# Four-State Telehealth Rollout Map: Compliance Analysis

**To:** Clearpath Behavioral Care Executive Leadership & Product Team  
**From:** Legal & Compliance Division  
**Date:** October 26, 2023  
**Subject:** Lawful Service Rollout and Marketing Restrictions  

## Executive Summary
Based on the governing law and provided state matrices, **Clearpath cannot launch fully virtual stimulant treatment in all four states as proposed.** While antidepressant management is permissible across all four states with appropriate staffing, controlled substance prescribing (stimulants) is restricted to Birch only for new patients. Alder and Cedar require physical practice-based initiation for stimulants; Dune prohibits telehealth stimulant prescribing entirely.

Below is the state-by-state compliance map and required operational changes.

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## 1. Clinician Authorization for Video Antidepressant Care
*Antidepressants are classified as non-controlled medications.*

| State | Required Authority | Authorized Clinician | Rationale |
| :--- | :--- | :--- | :--- |
| **Alder** | Full License (Compact/Registration invalid) | **Dr. Rowan Lee** | Dr. Lee holds a full Alder license; NP Vale does not. |
| **Birch** | Recognized Compact Privilege | **Dr. Rowan Lee** | Dr. Lee holds the recognized Birch compact privilege. |
| **Cedar** | Full License + Entity Permit (Both required) | **NP Amaya Vale** | Clearpath has the entity permit; NP Vale has the full license (Dr. Lee lacks Cedar license). |
| **Dune** | Approved Telehealth Registration | **Dr. Rowan Lee** | Dr. Lee holds an approved Dune telehealth registration. |

## 2. Entity Permit Compliance Status
*Rule 8 states entity permits and individual authority are separate requirements.*

*   **Alder:** Matrix does not mandate an entity permit for telehealth, only clinician licensure. **Status: Compliant.**
*   **Birch:** Matrix does not mandate an entity permit for telehealth. **Status: Compliant.**
*   **Cedar:** Matrix explicitly requires "telehealth company must hold a Cedar entity permit." Clearpath holds this permit. **Status: Compliant.**
*   **Dune:** Matrix requires registration for the clinician; no specific entity permit requirement is listed. **Status: Compliant.**

## 3. New-Patient Stimulant Prescribing (Controlled)
*Stimulants are controlled substances.*

| State | Proposal Status | Legal Barriers | Rationale |
| :--- | :--- | :--- | :--- |
| **Alder** | **BLOCKED** | In-Person Exam Required | Matrix requires "same practice conducted an in-person examination within the preceding 12 months." New patients lack this history. Outside exams do not count (Rule 7). |
| **Birch** | **APPROVED** | None | Video allowed for controlled meds. Requirement is PMD check + documentation before each rx. Platform supports this. Dr. Lee has compact privilege. |
| **Cedar** | **BLOCKED** | In-Person Exam Required | "First controlled prescription requires an in-person examination by the prescribing practice." Outside exams do not count (Rule 7). |
| **Dune** | **BLOCKED** | Banned by Statute | "Registrant may not prescribe a controlled substance by telehealth under any circumstance." Clearpath lacks a full Dune license clinician. |

## 4. Outside Primary-Care Examination Validity
*Rule 7: An outside clinician exam satisfies a state condition **only** if the matrix expressly says so.*

*   **Alder:** Matrix requires "same practice conducted an in-person examination." It does not mention unaffiliated clinicians. **Outside exams DO NOT satisfy this requirement.**
*   **Cedar:** Matrix requires "in-person examination by the prescribing practice." It does not mention unaffiliated clinicians. **Outside exams DO NOT satisfy this requirement.**

## 5. Lawful Stimulant-Renewal Pathways
*How Clearpath may legally manage existing stimulant patients.*

*   **Alder (Hybrid Model Only):** A patient must attend an in-person appointment at a **Clearpath Alder Clinic** first. Afterward, they are eligible for video renewals for 12 months. *Note: The proposed pathway of "renewals based on outside PCP exam" is illegal.*
*   **Birch (Fully Virtual):** Video renewals permitted indefinitely, provided the clinician checks and documents the State PMD check before **every** renewal prescription.
*   **Cedar (Hybrid Model Only):** A patient must attend an in-person appointment at a **Clearpath Cedar Clinic** first. Afterward, they are eligible for video renewals for 12 months. *Note: Outside PCP exams do not reset this clock.*
*   **Dune:** No lawful pathway exists for stimulant prescribing by Clearpath.

## 6. Required Compliance Steps (Platform Requirements)
The following workflows must be hard-coded into the scheduling and visit interface:

1.  **Location Verification (All States):** System must capture and document patient physical location at the start of *every* visit (Rule 2).
2.  **Telehealth Consent (All States):** System must enforce digital informed consent signature prior to the first video service (Rule 3).
3.  **PMD Check (Birch Only):** Before any stimulant prescription is generated in Birch, the provider must verify they have accessed and documented the state monitoring database check (Matrix). Platform must block Rx generation without this flag.
4.  **Clinician Routing Logic:**
    *   Route Alder/Birch/Dune visits to Dr. Lee.
    *   Route Cedar visits to NP Vale.
5.  **Stimulant Blockers:**
    *   Prevent video stimulant initiation in Alder, Cedar, and Dune.
    *   Prevent video stimulant renewal in Alder/Cedar unless the patient record contains a verified Clearpath in-person visit within the last 12 months.

## 7. Proposed Services to Be Blocked by Platform
Marketing and Product must disable the following configurations immediately:

1.  **Video New Patient Stimulants (Alder, Cedar, Dune):** Initiation of controlled substances via video without prior in-person clearance from Clearpath is prohibited.
2.  **Outside-Exam Renewals (Alder, Cedar):** The platform must not accept a "Yes" to an outside primary care exam as satisfying the 12-month in-person requirement for Clearpath renewals.
3.  **Video Stimulants (Dune):** No controlled substance prescribing logic should be enabled for Dune registrants under any circumstance.

## 8. Lawful Marketing Claim
**Proposed Claim:** *"Fully virtual ADHD treatment in all four states."*  
**Compliance Ruling:** **PROHIBITED.** This claim is false and misleading regarding Alder, Cedar, and Dune.

**Corrected Marketing Language:**
> *"Clearpath offers fully virtual ADHD evaluation and prescribing in Birch State. In Alder and Cedar States, telehealth stimulant treatment requires an initial in-person visit at a Clearpath clinic location. Currently, controlled substance prescribing is not available via telehealth for patients located in Dune State."*

**Antidepressant Marketing:**
> *"Clearpath offers fully virtual antidepressant management across all four states (Alder, Birch, Cedar, and Dune)."* (Accurate based on Matrix).