined by the Health
Insurance Portability and Accountability
Act (HIPAA)
• Privacy and confidentiality additions can
be made by state law, such as in
consumer protection states such as
California & Texas.
• Digital Data - Some states may have
additional protections above and beyond
HIPAA. See California Consumer Privacy
Act.
Across States
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5. Informed Consent. Providers must be aware of
and comply with the specific legal and regulatory
frameworks specifically governing telehealth.
Can vary widely.
• Florida, has a specific Telehealth Provider
Registration
• California only requires verbal telehealth
consent, but must be documented in the
patient record, and accompanied by a full
traditional informed consent.
• What about reimbursement issues?
Recording sessions? Interruptions?
Disconnects? Your termination procedures
and much more
Across States
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6. Continuity of Care
• Some states require continuity of care
regardless of employer policies asking
employees to cover “shifts” online.
• No single source for this information, but
states vary widely on their requirements.
• Resources:
• State boards
• State Health departments
• Legislative resources and legal
databases
• State Insurance Departments &
Commissioners
• Your informed telehealth attorney
Across States
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7. Mandatory Reporting – Duty to Report
States may differ in their requirements for
mandatory reporting of certain conditions or
situations encountered through telehealth.
Across States
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7. Mandated Reporting
• Child Abuse and Neglect - All states require
the reporting of suspected child abuse and
neglect. However, the specifics of what must be
reported, to whom, and within what timeframe
can vary.
• Legal definition of “child” – age 18?
• Do you report past abuse?
• Past abuse if children are not currently in
danger?
• Elder Abuse - Physical, sexual, emotional
abuse, or financial exploitation, is typically
mandatory, but the specifics can also vary by
state.
• Spousal - Differs by state, setting
Across States
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8. Duty to Warn
• National Conference of State
Legislators tracks Duty to Warn
(“Serious Harm”) Differences
Across States
• http://www.ncsl.org/research/he
alth/mental-health-
professionals-duty-to-
warn.aspx
What about Duty to Warn? (AKA
Duty to Protect or Tarasoff)
Regulations & Issues that
Can Differ Across States
Mandated Reporting
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https://www.ncsl.org/research/health/mental-health-professionals-duty-to-warn.aspx
8. Duty to Warn
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National Conference of State Legislators Website

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https://www.ncsl.org/health/
mental-health-professionals-
duty-to-warn
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National Conference of State Legislators Website

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9. Mandated Practitioner Reporting
• California Practitioner Misbehavior
• Impairment due to illness, drugs, alcohol
or physical condition
• Improper billing
• Sexual communications -
Licensees/registrants who are told by a
patient of sexual involvement with another
therapist are required to give the patient
the Department of Consumer Affairs
brochure: Therapy Never Includes Sexual
Behavior
Across States
38

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9. Mandated Reporting
• California Practitioner Misbehavior
Sexual Communications Regulation
URL:
• https://www.psychology.ca.gov/consu
mers/filecomplaint.shtml#:~:text=Lice
nsees%2Fregistrants%20who%20are
%20told,Therapy%20Never%20Inclu
des%20Sexual%20Behavior.
Across States
39

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10. Emergency Service Management
You must have a protocol for emergency
situations wherever your client or patient is
located.
• Informed Consent is cornerstone.
• Ask for ongoing information about local
hospital / EMT or Paramedics
• Get info from local police/sheriff station
about their respective policies
• Your “opening protocol” – where are they
now? Privacy? Child/elder care? Other
expected interruptions?
Across States
40

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Opening protocol:
• Ask client/patient to “attest” to
location at the start of every
session.
• Document their verbal attestation.
• Include the “location discussion”
in your informed consent process
• If client is not in your state(s) /
province(s) of licensure, ask if
they are having an emergency
• Use an “emergency protocol”
rather than full session
• End the meeting.
Say more about the opening
protocol and how I can establish
my client’s location…

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11. Prescribing Policies
States have varying regulations regarding the
prescription of medications via telehealth,
especially controlled substances.
• Providers must comply with both federal and
state prescribing regulations. DEA
• Imagine you don’t prescribe medication but are
seeing someone who takes medication. What
is your policy if they 1. run into trouble with
those medications, 2. they need medical care,
and 3. they are in a state where their prescriber
is not licensed and won’t treat?
• Did you mention your medical care policy in
your informed consent?
Across States
42

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12. Reimbursement Regulations: Terms and
rates for telehealth services are not uniform
across states for private or Medicaid insurers.
• Reimbursement requirements in different
states can vary significantly. State funded
services often have their own limits.
• Some states have parity laws that require
reimbursement for telehealth services at the
same rate as in-person services.
• Others do not, which allows insurers to cover
or not cover, as they choose, often for
unspecified reasons.
• Many private insurance companies test
“markets” in one state or another by
changing coverage before they
disseminate more widescale policies
across states.
Regulations & Issues that Can Differ Across
States
43
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12. Reimbursement Regulations
• Make sure your services are covered by
Medicare, Medicaid, or private insurance in
the state where the client patient is located
when receiving services.
• Medicare violations can land you in
prison, and incur hefty financial
penalties.
• Visit state insurance department or
“commission” websites for information and
to ask questions related to state policies of
relevance to your work.
Across States
44
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13. Documentation Requirements
In some states, mere mention of telehealth and your
notation that the mention occurred will suffice to meet
telehealth requirements (CA). Others require more.
Hwhichever, the implication is that you have performed
a completed a traditional informed consent process.
Steps:
• Have a copy of IC in your hands.
• Ask if they have read it. If not, summarize.
• If yes, ask for questions.
• Note questions and your answers on your copy.
• Mention having completed this IC process in your
patient notes.
• Have pt. review, sign, send/mail their copy to you.
Regulations That Can Differ Across
States
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14. Ownership of Patient Records Accurate and
thorough documentation of telehealth
services is essential, including compliance
with each state's laws regarding medical
records.
• Protects the people you serve.
• If you work for a group or employer,
protects them.
• Protects your profession’s reputation.
• Protects you.
Across States
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14. Ownership of Client/Patient Records In some
states, the provider owns the record.
• In others, the patient owns the record.
• Under HIPAA, patients are entitled to obtain
their digital records.
• The single most frequent HIPAA violation
is refusing to give ACCESS to digital
records.
• Always identify who owns the client or
patient record as well as your legal
requirements before giving or denying
access.
States
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13. Documentation & Ownership
Resources:
• State Boards
databases
• Insurance commissioners
• Your informed telehealth attorney.
States
48
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15. Supervision, Telesupervision & Documentation
• State definitions of supervision & telesupervision can differ.
(Also relates to approved modalities.)
• Some states have a specific number of hours of training
required for supervisors to offer services through telehealth.
• Others do not.
• Be mindful of requirements of supervisees.
• Their mandates can differ from yours within and across
different states.
• You must comply with your regulations and guide them
to comply with theirs.
• Understand & reconcile differences between
regulations.
Across States
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• Interjurisdictional Practice
(psychology & addictions)
• Interstate practice (SW)
• Interstate compact (counseling)
• License portability (MFTs)
• Multistate license (nursing)
• Interstate licensure (medicine)
What are discipline-specific
terms for referring to
practicing healthcare across
state lines and international
borders?

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2020

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https://www.cchpca.org/
IMPORTANT RESOURCE: Free, federally funded resource for identifying
current and future state laws related to interjurisdictional practice.

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17. Continuing Education Requirements
Some states require specific training to practice
telehealth, while others do not.
• Standard: “What would a reasonable
professional have done in a similar
circumstance?”
• Be able to demonstrate that you have
obtained formal, documented training
including detailed telesupervision training by
an approved CME or CE training group for
your profession.
• Make a copy of the course description page
(= to a syllabus) to demonstrate content
Across States
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18. Regulations from State Departments of
Insurance
• Providers should ensure that their professional
liability insurance covers telehealth services
across state lines.
• Read the fine print in your policy. (Seriously.
Read it all.)
• Write a letter to your malpractice carrier asking
for a written response to all your questions. Get
all answers to your questions about your
telehealth coverage in writing – in plain English.
• Get a cybersecurity policy.
Regulations & Issues That Can Differ
Across States
55
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• Malpractice & Liability Laws - The
malpractice and liability laws applicable to
telehealth can differ from state to state,
affecting how telehealth services are
delivered.
• Malpractice insurance companies, then, can be subject
to differing laws about how and when they will protect
you.
• Violating a state’s regulations could be
grounds for carriers to refuse paying your
benefits in a lawsuit.
• Your benefits (coverage) can be nullified if
you are practicing criminally or with criminal
intent.
Across States
56
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19. Professional Liability
Coverage (Malpractice
Insurance)
Let us state the issue overtly: Illegal practice over state
lines occurs when you practice without adhering to all
state-specific regulations issued by the state’s relevant
licensing board(s).
• Check your policy for fine print that includes any
mention of illegal or criminal activity.
• Write to your malpractice carrier and describe your
proposed service, including every state you enter to
deliver care. Ask for their approval, coverage, and
stipulations.
• Avoid being the provider or employer who tests
these insurance coverage limits.
How important is following all
these laws to your malpractice
coverage?
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https://telehealth.org/mental-health-telehealth-across-state-lines/

Questions for Your Liability or
Malpractice Carrier about
Practicing Across State Lines
1. Will you cover me for practicing over state
lines?
2. What if I am not licensed in the foreign state or
country, will you still cover me?
3. If you do cover me, will I be covered for
regulatory or civil actions?
4. What are the limits of each of those types of
coverage?
5. What if I do something illegal to meet the
requirements of my online employer, will you
cover me?

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20. Cultural Sensitivity, Disability & Language
Accommodations
• In some states, the professional or their
organization is mandated to provide culturally
sensitive, disability and/or language
accommodations.
• In other states, there is no mention of either.
• Resources:
• State boards
databases
• Insurance commissioners
• Speak to your informed telehealth
attorney.
Regulations & Issues That Can
Differ Across States
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• Available as a PDF at:
• https://www.socialworkers.org/includes/newIn
cludes/homepage/PRA-BRO-
33617.TechStandards_FINAL_POSTING.pdf
NASW, ASWB, CSWA &
CSWE Technology Standards

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Multicultural Sensitivity
& Diversity Issues
Over State Lines
7 Notable Diversity Issues
1. Acceptance & respect
2. Accommodation of beliefs
3. Ethnic & cultural
differences
4. Gender equality
5. Physical & mental
disabilities
6. Generation gaps
7. Language &
communication

Multicultural Sensitivity &
Diversity Issues Across
State Lines
• Essential aspect of telehealth
• Screening procedures must be well developed
• Referral options must be responsibly offered
• Knowing how to sensitively handle emergencies,
including at first visit, process must be error-proof
• Complaints involving cultural bias are some of the most
frequently reported by boards.

Cultural Sensitivity or
Training for Practicing
Over State Lines &
Internationally
Telehealth poses unique challenges to
respecting diversity:
• People can often present only from “neck
up” (when needed, ask people to back
away from screen so you can see them
more fully). Also ask for a “tour” of their
location if appropriate.
• Many speak a different form of English
• If “impossible,” telehealth & diversity
training is warranted.

Disparities
Telehealth providers must educate
themselves about telehealth and
disparities, especially in rural
areas.
• Digital Literacy
• Local idioms
• Local religious & political beliefs

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21. Definitions of Telehealth
• Telehealth Modality - Some states have
specific regulations about the types of
telehealth modalities that can be used
(video, audio, telephone, email, text,
remote patient monitoring, asynchronous
communication).
• Telehealth Platforms - The approval of
telehealth platforms and software may
also be subject to state-specific
regulations related to privacy, security,
and interoperability.
Across States
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22. Registration – some states allow you to register to
practice in their state.
Based on decades-old practice of professionals traveling
across state lines.
Limitations can be based on:
• # of Days (30, 45) = contacts in telehealth
terms
• Geographic distance = # of miles over the
state line
Across States
68
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m
Ethical Issues
Ethics Are Built on a Foundation of
Legal & Regulatory Adherence

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73
• Write all involved licensing boards
directly to voice your opinions
about current legislation.
• Register with your board to be on
their email list to receive news.
• Comment on documents they send
around for comments.
• Collaborate with your state-level
professional organizations who
lobby for you.
• Boards don’t know what you need
if you don’t tell them
How can providers advocate
for telehealth with licensing
boards?
B

©
1994-2024
Telehealth.org,
LLC
All
rights
reserved.
74
• Write your elected state officials to
voice your opinions about current
legislation.
• Follow legislation through the free
newsletters offered by
Telehealth.org
• https://telehealth.org/signup
• Comment on laws when
comments are requested.
• Legislators don’t know what you
need if you don’t tell them
• Profound repercussions for future
of telehealth and interjurisdictional
practice
What else can providers do
to advocate for telehealth?
B

©
1994-2024
Telehealth.org,
LLC
All
rights
reserved.
FREE Licensing Information
• Review and write to the regulatory board
website for your profession.
• Also write to the regulatory association for the
professions that you supervise:
• ASPPB.org – Psychology
• AASCB.org – Counseling
• FSMB.org – Medical (Psychiatry)
• ASWB.org – Social Work
• AMFTRB – MFT
• NCSBN - Nursing

©
1994-2024
Telehealth.org,
LLC
All
rights
reserved.
• Get state-based requirements is
this format (www.statename.gov)
• Review regulations on all invovled
board websites with an eye to
telehealth, even if the word is not
mentioned (will take you about an
hour per board)
• Write down everything that you must DO.

©
1994-2024
Telehealth.org,
LLC
All
rights
reserved.
• Develop spreadsheet to track issues
across states (see Telehealth.org
handout)
• Put all good links in spreadsheet for
easy access later
• Split states up with a study partner or
group to get help filling in your
spreadsheet with added states

©
1994-2024
Telehealth.org,
LLC
All
rights
reserved.
Interjurisdictional
Practice
Overview
• Only provide services where licensed.
• If you make exceptions, be prepared
to defend your position thoroughly
with arguments you have verified with
your attorney.
• Understand that common sense may
be irrelevant.
• Require every client/patient to attest
to their location at every contact.
B

©
1994-2024
Telehealth.org,
LLC
All
rights
reserved.
Interjurisdictional
Practice
Overview
• Take screenshots of URLS
& webpage content for
resources used.
• Download PDFs, highlight
relevant sections & store on
desktop as you go.
• Reference your sources in
policy statements and client
or patient notes.
B

©
1994-2024
Telehealth.org,
LLC
All
rights
reserved.
How to Get
Telehealth Licensing
Information
• Contact state professional
associations (ethical or legal office)
• Join association groups or ask to
form one if one doesn’t exist.
• Join our free Therapist Community
Network (TCN)– accessible through
the Telehealth.org Digital Training
Center. Just looks for it on your
dashboard.
• Details are here:
https://telehealth.org/therapist-
community-network/

©
1994-2024
Telehealth.org,
LLC
All
rights
reserved.
Use ChatGPT
to Ask Basic
Questions
Write to your malpractice
carrier to ask about your
telehealth coverage.
C 1994-2021 Telebehavioral Health Institute, LLC All rights reserved.

Telehealth.org
contact@telehealth.org
619-255-2788
Keep in touch! 
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