Licensure compacts in the U.S.: cross-border telehealth practice mechanisms

A sticky note on my monitor reads, “Where is the patient?” It looks like a riddle, but it’s my compass for telehealth days. I learned the hard way that in the U.S., a virtual visit is legally considered to occur where the patient sits, not where I’m sipping coffee and clicking “Join.” That simple sentence reframed how I think about cross-border care: it’s not just technology and scheduling; it’s licensure, compacts, and a web of rules designed to protect patients while (ideally) keeping access open. Today I’m jotting down what has helped me make sense of interstate practice—especially the practical mechanics of licensure compacts that can turn a patchwork into a plan.

The rule that keeps me out of trouble

When I feel lost in acronyms, I go back to the principle: for telehealth, the appointment is deemed to occur in the patient’s state. That means I need legal authority to practice there—via a full license, a compact privilege, or another allowable pathway. It sounds obvious once you’ve lived it, yet it’s easy to overlook in the rush to help someone on a screen. If you want a reliable primer that keeps this idea front and center, the federal overview at Telehealth.HHS.gov is a solid compass (see the licensure/compacts guidance here).

• High-value takeaway: Start every out-of-state visit plan by confirming the patient’s location at the time of care and the legal mechanism that authorizes you to practice there.
• Licensure choices aren’t interchangeable. “Privilege to practice” under a compact behaves differently from a full license.
• Rules and implementation timelines evolve. Bookmark authoritative sources and re-check before you promise a start date.

What compacts do—and what they don’t

Here’s how I explain compacts to colleagues in one breath: a compact is a deal between states that speeds or shares licensure authority across borders for certain professions. The details differ, but two big patterns help me remember:

• Multistate license model (mutual recognition) — You hold one license issued by your home state that grants you the legal ability to practice in other compact states, in person or via telehealth. The classic example is the Nurse Licensure Compact (NLC) from NCSBN, outlined clearly at NurseCompact.com.
• Privilege/authority model — You hold a regular license in your home state, then obtain a privilege to practice in other member states via the compact’s process. Think of it as a faster, standardized on-ramp rather than a new license. Psychology’s PSYPACT and the Physical Therapy Compact work this way (see PSYPACT FAQ and PT Compact FAQs).

Equally important are the limits. A compact does not erase state authority. You still practice under the scope, standards, and disciplinary oversight of the state where the patient sits. Privileges can be suspended, and you must meet each compact’s eligibility criteria. Also, compacts are profession-specific; being a physician with an IMLC-streamlined license doesn’t help if you’re also practicing as a psychologist—those pathways are separate. For physicians, the Interstate Medical Licensure Compact (IMLC) provides an expedited route to multiple full licenses (see the IMLC overview here), but it is not a multistate license like the NLC; you still end up holding multiple state licenses, just faster.

A quick tour of the major compacts I actually use

When I map out a multi-state telehealth program, I sort by profession and compact model. Here’s the cheat sheet I keep nearby:

• Nurses (RNs, LPN/VNs) — The NLC allows a multistate license issued by your primary state of residence; you can practice across all NLC states in person or via telehealth as allowed by each state. The official portal summarizes use cases and updates well: NurseCompact.com.
• Physicians (MD/DO) — The IMLC is an expedited licensure pathway (not mutual recognition). It streamlines getting separate licenses in multiple states. This is crucial for national telemedicine groups that need speed without sacrificing compliance. Details at IMLCC.com.
• Psychologists — PSYPACT grants authority to practice telepsychology (with E.Passport + APIT) and temporary in-person care across member states. The PSYPACT FAQ is excellent for scope and eligibility basics.
• Physical therapists and PTAs — The PT Compact issues compact privileges to practice in remote member states; care is delivered under the remote state’s practice rules whether the visit is in person or via telehealth. See PT Compact FAQs.
• Audiologists & Speech-Language Pathologists — The ASLP-IC is rolling out to facilitate multistate practice, including telepractice. For implementation status across professions, the federal overview at Telehealth.HHS.gov keeps a current list.

There’s more in the ecosystem: an Occupational Therapy Compact, a Counseling Compact, and a Social Work Licensure Compact are in various stages of enactment and implementation. I watch the same federal page above for these timelines because they change more often than my coffee mug.

Other cross-border routes besides compacts

Compacts are powerful, but they aren’t the only game in town. My planning worksheet always includes these alternatives:

• Full state licensure — Slow but universal. If a compact isn’t available (or I don’t qualify), I apply for the full license in the patient’s state.
• Telehealth-specific registrations or permits — A few states let out-of-state clinicians register to provide telehealth without arranging a full license. Florida is a well-known example with an out-of-state telehealth provider registration pathway under statute 456.47 (the Department of Health posts the details and forms on its telehealth page). For a national snapshot of these policies, the federal overview at Telehealth.HHS.gov also points to cross-state licensing options.
• Consultation or follow-up exceptions — Some states allow limited out-of-state involvement for episodic consultations with in-state clinicians, or narrow follow-up after an out-of-state procedure. These are not general care permissions and can be easy to overstep. When I see “exception,” I slow down and read the fine print.

One more nuance that helps me sleep at night: whatever route I use, I document the patient’s location, the legal mechanism for my authority (e.g., “TX compact privilege #… valid through …”), and the policy reference in my compliance notes. Future-me always says thanks.

How I actually decide the path for a cross-state visit

I used to ping legal and wait. Now I do a quick triage that surfaces the right questions for them (and often answers most of it):

• Step 1: Confirm the patient’s location and my role — Where will the patient be during the visit, and under which license am I practicing (physician, psychologist, PT, etc.)? If multiple roles apply, I separate them.
• Step 2: Check the compact map for my profession — For physicians, I scan the IMLC site (IMLCC); for nursing, the NLC portal (NurseCompact); for psychology, PSYPACT (FAQ); for PT, the PT Compact (FAQs). If the destination state is covered, I confirm whether I qualify for the compact pathway and whether I need a privilege vs. a new license.
• Step 3: If no compact path, look for telehealth registration — I search the state board’s site for “telehealth registration” or “special telemedicine license.” If nothing exists, I plan for full licensure.
• Step 4: Validate payer-side rules — Licensure ≠ payment. I make sure my pathway is acceptable to the patient’s health plan, and that telehealth modality requirements are met.
• Step 5: Re-check scope and supervision rules — Even with a compact, scope is determined by the patient’s state. I confirm any modality limits, supervision requirements, or documentation specifics.

Gotchas I’ve learned to spot early

Some lessons were expensive. Here are the ones I now catch in Week 1 instead of Week 12:

• “IMLC = multistate license” — It’s not. IMLC accelerates multiple licenses; the NLC is the true multistate license model.
• Scope drift — A compact privilege doesn’t transplant your home-state scope. The remote state’s rules apply, including supervision and modality limits.
• Address and residency rules — Some compacts (like the NLC) hinge on primary state of residence and may change status if you move.
• Operationalization lag — A state can enact a compact but not yet accept applications. I now check the compact’s “operational” status before setting a launch date.
• Prescribing ≠ licensure — Whether you can prescribe certain medications via telehealth may be governed by separate federal and state rules and may have their own timelines. I treat prescribing as a separate compliance track.

The small systems that make this manageable

Because rules move, I stopped relying on memory and built tiny guardrails:

• A shared spreadsheet with columns for patient state, pathway (compact/full/registration), status, renewal/privilege dates, and policy links (to the exact page I used—e.g., HHS on compacts, IMLC, NLC, PSYPACT, PT Compact).
• Calendar reminders 60/30/7 days before any privilege or license renewal.
• A one-page intake script that politely verifies the patient’s location at the start of each visit and records it in the note.

When I hit the brakes on a cross-state plan

There are days when the safest move is to pause and ask for help. These are my red/amber flags:

• Ambiguous location — The patient travels during a program of care (e.g., students, truck drivers, snowbirds) and the plan doesn’t reflect that. I map out likely locations and secure the matching authority first.
• New or non-operational compact — The state enacted a compact but the commission hasn’t opened applications. I adjust timelines and communicate clearly.
• Mixed professional roles — If I’m serving in a role that spans professions (e.g., a physician who also supervises allied clinicians), I check each role’s pathway separately.
• Modality or prescribing complexity — If the care plan involves controlled substances or specialized modalities, I open a parallel compliance checklist and do not assume licensure answers cover it.

What I’m keeping and what I’m letting go

I’m keeping three principles on my sticky note pile:

• Patient location is the anchor — It guides licensure, scope, and documentation.
• Compact ≠ shortcut for everything — It’s a structured pathway, not a hall pass. Read the eligibility, scope, and operational notes closely.
• Update discipline — Rules move; my systems must keep pace. A saved link is only as good as the last time I re-checked it.

And I’m letting go of magical thinking. There’s no one-click solution for all cross-border telehealth. But with compacts, careful documentation, and clear expectations with patients and teammates, the work feels less like bureaucracy and more like what it was always meant to be—connecting people to care without making the highway the hardest part.

FAQ

1) Do compacts replace payer enrollment and credentialing?
Answer: No. Compacts address legal authority to practice across state lines. Health plans, Medicare/Medicaid, and hospitals may still require their own credentialing or privileging steps. I verify licensure first, then ask each payer about telehealth requirements.

2) If my patient travels to another state for a week, can I continue virtual visits?
Answer: Only if you’re authorized to practice in the state where the patient will be located for that visit—via a compact pathway, telehealth registration (if available), or a full license. When in doubt, I reschedule until authority is secured.

3) Does a compact let me use my home state’s scope of practice everywhere?
Answer: No. Even with a compact privilege or multistate license, you practice under the remote state’s scope and standards. The PT Compact FAQ spells this out for PTs, and the principle generalizes across compacts (see PT Compact FAQs).

4) Are counseling, OT, audiology/speech, and social work compacts ready now?
Answer: Many are enacted and in various phases of implementation. Before planning a go-live, I check the compact’s official site or the federal overview, which tracks current status across professions (see Telehealth.HHS.gov).

5) I’m a physician—should I use the IMLC or apply state-by-state?
Answer: If you meet IMLC eligibility, it often saves time because it’s an expedited route to multiple full licenses. It’s not a multistate license (like the NLC), but it can dramatically shorten timelines for multi-state practice (see IMLC).

Sources & References

• Telehealth.HHS.gov — Licensure compacts overview
• Interstate Medical Licensure Compact (IMLC)
• Nurse Licensure Compact (NLC)
• PSYPACT — Frequently Asked Questions
• Physical Therapy Compact — FAQs

This blog is a personal journal and for general information only. It is not a substitute for professional medical advice, diagnosis, or treatment, and it does not create a doctor–patient relationship. Always seek the advice of a licensed clinician for questions about your health. If you may be experiencing an emergency, call your local emergency number immediately (e.g., 911 [US], 119).