The 10 Best and 10 Worst States for Telehealth (According to Best Practices)

During the Covid-19 pandemic, physically going just about anywhere has been discouraged, and at times even forbidden, in order to prevent the spread of the virus. And, just like many other industries during the pandemic, healthcare has had to figure out a way to function remotely in order to limit human contact. Telehealth, the method of providing healthcare services via technology, has been the answer.

However, when any industry or service makes big strides in a new direction, the right way to do things is not always obvious — especially when the new facets of the industry grow significantly in popularity over a short period of time. And that’s where best practices — the checks and balances of any procedure — come into play.

So in January 2022, the Cicero Institute, the Pioneer Institute, and the Reason Foundation conducted a study that identifies eight best practices, and quantitatively rates every state according to how well they abide by each of those best practices. The study is titled Rating the States on Telehealth Best Practices: A Toolkit for a Pro-Patient and Provider Landscape, and the eight best practices are as follows:

• No In-person Requirements
• Modality Neutral
• No Barriers to Across-State-Line Telehealth
• All Providers Can Use Telehealth
• Independent Practice
• No Coverage Mandate
• No Payment Mandate
• Compacts

The ratings in the study include green, yellow, and red — with green being the best and red being the worst. For the purposes of this article, we’ve interpreted green as “good,” yellow as “fair,” and red as “poor,” which are in accordance with response options commonly used in Likert Scale surveys.

As far as what those colors and interpretations mean, below is a description for each one.

• Good: the state completely follows the best practice.
• Fair: the state somewhat follows the best practice, but has room for improvement.
• Poor: the state does not follow the best practice, and requires significant improvement.

From there, ​​we aggregated the ratings given to each state to determine the best and worst states for telehealth. Further down this page is a detailed explanation of the eight best practices included in the study, as well as the methodology used to determine the best and worst states for telehealth.

In general, the following 10 states received a “good” or “fair” rating for the greatest number of best practices, as well as a “poor” rating for the least number of best practices:

Florida

• Good: No In-person Requirements, Modality Neutral, No Barriers to Across-State-Line Telehealth, Independent Practice, No Coverage Mandate, No Payment Mandate
• Fair: Compacts, All Providers Can Use Telehealth
• Poor: N/A

South Dakota

• Good: No In-person Requirements, Modality Neutral, All Providers Can Use Telehealth, No Coverage Mandate, No Payment Mandate, Compacts
• Fair: No Barriers to Across-State-Line Telehealth, Independent Practice
• Poor: N/A

Utah

• Good: No In-person Requirements, Modality Neutral, Independent Practice, No Payment Mandate, Compacts
• Fair: No Barriers to Across-State-Line Telehealth, All Providers Can Use Telehealth, No Coverage Mandate
• Poor: N/A

Idaho

• Good: No In-person Requirements, Modality Neutral, Independent Practice, No Coverage Mandate, No Payment Mandate, Compacts
• Fair: All Providers Can Use Telehealth
• Poor: No Barriers to Across-State-Line Telehealth

Alaska

• Good: No In-person Requirements, All Providers Can Use Telehealth, Independent Practice, No Payment Mandate,
• Fair: No Coverage Mandate, No Barriers to Across-State-Line Telehealth, Modality Neutral
• Poor: Compacts

Arizona

• Good: No In-person Requirements, Modality Neutral, No Barriers to Across-State-Line Telehealth, Independent Practice,
• Fair: All Providers Can Use Telehealth, No Payment Mandate, Compacts
• Poor: No Coverage Mandate

Louisiana

• Good: No In-person Requirements, Modality Neutral, No Coverage Mandate, Compacts
• Fair: No Barriers to Across-State-Line Telehealth, All Providers Can Use Telehealth, No Payment Mandate
• Poor: Independent Practice

Nebraska

• Good: No In-person Requirements, Modality Neutral, Compacts
• Fair: All Providers Can Use Telehealth, Independent Practice, No Coverage Mandate, No Payment Mandate
• Poor: No Barriers to Across-State-Line Telehealth

Wyoming

• Good: No In-person Requirements, Independent Practice, No Coverage Mandate, No Payment Mandate, Compacts
• Fair: Modality Neutral
• Poor: No Barriers to Across-State-Line Telehealth, All Providers Can Use Telehealth

Mississippi:

• Good: No In-person Requirements, Modality Neutral, All Providers Can Use Telehealth, No Payment Mandate, Compacts
• Fair: N/A
• Poor: No Barriers to Across-State-Line Telehealth, Independent Practice, No Coverage Mandate

The following 10 states received a “poor” rating for the greatest number of best practices:

Hawaii

• Good: All Providers Can Use Telehealth, Independent Practice, No In-person Requirements, Modality Neutral
• Fair: N/A
• Poor: No Barriers to Across-State-Line Telehealth, No Coverage Mandate, No Payment Mandate, Compacts

Rhode Island

• Good: No Barriers to Across-State-Line Telehealth, No Coverage Mandate, No Payment Mandate, Compacts
• Fair: N/A
• Poor: No In-person Requirements, Modality Neutral, All Providers Can Use Telehealth, Independent Practice

Iowa

• Good: No In-person Requirements, All Providers Can Use Telehealth, Independent Practice, Compacts
• Fair: N/A
• Poor: Modality Neutral, No Barriers to Across-State-Line Telehealth, No Coverage Mandate, No Payment Mandate

Illinois

• Good: No In-person Requirements, Modality Neutral, All Providers Can Use Telehealth
• Fair: Compacts
• Poor: No Barriers to Across-State-Line Telehealth, Independent Practice, No Coverage Mandate, No Payment Mandate

Kentucky

• Good: No In-person Requirements, Modality Neutral, Compacts
• Fair: All Providers Can Use Telehealth
• Poor: No Barriers to Across-State-Line Telehealth, Independent Practice, No Coverage Mandate, No Payment Mandate

Vermont

• Good: No In-person Requirements, All Providers Can Use Telehealth, Compacts
• Fair: Independent Practice
• Poor: Modality Neutral, No Barriers to Across-State-Line Telehealth, No Coverage Mandate, No Payment Mandate

Connecticut

• Good: No In-person Requirements, Modality Neutral
• Fair: All Providers Can Use Telehealth, Independent Practice
• Poor: No Barriers to Across-State-Line Telehealth, No Coverage Mandate, No Payment Mandate, Compacts

New York

• Good: No In-person Requirements, No Payment Mandate
• Fair: Modality Neutral, All Providers Can Use Telehealth
• Poor: No Barriers to Across-State-Line Telehealth, Independent Practice, No Coverage Mandate, Compacts

California

• Good: No In-person Requirements
• Fair: Modality Neutral, All Providers Can Use Telehealth, Independent Practice
• Poor: No Barriers to Across-State-Line Telehealth, No Coverage Mandate, No Payment Mandate, Compacts

Tennessee

• Good: Compacts
• Fair: No Payment Mandate, All Providers Can Use Telehealth, Modality Neutral
• Poor: No In-person Requirements, No Barriers to Across-State-Line Telehealth, Independent Practice, No Coverage Mandate

The popularity of telehealth during the Covid-19 pandemic provided an opportunity to evaluate its strengths and weaknesses in order to determine the most effective methods of delivering healthcare services remotely. It has helped the healthcare industry and millions of patients learn what works and what doesn’t.

However, the pandemic also forced states to implement changes to better accommodate telehealth services. And over time, due to a variety of factors, including the availability of vaccinations, telehealth is no longer considered a necessity in some places; it’s considered more of a stand-in rather than a viable replacement, despite the many benefits it offers to both patients and providers alike.

Some of those benefits include:

• Reducing the time it takes for patients to be seen by providers.
• Eliminating inequities due to location for patients who are unable to travel great distances.
• Reducing waiting room traffic and limiting patients’ exposure to germs.
• Reducing providers’ exposure to germs.
• Relieving the pressure on overburdened providers to see patients in person versus remotely.

That’s why the research performed by the Cicero Institute, the Pioneer Institute, and the Reason Foundation is so important. It offers clear definitions of the factors that need to be considered in order for telehealth to operate effectively. It also establishes those factors as the most important criteria to consider when creating new — and addressing existing — legislation related to telehealth.

Below are detailed definitions of the eight telehealth best practices:

No In-Person Requirement

The in-person requirement best practice stipulates that a patient cannot receive care from a provider via telehealth until an in-person visit has occurred — generally to establish a patient-provider relationship.

However, the in-person requirement restricts access to telehealth for patients who:

• Live in an area that already faces an acute provider shortage.
• Live in rural communities.
• May lack adequate transportation to attend an in-person appointment.

Removing the barrier of an in-person requirement provides greater flexibility to providers and patients to determine the best steps of care and greater overall access.

Additionally, in-person requirements force sick patients to attend in-person appointments, which may increase the chances of transmission for both patients and providers.

Modality Neutral

Supporting modality-neutral options allows for all kinds of telehealth service delivery, including but not limited to live video, remote monitoring, and recorded messages — i.e. store and forward, across devices deemed best for the patient and provider and for establishing patient-provider relationships.

Modality neutral options also allow patients to be monitored from a different physical location from their provider and allow patients to avoid readmissions or admission to a skilled nursing facility, as the patient can be monitored from their own home or domicile. Storing and forwarding recorded medical information allows specialists and healthcare providers the opportunity to review medical information after it has been collected, providing patients access to specialty care in a more timely manner — without needing to coordinate schedules and travel arrangements.

No Barriers to Across-State-Line Telehealth

Barriers to access telehealth across state lines restrict patients’ access to certain types of providers when telehealth may present the only option to seek out a second opinion, access team-based care, or to see a specialist. For patients who lack the economic means to travel out of state, telehealth also allows them to see an out-of-state provider. Additionally, removing barriers to across-state telehealth allows mobile Americans to continue care with providers they already know and trust, and who already know the patient’s history. Removing barriers to across-state-line telehealth services benefits providers as well by removing costly and time-consuming registration requirements to become certified in another state.

All Providers Can Use Telehealth

Supporting access to care allows all kinds of providers to offer telehealth services rather than only some. Greater access to care also supports team-based care and prohibits charging facility fees to patients for services that can effectively be delivered by providers remotely from their home or office.

Independent Practice

Independent practice within this study was determined based on whether nurse practitioners require a doctor to provide oversight and co-sign their work. With current and future shortages of practicing doctors, expanding the ability for high-quality nurse practitioners to provide telehealth services without a doctor’s supervision increases patient access to care by widening the available providers, while also freeing up doctors’ time to focus on more complex cases and procedures.

However, it should be noted that while this study focused on nurse practitioners, specifically, other types of independent practices should be included in this category as well, including but not limited to: dentists, physician assistants, pharmacists, and more.

No Coverage Mandate

Blanket coverage parity mandates requiring all services provided via telehealth to be covered does not reflect the fact that not all telehealth care, services, and outcomes are equal. States typically require that telehealth services provide the same standard of care as in-person visits, yet this is often at the discretion of the provider, making it impossible to ensure the same standard of care is maintained.

As providers gain experience offering telehealth services, it will become clearer which services can be provided via telehealth at the same standard of in-person care. By prioritizing flexibility over blanket coverage mandates, insurers will not be required by state law to cover them, which will discourage providers from offering telehealth care in situations where in-person care may be more effective.

No Payment Mandate

Payment parity mandates require telehealth services to be paid by insurance companies at the same rate as in-person visits. But this can render the potential cost savings of telehealth services moot, as insurers and individuals end up footing the bill for items like facility fees even when they receive care remotely.

Compacts

Compacts allow certain providers to offer services in more than one state. However, being a part of a compact is time-consuming and expensive. Some, like the Interstate Medical Licensure Compact (IMLC), require providers to have a license in every state they service, and that costs time and money.

So, while states that are members of compacts – specifically the IMLC and the Nurse Licensure Compact – are technically in line with the best practice, the study also notes that compacts in and of themselves “are a barrier to a more flexible patient-centered health system.”

While the study rated every state across eight best practices, the states were not ranked. In order to rank them and determine which ones were the best and the worst, we assigned a point value to each of the three ratings — green, or “good,” yellow, or “fair,” and red, or “poor” — that each state received for each best practice. The points that were allocated to each rating — good, fair, and poor — are as follows:

• Good: +2
• Fair: +1
• Poor: -2

The “good” and “poor” ratings were assigned scores of +2 and -2, respectively, as those ratings signify a state either completely follows a best practice or does not follow it at all. The “fair” rating was assigned a score of +1, as that rating signifies a state somewhat follows a particular best practice. In other words, good and bad ratings are valued equally positive and negative, and fair ratings are valued minimally.

The following table includes how each state’s rating translates into a score, based on the values assigned to each rating. The higher the score, the more closely a state follows telehealth best practices, generally.

*Note that Mississippi was included in our selection of best states for telehealth due to the number of best practices followed — five — even though its total score was lower than many other states.

**Additionally, note that North Carolina and Pennsylvania did not receive ratings for two best practices. The scores for those two states are based on only six best practice ratings versus eight.