Virginia Telemedicine Laws: Licensure, Prescribing, Consent

Virginia took a different path from most East Coast states: instead of joining the physicians' licensure compact, it wrote unusually practical exceptions directly into its medical practice act — including one that lets an out-of-state physician keep treating an established patient by telemedicine. It's a state where the licensure answer is often "no, but," and where the parity answer requires reading the fine print.

Licensure: no compact, but real exceptions

The default rule is standard: the practice of medicine occurs where the patient is located, so treating a Virginia patient requires a Virginia license. Virginia is not an IMLC member — a 2022 bill to join, HB 527, died in committee — though it participates in nine other compacts including nursing, PSYPACT, physical therapy, occupational therapy, counseling, and social work. (Some directories wrongly list Virginia as an IMLC state; the official state compacts page is the authority.)

What Virginia offers instead, in § 54.1-2901, is a set of exceptions with actual clinical utility:

• Continuity of care. A physician, PA, APRN, respiratory therapist, or occupational therapist who holds an active, unrestricted license in another state or the District of Columbia and is in good standing there may treat a current patient located in Virginia by telemedicine for the purpose of continuity of care, if the provider previously established the practitioner-patient relationship and performed an in-person examination within the previous 12 months (§ 54.1-2901(A)(35)). If that provider is unavailable, another practitioner of the same subspecialty in the same practice group, with access to the patient's treatment history, may provide continuity of care by telemedicine until the original provider is available.
• Behavioral health continuity. An out-of-state physician, PA, or APRN in good standing who provides behavioral health services may continue care by telemedicine for a patient in Virginia if the practitioner previously established the relationship and performed an in-person evaluation of the patient within the previous year, for no more than one year from the date the telemedicine services began (§ 54.1-2901(A)(33)). Parallel provisions for out-of-state psychologists, clinical social workers, and professions regulated by the Board of Counseling require good standing and a previously established relationship, with the same one-year limit but no prior in-person evaluation (§§ 54.1-3601(11), 54.1-3701(6), 54.1-3501(7)).
• Consultation. The traditional exception for out-of-state practitioners consulting with Virginia-licensed colleagues.

Both continuity exceptions, and the behavioral health versions for psychologists, clinical social workers, and Board of Counseling professions, apply only to "telemedicine services" as defined in the insurance code (§ 38.2-3418.16), and that definition excludes an audio-only telephone call, email, fax, and online questionnaires. An audio-only phone visit therefore does not fall within these exceptions.

For practices in DC, Maryland, and North Carolina with patients who move or travel into Virginia, these exceptions do real work — a snowbird or college-student patient doesn't force an immediate licensure scramble the way they would in New York or New Jersey.

Prescribing: bona fide relationship, formed remotely only when every condition is met

Virginia's prescribing statute (§ 54.1-3303(B)) requires a bona fide practitioner-patient relationship: a medical or drug history, information about the drug's benefits and risks, an appropriate examination, and follow-up where needed. The examination may be done physically or through instrumentation and diagnostic equipment that transmits images and records electronically. Except in a medical emergency, that examination must be performed by the prescriber, a practitioner in the same group, or a consulting practitioner. For Schedule II through VI drugs (Schedule VI covers most prescription drugs), a prescriber may establish the relationship by real-time two-way audio-video or store-and-forward only when every statutory condition is met:

• the patient's medical history is available for review, and the prescriber obtains an updated history and makes a diagnosis at the time of prescribing;
• the prescriber meets the in-person standard of care, using peripheral devices where the standard of care calls for testing or a physical exam;
• the prescriber is actively licensed in Virginia and authorized to prescribe;
• if the patient is a health plan member, the prescriber is credentialed by that plan as a participating provider, and the diagnosing and prescribing meet the plan's reimbursement requirements under § 38.2-3418.16;
• the prescriber provides patient records on request;
• the standard of care does not require an in-person examination for diagnosis; and
• establishing the relationship by telemedicine is consistent with federal law and any waiver.

On-call coverage, prescriber-to-prescriber consultation, and hospital orders are carved out. Once a relationship exists, telemedicine prescribing of Schedule II through VI drugs must comply with federal telemedicine requirements, and for Schedules II–V the prescriber must either maintain a practice at a physical location in Virginia or be able to refer the patient to a Virginia-licensed practitioner for an in-person examination when the standard of care calls for one.

Other state duties apply to telemedicine exactly as they do in person:

• Registration. Virginia's separate controlled substances registration certificate does not apply to licensed practitioners of medicine, osteopathy, podiatry, dentistry, optometry, or nursing, or to licensed physician assistants (§ 54.1-3422(A)). Any prescriber licensed in Virginia to treat human patients and authorized to prescribe a covered substance must be registered with the Prescription Monitoring Program (§ 54.1-2522.1(A)).
• PMP. When starting a new course of treatment that includes opioids expected at the outset to last more than seven consecutive days, the prescriber or a delegate must query the Prescription Monitoring Program. Any prescriber of a controlled substance approved for opioid addiction therapy must query it before or when executing the treatment agreement. Exceptions include hospice or palliative care patients, inpatient admissions and discharges, certain nursing home and assisted living residents, sickle cell pain, and a program outage (§ 54.1-2522.1(B)–(C)). A version effective July 1, 2027 changes the trigger to a new course of a benzodiazepine or opiate expected to last more than 90 consecutive days and replaces the exception list.
• Opioid limits. Board of Medicine rules bar prescribing an opioid for acute or subacute pain in a quantity above a 14-day supply, and limit opioids for a surgical procedure to 14 consecutive days, unless extenuating circumstances are documented. The prescriber must document the reasons for exceeding 50 MME a day, and must document a justification or consult a pain specialist before exceeding 120 MME a day. Before starting an opioid for acute or subacute pain, the prescriber must perform an appropriate history and physical examination, query the PMP, and assess the patient's risk of substance misuse. The rules apply to physicians, podiatrists, and PAs, and do not apply to pain related to cancer or sickle cell, patients in hospice or palliative care, inpatient hospital care, patients in a nursing home or in an assisted living facility that uses a sole-source pharmacy, or patients enrolled in a clinical trial (18VAC85-21-10, -30, -40).
• E-prescribing. Any prescription for a controlled substance that contains an opioid must be issued electronically. Exceptions include temporary technological failure, patients in hospitals, nursing homes, or hospice, prescriptions that cannot be sent electronically in time when the patient's condition is at risk, and board-granted waivers of up to one year (§ 54.1-3408.02). Medicare Part D separately requires at least 70 percent of Part D Schedule II–V prescriptions to be electronic under 42 CFR 423.160, subject to exceptions and waivers.

Federal law adds a separate layer for controlled substances. Under the temporary rule DEA and HHS published December 31, 2025 (90 FR 61301), which runs through December 31, 2026, a DEA-registered practitioner may prescribe Schedule II–V controlled substances after a real-time audio-video telemedicine encounter without a prior in-person evaluation, when the rule's other conditions are met; audio-only encounters qualify only for Schedule III–V narcotic medications approved by the FDA to treat opioid use disorder. See our DEA prescribing report.

Consent

There's no standalone all-payer consent statute. The Board of Medicine's telemedicine guidance (document 85-12) says evidence of informed consent for telemedicine must be obtained and kept, and lists baseline elements such as practitioner identity and credentials, the activities telemedicine will be used for, and privacy and security measures. Virginia Medicaid goes further for its members: documented consent covering the nature of the service, voluntariness, confidentiality, who is present at each site, and the right to refuse recording.

Medicaid: one of the more complete coverage sets

Virginia Medicaid (DMAS) covers the full modality stack: live video statewide, audio-only for specified services (modifier 93), store-and-forward for radiology and select services, and remote patient monitoring — with 2025 legislation expanding RPM for high-risk pregnancies, including maternal diabetes and hypertension. The originating site is wherever the member is: home, work, school, or a facility, with no geographic restriction. Notably for virtual-first groups, telemedicine-only providers don't need a physical Virginia location to enroll. The details live in the DMAS Telehealth Services Supplement, updated January 2026 — the controlling document for billing specifics, and worth reading alongside our RPM guide.

Private insurance: read "same basis" carefully

Virginia's § 38.2-3418.16 delivers clear coverage parity — insurers can't exclude a service from coverage solely because it was delivered via telemedicine, they must cover medically necessary RPM, and there are no originating-site restrictions. Deductibles, copayments, and coinsurance may not exceed the in-person amounts. Insurers may conduct utilization review of telemedicine only in the same manner as for any other covered condition, and utilization review may not require preauthorization of emergent telemedicine services. The statute's definition of telemedicine excludes audio-only telephone, email, fax, and online questionnaires, so the mandate does not reach audio-only care, though it does not bar plans from covering it. It says nothing about out-of-network providers, and it does not apply to short-term travel, accident-only, limited or specified disease, or Medicare-supplement and other federal-program policies. On payment, the statute says insurers shall reimburse telemedicine "on the same basis" as face-to-face services while expressly allowing them to decline to pay technical fees or costs. Whether "same basis" means "same rate" is a genuinely contested reading — the leading policy trackers treat Virginia as having no explicit rate-parity mandate. The honest operational advice: don't build a pro forma on assumed parity; check what your actual payer contracts say. Context on how state parity laws interact with Medicare is in our reimbursement guide.

What to watch

Virginia's telehealth policymaking runs through Richmond every session — recent years brought school-based telehealth, correctional telehealth, and a steady expansion of maternal RPM. Virginia's Medicaid law covers remote patient monitoring for high-risk pregnant persons through 12 months postpartum (§ 32.1-325(A)(28)), and HB 425, signed in April 2026, addressed Medicaid remote monitoring for pregnant members at greater risk of complications; confirm current eligibility in the DMAS Telehealth Services Supplement. The two structural questions are whether Virginia eventually joins the IMLC and whether the parity language gets sharpened either way. Verify current rules with the Board of Medicine and DMAS before acting, and see the national overview for the cross-state picture.