Upon graduation, new genetic counselors (GCs) frequently question: What is licensure? How do I apply for it? Do I even need it? Do I need multiple licenses? For the newly initiated, the general guidance is this: GCs need licensure in the state in which they are practicing (unless licensure is not written into that state’s law), and in the state in which their client receives genetic counseling. States implement licensure requirements primarily for legal protection against malpractice and to standardize GC professional requirements. However, licensure benefits our profession as well. It is broadly supported by GCs, and increases influence among medical providers, institutions and in the eyes of patients (Mester et al., 2009). Of particular importance, state licensure is a requirement for many institutions to receive insurance reimbursement for GC appointments.

If having a GC state license has strong benefits, would it not be better to be licensed in multiple states? Certainly, some find value – the 2024 Professional Status Survey reports nearly 20% of GCs are licensed in more than one state. A major benefit of having multiple licenses is that GCs can counsel patients in other states, even if the patient is not receiving ongoing care at the GC’s institution. Therefore, telehealth or industry GCs may be more likely to be asked to apply for multiple licenses to expand their employer’s customer base. Multiple licenses could also allow GCs in private practice to see more patients. Similarly, family members of gene-positive patients or participants in genomic research studies may not be receiving care at a facility that offers genetic counseling, so GCs who facilitate cascade testing or return of results may also be more likely to have multistate licensure. Multistate licensure may make it easier for patients to receive care across state lines, reducing barriers in access to GC services. For these reasons, we anticipate that multistate licensure will likely be increasingly desired as telegenetic services become more commonplace.

However, there remains a major barrier to multistate licensure: lack of standardization. State-based inefficiencies in the application process, costs and varying timelines for approval make obtaining multistate licensure a huge undertaking for any individual GC. Some states, like Montana, require only an online application and certification verification. Other states, like Pennsylvania, require these items plus malpractice insurance, mandated reporter training and more. Fingerprint background checks and notarized proof of identity are frequently required. These materials are managed through state-based portals or applications, with approval processes varying by state (e.g., automatically, after quarterly board review, etc.). This says nothing of the cost – some states demand exorbitant fees, such as newly licensed South Carolina, which charges $600 for a two-year license, whereas states like Florida ask a measly application fee of $5. Currently, licensure for all states costs nearly $7,000, not including additional fees associated with background checks, verification of current licenses or renewals. Another barrier is the enormous amount of personnel time required for applications. One abstract reported an average of 7.7 hours per application per GC (Tschirgi et al., 2019). For 35 states, that is a cumulative 262 hours – or 6.5 full-time workweeks, assuming the GC is focusing only on licensure applications. For those juggling applications on top of patient care or other roles, this process may be even more drawn out. The time required will likely increase as states in lawmaking approve licensure and subsequently request verification of held licenses from other states.

Because of the challenges with obtaining multistate licensure, we suggest that a national application be implemented. A single portal where GCs supply all required documents and proof of identity, manage new applications, verify previously obtained licenses and complete renewals would vastly decrease the time needed for GCs to apply for multistate licensure. A national application would standardize licensure across all states, improving efficiency for state governments and implementing safeguards for GCs who otherwise must juggle dozens of licenses. A national application would allow GCs to share their services more broadly, improving patient access and smoother care handoffs.

This opinion is not new – it has been previously suggested that a single central information repository for licensees would alleviate professional burden and improve patient care (Mackall & Tschirgi, 2024; Tschirgi et al., 2022). The existing infrastructure could be co-opted for a “one-size-fits-all” application. For example, multiple medical boards use programs such as Veridoc or IdentoGo, which offer easy ways to request licensure verification and background checks respectively. The American Board of Genetic Counseling (ABGC) also has a process to send proof of certification to each state department.

Other professions have implemented this already, with allied health professionals utilizing universal licensure services called compacts. Nurses use the enhanced Nurse Licensure Compact, a program run by the National Council of State Boards of Nursing that partners with state departments to ensure that all requirements of licensure are met. Psychologists take advantage of a similar system called the Psychology Interjurisdictional Compact (PSYPACT®), which allows practice across state lines through license reciprocity. The Interstate Medical Licensure Compact works similarly but is utilized primarily by physicians caring for rural or underserved populations. States can choose whether to implement these systems; states that do will likely see a reduction in administrative burden.  

We acknowledge that this will be a heavy lift. ABGC, NSGC or similar organizations will need to take the lead. Challenges regarding licensure and reimbursement will need to be overcome, especially as it relates to telemedicine. There are nuances with bureaucracy that will only be understood after close collaboration with each state department. Experts in the field will need to be consulted, such as the founders of MeetElsie, who have dedicated their business to tracking, obtaining, and maintaining multistate licenses for GCs. But there is hope! With advancements in artificial intelligence, many of these processes could be automated, saving hours of work by applicants currently spent repetitively filling out forms. 

A national system for multistate licensure will alleviate professional burdens for GCs and reduce statewide administrative effort, subsequently improving access to genetic testing and counseling services for patients across state lines. Let us follow the lead of longer-established professions and take GC licensure to the next level.

Acknowledgements: A huge thank you to the NSGC Multi-State Licensure (MSL) Workgroup who have developed and maintained excellent resources for multistate applicants.  

Photo by Markus Winkler on Unsplash

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