What are Interstate Occupational Licensure Compacts and how do they work?

Compacts: What are they and where did they come from?

As defined by the Council of State Governments, National Center for Interstate Compacts, an interstate compact is “a legislatively enacted agreement between states in the sovereign capacity as states”. In other words, a compact is a contract between states that allows them to respond in concert to regional and national concerns while retaining state control over issues belonging solely to those states. There are currently over 200 active interstate compacts. Compacts have proliferated because they are “simple, versatile, proven, and effective”.  Interstate compacts provide the following:

• A formal, legislatively enacted, relationship between two or more states to address common concerns and/or promote mutually beneficial agendas
• Commissions that enable the states to address issues more effectively than a single state could alone
• Guidelines and standards for the member states
• Assistance in developing and enforcing the guidelines and standards developed and the ability to enable them to evolve as new demands arise. Interstate Compacts – Occupational Licensure Policy

The first interstate compact was the New York-New Jersey Port Authority Compact of 1921. It is an interstate compact between New York and New Jersey that was created to improve the coordination of transit between the two states, especially involving the New York-New Jersey Terminal. A more modern example of an interstate compact is the Driver License Compact. Forty-six of the fifty states came to an agreement regarding driving offenses. The compact’s theme is “One Driver, One License, One Record”. The Driver’s License Compact includes the following:

• Surrender of of an out-of-state license when applying for a new license
• One complete driver record maintained by the state of residence
• Reporting all traffic convictions and other pertinent information to the home state licensing agency
• Assurance of predictable treatment of drivers committing offenses in other states as they would have been treated in their home state. Driver License Compact

Similar assurances apply to occupational licensure compacts.  No matter in which compact state you have a compact occupational license, the compact guidelines, rules, and restrictions apply to your practice.

The Center for Medicare and Medicaid Services recognizes interstate licensure as valid and full licenses. (National Center for Interstate Compacts, CSG Driver License Compact,  Medicare Learning Network).

Why are compacts so important for telehealth providers?

Since the inception of the COVID-19 pandemic, the healthcare environment has been changing more rapidly than ever.  Due to the influx of patients in all healthcare settings and the need for social distancing, the demand for healthcare professionals and alternative access points to healthcare has risen dramatically. License portability helps ease this burden by enabling the healthcare professional to more easily obtain a multi-state license to practice their occupation in all participating compact states and to provide telehealth across state lines and even into a patient’s home. 

As a result of the loosening of restrictions and requirements involved in telehealth a patient in a rural area, for example south-central Pennsylvania, has access to out-of-state specialists and general practitioners that would not otherwise be available to them. Finally, the exchange of licensure, investigatory, and disciplinary information between compact states is enhanced which leads to a more cohesive and consistent regulatory environment for the healthcare professional and, ultimately, benefits the patients. Opportunities and Barriers for Telemedicine in the US During the COVID-19 Emergency and Beyond | KFF

What are the typical elements of a compact?

• Participation is voluntary for states and licensees
• State licensure processes remain in place
• Licensees based in a compact state can practice their occupation in other compact states through their home-state license. This reduces the amount of paperwork, fees, and amount of time spent on maintaining multiple state licenses.
• Agreement on uniform licensure requirements; uniform statutory authority and regulations. 
• A data system allowing electronic processing of interstate licensure and sharing of data and licensure information.
• National office and staff to interface with external stakeholder and national organizations and to coordinate with other interstate compacts.
• Each compact state keeps the ability to regulate the occupation. State practice acts are not impacted. 
• Scope of practice for each occupation does not change which ensures that the compact practitioners are clear regarding what services they are permitted to provide in a compact state. 
• The compact states retain full authority to investigate and discipline compact practitioners, when necessary. This provides the accountability necessary for practice in multiple states. 
• Compact practitioners cannot go from state to state avoiding their poor professional practices without consequences. Disciplinary procedures are streamlined in compact states.
• FBI fingerprint-based criminal background checks are required. The public is protected through ensuring interstate practitioners do not have a criminal background of a violent nature.  Background checks have the potential to allow prospective employers to decrease the chances of workplace violence through avoiding engagement with practitioners with a documented history of violence.
• Compact states administer the compact through an Interstate Commission composed of state officials. The compact states work together to administer the compact which leads to consistency, shared ownership, and shared responsibility.

Interstate compacts DO NOT:

• Supplant state policies
• Give control to outside organizations
• Obstruct state control
• Enhance state power as it relates to National Government (Harvard Center for Ethics).

What is the process for creating and implementing an interstate occupational licensure compact?

An interstate compact is a state-driven and championed answer to a common regional or national concern. As such, interstate occupational licensure compacts are an obvious, but often complex and time-consuming, solution to the need for expanded healthcare access to patients through telehealth. The following are, in general, key steps to the development process of a compact as described by the Counsel of State Governments. It all starts with an advisory group.

1. Advisory Group- usually made up of about 20 state officials and other critical stakeholders representing various groups and states, this group proposes possible solutions and makes recommendations for the structure of the interstate compact. The advisory group’s work results in a set of recommendations as to what the final product should look like.
2. Drafting Team- typically composed of issue and compact experts, the drafting team uses the suggestions of the advisory group  to create a draft compact that will be circulated to state officials, stakeholders, and the public for comment. After these comment periods, the compact will be revised as needed and sent back to the advisory group for a final review. A drafting team would meet three to four times over a period of 10–14 months.
3. Education- Once completed, the interstate compact would be available to states for legislative approval. Education occurs before and during state legislative sessions.
4. Enactment- Interstate compacts do not usually become active immediately.They typically become active when a predetermined number of states join the compact. Historically, interstate compacts have taken up to 7 years to reach the required number of member states. However, to meet the new increased demand for healthcare and to accommodate social distancing through telehealth, this process seems to be occurring a bit faster than it has in the past.
5. Transition- Following enactment by the required minimum number of states, the new compact becomes operational and goes through typical start-up activities which includes, at a minimum,
1. State notification
2. Planning the first commission or state-to-state meetings
3. Hiring of staff to oversee the agreement and its requirements

A critical component of the transition will be the development of rules, regulations, forms, standards by which the compact will need to operate. Due to transition activities, it is typically 12 to 18 months until the compact board is running independently. Interstate Compacts – Occupational Licensure Policy

Existing occupational licensure compacts include:

• Advanced Practice Registered Nurse (APRN) Compact
• Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC)
• Counseling Compact
• EMS Compact
• Interstate Medical Licensure Compact (IMLC)
• Nurse Licensure Compact (NLC)
• Occupational Therapy LIcensure Compact (OT Compact)
• Physical Therapy Licensure Compact (PT Compact)
• Physician Associates Compact (PA Compact)
• Psychology Interjurisdictional Compact (PSYPACT) (National Center for Interstate Compacts).

Compacts currently under development:

• Cosmetology/Barbering
• Dentistry/Dental Hygiene
• K-12 Education
• Massage Therapy
• Counseling Compact
• Physician Assistant Compact
• Social Work (National Center for Interstate Compacts).

Interstate Occupational Licensure Compacts simplify the delivery of healthcare across state lines. Next, we will discuss the individual compacts and their impact on practitioners and patients alike.

Additional information can be found here:

• National Center for Interstate Compacts:https://compacts.csg.org/
• Medicare clarifies recognition of interstate licensure compact pathways: https://www.cms.gov/sites/default/files/2021-11/SE20008.pdf
• Harvard Center for Ethics: https://ethics.harvard.edu/files/center-for-ethics/files/interstatecompactsprimer.pdf
• American Journal of Managed Care: https://www.ajmc.com/view/eliminating-barriers-to-virtual-care-implementing-portable-medical-licensure
• American Telehealth Association: https://www.americantelemed.org/