Scaling a telehealth company across all 50 states is one of the most compelling opportunities in healthcare, but it is also one of the most complex regulatory challenges a founder can face. Each state has its own rules for telehealth delivery, provider licensure, prescribing, and corporate practice of medicine. Getting it right means building a compliance infrastructure that can flex across dozens of different legal frameworks simultaneously.
This guide walks through the key regulatory pillars you need to address before going live in any new state.
State Licensure: The Foundation of Multi-State Telehealth
The single most important rule in telehealth is this: providers must be licensed in the state where the patient is located at the time of service. It does not matter where the provider is sitting. What matters is where the patient is.
This means that to offer telehealth in all 50 states, you need providers licensed in all 50 states, or a strategy to cover each market. There are several approaches:
- Individual state licensure — Providers apply for and maintain licenses in each state. This is the most straightforward approach but also the most time-consuming and expensive.
- Interstate Medical Licensure Compact (IMLC) — Physicians in participating states can obtain expedited licenses through the compact. As of 2026, over 40 states participate.
- Nurse Licensure Compact (NLC) — Allows registered nurses and LPNs to practice across compact states with a single multistate license.
- APRN Compact — A newer compact for advanced practice registered nurses, including nurse practitioners, that is gaining adoption.
- Psychology Interjurisdictional Compact (PSYPACT) — Enables psychologists to practice telepsychology across member states.
Pro tip: Start with the states where your target patients are concentrated, then expand systematically using compacts to reduce licensing overhead.
Telehealth-Specific Rules by State
Beyond licensure, each state has specific rules governing how telehealth can be delivered. These vary widely and include:
Modality Requirements
Some states require synchronous video visits for certain types of care, while others allow audio-only or asynchronous (store-and-forward) encounters. A few states still have restrictions on establishing a new patient relationship via telehealth, though most of these were relaxed during the COVID-19 pandemic and made permanent since.
Informed Consent
Most states require providers to obtain informed consent for telehealth services, but the specifics differ. Some require written consent, others accept verbal consent, and several require specific disclosures about the limitations of telehealth.
Prescribing via Telehealth
Prescribing rules are among the trickiest areas of multi-state telehealth. Key considerations include:
- Controlled substances — Federal law (the Ryan Haight Act) generally requires an in-person examination before prescribing controlled substances, though DEA telemedicine exceptions and pandemic-era flexibilities have expanded what is possible.
- State prescribing registrations — Providers may need a separate prescribing registration or state-level controlled substance registration in addition to their medical license.
- Formulary restrictions — Some states restrict which medications can be prescribed via telehealth, particularly for initial visits.
CPOM Compliance Across Multiple States
If your telehealth company is not physician-owned, you will need to address CPOM compliance in every state where you operate. This typically means establishing a Professional Corporation or PLLC in each state that enforces the doctrine, with a licensed physician owner in that state.
The MSO-PC model scales for multi-state operations through a hub-and-spoke approach:
- One central MSO — Your management company that owns the technology, brand, and business operations.
- State-specific PCs — Individual professional corporations in each state where CPOM applies, each owned by a physician licensed in that state.
- Standardized MSAs — Management Services Agreements between the MSO and each PC, adapted for state-specific requirements.
Not every state requires a separate PC. States without meaningful CPOM enforcement may allow your clinical operations to run through a single entity. But for states like California, Texas, and New York, a dedicated PC is essential.
Technology and Infrastructure Requirements
Your technology stack must meet regulatory requirements in every state where you operate. At a minimum, you need:
- HIPAA-compliant video and messaging — End-to-end encryption and BAAs with all technology vendors.
- Electronic prescribing (EPCS) — For controlled substances, you need an EPCS-certified system with two-factor authentication.
- State-compliant consent workflows — Your platform should collect and document informed consent per each state's requirements.
- Medical records management — Records must meet retention requirements for each state, which can range from 6 to 10+ years.
- Geographic verification — You need a reliable way to confirm where the patient is physically located at the time of the visit.
Building Your State Launch Playbook
Given the complexity, the most successful telehealth companies approach multi-state expansion methodically. A state launch playbook should include a regulatory assessment for each new state, licensure timelines, entity formation requirements, payor enrollment, and compliance monitoring setup.
Rushing into a new state without completing this groundwork creates real legal exposure. Take the time to do it right, and you will build a foundation that supports sustainable nationwide growth.