Washington Telemedicine Laws: Licensure, Audio-Only, Parity

Washington is a full-license state with a short list of statutory exceptions, and one of the few states with genuine payment parity written into insurance law. The 2024 Uniform Telehealth Act, chapter 18.134 RCW, codified what the Medical Commission had long said — care happens where the patient is — and named exactly three situations in which an out-of-state license is enough. Carriers and Medicaid managed care plans must pay telemedicine at the in-person amount, with one carve-out for larger groups, and audio-only rides on an "established relationship" rule the Legislature loosened in 2024.

Licensure: the Uniform Telehealth Act names the exceptions

RCW 18.134.060 fixes a telehealth service at the patient's location. Under RCW 18.134.050, an out-of-state practitioner may treat a Washington patient only if they hold a Washington license or are otherwise authorized here, "including through a multistate compact of which this state is a member," or if they hold a license in good standing elsewhere and the service takes one of three forms: a consultation with a Washington practitioner who keeps responsibility for diagnosis and treatment; a specialty assessment, diagnosis, or treatment recommendation that does not include providing treatment; or follow-up to maintain continuity with an established patient temporarily in Washington who was treated in the practitioner's home state. The older consultation exemption in RCW 18.71.030(6) says much the same thing for physicians.

None of those covers a virtual practice marketing to Washington residents, and there is no telehealth registration of the Florida kind. The Act's enabling bill asked the state's telehealth collaborative to review a registration model and report by December 1, 2024; the collaborative has since wound down, and we found no registration enacted as of this writing.

The practical route for physicians is the Interstate Medical Licensure Compact. Washington enacted membership through SB 5221 in 2017, and the Commission lists the compact as an expedited pathway alongside its standard application. Washington also participates in the Physical Therapy Compact. For the nursing, psychology, and counseling compacts, use our tracker, which does not yet show verified Washington status.

Two more points. RCW 18.134.030 lets a practitioner-patient relationship form through telehealth but not "through email, instant messaging, text messaging, or fax," and RCW 18.134.040 bars a disciplining authority from setting a different standard because the care was remote. RCW 43.70.495 requires non-physician professionals who provide clinical services through telemedicine to complete a telemedicine training and retain a signed attestation; physicians are exempt. The Commission's 2021 telemedicine policy, which stated the patient-location rule, was taken up for rescission after the Act passed; verify with the Commission which guidance remains in force.

Prescribing: no state schedule ban; the PMP rule does the work

Washington has no statute barring any drug schedule by telehealth, and because the relationship can form remotely, the federal DEA framework is the operative constraint on controlled substances — see our DEA prescribing report, which covers the flexibilities currently extended through the end of 2026; verify current status before relying on them.

The state-specific obligations are the Commission's opioid rules. WAC 246-919-985 requires a physician who prescribes Schedule II–V medications to register for the Prescription Monitoring Program or show assured access, and to ensure a query is run at the first refill or renewal of an opioid for acute pain, at the transitions to subacute and chronic pain, and for chronic pain at a frequency set by risk — at least quarterly for high-risk patients, semiannually for moderate, annually for low. Where the EHR integrates the PMP, a query is expected for every opioid prescription; queries can be delegated. Nothing in the rule distinguishes a telehealth prescription from an office one, so telepsychiatry and pain practices should build the check into the visit. Controlled substances must also be transmitted electronically under RCW 69.50.312, subject to its exceptions and a waiver process. The Commission opened a rewrite of the opioid chapter in 2025 (WSR 25-10-039) with workshops running through late 2026; the current text stands until a final rule is filed.

Consent: no general mandate, but audio-only billing needs it in advance

Washington has no telemedicine-specific informed-consent statute for video visits; general consent duties and each profession's standards apply. The consent the state does mandate is financial. If a provider intends to bill a patient or plan for an audio-only visit, RCW 48.43.735 and the Insurance Commissioner's rule, WAC 284-170-433, require patient consent before the service, documented, retained at least five years, and revocable prospectively. RCW 74.09.325 and 71.24.335 impose the same requirement on Medicaid managed care and behavioral health, and HCA wants it in the client record. Separately, RCW 18.134.070 bars billing a patient directly for telehealth a plan will not reimburse unless the patient consented in advance.

Medicaid: fee-schedule parity, audio-only with conditions, e-consults

Apple Health, run by the Health Care Authority, pays the distant-site professional service at the current fee schedule amount for the code — the same as in person — and RCW 74.09.325 requires managed care organizations to pay the in-person amount as well, with the same eleven-provider carve-out found in insurance law. Bill with place of service 02 or 10 and add modifier 95 when the distant site is nonfacility; GT survives only for critical access hospitals on the optional payment method. HCA ties telemedicine billing to Washington licensure or a compact Washington recognizes, and requires the provider's state location in the record.

Audio-only follows the statutory established-relationship test — an in-person or video visit within three years with the practitioner or same group, or a referral from a practitioner who had one — plus documented consent. It is billed with modifier 93 for physical health and Part I mental health codes or FQ for substance use disorder and Part II behavioral health codes; a mixed encounter counts as audio-only when half or more of it was audio. No originating-site facility fee (Q3014) is paid for audio-only, store-and-forward, the home, inpatient hospital, or skilled nursing settings. Effective January 1, 2025, HCA rebuilt store-and-forward around e-consults (CPT 99451 and 99452) and deleted the teledermatology section. Remote patient monitoring is not in the telemedicine guide; check the program-specific guide before billing it.

Private insurance: payment parity with a size carve-out

RCW 48.43.735 requires a carrier to reimburse a telemedicine service when the service is covered in person, medically necessary, an essential health benefit, and safely and effectively deliverable remotely. For plans issued or renewed on or after January 1, 2021, the carrier must pay "the same amount of compensation" it would pay in person — payment parity, not just coverage parity — except that hospitals, hospital systems, telemedicine companies, and provider groups of eleven or more may negotiate a different rate. Store-and-forward is paid only for services listed in the provider's contract, and originating sites include the home. Audio-only has required an established relationship since January 1, 2023; SB 5821 (2024 c 215) stretched the look-back from two years to three. RCW 41.05.700 applies the same rules to public and school employee plans. Self-funded employer plans sit outside all of it — the reimbursement guide covers that split.

What to watch

Three items: whether the Legislature revives an out-of-state registration now that the collaborative's review has lapsed; the Commission's opioid-rule and chapter 246-919 rewrites, which could change PMP timing; and the federal side, where the DEA framework and Medicare's flexibilities decide what Washington's permissive prescribing posture is worth — verify current status. Confirm current requirements with the Washington Medical Commission and the Health Care Authority before acting, and compare Washington with its neighbors in the national overview.