State Licensure Laws
NCSB RESPONSE TO AMA SCOPE OF PRACTICE SERIES - See below
November 23, 2009
Michael D. Maves, M.D. MBA
Executive Vice President, CEO
American Medical Association
515 N. State Street
Chicago, Illinois 60615
Re: RESPONSE TO AMA SCOPE OF PRACTICE SERIES
Dear Dr. Maves:
The Scope of Practice Partnership, formed in 2006 by the American Medical Association (AMA) to aid state medical societies in opposing scope of practice expansions by non-physician providers, has drafted a practice data module for the profession of audiology. It has been brought to the attention of the National Council of State Boards of Examiners for Speech-Language Pathology and Audiology (NCSB) that information included in this document not only fails to accurately reflect the scope of practice for the profession of audiology, but may in fact, contain information that may be misleading to the public. Of particular concern to NCSB, an organization whose mission is to facilitate communication among licensure boards, are the descriptions included in the scope of practice document for audiology, the references to the education and training of audiologists, and the lack of information regarding direct access to audiological services.
As with many other professions, scope of practice statements began as an outgrowth of the needs of a professional association to define the practice. On a national level, scope of practice definitions, as well as preferred practice patterns for audiology, were initially developed by the American Speech-Language-Hearing Association (ASHA) and later by the American Academy of Audiology (AAA). Since the advent of the first audiology licensure act in 1969, states have been given the statutory authority to develop and promulgate laws, rules and regulations. Licensure for the practice of audiology is now required in all fifty states and in the District of Columbia. Inherent in all of these enabling statutes are scope of practice statements that specifically define the practice of audiology. Many of these statements were adapted from those of the professional associations, but the primary authority for defining the practice of audiology lies with the legislative powers given to states in formulating the laws, rules and regulations that govern audiology and the licensed audiologists within that state. As the profession of audiology has changed, so has its expanded scope of practice. These changes are reflected in the ever-changing scopes of practice by the national organizations that represent audiologists, and ultimately in the changes made in the enabling statutes for individual states.
Having phased out its Master’s level training programs in 2006, the profession of audiology has undergone a transition to the doctoral level, as evidenced by the sixty-nine accredited universities that provide educational and clinical training leading to a clinical doctorate in audiology. Utilizing scope of practice guidelines developed by professional associations and state licensing boards, universities now provide a curriculum of academic and clinical training ensuring that students have opportunities to acquire the knowledge and skills necessary for entry into independent professional practice across the range of practice settings with all age groups. Additionally, licensure boards across the country have recognized the need to modify their entry-level requirements to continue with their mission of public protection. To date twenty-two states have promulgated revised laws and/or rules that mandate a doctoral degree in audiology as the minimum standard to engage in the practice of audiology in that particular state. A number of other states have passed legislation with date-certain mandates for change.
The issue of direct access to audiologists and the services they provide is particularly troublesome to NCSB as it continues its efforts to share information with licensure boards and to advocate for the protection of the consumers of our services. Audiologists, by virtue of academic training and clinical experiences, are qualified to engage in the autonomous practice of audiology, and are recognized as independent providers of services by state licensing laws and regulations in fifty states. Additionally, audiologists are recognized as essential health care providers in the performance of their duties and are eligible for reimbursement for their services. The expanding needs of the American health care system will be compromised if patients are denied access to the health care providers of their choice. Legislation across the country to mandate newborn hearing screening has heightened the awareness of the profession of audiology and has increased the demand for audiologists. The demand from this population, coupled with the ever-increasing needs of the geriatric population, highlights the importance of direct access to audiologists.
The continuously expanding scope of practice in audiology should not be construed as an encroachment on other professions. Rather, it should be viewed as a means of expanding services to a population that might not otherwise be served. The scope of practice in audiology should remain within the purview of its stakeholders—the universities providing the training, the professional associations representing audiologists, and most importantly, the individual licensure boards that possess the statutory authority to protect the consumers of audiological services.
The National Council of State Boards of Examiners for Speech-Language Pathology and Audiology (NCSB), in recognition of the fact that audiologists are regulated by statute to provide direct services to consumers in all fifty states, understands and promotes public protection. Existing state licensure laws ensure such protection, and regulation and/or restriction beyond what has been established by statute in all fifty states, is not only unwarranted but may indeed be harmful to consumers by restricting their ability to access care from qualified providers. NCSB respectfully requests that members of allied health professions assist the organization and the profession of audiology in their mission to hold paramount the welfare of the public by recognizing audiologists as independent providers and by removing any barriers that might restrict access to the provision of health care by audiologists.
Thank you for your consideration in this matter.
Lisa C. O’Connor, President
State licensure boards have a legal, moral and ethical responsibility to protect consumers from unscrupulous and unqualified practitioners through regulation of standards of practice. It is incumbent upon regulatory boards to address the provision of services including those that transcend traditional service delivery models. Designed initially to deliver health care at a distance, the use of telepractice has evolved not only as an alternative method, but in many cases, as the primary mode of service delivery. Given that speech-language pathology and audiology regulatory boards have had a long-standing commitment to public protection, there is a renewed responsibility to ensure that enabling statutes and rules and regulations encompass the current practice of the professions, including the utilization of telepractice (telehealth) as an appropriate, contemporary service delivery model.
The U. S. Department of Health and Human Services Health Resources and Services Administration (HRSA) defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration (retrieved September 27, 2014 from http://www.hrsa.gov/ruralhealth/about/telehealth/). Each state agency or occupational licensing board that regulates the practice of speech-language pathology and/or audiology should develop policies necessary to provide for, promote, and regulate the use of telepractice in the delivery of services within the scope of practice regulated by the licensing entity.
It is the position of the National Council of State Boards of Examiners for Speech-Language Pathology and Audiology (NCSB) that telepractice constitutes the practice of speech-language pathology and audiology in both the patient site and the provider site. Further, state licensure boards should address protection of the consumer by requiring out-of-state practitioners to notify the board of their intent to engage in the practice of speech-language pathology and/or audiology in the state where the patient resides. The provision of services by telepractice shall encompass the following essential standards:
Although there is not a uniform practice act, and standards do vary to some extent from state to state, licensure boards nevertheless share the responsibility to protect consumers regardless of the mode of service delivery. The establishment of a mechanism for telepractice services, whereby licensure boards can expand services to individuals with speech, language, or hearing problems, can remove barriers to care while also ensuring that protection of the public’s health, safety and welfare is maintained. It shall be the responsibility of each state licensing board to develop rules, policies, and procedures consistent with the laws of that state for the regulation and enforcement of services provided by telepractice.
Revised March 2015
July 28, 2003
Susan Pilch, Director
State Legislative and Regulatory Advocacy
American Speech-Language-Hearing Association
10801 Rockville Pike
Rockville, Maryland 20852-3279
Dear Ms. Pilch:
In response to your invitation for review of the draft of the ASHA Model Licensure Bill, the following comments are provided.
The Model Bill for State Licensure of Speech-Language Pathologists and Audiologists appears to be comprehensive and the "explanation" column is helpful in clarifying points discussed under the provisions of the "act". Below are points picked up by me and members of the Board of the NCSB which you may wish to consider.
1) Under Article 4 Disciplinary Actions, 4.01(1) Penalties (Pg.20). The disciplinary actions listed are fairly comprehensive; however, consideration might be given to including in that listing "Impose other disciplines as deemed appropriate by the board." Since there is no way to make such a list all inclusive, this leaves it open for boards to impose sanctions unique to a given reason for a disciplinary action, ( e.g. self study in a particular area; take exam on state law, etc.). This may have been what you had in mind under 4.01 (1)(g). However, to make it broader and clearer, it might be helpful to include the above highlighted statement to this item, or list it as a separate penalty under 4.01(1).
2) There was question by members of the NCSB Board whether there was language in the model bill establishing governance of unlicensed practice. This may be what you are referring to under Article 4, 4.07(2) Injunction (pg. 25). However, to provide enabling legislation to a board's Practice Act (which a couple of states now have), the following, taken from the NABP Model State Pharmacy Act, might be useful. (I have paraphrased and adapted the following to the fields of audiology & speech-language). Section_____ of this Act makes it unlawful for any unlicensed person to engage in the practice of Audiology or Speech-Language Pathology, and by enabling the Board to exact penalties for unlawful practice. Any individual who, after a hearing, shall be found by the Board to have unlawfully engaged in the practice of Audiology or Speech-Language Pathology shall be subject to a fine to be imposed by the Board not to exceed $_____ for each offense. Each such violation of this Act or the rules promulgated hereunder pertaining to unlawfully engaging in the practice of Audiology or Speech-Language Pathology shall also constitute a (misdeameanor) punishable upon conviction as provided in the criminal code of the state'.
3) Members of the Board of NCSB had questions about "assistants" and a board's statutory authority for consumer protection. While we recognize this is a controversial issue, under Article 1, l.04 (pg. 6), there is considerable detail about "Audiology Support Personnel and Speech-Language Pathology Assistants". In l.04(1)(a), it is noted that assistants shall be 'registered' with the Board, and in l.04(2)(f) it's noted that the Board shall establish procedures for renewing registration of assistants & terminating duties. Given this explicit detail, consideration should be given to detailing Assistants' registration requirements under Article 3-Licenses, and Article 4-Disciplinary Actions delineating penalties the Board can impose if registration and renewal procedures are not followed.
4) The issue of "Telepractice" is not addressed anywhere that I can see in this model bill except possibly under Article 4, 4.02(1)(s)(pg. 22) in which is stated that diagnosing or treating by mail or 'phone' unless previously examined by the licensee is prohibited. The issue of "telepractice" (or the numerous related names) and licensure is a very hot topic and a very important one. For a Model Licensure Bill to ignore this topic all together makes it conspicuous by it absence. It would be helpful to all licensure boards to have a Model Bill provide guidance in this area. The NCSB has developed a position paper to assist licensure boards on regulatory issues related to telepractice.
These are key areas we noted in the Model Bill. If you have any questions or wish to discuss this further, contact me at 301-670-2256/60 or 301-762-2093.
Louise Colodzin, President
May 15, 2003
Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 3016
Baltimore, Maryland 21244-3016
To Whom It May Concern:
On behalf of the National Council of State Boards of Examiners for Speech- Language Pathology and Audiology (NCSB), I am writing in support of the proposed regulation to revise the Medicaid provider requirements for audiologists under the Medicaid Program. We commend Secretary Thompson and Centers for Medicare & Medicaid Services (CMS) for publication of this proposed rule.
While the NCSB supports the proposed regulation, we wish to express concerns and recommendations to the CMS regarding the issue of the professional standard used to identify quality services by audiologists; that is, voluntary certification vs mandated state licensure. Since the CMS proposed ruling was open for comment, there has been much written by national professional organizations which has been misleading with respect to state licensure laws. The NCSB would like to provide the CMS with relevant information.
The NCSB is a national organization that represents state licensure boards in audiology and speech-language pathology across the Country. In our work with licensing boards nationwide, we gather data relative to licensing characteristics and national trends and appreciate and respect the importance and effectiveness of statutory authority imposed by states in the interest of consumer protection.
For the following reasons, the NCSB strongly encourages the CMS to recognize state licensure as the sole national standard for Audiology:
State Licensure is the legal authority to practice a health care profession in a given s tate. For a Federal agency not to support the authority of states' licensure laws is at best inappropriate and at worst it undermines the statutory authority of those laws. As in other health-care professions, state licensure should be used as the criteria for provider status in the field of Audiology. This will also provide direction to other agencies and private carriers in using a consistent definition of who is a qualified audiologist.
There are 48 states that have licensure laws for the practice of Audiology, and in 15 of these states this includes school-based professionals as well. In many if not most states, standards are in place that equal or exceed the requirements of the private certification (CCC) sponsored by the American Speech-Language-Hearing Association(ASHA) which the CMS has used as its definition of a qualified practitioner. (As for the 2 states without a licensure law in place, the new CMS regulation creates a generic definition of an audiologist which could be used and which mirrors the basic requirements of states' laws.) While the NCSB appreciates the value of national certification, it is no longer necessary to use a credential of a private professional organization in lieu of state licensure. In fact, legal counsel has advised licensure boards nationwide that a clear separation must be maintained between licensure boards and private professional associations to avoid any suggestion of influence. The NCSB believes that a Government agency should not be seen as promoting the credential of any private organization.
In addition, the NCSB believes there should be sensitivity to financial demands placed on audiology professionals in a field that is not always highly paid. Requirements to pay fees for mandated state licensure and certification from a private professional organization is a hardship for many. The NCSB believes that an audiologist should meet academic and professional practice standards as defined by the state licensure law. Private certification should be a matter of personal choice and not a requirement for participation in a Government sponsored program.
The NCSB appreciates the opportunity to provide comments on this important proposal. We urge the CMS to recognize state licensure as the sole national standard for defining an audiologist.
Louise Colodzin, President
May 1, 2003
Glenda Ochsner, Ph.D., President
American Speech-Language-Hearing Association
10801 Rockville Pike
Rockville, Maryland 20852-3279
Dear Dr. Ochsner:
The National Council of State Boards of Examiners for Speech-Language Pathology and Audiology (NCSB) wishes to express concerns relative to your March 24 letter to audiologists. NCSB recognizes the importance of the credential issued by ASHA and appreciates the value of national certification. At the same time, NCSB, through its work with state licensing boards across the country, also appreciates the importance of statutory authority imposed by the states and each year gathers data relative to licensing characteristics and national trends.
There is a misstatement in the content of the letter concerning work-setting exemptions. The letter indicates that only four states do not exempt school employees from licensure; however, the information on the ASHA web site, information presented at a poster session at the 2002 ASHA convention, and information on the NCSB web site provide conflicting data with regard to this information. ASHA's web site lists fourteen states with exemption-free licensure, and at present, there are fifteen states that require professionals to be licensed regardless of work setting. The information in your letter is misleading, not only to audiologists across the country, but also to officials at the Centers for Medicare and Medicaid Services (CMS).
NCSB also takes issue with the implication that licensure is not a sufficient credential for Medicaid and Medicare reimbursement. In many states, standards are in place that equal or exceed the requirements for the ASHA CCC's. Legal counsel has advised that licensure boards should not reference in statute the standards established by professional associations even though the standards may mirror those of the professional association.
While it was probably not your intent, the content of the letter and the misinformation contained therein undermine statutory authority in the forty-eight states that have licensure laws. NCSB respectfully requests that information provided to agencies such as CMS be accurately stated and that the legal mandates for consumer protection across the country not be minimized. Thank you for your consideration of this matter.
Louise Colodzin, President