Understanding Behavioral Health Licensure Compacts: Insights for Governors and Other State Leaders

Given ongoing health workforce shortages, many states have adopted licensure compacts into statute over the past several years. Governors and executive branch regulatory entities are responsible for implementing these compacts and monitoring their impact on the workforce within their states.

(Print/Download)

Background

Behavioral Health Workforce Challenges

Addressing the behavioral health crisis and unmet mental health and substance use disorder needs is a top priority for states and Governors. However, shortages of behavioral health professionals threaten the ability of states to address the needs of their residents. As of 2024, approximately 123 million Americans lived in a community recognized as a Mental Health Professional Shortage Area (MHPSA). States are developing and implementing policies to grow and strengthen the behavioral health workforce. These strategies include new education and career pathways in behavioral health, recruitment and retention initiatives, efforts to expand of telehealth, and reviewing regulatory policies such as occupational licensure compacts that encourage interstate workforce mobility.

Licensure Compacts: A Popular State Solution

Licensure compacts are legal agreements between states that enable licensed professionals to practice across state lines. Prior to the development and adoption of these compacts, professionals were required to seek individual licensure in each state where they practiced (including the delivery of telehealth services). States also had responsibilities to review licensure qualifications and administer these licenses. Compacts work to remove these duplicative processes across states. This is done by establishing uniform standards which facilitate providers to access practice privileges in multiple states while preserving a state's practice act and initial licensure process. Compacts also provide data systems that allow member states to share licensure data, including disciplinary actions.

Compacts vary in their design and implementation, with differences in their general design (such as the process by which an individual accesses multi-state practice privileges), administrative details (such as the cost of maintaining the system and the data that is reported through it), state roles in adopting and implementing the compact, and how disciplinary actions are handled. States wishing to participate must pass legislation containing compact language to approve a compact. Once approved, compacts are implemented by the executive branch, typically through regulatory boards or agencies. After a compact is active and operational, professionals can obtain a multi-state license or seek privileges to practice in other compact-participating states.

Behavioral Health Licensure Compacts

The behavioral health workforce includes a variety of roles that require a state license. Currently, there are three licensure compacts for dedicated behavioral health occupations: the Counseling Compact, Psychology Interjurisdictional Compact (PSYPACT^®), and Social Work Licensure Compact. PSYPACT® has been around for several years and has been passed in 40 states. Although the Counseling Compact and Social Work Licensure Compact have met the threshold of state adoption for activation (with 37 states participating in the Counseling Compact, and 22 participating in Social Work Licensure Compact), these compacts are not yet operational as the compact commissions are still developing compact-specific implementation processes.

Hover over a State/Territory for more information.

Common Terms

• Member State: Refers to any state, territory, or jurisdiction participating in the compact.
• Home State: The member state where the individual resides and holds their license.
• Remote State: Any member state where the compact-participating individual practices (in-person or through telehealth).

Counseling Compact

The Counseling Compact allows licensed professional counselors to practice across state lines using a privilege-to-practice model. Member states must align their licensing criteria with the compact's requirements. Counselors receive a home state license, which they use to obtain privilege to practice in other member states. To do this, they must apply to the Commission, pay an administrative fee, and complete any additional requirements set by the remote state, such as passing a jurisprudence exam and paying state fees. The compact's application system is not yet active. Although professionals cannot currently access these compact-related privileges, the compact is expected to become operational in 2025.

PSYPACT®

PSYPACT® (the Psychology Interjurisdictional Compact) facilitates the practice of psychology through telehealth modalities or temporary in-person services for psychologists meeting Compact requirements. The Compact Commission plays a major role in determining providers' eligibility to access privilege to practice through the Compact by reviewing each professional's credentials. PSYPACT®'s data system is more advanced than the other behavioral health compacts (which are still working to establish their data systems). PSYPACT® offers a publicly accessible registry which allows verification of a psychologist's compact privileges serves as a communication tool and reporting system for PSYPACT psychology licensing boards. It is also a critical resource for oversight and administration of the PSYPACT.

Social Work Licensure Compact

The Social Work Licensure Compact enables practitioners to practice in any compact-participating state under a multi-state license. This compact functions similarly to a driver's license, allowing a multi-state license to be issued by an individual's home state to be used seamlessly to access privileges in any member state. The Social Work Licensure Compact covers various categories of professionals, including social workers at the bachelor's, master's, and clinical levels. Participating states may ensure alignment of their licensing requirements with that of the compact or may offer both a single state license and the additional pathway of the compact-aligned multi-state license. States may establish a fee for the multi-state license issued to practitioners that are residents of their state, but there is no mechanism to collect fees or workforce data from out-of-state practitioners working under practice privileges at this time.

Compact Review Findings

General Information about Behavioral Health Compacts

Current behavioral health compacts cover psychologists, licensed professional counselors, and social workers. These compacts have been rapidly adopted into statute across the country. Although PSYPACT® is the only behavioral health compact that is currently active and granting practice privileges, the other compacts are anticipated to launch within the next year. Each compact takes a different design to facilitate the practice of behavioral health professionals across state lines, with unique implications for the roles of home and remote states under each model. In the compact development process, the Council of State Governments supports the convening of profession-specific subject matter experts to determine the specifics of each compact design. Once a draft is prepared, there is an opportunity for public review and comment prior to finalization. Therefore, although there may be some similarities across the compacts, each compact is designed separately. After a compact has been developed, a Compact Commission (Commission) supports compact administration. The Commissions generally include individuals and representatives from each compact-participating state.

Administrative Details

Costs: PSYPACT® is the only behavioral health compact with a finalized fee structure. Practitioners seeking PSYPACT® privileges pay approximately $440 ($120 annual renewal) for telepsychology privileges (initial authority and E.Passport) and $240 ($70 annual renewal) for temporary in-person practice privileges (initial authority and Interjurisdictional Practice Certificate). The state assessment fee for PSYPACT® participating states is $10 per authorization holder (licensee that participates in PSYPACT®). The other two compacts have not yet finalized or published their fee structures. However, the Counseling Compact's authorizing legislation allows member states to levy a state fee for practitioners seeking practice privileges, which can offset the loss of revenue associated with licensing fees for out-of-state practitioners. Similarly, the Social Work Licensure Compact requires participating states to develop processes for administration of multi-state licenses, another mechanism for states to recuperate lost licensing revenue associated with compact participation.

Workforce Data: One area that requires further exploration with the implementation of compacts is the impact they have on state workforce data. Removal of a licensing requirement results in a loss of workforce data. Counseling Compact states can quantify the number of individuals with a privilege to practice within their state. For PSYPACT®, although the online registry demonstrates where participating practitioners are licensed, there is no current mechanism to track where these psychologists are practicing. Some information relating to use of compact privileges is reported quarterly. In the most recent report, there were 7,692 practice authorities provided, with approximately 82% of authority-holders reporting that they have used their compact privileges. Most Social Work Licensure Compact states may struggle to track practitioners operating within their state, but are able to quantify those social workers within their state who are seeking practice privileges elsewhere (through the number of multi-state licenses issued).

Compact Adoption and Implementation

Behavioral health compacts outline practitioner qualifications for participation, which all participating states acknowledge and adopt. For example, in PSYPACT®, compact privilege seekers apply for privileges directly to compact authorities by submitting their transcripts and other required documents within their application to the host organization. Therefore, not all individuals holding a psychologist license within a member state may qualify for PSYPACT® participation. Additionally, in the Social Work Licensure Compact, if a state's licensing requirements do not align with compact requirements prior to compact adoption, they may offer a multi-state license as an additional pathway (to qualify for compact participation) instead of modifying their traditional single-state license requirements. These potential variations in licensing highlight the importance of information sharing to licensees and clarifying the roles of state regulatory staff versus compact staff.

Compact Privileges & Interstate Mobility

All behavioral health compacts enable practitioners to practice across state lines. For the Counseling and Social Work Licensure Compacts, this includes both in-person and telehealth services. In contrast, PSYPACT®, has separate processes for accessing telehealth (telepsychology) and temporary in-person practice privileges. Under PSYPACT, practitioners must secure an individual state license in a remote state if they practice more than 30 calendar days per year. Although differences exist in scopes of practice across state lines, the remote state's scope of practice prevails in all behavioral health compacts.

Discipline/Adverse Action

The roles of home states and remote states vary widely among the compacts. Home states generally have the authority to investigate and act on a practitioner's license, while remote states can perform investigations but can only act on a practitioner's privilege to practice within their state. However, in the case of PSYPACT®, once an adverse action is taken on practice privileges in one remote state, those privileges are suspended in all other participating states (excluding the home state).

Considerations for Governors and States

What actions can states take to become better informed on compacts prior to adoption?

• Assess Licensing Requirements: For the Counseling and Social Work Licensure Compacts, determine whether state licensing requirements align with those needed for compact adoption. General counsel from state occupational regulatory entities can collaborate with compact staff to review this alignment. If licensing policies differ significantly, the state may not be allowed to become a member state unless policy change occurs (Counseling Compact) or may need to create a new pathway to licensure for multi-state privileges (Social Work Licensure Compact).
• Evaluate Fiscal Impact: Executive branch regulatory officials can work with legislative and fiscal analysts to estimate the fiscal impact of compact participation and implementation. For example, Vermont's PSYPACT® legislative proposal included a fiscal note that used license data to identify psychologists from PSYPACT®-participating states, estimating the revenue loss from current Vermont licenses held by those psychologists.
• Develop Revenue Strategies: Regulatory officials may develop strategies to offset lost revenue. Depending on the compact, states might establish a fee structure for compact participants to collect additional revenue from those seeking multi-state privileges. For instance, the Counseling Compact allows states to charge a state fee for practice privilege to practitioners from member states. Although the Social Work Licensure Compact currently lacks a mechanism to collect fees from out-of-state multi-state license holders, a fee for administering multi-state licenses to practitioners within the state could be implemented to offset lost revenue.
• Prepare Baseline Workforce Assessment: Executive branch agencies may prepare assessments of the supply and distribution of the workforce prior to compact adoption. Such information could be used to evaluate the impact of future compact participation on workforce capacity within the state. These workforce assessments could use existing regulatory data, labor/workforce data, and/or revenue data to triangulate existing workforce capacity.

What actions can states take post-adoption to enhance administration?

• Develop a Strategic Communications Plan: After compact adoption, create a strategic communications plan to enhance the licensee experience. Clear communication to licensees will be crucial as states establish processes for compact implementation. Licensees should be informed about what a compact is, what the compact will and won't do, when compact privileges will take effect, what is required of them, and whom to contact for more information. Each behavioral health compact offers resources on their websites that can be integrated into state licensing pages, but these resources should be accompanied by state-specific information, including timelines and points of contact. Partnerships with local profession-specific organizations (such as professional associations and employers) can maximize the reach of education efforts.
• Identify Efficiency Opportunities in Compact Data Reporting: Each compact has specified data reporting requirements, whereby states must submit datasets to the respective compact commissions. States should explore how to streamline licensing data reporting processes to minimize duplication of efforts across various professions' compacts. This could involve creating a single in-state database that houses information from all relevant regulatory entities or sharing staff to handle similar job responsibilities across the various professions' licensing data.
• Explore Alternative Workforce Data Strategies: Many states traditionally rely on licensure data to quantify and describe the behavioral health workforce practicing within their borders. With the adoption of these compacts, states should explore new data approaches, such as quantifying privilege-to-practice designations (for the Counseling Compact), examining accessible data from the Compact Commission(s), and considering alternative in-state data sources, such as unemployment insurance or tax records. Additionally, assessments performed at baseline prior to compact adoption can be re-visited post-implementation to evaluate the impact on the workforce.

References

• Counseling Compact website, model legislation, and other governance documents
• PSYPACT website, model legislation, and other governance documents
• Social Work Licensure Compact website, model legislation, and other governance documents

Attribution and Acknowledgements

The NGA Center would like to thank the Health Resources and Services Administration in the U.S. Department of Health and Human Services for their generous support in the development of this publication under National Forum Cooperative Agreement No. U98OA09028. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of HRSA or the U.S. Department of Health and Human Services.

Recommended Citation: Medlock, C., & Maxey, H. (2024, November). Understanding behavioral health compacts: Insights for governors and other state leaders. National Governors Association.

Author Attribution: This report, including the concepts and research findings presented herein, were authored by Courtney Medlock, MPH, and Hannah Maxey, PhD, MPH, RDH, of Veritas Health Solutions on behalf of the National Governors Association Center for Best Practices (the NGA Center).

Acknowledgements: The authors would like to thank Dan Logsdon and Carl Sims of the Council of State Governments for their expert review of the publication tables.

Public link

Please use the above public link if you want to share this noodl on another website.