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S Phillips 2022 34th Annual APRN Legislative Update
Maternity Nursing Practicum (NURS 335)
San Francisco State University
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tnpj The Nurse Practitioner • January 2022 21
Abstract: Relaxation of existing regulations
in supervision, collaboration, license renewal,
and portability due to the continuing
COVID-19 pandemic improved practice
authority for advanced practice registered
nurses (APRNs) in reduced- and restricted-
practice states. This 34th Annual Legislative
Update covers the scope of practice changes,
and legislative and regulatory decisions that
most impacted APRNs across the US in 2021.
By Susanne J. Phillips, DNP, APRN, FNP-BC, FAANP, FAAN
####### n January 2021, the Annual Legislative Update
####### focused on how adoption of temporary emer-
####### gency regulations in 2020 positively affected
####### advanced practice registered nurse (APRN) practice
####### authority in reduced- and restricted-practice states. 1
####### By relaxing existing regulations in areas of supervi-
####### sion, collaboration, license renewal, and portability,
####### APRNs were able to make a signifi cant difference in
####### the populations they served. These changes improved
####### practice authority for not only NPs or CNPs but also
####### certifi ed nurse midwives (CNMs), clinical nurse spe-
####### cialists (CNSs), and certifi ed registered nurse anes-
####### thetists (CRNAs). Since that time, many states have
Keywords: APRN, certifi ed nurse midwife (CNM), certifi ed registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), COVID-19, NP, practice authority, regulations
34
th
Annual
APRN Legislative Update:
Trends in APRN practice authority during
the COVID-19 global pandemic
I
AN NP EXCLUSIVE
22 The Nurse Practitioner • Vol. 47, No. 1 tnpj
####### permanently adopted regulations and enacted new
####### laws authorizing full-practice authority (FPA) with
####### and without transition to practice (TTP) periods (see
####### Summary of practice authority for NPs ). 1
####### This year will highlight those states that passed
####### legislation or permanently adopted APRN practice
####### changes leading to FPA, as well as states that have en-
####### acted laws pertaining to the provision and reimburse-
####### ment of home health services, and telehealth services
####### by NPs and CNSs as a result of the Coronavirus Aid,
####### Relief, and Economic Security (CARES) Act. 2 Boards
####### of Nursing (BONs) and/or state nursing associations
####### provided the total number of active clear licensed/
####### certifi ed APRNs in 2021 for this report (see Total num-
####### ber of active clear licensed/certified APRNs reported
####### by BONs and/or state nursing associations in 2021 ).
####### Further supporting FPA legislation and regulatory
####### changes, a new study published by Yang et al. provides
####### a systematic review of state NP practice regulations
####### and care delivery outcomes. 3 Their fi ndings suggest
####### that states with FPA are associated with improved
####### access to care in underserved and rural communities
####### without compromising quality of care. 3 This review
####### provides policy makers supporting FPA for NPs with
####### additional evidence for positive change.
####### ■ Practice authority
####### Advancements in scope of practice
####### In this edition of the Legislative Update, we highlight
####### Delaware and Massachusetts where stakeholders
####### were successful in passage of statutory amendments or
####### adoption of regulatory amendments resulting in FPA. 1
####### Additionally, we highlight Arkansas and Virginia ,
####### which have signifi cantly improved their practice au-
####### thority. On August 4, 2021, Delaware Governor John
####### Carney signed House Bill No. 141 (Chapter 111), re-
####### pealing the TTP period requirement of 2 years and a
####### minimum of 4,000 full-time hours
####### and a collaborative agreement with
####### a physician, podiatrist, or healthcare
####### delivery system. 4 This provision is
####### effective on the date of the gover-
####### nor’s signature. Additionally, this
####### legislation aligned the BON statute
####### with the APRN Compact allowing Delaware to join
####### North Dakota as the fi rst states to join the Compact. 5
####### In Massachusetts , the Board of Registration
####### in Nursing voted to adopt emergency regulatory
####### amendments authorizing independent practice
####### of APRNs on June 9, 2021. 6 Specifically, CRNAs,
####### NPs, and Psychiatric Nurse Mental Health Clinical
In Delaware and Massachusetts, stakeholders
were successful in passage of statutory
amendments or adoption of regulatory
amendments resulting in FPA.
Legislative update key
ANP advanced nurse practitioner APN advanced practice nurse APNP advanced practice nurse prescriber APRN advanced practice registered nurse ARNP advanced registered nurse practitioner ASTC ambulatory surgical treatment center BC/BS Blue Cross/Blue Shield BOM Board of Medicine BOME Board of Medical Examiners BON Board of Nursing BOP Board of Pharmacy BRN Board of Registered Nursing CHAMPUS Civilian Health and Medical Program of the Uniformed Services CNM certifi ed nurse midwife
CNP certifi ed nurse practitioner CNS clinical nurse specialist CPA collaborative practice agreement CPNP certifi ed pediatric nurse practitioner CRNA certifi ed registered nurse anesthetist CRNP certifi ed registered nurse practitioner CS controlled substance DEA Drug Enforcement Administration DO Doctor of Osteopathic Medicine FNP family nurse practitioner FPA full practice authority GNP geriatric nurse practitioner HMO Health Maintenance Organization MCO Managed Care Organization
NCSBN National Council of State Boards of Nursing NM nurse midwife NPA Nurse Practice Act NPI National Provider Identifi er PA physician assistant PCP primary care provider PCNS psychiatric clinical nurse specialist PDMP Prescription Drug Monitoring Program PMHNP psychiatric-mental health nurse practitioner PNP pediatric nurse practitioner RNP registered nurse practitioner R&R Rules and Regulations SOP scope of practice TTP transition to practice WHNP women’s health nurse practitioner
24 The Nurse Practitioner • Vol. 47, No. 1 tnpj
Total number of active clear licensed/certifi ed APRNs reported by BONs and/or state nursing associations in 2021
State Total APRNs NPs CNSs CNMs CRNAs Alabama 7,965 5,995 62 19 1, Alaska ¥ 1479 1143 35 113 188 Arizona 12,325 10,829 148 300 1, Arkansas 5,629 4,592 153 30 854 California 37,329 29,940 3,282 1,351 2, Colorado ¥ 9,274 7,145 569 497 1, Connecticut 6,963 * *! * Delaware 2,643 2,073 142 52 376 District of Columbia ¥ 1162 1375 44 96 147 Florida 39, Georgia 17,720 14,913 159 625 2, Hawaii £ 1,914 * * * * Idaho £ 3,547 * * * * Illinois 17,866 12,952 889 459 2, Indiana ¥ 7,518 6,593 274 126 525 Iowa 6,832 5,320 564 160 788 Kansas 7,798 5,956 464 100 1, Kentucky 10,893 9,084 145 130 1, Louisiana 7,678 5,894 148 66 1, Maine 3,239 2,445 66 108 540 Maryland £ 9,063 7,749 118 308 888 Massachusetts 15,645 12,852 686 577 1, Michigan ¥ 11,635 8,600 235 200 2, Minnesota 10,310 7,252 472 385 2, Mississippi 6,408 5,431! 32 945 Missouri 12,938 10,511 303 158 1, Montana 2,193 1,865 40 78 210 Nebraska 3,901 3,012 84 61 744 Nevada £ 2,872 2,857 9 6! New Hampshire 2,656 2,103 19@ 123 411 New Jersey 11,667 * *! (BOME) * New Mexico 2,197 1,655 41 218 283 New York 31,663~ 31,663!!! North Carolina 14,732 10,537 260 373 3, North Dakota 1,923 1,445 34 24 403 Ohio 23,183 18,201 1,096 468 3, Oklahoma 5,403 4,252 292 74 785 Oregon £ 6,122 5,595 153 403 655 Pennsylvania 16,307~ 16,307 249!! Rhode Island ¥ 309 207 6 83! 13 South Carolina 8,890 5,120 175 254 3, South Dakota 2,123 1,512 56 49 506 Tennessee 14,316 * * * * Texas £ 32,619 27,457 1,242 538 4, Utah 4,496 3,872 17 204 403 Vermont 1,459 1,225 40@ 83 111 Virginia 15,776 12,753 395 408 2, Washington 10,847 9,052 86 552 1, West Virginia 4,419 3,446 31 74 868 Wisconsin £ 8,712+ + + 283 + Wyoming 1,045 828 25 27 165
¥ BON did not update this information & no information available on website; numbers reported last year
- Combined with total number of APRNs/APNs/APNPs for that state ~ “APRN” term is not defi ned in statute or regulation ! Not recognized as an APRN/ARNP/APN by the BON and not included in Total APRNs @ Psychiatric clinical nurse specialists recognized as APRNs only
- Certifi ed as APNPs (Advanced Practice Nurse Prescribers) £ Licensee/certifi cation numbers obtained from BON website
tnpj The Nurse Practitioner • January 2022 25
####### Independent Practice Credentialing Committee ” within
####### the Arkansas Department of Health which includes
####### four NP and four MD voting members, and two ex
####### offi cio nonvoting members (Directors of the Arkansas
####### State Medical Board and the Arkansas State Board of
####### Nursing). 8 Arkansas also enacted House Bill 1215 (Act
####### 607) amending Ark. Code to authorize “ full practice
####### authority ” for CNMs as described for NPs; however,
####### a CPA is required for CNMs to prescribe schedule II
####### controlled substances (CSs). 9 Finally, Arkansas also
####### removed supervisory language pertaining to CRNAs,
####### amending the statute to use “ in consultation with ” a
####### licensed physician, dentist, or other person who may
####### order anesthesia by law. 10
####### Effective July 1, 2021, Virginia ’s 5-year full-time
####### TTP period for NPs was lowered to a 2-year full-time
####### TTP period, authorizing NPs to practice without a
####### written or electronic practice agreement upon comple-
####### tion and attestation of completion of the TTP by the
####### NP among other provisions. 11 The TTP provisions
####### amended in House Bill No. 1737 nurse practitioners;
####### practice without a practice agreement will expire on
####### July 1, 2022. At that time, the TTP period will go back
####### to a minimum of 5-year full-time practice. Addition-
####### ally, CNSs are now recognized as an NP licensed by
####### the Boards of Medicine and Nursing in the category
####### of CNS. CNSs are required to practice in consultation
####### with a licensed physician under a written or electronic
####### practice agreement. 12
####### Eight additional states have enacted statutes or
####### adopted regulatory amendments improving practice
####### authority. In Florida , the BON amended regulatory
####### defi nitions to include a defi nition for “primary care
####### practice,” which includes physical and mental health
####### promotion, assessment, evaluation, disease preven-
####### tion, health maintenance, counseling, patient educa-
####### tion, diagnosis, and treatment of acute and chronic
####### illnesses, inclusive of behavioral and mental health
####### conditions. 13 Effective January 1, 2022, Illinois Gen-
####### eral Assembly’s Public Act 102-0257 (2021) autho-
####### rizes APRNs to complete death certifi cates, defi ning
####### APRNs as a “certified health care professional.” 14
####### Additionally, Illinois passed Public Act 102-
####### (2021) amending the Nurse Practice Act authorizing
####### attestation of completion of the TTP by either a col-
####### laborating physician or an employer. 15 This action,
####### which is effective January 1, 2022, was necessary for
####### circumstances when the collaborating physician is
####### unable to attest the completion of the clinical experi-
####### ence. Effective August 1, 2021, Louisiana ’s psychiatric
Reported state policy changes for the provision of home health services
State Law or Regulation (Rule) Legislative or Regulatory Link Effective Date
AL Rule No. 560-X-12- (2020) medicaid.alabama/documents/9.0_Resourc- es/9.2_Administrative_Code/9_Adm_Code_Chap_12_Home_ Health_12-14-20
12/14/
AZ ARS 36-2939 (2021) azleg/legtext/55leg/1r/laws/0265.htm 4/20/
CT Conn. Pub. Act 21- §19a-496a (2021)
cga.ct/asp/cgabillstatus/cgabillstatus. asp?selBillType=Bill&which_year=2021&bill_num=6666#
7/1/
IN Public Law 207 HB 1468 legiscan/IN/bill/HB1468/2021 4/29/
KY Ky. Acts Ch. 59 (2021) apps.legislature.ky/law/acts/21RS/docu- ments/0059
3/22/
MD CR 11330 (2019) cms/Outreach-and-Education/Medicare-Learning- Network-MLN/MLNMattersArticles/Downloads/MM11330
Retroactive 1/1/
OK 63 O. 2011 §1-1961(4) (2021)
sos.ok/documents/legislation/58th/2021/1R/ SB/0388
Retroactive 3/27/
SC S. C. Acts 55 § 40-33-34(D) (2)(h) (2021)
scstatehouse/sess124_2021-2022/bills/503.htm 7/16/
TN Pub. Ch. No. 124 (2021) publications les.com/acts/112/pub/pc0124 4/13/ WA Rule No. WSR 21-12-051 hca.wa/assets/103P-21-12-051.pdf 6/26/
tnpj The Nurse Practitioner • January 2022 27
####### In Louisiana , legislation passed requires that any
####### healthcare coverage plans delivered or issued for de-
####### livery that provide benefi ts for maternity services in-
####### clude coverage for CNM services. Effective January 1,
####### 2022, plans must include policies for reimbursement
####### to CNMs for any services within the scope of CNM
####### practice. 23 Effective January 1, 2022, insurance carriers
####### in the state of Maine must provide coverage for CRNA
####### services and may not prohibit a CRNA from partici-
####### pating in their provider network or billing directly
####### for those services. 24 The state of Washington reports
####### an increase in reimbursement for Medicaid providers
####### with the passage of SB 5092, making 2021-2023 fi scal
####### biennium operating appropriations. 23
####### In what follows, each state’s APRN practice author-
####### ity is updated where applicable, and described with
####### emphasis on NP practice. The author has provided
####### extensive references for each act reported and the in-
####### tent of this overview is to provide a summary of APRN
####### practice changes across the country. The author would
####### like to thank individual state BON representatives and
####### APRN association representatives who contributed to
####### this annual update through completion of an annual
####### survey. All efforts are made to ensure the information
####### provided to readers is accurate and up-to-date through
####### validation of adopted regulations and enacted legisla-
####### tion provided in the article.
REFERENCES
American Association of Nurse Practitioners. State practice environment.
aanp/advocacy/state/state-practice-environment.
Coronavirus Aid, Relief, and Economic Security Act, 15 USC 9001 §§ 3706 –
- congress/116/plaws/publ136/PLAW-116publ136.pdf.
Yang BK, Johantgen ME, Trinkoff AM, Idzik SR, Wince J, Tomlinson C. State nurse practitioner practice regulations and U. health care deliv- ery outcomes: a systematic review. Med Care Res Rev. 2021;78(3):183-196. doi:10/1077558719901216.
An Act to amend Title 24 of the Delaware Code relating to advanced practice registered nurses, 24 Del. Laws ch. 83 §1902, -24 Del. Laws ch. 83 §1922, 24 Del. Laws ch. 83 §1934, 24 Del. Laws ch. 83 §1935 & eliminating -24 Del. Laws ch. 83 §1936. 2021. legis.delaware/json/BillDetail/GenerateHtmlDocument SessionLaw?sessionLawId=58536&docTypeId=13&sessionLawName=chp111.
“The APRN Compact is a modern licensure solution.. allows for APRNs to have one multistate license with the ability to practice in all compact states.” aprncompact/index.htm.
244 Code Mass. Regs [CMR] 4 – 4. 2012. mass/doc/244-cmr- 400-advanced-practice-registered-nursing-redline-emergency-amendments.
244 CMR 4. 2012. mass/doc/244-cmr-400-advanced-practice- registered-nursing-redline-emergency-amendments/download.
An Act to authorize full independent practice authority for certifi ed nurse practitioners who meet certain requirements; and to create the Full Independent Practice Credentialing Committee, 17 Ark. Acts ch. 87 §314. 2021. arkleg.state.ar/Bills/Detail?tbType=&id=hb1258&ddBienniumSession =2021%2F2021.
An Act to grant full practice authority to certifi ed nurse midwives; and for other purposes, 17 Ark. Acts ch. 87 §302 & 17 Ark. Acts ch. 87 §314. 2021. http://www. arkleg.state.ar/Bills/Detail?id=HB1215&ddBienniumSession=2021%2F R&Search=.
An Act to amend the defi nition of “Practice of Certifi ed Registered Nurse Anesthesia” by removing supervision requirements, 17 Ark. Acts ch. 87 § 102(7).
arkleg.state.ar/Bills/Detail?id=HB1198&ddBienniumSession= 1%2F2021R&Search=.
An Act to amend and reenact §54-2957 of the Code of Virginia, relating to nurse practitioners; practice without a practice agreement, 54 Va. Acts ch. 1.
lis.virginia/cgi-bin/legp604.exe?212+ful+CHAP0001.
An Act to amend and reenact §§ 54-2900, 54-2901, 54-2957, 54- 2957, and 54-3000 of the Code of Virginia and to repeal § 54.1-3018 of the Code of Virginia, relating to clinical nurse specialist; licensure by the Boards of Medicine and Nursing. 54 Va. Acts ch. 157. 2021. lis.virginia/ cgi-bin/legp604?212+ful+CHAP0157.
Administrative policies pertaining to certifi cation of advanced practice registered nurses. Fla. Admin. Code Ann r. 64B9-4(12). 2021. fl rules. org/gateway/RuleNo.asp?id=64B9-4.
An Act concerning health, Public Act 102-0257 Ill. Laws §535[17], §535[18]. 2021. ilga/legislation/publicacts/fulltext. asp?Name=102-0257.
An Act concerning regulation, Public Act 102-0075 Ill. Laws §65-43(b).
ilga/legislation/publicacts/fulltext.asp?Name=102-0075.
An Act to amend and reenact R. 28:51 (A)(3)(introductory paragraph), 52(B), (E), and (G)(1), 3 52(A), 52(B), and 53(L)(2) and (P)(1)(b), No. 373 L. Acts. 2021. legis.la/legis/BillInfo.aspx?i=240007.
An Act to make clarifi cations regarding the conditions in which a physician assistant or nurse practitioner must consult with a supervising physician prior to prescribing a targeted controlled substance, Ch. SL 2021-70 N. Laws §90-
- ncleg/Sessions/2021/Bills/House/PDF/H629v3.pdf.
An Act to make modifi cations to Covid-19 Relief Legislation and provide additional appropriations for the expenditure of Federal Covid-19 Pandemic Relief Funds, Ch. SL 2020-3 N. Laws §3D(e). 2020. ncleg/Ses- sions/2021/Bills/House/PDF/H196v8.
An Act relating to public health; amending 63 O. 2011, 63 OK Laws §1-317. 2021. webserver1.lsb.state.ok/cf_pdf/2021-22%20ENR/hB/ HB2009%20ENR.
An Act relating to professional nursing law - Omnibus Amendments, Penn. Laws Act of Jun. 30, 2021 P. 326, No. 60 (2021). legis.state.pa/ cfdocs/legis/li/uconsCheck?yr=2021&sessInd=0&act=
Coronavirus Aid, Relief, and Economic Security Act, 15 USC 9001 §§ 3706 –
- congress/116/plaws/publ136/PLAW-116publ136.pdf.
An Act to authorize the Arkansas Medicaid Program to recognize and advanced practice registered nurse as a primary care provider, 20 Ark. Acts 569 §20-77-140. 2021. arkleg.state.ar/Acts/FTPDocument?fi le=569&path= %2FACTS%2F2021R%2FPublic%2F&ddBienniumSession=2021%2F2021R& Search=.
An Act relating to fi scal matters, 67 Wash. Laws ch. 334. 2021. https://lawfi - lesext.leg.wa/biennium/2021-22/Pdf/Bills/Session%20Laws/Senate/5092-S. SL#page=1.
An Act to allow certifi ed registered nurse anesthetists to bill for their ser- vices, 24-A Me. Acts Ch. 39 §4320-P. 2021. mainelegislature/legis/bills/ getPDF?paper=HP0175&item=3&snum=130.
Susanne J. Phillips is associate dean of clinical affairs and a practicing family NP at the Sue & Bill Gross School of Nursing, University of California, Irvine.
The author and planners have disclosed no potential confl icts of interest, fi nancial or otherwise.
DOI:10.1097/01.NPR.0000802996.14636
28 The Nurse Practitioner • Vol. 47, No. 1 tnpj
Alabama
npalliancealabama abn.alabama campaignforaction/state/alabama ncsbn/APRNState_COVID-19_ Response
■ Practice authority The Alabama State Board of Nursing (BON) has sole regulatory authority to establish qualifi cations and certifi cation requirements of APRNs; however, the BON and BOME jointly regulate the collaborative practice of CRNPs and CNMs. APRNs are defi ned as APNs in Alabama statute and include the CNP (CRNP in statute), CNS, CNM, and CRNA roles. CRNPs and CNMs practice within BON- and BOME-approved written collaborative practice agreement (CPA) protocols; however, collaboration does not require direct, on-site supervision by the collaborating physician. Professional oversight and direction is re- quired as outlined in Alabama BON Adminis- trative Code Chapter 610-X-5- and Chapter 610-X-5- and includes a requirement (minimum of 10% of CRNP/CNM’s scheduled hours) for on-site physician attendance when the CRNP or CNM has fewer than 2 years of collaborative practice experience. Alabama meets the American Associa- tion of Nurse Practitioners’ defi nition for Reduced Practice. APN scope of practice is defi ned in regulation and in accordance with national standards and functions identifi ed by the appropriate specialty-certifying agency, congruent with Alabama law. Following passage of the CARES Act signed in March 2021, Alabama now autho- rizes CRNPs, CNSs, and CNMs to order initial home healthcare, recertify those services, and provide management for patients in home healthcare services. CRNPs and CNMs must hold a master’s or higher degree in advanced practice nurs- ing and hold and maintain national board certifi cation, with a few exceptions, pursuant to Alabama Board of Nursing Administrative Code Chapter 610-X-5- and Chapter 610- X-5-. There is no transition to practice re- quirement for APRNs in the state of Alabama. CRNPs and CNMs may prescribe, admin- ister, and provide therapeutic tests and drugs within a BON- and BOME-approved protocol and formulary. CRNPs and CNMs in collabora- tive practice with a physician may prescribe schedule III, IV, and V controlled substances (CSs), and, under limited circumstances, may prescribe schedule II CSs, pursuant to BOME Administrative Code Chapter pursuant to the rules of Alabama BOME Chapter 540-X-18-. In addition to DEA registration, qualifi ed CRNPs and CNMs must hold a Qualifi ed Alabama Controlled Substances Registration Certifi cate.
CRNPs and CNMs are required to complete 12 continuing medical education contact hours in advanced pharmacology and prescribing trends, and 4 additional contact hours every 2 years for renewal of the Qualifi ed Alabama Controlled Substances Certifi cate under current regulation for schedule III-V CS authority. All CRNPs and CNMs are required to access the Alabama Controlled Substances Database.
■ Reimbursement There are no legislative restrictions for APNs on managed-care panels. The Alabama Med- icaid Program enrolls and reimburses CRNPs independently pursuant to supervision rules; however, a CRNP who is employed and reim- bursed by a facility that receives reimburse- ment from the Alabama Medicaid program for services provided by the CRNP may not enroll. BC/BS will reimburse CRNPs and CNMs in collaboration with a preferred physician provider at 70% of the physician rate.
Alaska
commerce.alaska/web/cbpl/ professionallicensing/boardofnursing anpa.enpnetwork campaignforaction/state/alaska aprnalliance/ ncsbn/APRNState_COVID-19_ Response
■ Practice authority The Alaska State BON regulates APRNs including statutory defi nitions of the CNP, CNS, CNM, and CRNA roles. APRNs are further defi ned as RNs who, due to specialized education and experience, are certifi ed to perform acts of medical diagnosis and prescription as well as dispense medical, therapeutic, or corrective measures under regulations adopted by the BON. Alaska meets the American Association of Nurse Practitioner’ Full Practice Authority defi nition. APRN SOP is defi ned under Alaska Administrative Code 12 AAC 44. Regulations require that an APRN have a plan for patient consultation and referral, but a physician relationship is not required. APRNs in Alaska are statutorily recognized as PCPs. Nothing in the law precludes admitting privileges for APRNs. Entry into APRN practice requires a graduate degree in nursing and national board certifi cation. There is no transition to practice requirement in the state. Authorized APRNs have independent prescriptive authority, including Schedule II–V CSs. APRNs are legally required to review the Prescription Drug Monitoring Program database prior to prescribing CSs and must complete 2 CE
hours in pain management and opioid use and addiction each 2-year license renewal cycle. They are legally authorized to request, receive, and dispense pharmaceutical samples in Alaska. To renew prescriptive authority, APRNs must maintain national certifi cation and complete the opioid CE requirement. Opioid prescribing limitations provide restrictions on the number of therapy days when prescribed by an APRN.
■ Reimbursement All healthcare in Alaska is provided on a fee-for-service basis. FNPs, PNPs, PMHNPs, CNMs, and CRNAs are authorized by law to receive Medicaid reimbursement; NPs receive 85% of the physician payment. A nondiscriminatory clause in the insurance law allows for third-party reimbursement to NPs; Alaska legally requires insurance companies to credential, empanel, and/or recognize APRNs.
Arizona
azbn arizonanp.enpnetwork campaignforaction/state/arizona
■ Practice authority The Arizona State Legislature grants APRNs authority and the BON alone regulates their practice. APRNs include CNPs (RNPs in statute), CNSs, CNMs, and CRNA roles. According to Arizona Revised Statutes Title 32, Chapter 15 32-1601; 20 (vi), the following language was added to both the RNP and the CNM defi nitions: “.. the limits of the nurse’s knowledge and experience by consult- ing with or referring patients to other appropriate healthcare professionals if a situation or condition occurs that is beyond the knowledge and experi- ence of the nurse or if the referral will protect the health and welfare of the patient.” No formal collaboration agreement is required. RNP SOP is defi ned in Arizona Ad- ministrative Code R4-19-508. In the SOP, RNPs are authorized to admit patients to health- care facilities, manage the care of admitted patients, and discharge patients. However, Arizona Department of Health regulations require an attending physician for patients admitted to an acute care facility. Acute care facilities apply this citation as the basis to deny independent admitting and hospital privileges to RNPs. RNPs, CNMs, and CNSs must have a graduate degree in nursing and national board certifi cation in their focus area to begin practice. CRNAs must have a graduate
30 The Nurse Practitioner • Vol. 47, No. 1 tnpj
All prescribers are mandated to consult the Controlled Substance Utilization Review and Evaluation System (CURES) the fi rst time a patient is prescribed, ordered, adminis- tered, or furnished a CS (with some exemp- tions) and at least once every 4 months if the CS remains a part of the patient’s treatment plan (with some exemptions). CNPs and CNMs may request, receive, and dispense pharmaceutical samples and dispense drugs, including CSs. CNSs and CRNAs do not have prescriptive authority in California.
■ Reimbursement All nationally board-certifi ed CNPs are reim- bursed independently by the Medi-Cal sys- tem. Medi-Cal-covered services performed by CNPs, CNMs, and CRNAs are reimbursed at 100% of the physician reimbursement rate. Blue Cross of CA Medi-Cal Provider Directory lists CNPs as PCPs under their specialty. There is no legal preclusion to third-party reimbursement of services, and policies vary from payer to payer; however, third-party payers are legally required to reimburse CNMs and BRN-listed psychiatric-mental health nurses for qualifying services. Partici- pants in the state’s managed-care programs for specifi ed Medi-Cal benefi ciaries may select CNPs and CNMs as their PCPs.
Colorado
dpo.colorado/Nursing coloradonurses campaignforaction/state/colorado ncsbn/APRNState_COVID-19_ Response
■ Practice authority The Colorado State BON (Board) grants advanced practice authority to RNs who meet the criteria set forth in the Colorado Nurse and Nurse Aide Practice Act (Practice Act) CRS 12-255-101 et seq and the Nursing Rules 3 CCR 716-1 (Rules) Rule 1 for inclusion on the Advanced Practice Registry (APR). The Board regulates the practice of APRNs, and affords title protection. APRNs include the CNP (NP in statute), CNS, CNM, and CRNA roles. APRNs listed on the registry prior to July 1, 2010, may retain their listing on the APR without certifi cation as long as the APRN does not allow his or her advanced practice authority to lapse or expire. Professional liability insurance is required for all APRNs engaged in an independent practice. The scope of advanced practice nursing is an expanded scope of professional nursing practice within the APRN role and population focus, which may include, but is not limited to, performing acts of advanced assessment, diagnosing, treating, prescribing, ordering,
selecting, administering, and dispensing diagnostic and therapeutic measures. The scope of advanced practice nursing does not include prescribing medication; however, the Board grants separate prescriptive authority. APRNs are considered independent practi- tioners. NP practice in Colorado meets the American Association of Nurse Practitioners’ defi nition for Full Practice Authority. The Practice Act and Rules do not ad- dress, and therefore do not prohibit, APRNs being designated as PCPs or being granted hospital privileges; however, APRNs are not currently recognized as PCPs in statutes and regulations under the jurisdiction of state agencies regulating healthcare. National certifi cation in a role and, if applicable, popu- lation focus, is required of all APR applicants. The APRN may be granted prescriptive authority by the Board within the APRN’s role and population focus, including prescribing schedule II-V CSs. APRNs applying for original prescriptive authority and prescriptive author- ity by endorsement must have 3 years of clini- cal work experience as an RN to be eligible to apply for provisional prescriptive authority (RXN-P) or full prescriptive authority (RXN) by endorsement. Effective July 1, 2020, the RXN-P must complete a 750-hour prescribing mentor- ship (decreased from the previously required 1,000 hours) with a physician or an APRN with RXN and an active unrestricted DEA registra- tion. APRNs who have active prescriptive authority in another state and more than 750 hours of safe prescribing experience in that state are not required to complete the mentor- ship period. Effective July 1, 2020, Articulated Plans are no longer required. In May 2019, the Substance Use Disorders Prevention Act became law, requiring the Board and other healthcare provider boards to adopt rules on substance use disorder training for prescribers. Training must consist of at least 2 credit hours per licensing cycle related to best practices of opioid prescribing, recognition of substance use disorders, referral for and treat- ment of substance use disorders, and use of the PDMP. This new law restricts APRNs and other prescribers from accepting direct or indirect benefi ts for prescribing specifi c medications. Nursing rules authorize APRNs with prescriptive authority to receive and distribute a therapeutic regimen of prepackaged and labeled drugs, including free samples.
■ Reimbursement Medicaid reimburses APRN services; however, some managed-care Medicaid companies restrict independent APRNs from joining networks. Third-party reimbursement is available to APRNs, but third-party payers are not mandated to credential, empanel, or reimburse APRNs. APNs with prescriptive authority are authorized to receive Level I
accreditation for purposes of receiving 100% reimbursement under the medical fee sched- ule within the Workers’ Compensation Act of Colorado. CNMs are a recognized provider type for Colorado’s Medicaid program, which is known as Health First Colorado. The State of Colorado passed legislation to establish a standardized health benefi t plan to be offered in Colorado. APRNs are recognized as “healthcare providers” throughout the new law, including reimburse- ment for services.
Connecticut
portal.ct/DPH/Public-Health-Hear- ing-Offi ce/Board-of-Examiners-for-Nursing/ Board-of-Examiners-for-Nursing ctaprns campaignforaction/state/ Connecticut ncsbn/APRNState_COVID-19_ Response
■ Practice authority The Connecticut Board of Examiners for Nurs- ing regulates APRNs, defi ning APRNs in statute including the CNP (NP in statute), CNS, and CRNA roles. APRN SOP, independent practice, and collaborative practice are defi ned in statute. Certifi ed nurse-midwife (CNM) author- ity is regulated by the Department of Public Health, and SOP is recognized under a separate statute (Chapter 377, Midwifery). The passage of Public Act No. 19-98 in 2019 further acquired global signature authority, including worker’s compensation, pharmacy collaborative drug management agreement, and psychiatric stat- ute changes. APRNs are authorized to certify patients for medical marijuana use. A graduate degree in nursing or other re- lated fi eld and national board certifi cation are required to practice and APRNs are statutorily recognized as PCPs and authorized to hold hospital privileges including admission of pa- tients. Following passage of the federal CARES Act, Public Act No. 19-141 was signed by Connecticut’s governor including authorization by APRNs to issue orders for home healthcare services, hospice agency services, and home health aide agency services. A TTP require- ment exists in Connecticut. APRNs must prac- tice in collaboration with a physician licensed in Connecticut for the fi rst 3 years after obtaining a license in Connecticut. APRNs are authorized to practice without a collaborative agreement following no less than 3 years and no fewer than 2,000 hours of APRN practice. NP practice in Connecticut is considered Full Practice Authority as defi ned by the American Association of Nurse Practitioners. APRNs are authorized to prescribe, dis- pense, and administer medications, including
tnpj The Nurse Practitioner • January 2022 31
CSs pursuant to a CPA. APRNs may indepen- dently prescribe, dispense, and administer medications including schedule II-V CSs fol- lowing a TTP period of no less than 3 years and no less than 2,000 hours. APRNs and CNMs are legally authorized to request, receive, and dispense pharmaceutical samples. Opioid prescribing limitations for acute pain include that initial prescriptions for acute pain in adults are limited to 7 days and that any opioid prescribing for minors is limited to 5 days. Exceptions to the limitations include chronic pain, cancer pain, palliative care, pro- vider judgment, and substance abuse disorder or medication-assisted treatment (MAT).
■ Reimbursement Medicaid regulations govern reimbursement to APRNs under the remaining Medicaid fee-for-service programs. NPs, psychiatric clinical nurse specialists (PCNSs), and CNMs are reimbursed for services under state insurance statutes, which affect only private insurers. Reimbursable services must be within the individual’s SOP and must be ser- vices that are reimbursed if provided by any other healthcare provider. The law further states that insurers cannot require supervi- sion or signature by any other healthcare provider as a condition of reimbursement.
Delaware
dpr.delaware/boards/nursing denurses campaignforaction/state/delaware ncsbn/APRNState_COVID-19_ Response
■ Practice authority The Delaware BON regulates the practice of APRNs, including the CNP, CNS, CNM, and CRNA roles. The BON has sole regulatory au- thority over APRNs and grants full-practice au- thority (FPA) upon issuance of an APRN license. APRNs are now authorized to practice to their full scope of practice without a collaborative agreement following enactment of Chapter 111 of the 151st General Assembly (formerly HB 141). APRN SOP is defi ned in statute, recognizing that APRNs are independent licensed practitioners. This new law removes the previously required TTP requirement for “independent practice,” removes the term “independent practice,” and incudes FPA. APRNs must graduate from or complete a graduate-level APRN program accredited by a national accrediting body and hold current certifi cation by a national certifying body in the appropriate role and population focus area to be licensed in Delaware. APRNs have authority to serve as PCPs by an insurer or healthcare services corporation. APRNs licensed by the BON
may prescribe, order, procure, administer, store, dispense, and furnish over-the-counter (OTC), legend, and schedule II-V CSs pursu- ant to applicable state and federal laws and within the APRN’s role and population focus. Additionally, APRNs may order and prescribe nonpharmacologic interventions including: medical devices and durable medical equipment, nutrition, blood and blood products, and diagnostic and supportive services including home healthcare, hospice, and physical and occupational therapy. APRNs may receive, sign for, record, and distribute sample medications to patients in accordance with state law and US DEA laws, regulations, and guidelines.
■ Reimbursement Delaware has statutory provisions requiring health insurers, health service corpora- tions, and health maintenance organiza- tions (HMOs) to provide benefi ts for eligible services when rendered by an APRN acting within his or her SOP. APRNs may be listed on provider panels, and some providers recognize APRNs on managed-care provider panels. CNMs have legislative authority under the Board of Health for third-party re- imbursement. Family and pediatric NPs also receive Medicaid reimbursement at 100% of the physician payment.
Florida
fl oridasnursing fl oridanurse campaignforaction/state/fl orida
■ Practice authority The Florida BON regulates APRN practice, which is defi ned in statute and includes the CNP, CNS, CNM, and CRNA roles. APRNs practice within established protocols under the supervision of a physician. APRNs in pri- mary care practice (family medicine, general pediatrics, and general internal medicine) may register for autonomous practice fol- lowing 3,000 clinical practice hours, within the last 5 years immediately preceding the registration request. The term “primary care practice” has been defi ned by the BON in Florida Administrative Code 64B9-4. CNMs may engage in autonomous practice pursuant to Chapter 464. SOP for autono- mous APRN practice is defi ned in Title XXXII, Chapter 464, Sections 464, 464(3), and 464(4)(c) of the Florida Statutes, and includes prescriptive authority including CSs. APRNs practicing outside of primary care continue to practice pursuant to protocols established between an APRN and a doctor of medicine (MD), doctor of osteopathic medicine (DO), or dentist, which include the
performance of medical acts of diagnosis, treatment, and operation. Within the frame- work of established protocols, APRNs may order diagnostic tests, physical therapy, and occupational therapy. Supervision is defi ned as the ability to communicate or establish contact by telephone; the supervising practi- tioner’s on-site presence is not required. APRNs are authorized to admit patients to a hospital and hold hospital privileges dependent on privileges granted by the institu- tion and the supervising physician. APRN applicants must have a master’s degree to qualify for initial certifi cation and are required to hold national board certifi cation to practice. CNSs must hold a master’s degree in a clinical nursing specialty and either national certifi ca- tion in a CNS specialty or proof of completed clinical experience in a CNS specialty for which there is no national certifi cation. APRNs without autonomous practice authority are authorized by supervisory pro- tocol to prescribe, dispense, administer, or order any drug, including schedule II-V CSs as authorized in a BON-adopted CS formulary with certain exceptions. Additionally, psychi- atric mental health board-certifi ed APRNs may prescribe psychotropic CSs. APRNs are authorized to request, receive, or dispense pharmaceutical samples. Opioid prescribing restrictions limit opioid prescribing for acute pain to 3 days; exceptions in dispensing restrictions allow for MAT. A 7-day supply is permitted if medically necessary based on professional judgment.
■ Reimbursement APRNs receive Medicaid, Medicare, CHAMPUS, and third-party reimbursement; Medicaid reimburses APRNs at 100% of the physician rate only if the on-site physician countersigns within 24 hours. Medicaid reimburses APRNs at 85% of the physician rate if the physician is not on-site and does not countersign. Managed-care companies are prohibited from discriminating against the reimbursement of APRNs based on licensure. Private insurers must reimburse CNM ser- vices if the policy includes pregnancy care.
Georgia
sos.ga/plb/nursing uaprn.enpnetwork georgianurses campaignforaction/state/georgia
■ Practice authority APRNs are defi ned in statute and include CNP (NP in statute), CNM, CRNA, and CNS roles. A master’s degree or higher in nursing or another related fi eld and national board certifi cation are required for all APRNs at
tnpj The Nurse Practitioner • January 2022 33
training and at least 4,000 hours of clinical experience in collaboration with a physi- cian following national certifi cation in the APRN role. Once completed, the APRN may apply for FPA, which includes submitting an attestation of completion with the department in accordance with amended section 65- of the Nurse Practice Act. APRN scope of practice is defi ned in 225 ILCS 65/65-30. All APRNs may practice only in accordance with their national certifi cation. Prior to receiving an FPA license, APRNs must have a written collaborative agreement with a physician, podiatrist, or dentist, except for APRNs who provide services in a hospital, hospital affi liate, or ambulatory surgical treat- ment center (ASTC), and have been granted clinical privileges by that facility. Legislation effective as of January 1, 2018, prohibits new collaborative arrangements with podiatric physicians, except for CRNAs. APRNs who had an existing collaborative agreement with a podiatric physician prior to the enact- ment of P. 100-513 on January 1, 2018, may continue to practice in that collaborating relationship or enter a new written collabora- tive relationship with a podiatric physician. The APRN must hold a graduate degree, current RN licensure, and national certifi ca- tion as a CNP, CNS, CNM, or CRNA from the appropriate national certifying body as determined by rule of the IDFPR. CRNAs who completed their CRNA program prior to Janu- ary 1, 1999, and have kept their certifi cation current may be exempt; however, this excep- tion will expire on June 30, 2023. APRNs with FPA are authorized to pre- scribe both legend drugs and schedule II-V CSs and this applies to selection of, orders for, administration of, storage of, acceptance of samples of, and dispensing of OTC medica- tions, legend drugs, and other preparations, including, but not limited to, botanical and herbal remedies. Application for an Illinois Controlled Substances License is required to prescribe CSs, in addition to the US DEA registration. All prescribers are required to enroll in the Illinois Prescription Monitoring Program and check the program prior to initial prescription of schedule II narcotics, such as opioids, and document the attempt in the patient’s record. Prescribing benzodiazepines or sched- ule II narcotic drugs is authorized only in a consultation relationship with a physician, which must be recorded using the Illinois Prescription Monitoring Program website by the physician and APRN with FPA and is not required to be fi led with the IDFPR. At least monthly, the APRN and physician must dis- cuss the condition of any patients for whom a benzodiazepine or opioid is prescribed. APRNs without FPA have prescriptive authority, including prescribing schedule
II–V CSs, which may be authorized by clinical privileges in a hospital, hospital affi liate, or ASTC, or may be delegated to an APRN by a physician or podiatrist as part of the written collaborative agreement during the TTP period. Delegation to prescribe CSs must be noted in the written collaborative agreement. The APRN must apply for a Mid-Level Practi- tioner Controlled Substance License. For APRNs prescribing CSs under a written collaborative agreement, the col- laborating physician or podiatric physician must have a valid, current Illinois CS license and federal registration. Of the 80 hours of CE required for 2-year APRN licensure renewal, a minimum of 20 hours of pharmacotherapeu- tics must be completed, including 10 hours of opioid prescribing or substance abuse education.
■ Reimbursement The Illinois Department of Healthcare and Family Services (HFS) administers the Illinois Medicaid program. APRNs who enroll as pro- viders in the department’s medical programs are reimbursed at 100% of the physician rate. Medicaid recipients are being transi- tioned to Medicaid managed-care organiza- tions (MCOs); therefore, in addition to enrolling as HFS providers, APRNs must also enroll as providers for each Medicaid MCO of which any of their patients are members. Statutory prohibition for third-party reimbursement to APRNs does not exist. APRNs receive direct or indirect reimbursement from some third- party payers.
Indiana
in/pla/nursing.htm indiananurses campaignforaction/state/indiana ncsbn/APRNState_COVID-19_Re- sponse
■ Practice authority The Indiana State BON grants authority to and regulates APRNs, defi ned in IC 25-23- 1-1, and includes CNP (NP in regulation), CNM, CNS, and CRNA roles. APRNs, except CRNAs, practice in collaboration with a licensed practitioner under a written CPA approved by the board that includes how the APRN and licensed physician will cooperate, coordinate, and consult with each other on the provision of healthcare. Additionally, the CPA includes the specifi cs of the licensed physician’s reasonable and timely review of the APRN’s prescribing practices, including the provision for a minimum weekly review of 5% random chart sampling. SOP is defi ned in regulation 848 IAC Article 4. APRNs with prescriptive authority are authorized to sign
death certifi cates. The American Association of Nurse Practitioners considers NP practice in Indiana Reduced Practice. APRNs are authorized to practice in hospitals in collaboration with a licensed practitioner as evidenced by a CPA when the APRN is granted privileges by the gov- erning board of a hospital licensed under IC 16-21 (hospitals) that sets forth the manner in which the APN and licensed practitioner will cooperate, coordinate, and consult with each other or by privileges granted by the governing body of a hospital operated under IC 12-24-1 (state hospitals) that set forth the manner in which the APRN and licensed practitioner will cooperate, coordinate, and consult with each other. In 2021, APRNs obtained authority to order home health services as defi ned in IC 16-27-1-5. The BON does not issue additional, separate licenses or certifi cation to NPs or CNSs; however, CNMs apply for “limited licensure” to practice in that role. APRNs seeking prescriptive authority must complete a graduate, postgraduate, or doctoral APRN program, hold national board certifi cation in their APRN role, and submit proof of a written CPA with a licensed practitioner (licensed physician, dentist, podiatrist, or optometrist). The BON has legal authority to establish prescriptive authority rules, and with the approval of the BOM, authorize prescriptive authority for APRNs, including legend and schedule II-V CSs. APRNs must obtain a BON-issued prescriber authority ID number, Indiana State Controlled Substances Reg- istration in addition to US DEA registration. NPs are authorized to prescribe legend drugs to patients receiving care via telemedicine if they have established a provider-patient relationship and satisfy the standard of care and standard of documentation. CRNAs are not required to obtain pre- scriptive authority to administer anesthesia. Opioid prescribing legislation passed in 2017 (IC 25-1-9) limited initial opioid prescriptions for acute pain in adults and children to 7 days. Exemptions to the number of days include cancer, palliative care, provider judgment, substance use disorder/MAT, and other exemptions adopted by medical licensing board rule.
■ Reimbursement Indiana is considered an “any willing pro- vider” state backed by current law. APRNs may receive third-party reimbursement as determined by payers. NPs receive Medic- aid reimbursement at 85% of the physician payment and Medicaid managed-care and fee-for-service plans must reimburse both NPs and CNSs employed by commu- nity mental health centers for services as specifi ed.
34 The Nurse Practitioner • Vol. 47, No. 1 tnpj
Iowa
nursing.iowa campaignforaction/state/iowa/ ncsbn/APRNState_COVID-19_Re- sponse
■ Practice authority The Iowa BON regulates the licensure, education, and practice of APRNs, which are defi ned as advanced registered nurse prac- titioners (ARNPs) in regulation and include CNP, CNS, CNM, and CRNA roles. ARNPs practice autonomously within their specifi ed role and population focus in accordance with national professional associations, which is broadly defi ned in IAC 655–7. NP practice in the state of Iowa is considered Full Practice by the American Association of Nurse Practitioners. ARNPs are statutorily recognized as PCPs; however, state law does not contain “any willing provider” language. ARNPs may hold hospital clinical privileges. Licen- sure as an ARNP requires active licensure as an RN and national board certifi cation in at least one population focus, which includes family/ individuals across the lifespan, adult/ gerontology, neonatal, pediatrics, women’s health/gender-related, and psychiatric mental health. The majority of ARNPs are educated at the master’s or doctoral level. Authorized ARNPs are granted full pre- scriptive authority within their specifi c role and population focus, including schedule II-V CS medications. ARNPs may prescribe, deliver, distribute, or dispense noncon- trolled and controlled drugs, devices, and medical gases, including pharmaceutical samples. ARNPs are required to complete a minimum of 2 contact hours of CE regarding the CDC guideline for prescribing opioids for chronic pain and must query the Prescrip- tion Monitoring Program database prior to prescribing or dispensing an opioid with some exceptions (IAC Chapter 7 Sections 655-7, 7).
■ Reimbursement Iowa’s Medicaid managed-care and prepaid service programs reimburse ARNPs. Payment of necessary medical or surgical care and treatment is provided to an ARNP via third- party reimbursement if the policy or contract would pay for the care and treatment when provided by a physician. MCOs are not man- dated to offer ARNP coverage unless there is a contract or other agreement to provide the service. All ARNPs are approved as providers of healthcare services pursuant to managed care or prepaid service contracts under the medical assistance program.
Kansas
ksbn ksnurses/ campaignforaction/state/kansas
■ Practice authority The Kansas BON grants authority to APRNs and regulates their practice. Recognized APRN roles include the CNP (NP in regula- tion), CNS, CNM (NM in regulation), and CRNA (registered nurse anesthetist [RNA] in statute). SOP is defi ned in statute and regula- tion with CNPs, CNSs, and CRNAs functioning in collaborative relationships with physi- cians and other healthcare professionals in the delivery of primary healthcare services. CNMs are authorized to practice without a collaborative agreement when such services are limited to those associated with a normal, uncomplicated pregnancy and delivery. Any CNP, CNS, or CRNA who interdepen- dently develops and manages the medical plan of care for patients or clients is required to have a signed authorization for collabora- tive practice with a physician who is licensed in Kansas (60-1 1-010 [b]). Each authorization for collaborative practice is maintained at the APRN’s principal place of practice. APRNs make independent decisions about the nurs- ing needs of patients and interdependent de- cisions with physicians in carrying out health regimens for patients; however, the physical presence of a physician is not required when care is provided by an APRN. APRNs are not recognized as PCPs in Kansas. No specifi c language in statute authorizes or prohibits hospital privileges; ad- mitting and hospital privileges are determined by individual institution policy and procedure. APRN applicants in all categories require a master’s degree or higher in nursing, and national board certifi cation is not required to enter practice in Kansas (except for RNAs). APRNs, except for CRNAs, are legally authorized to prescribe medications, including schedule II-V CSs, pursuant to a CPA and writ- ten protocol. The protocol must contain a pre- cise and detailed medical plan of care for each classifi cation of disease or injury for which the APRN is authorized to prescribe and shall specify all drugs that may be prescribed by the APRN. These can be published protocols or practice guidelines that have been agreed upon by both the APRN and physician. In addition to DEA registration, APRNs must register with the BON to prescribe CSs. Prescription orders and labels must include the physician’s name in addition to the name of the prescribing APRN. APRNs are authorized to request, receive, and distribute pharmaceutical samples, except for CSs, if the drug is within their protocol. CNMs may prescribe drugs and devices without a CPA when the service is associ-
ated with family planning services, including treatment or referral of a male partner for sexually transmitted infections, initial care of a newborn, and a normal, uncomplicated pregnancy and delivery.
■ Reimbursement Insurance companies are legally required to reimburse all APRNs for covered services in health plans. Medicaid has expanded pay- ment to include all covered services at 80% of the physician rate (except for practitio- ners performing early periodic screening diagnosis and treatment who receive 100%). Nurse anesthetists receive 85% of physician payments. Some insurance companies pay 85% of physician payments to APRNs.
Kentucky
kbn.ky/ kcnpnm campaignforaction/state/kentucky ncsbn/APRNState_COVID-19_ Response
■ Practice authority The Kentucky BON grants APRNs authority to practice and regulates their practice. APRNs are defi ned in statute as CNPs, CNSs, CNMs, and CRNAs. APRNs practice autonomously within their relative SOPs; however, they must practice in accordance with the SOP of the national certifying organization as ad- opted by the BON in regulation (collaborative agreement is required for certain prescriptive authority; see detail below). CNP SOP is defi ned in Kentucky statute KRS 314. “APRNs shall seek consultation or referral in situations outside their SOP ( KAR 20:057, Section 3).” APRNs are recog- nized as practitioners in statute (KRS 314), included in the defi nition of “practitioner” for prescribing (KRS 217 [35], KRS 218A. [33]), and are legally authorized to admit pa- tients to a hospital and hold hospital privileges; however, hospital regulations permit medical staff to set conditions (902 KAR 20:016 Section 3 [8][b][2] [b]). A master’s degree, doctor- ate, or postmaster’s certifi cate as an APRN and national board certifi cation are required to practice in Kentucky. The American As- sociation of Nurse Practitioners considers NP practice in Kentucky Reduced Practice. APRNs must pass a jurisprudence exam for prescriptive authority, ensuring APRNs are familiar with the requirements of obtaining and maintaining prescriptive authority for nonscheduled legend drugs and CSs. APRNs have autonomous prescriptive authority for nonscheduled legend drugs following 4 years of prescribing experience under a Collaborative Agreement for Prescriptive Authority for Non-
36 The Nurse Practitioner • Vol. 47, No. 1 tnpj
to the nurse’s specialty. CNPs and CNMs may prescribe schedule II-V CSs and drugs off- label, according to common and established standards of practice. CNPs and CNMs may receive and distribute drug samples. CRNAs are authorized to order and pre- scribe medication during the perioperative and postoperative periods. CRNAs may prescribe schedule II-V CSs only for a supply of no more than 4 days with no refi lls; and for an individual who is an established client or patient of record. Opioid prescribing is limited for all prescrib- ers. Prescribers must successfully complete 3 hours of CE every 2 years on the prescription of opioid medication as a condition of prescribing opioid medication (Public Law, Chapter 488).
■ Reimbursement The 1999 Act to Increase Access to Primary Health Care Services requires reimbursement under an indemnity or managed-care plan for patient visits to an NP or CNM when referred from a PCP; requires insurers to assign sepa- rate provider ID numbers to CNPs and CNMs; and allows managed-care enrollees to desig- nate a CNP as their PCP. However, MCOs are not required to credential any physician or CNP if their access standards have not been met. Reimbursement under indemnity plans is mandated for master’s-prepared, certifi ed psychiatric/mental health CNSs; no other third-party reimbursement for APRNs is required by law. Some insurance carriers reimburse independent CNPs. Medicaid reimburses in full for services provided by certifi ed family NPs, CPNPs, and CNMs on a fee-for-service basis. In 2021, 24-A MRSA § 4320 was enacted requiring insurance carriers offering health plans within the state to cover CRNA services billing. Additionally, the Act states that carriers may not prohibit CRNAs from participating in their provider network or bill- ing the carrier directly because the provider is a CRNA. CRNAs must meet the same terms and conditions as other participants.
Maryland
mbon npamonline maapconline campaignforaction/state/maryland ncsbn/APRNState_COVID-19_ Response
■ Practice authority The Maryland BON regulates APRN practice, statutorily defi ning APRN in regulation ( COMAR 10.27.07). The APRN title includes the CNP (NP or CRNP in statute), CRNA, CNM, and CNS roles. Maryland also recognizes nurse psychothera- pists as APRNs (APRN/PMH). NP SOP is defi ned in statute and regulations in accordance with
the Standards of Practice of the American As- sociation of Nurse Practitioners. The American Association of Nurse Practitioners considers NP practice in the state of Maryland Full Practice. NP applicants who have never been certifi ed as an NP in Maryland or any other state are required to name a mentor (NP or physician licensed in Maryland) upon applica- tion to the BON who is available for advice, consultation, and collaboration as needed throughout an 18-month TTP period beginning the date of application. CRNAs maintain an affi rmation of collaboration with the BON containing the name and license number of an anesthesiologist, physician, or dentist; however, there is no direct supervision re- quirement. A master’s degree is the minimum required degree to enter practice in Maryland in addition to national board certifi cation. NPs and CNMs who hold a state-con- trolled dangerous substances registration, registration with the Maryland Medical Can- nabis Commission, and are in good standing with the state BON may issue written certifi - cation for medical marijuana use to qualifying patients. CNPs and CNMs have full prescrip- tive authority, including for schedule II-V CSs. In addition to federal DEA registration, CNPs and CNMs are required to obtain state controlled dangerous substances registra- tion. CNPs are legally authorized to prepare and dispense medications, including CSs, in occupational health facilities, nonprofi t clin- ics or health facilities, student health clinics within institutions of higher education, public health facilities, and nonprofi t hospitals or nonprofi t hospital outpatient facilities.
■ Reimbursement All nurses are entitled to private third-party and Medicaid reimbursement for services if they are practicing within their legal SOP. All Medicaid recipients have been assigned to an MCO; CNPs (except for neonatal and acute care) and CNMs have been designated as PCPs and may apply for placement on a provider panel. Medicaid reimburses at 100% of physician payment. PCPs are reimbursed for telemedicine services by Medicaid. The law allows due process for APNs listed on managed-care panels; APRNs are not to be arbitrarily denied. The law does not require that an HMO include CNPs on the HMO panel as PCPs. Several commercial insurers reimburse NPs directly; however, reimbursement is generally at a rate of 75% to 85% of a physician’s fee schedule.
Massachusetts
mass/dph/boards/rn mcnpweb campaignforaction/state/ massachusetts
■ Practice authority The Massachusetts BON grants APRNs the au- thority to practice and regulates their practice. APRNs include CNP, CRNA, Psychiatric Nurse Mental Health Clinical Specialist (PNMHCS), CNS, and CNM roles. APRNs enjoy FPA with a TTP for full prescriptive authority. SOP for all APRNs is consistent with the scope and standards of their APRN practice for which they are nationally certifi ed, which is defi ned within the BON rules and regulations. CNPs are authorized to issue written certifi cations of medical marijuana use within their SOP. Massachusetts recognizes CNMs and CNPs as PCPs. Credentialing for hospital privileges varies according to hospital poli- cies. Massachusetts mandates a minimum of a graduate degree for initial (not reciprocal) APRN authorization. National certifi cation is required to enter and remain in practice. Massachusetts state law provides for prescriptive authority for CNPs, CNMs, CRNAs, and PNMHCSS, including schedule II-IV CSs. Authorized APRNs must apply to the Massachusetts Department of Public Health for MA Controlled Substance Registration (MCSR) in addition to the DEA for DEA regis- tration. CNPs, CRNAs, and PNMHCSS with less than 2 years supervised practice must estab- lish written guidelines developed in collabora- tion between the nurse and the supervising qualifi ed healthcare professional. Written guidelines include a defi ned mechanism to monitor prescribing practices and must designate a qualifi ed healthcare professional, as defi ned in 244 CMR
S Phillips 2022 34th Annual APRN Legislative Update
Course: Maternity Nursing Practicum (NURS 335)
University: San Francisco State University
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