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Nurse Practitioner:
doi: 10.1097/01.NPR.0000366130.98728.34
Feature: NP PRACTICE

22nd Annual Legislative Update: Regulatory and legislative successes for APNs

Phillips, Susanne J. MSN, FNP-BC

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Susanne J. Phillips is an associate clinical professor in the Department of Nursing Science, University of California, Irvine, Calif. She is the immediate Past President of the California Board of Registered Nursing and served as the Director of Health Policy and Practice for the California Association for Nurse Practitioners for 10 years.

Where were you in 1972? That year marks the first time practice authority was granted to NPs in state law (Idaho), followed shortly by Washington and South Carolina in 1973. Since that time, all states have passed legislation granting NPs supervisory, collaborative, or independent authority to practice. With information provided by each state's Board of Nursing and professional associations, we have compiled a timeline of practice authority, including when successful amendments were passed to improve that authority. We hope you find this additional information valuable as you continue your quest to improve the practice environment in your state (see Timeline of practice authority).

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As in previous years, advanced practice registered nurses have much to celebrate in the areas of legislative and regulatory reform. In addition to the annual updates from each state in the areas of practice authority, reimbursement, and prescriptive authority, we have included information reported by states considering regulatory implementation of the Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education. Developed over a 3-year period through a consensus process, the goal of this model is to provide states with standardized regulatory language intended to improve access to patient care by eliminating practice barriers. According to the National Council of State Boards of Nursing, implementation of this model by individual states will enhance workforce mobility and utilization. A copy of the Consensus Model is available at https://www.ncsbn.org/7_23_08_Consensue_APRN_Final.pdf. This document is an invaluable tool to use when educating state lawmakers about the practice of APRNs.

The Boards of Nursing in 17 states said they are considering implementation of the Model Regulations in 2010 in at least one of the areas of licensure, accreditation, certification, or education. Two state associations reported they will be involved in legislation pertaining to one of the four areas. As we look forward, The Nurse Practitioner will publish future updates to state regulation or statutes reflecting changes necessary for consistent regulation throughout all states.

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Practice authority

In 2009, 18 states reported legislative or regulatory activity pertaining to NP practice authority in the areas of scope of practice (SOP), PCP status, titling, global signature authority, mental health, and provider-neutral language. California reported the passage of SB 819, clarifying the authority of NPs to order durable medical equipment (DME), to approve, sign, modify, or add to care plans for home health services, and to certify disability. Florida passed HB 53 / SB 408, mandating acceptance of APRN-ordered specimens by clinical laboratories, and the New Jersey Administrative Code was also amended acknowledging APN statutory authority to initiate lab and diagnostic tests. Hawaii and Maine both reported passing legislation granting global signature authority to APRNs, NPs, and CNMs; Hawaii now recognizes APRNs as primary care providers (PCPs) and Maine has expanded existing law to include psychiatric/mental health CNSs and NPs as providers authorized to admit a person to a state mental health institute who fails to fully participate in a progressive treatment program. In Massachusetts, the Division of Insurance 211 CMR 52.00 was amended to grant PCP status to NPs by managed care organizations.

Regulatory changes to Chapter 7 of the Iowa Administrative Code grant ARNPs the authority to supervise radiology technicians in the use of fluoroscopy under specific educational requirements. Missouri state legislature passed HB 247, clarifying the collaborative practice review process under which NPs practice in that state. Both New Hampshire and Texas report changes to rules, adopting the term Advanced Practice Registered Nurse (APRN) to collectively define all APNs for the purposes of maintaining consistency with other states, definitions. New Jersey's APNs were added to code sections as those who, when appropriately certified, may serve as Directors of Substance Abuse Counseling Centers; as those who are authorized to complete physical examinations of patients; and as those who are authorized to prescribe medications. House Bill 170 was passed in New Mexico granting CNPs authority to declare death and to sign death certificates. Additionally, New Mexico's APRNs were successful in suppressing a legislative attempt to form a physician-led board to oversee all SOP changes for healthcare providers in the state.

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North Dakota was successful in passing SB 2158, authorizing NPs to be listed as PCPs in the state's Medicaid Program and Oklahoma authorizes APNs to order sleep diagnostic tests through the passage of SB 810. In South Dakota, amendments to Administrative Rules 20:62:03:03 and 20:62:03:05 clarify the requirements of "collaboration" between the NP and the physician. The code states that "collaboration" must occur by direct personal contact with each collaborating physician no less than twice each month unless it is established in the agreement that one of the twice monthly meetings may be held by telecommunication. The collaborating physician must be physically present on-site every 90 days at each practice location (exceptions: patient homes and school health screening events). Vermont reported that a proposed Rules and Regulation change is before the BON to remove the written collaborative agreement between an APRN and a physician; at press time, the outcome was still pending.

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Virginia reported the passage of SB 1195 / HB 2211, Adoption of Guidance Document 90-33, which clarifies NP authority to sign DNR orders. Washington passed legislation amending the term "ARNP" in statutes where only the term "physician" appeared. Additionally, Washington passed regulatory changes to licensing categories, criteria for continued licensure, and reactivation of ARNP licenses. Finally, after 7 years, Wisconsin's Outpatient Mental Health Clinic Rule HFS 35 has been clarified to include psych/mental health advanced practice nurse prescribers (APNPs) throughout the rules. Appropriately trained psych/mental health APNPs may provide psychotherapy through certification and BON recognition or 3,000 hours of supervised postgraduate clinical experience.

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Reimbursement

Reimbursement of NP services continues to be an area where little regulatory or legislative progress has been made over the last several years. In 2009, only two states have reported successful passage of legislation or adoption of regulations improving the ability for NPs to be reimbursed. New Jersey has amended their rules (N.J.A.C. 10:49), adding APNs to the list of "specialists and other practitioners" eligible to receive co-payments to beneficiaries as indicated on their HMO card and Wisconsin reported clarification in rules authorizing direct billing by psychiatric APRNs.

There continues to be reimbursement policy inconsistencies among private insurers and progress toward effective change is sluggish. State NP organizations have attempted both legislative and regulatory reform, with little improvement, despite citing successful relationship-building with executives in these organizations. Medicaid and Medicare continue to support NP services and reimbursement and these payers appear to be consistent. In the coming years, we hope to see a growing trend of successful policy change in this area.

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Prescriptive authority

Seven states reported legislative or regulatory changes to prescriptive authority ranging from the removal of official formularies to expansion of authority. Hawaii was successful in removing the Board of Medicine (BOM) formulary of exclusion, granting sole authority to the BON. This includes all controlled substance (CS) medications, all medical devices and equipment, nutritional prescriptions, diagnostics, home health, hospice, physical therapy, and occupational therapy orders. Similarly, New Hampshire repealed the Joint Health Council and attached formulary through the passage of SB 66.

In Illinois, progress was made by removing some of the restrictions on CS II-V prescriptive authority. Nevada reports pending Rules and Regulations to grant APRNs authority to prescribe CS III-V as delegated by a physician pursuant to a written collaborative practice agreement.

Texas amended its law by increasing CS III-V refills to 90 days; however, this law also requires a physician to register the name and license number of the APRN to whom the MD delegates prescriptive authority. Virginia successfully removed the requirement for consent from a recipient of a prescription prior to requesting information on that patient for the purpose of establishing treatment history and West Virginia, through the passage of SB 664, expanded its prescriptive authority by authorizing APNs to prescribe a 90-day supply with up to three 30-day renewals for some CS VI and V medications. Some restrictions still apply.

The following updates have been provided through a survey of each state's BON and professional association. Every attempt is made to bring you the most up-to-date information. In some instances, laws or regulations may have passed since the report of the survey. If corrections are necessary, we will address them immediately.

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Alabama

http://www.abn.state.al.us

http://www.npalliancealabama.org/

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Legal authority

The BON has sole authority to establish the qualifications and certification requirements of APNs through R&Rs. APNs are defined as CRNPs, CNMs, CRNAs, and CNSs. CNSs and CRNAs are not regulated by the joint committee (BON and BOME), and are not eligible for prescriptive authority. The BON and BOME regulate the collaborative practice of physicians, CRNPs, and CNMs, and require them to practice with BON- and BOME-approved protocols. The collaborating physician and NP or CNM practicing with the physician must sign the protocol. The term "collaboration" does not require direct, on-site supervision of the activities of a CRNP or CNM by the collaborating physician. The term does require such professional oversight and direction as may be required by the R&R of the BOME and BON. The CRNP or CNM and collaborating physician shall be present in any approved practice site a minimum of 10% per month (if the CRNP's or CNM's collaboration time is 30 or more hours per week) and a minimum of 10% on a quarterly basis (if the collaboration time is less than 30 hours per week). Proposed rules in promulgation September 2006 define "remote practice site," where the collaborating physician must visit each remote site at least quarterly. The APN shall practice in accordance with national standards and functions identified by the appropriate specialty-certifying agency and as congruent with Alabama law. CRNP scope of practice (SOP) is defined in statute and regulation. Alabama does not recognize APNs as "PCPs" and does not have "any willing provider" language in statute. CRNPs are required to have an MSN and national certification upon entry into practice, with a few exceptions: initial CRNP applicants are exempt from requirement for MSN on discretion of the BON if graduation was prior to 1996 in a post-BSN NP program, or graduation prior to 1984 from a non-BSN program preparing NPs. CRNAs must have a minimum of a master's degree from an accredited nurse anesthesia graduate program and be currently certified as a CRNA; CRNAs who graduated prior to December 31, 2003, are exempt from the master's degree requirement. CNS approval requires MSN as a CNS and national certification.

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Reimbursement
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There are no legislative restrictions against APNs on managed-care panels. The Alabama Medicaid Nurse Practitioner Program reimburses NPs; Alabama Medicaid does not reimburse for services provided in a hospital or ED. NPs are reimbursed through the Kids First Program. BC/BS will reimburse CRNPs and CNMs in collaboration with a preferred physician provider at 70% of the physician rate.

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Prescriptive authority

CRNPs and CNMs may prescribe, administer, and provide therapeutic tests and drugs excluding Schedules II-V controlled substances, within an approved formulary. A BON and BOME joint committee (composed of one CNM, CRNP, RN, and three physicians) recommends R&R governing the collaborative relationship between physicians and CRNPs and CNMs and the prescription of legend (noncontrolled) drugs. The R&Rs limit the physician to three full-time equivalent (FTE) CRNPs (120 hours weekly) without limit on the number of CRNPs. The physician is limited to four CNMs per three FTEs. Exemptions to this specification include public health employees and practices in place before the R&Rs took effect. The joint committee considers applications for ratio exemptions. The BON and BOME shall approve the protocols and formulary of legend drugs that may be prescribed by authorized CRNPs and CNMs. Authorization is tied to the collaborative agreement; if CRNPs or CNMs change physicians, they must reapply. The CRNP or CNM is issued a four-digit Rx number by the BON; the Rx pad must include the physician name and address and the CRNP or CNM name, RN license number, and Rx number. The CRNP or CNM who is in collaborative practice and has Rx privileges may sign for and dispense approved formulary drugs. The physician must notify the BOME in writing within 5 days of commencing or terminating a collaborative agreement with a CRNP or CNM. CNSs and CRNAs are not regulated by the joint committee (BON and BOME) and are not eligible for prescriptive authority.

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Alaska

http://www.dced.state.ak.us/occ/pnur.htm

http://www.alaskanp.org/

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Legal authority

ANPs are regulated by the Alaska BON. ANPs include NPs and CNMs, and are defined as an RN who, because of specialized education and experience, is certified to perform acts of medical diagnosis and prescription, as well as dispense medical, therapeutic, or corrective measures under regulations adopted by the BON. Regulations require that an ANP must have a plan for patient consultation and referral, but a physician relationship is not required. SOP for ANPs is not directly defined in statute or regulation; however, regulation refers to the national certifying body for definition of SOP in specialty areas. ANPs in Alaska are statutorily recognized as "PCPs." Nothing in the law precludes admitting privileges for ANPs; however, hospitals require a physician preceptor with the exception of the Federal Alaska Native Hospital. Entry into NP practice requires a master's degree in nursing and national board certification. Continuing education requirements for ANPs are 30 CEUs (8 of these must be Rx hours) every 2 years. CRNAs practice under separate rules and regulations, and CNSs are not licensed or recognized separately from their RN license.

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Reimbursement

All healthcare in Alaska is provided on a fee-for-service basis; managed care does not exist. FNPs, PNPs, and CNMs are authorized by law to receive Medicaid reimbursement; NPs receive 80% of the physicians' payment. A nondiscriminatory clause in the insurance law allows for third-party reimbursement to NPs; however, the BC/BS federal plan charges patients a $200 deductible to see NPs. This plan does not charge a deductible to see a physician. Alaska legally requires insurance companies to credential, empanel, and/or recognize ANPs. Alaska does not have "any willing provider" language in current law.

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Prescriptive authority

Authorized NPs and CRNAs have independent prescriptive authority, including Schedules II-V controlled substances, and may apply for DEA registration. They are legally authorized to request, receive, and dispense pharmaceutical samples in Alaska. The Alaska Nurses Association reports that problems have been documented with pharmacy warehouses refusing to fill prescriptions written by ANPs. Prescriptions are labeled with the APN's name only. Continuing education credits (30) are required for renewal of licensure (8 of which must be in Rx) every 2 years.

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Arizona

http://www.azboardofnursing.orghttp://www.azbn.gov

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Legal authority

The Arizona State Legislature grants APRNs authority and the BON alone regulates their practice. APRNs include NPs (inclusive of CNMs), CRNAs, and CNSs. According to the BON, an RNP will refer a patient to a physician or other healthcare provider if a situation or condition occurs in a patient that is beyond the RNP's knowledge and experience. No formal collaboration agreement is required. RNP SOP is defined in regulation R4-19-507. RNPs are not statutorily recognized as "PCPs"; however, they are legally authorized to hold admitting and hospital privileges through R&Rs. RNPs must have a graduate degree in nursing and national certification to enter into practice.

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Reimbursement

NPs and other ARNPs may receive third-party reimbursement, enabled by the Department of Insurance statutes. There is no Medicaid; the Arizona Health Care Cost Containment System (AHCCCS) contracts with MCOs and other provider networks on a capitated basis. AHCCCS NP reimbursement is 90% of the established physician rate.

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Prescriptive authority

NPs have full prescriptive and dispensing authority, including controlled substances Schedules II-V, on application and fulfillment of BON-established criteria. NPs' prescriptive and dispensing authority is linked to the NP's SOP (according to the BON, prescribing to an adult is outside of a PNP's SOP). Prescribing without documenting an exam is considered by the BON to be a violation of the NPA. An NP with prescriptive and dispensing authority who wishes to prescribe a controlled substance must apply to the DEA for a registration number and file this number with the BON. Drugs, other than controlled substances, may be refilled up to 1 year. CRNAs may prescribe drugs to be administered by a licensed certified or registered healthcare provider preoperatively, postoperatively, or as part of a procedure; CRNAs are not authorized to dispense.

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Arkansas

http://www.arsbn.org

http://www.arna.org/

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Legal authority

The BON grants APNs authority to practice via second licensure, separate from RN licensure. APNs are licensed and defined as an ANP, CNM, CNS, or CRNA. APNs practice independently with the exception of NPs who are not nationally certified. NPs who are not nationally certified qualify for licensure as an RNP; however, they must practice under physician direction/protocol. The BON ceased issuing RNP licenses in 1996. Hospital privileges for APNs are determined on a hospital-to-hospital basis according to the credentialing committee of each hospital. In 2005, "any willing provider" language was enacted. Graduate-level APN education and national board certification is required for initial APN licensure.

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Reimbursement

The NPA mandates direct Medicaid reimbursement to APNs and RNPs. Medicaid reimbursement is 80% of a physicians' rate. APNs are not recognized as PCPs for Medicaid. CNMs and some NPs are listed on managed-care panels. APNs are included in the any willing provider law that was upheld in the 8th Circuit Court of Appeals. A statutory provision exists for third-party reimbursement for CRNAs.

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Prescriptive authority

The NPA authorizes the BON to provide a certificate of prescriptive authority, including Schedules III-V controlled substances, to qualified APNs in collaborative practice with a physician of comparable specialty/scope and using protocols for prescribing. Neither protocols nor collaborative practice agreements with a physician are required unless the APN has prescriptive authority. Under R&R, an initial applicant for Rx authority must (1) be an APN with completion of pharmacology course work of 3 graduate credit hours or 45 contact hours in a competency-tested pharmacology course; (2) have 300 hours of precepted prescribing experience; and (3) include a collaborative practice agreement with a physician. Endorsement applicants must provide Rx evidence of at least 500 hours in the last year and have a clear DEA history. APNs who have fulfilled requirements for prescriptive authority may receive pharmaceutical samples and therapeutic devices appropriate to their area of practice, including Schedules III-V controlled substances. APNs with prescriptive authority have implied authority to give sample Rx drugs to patients.

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California

http://www.rn.ca.gov/

http://www.canpweb.org

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Legal authority

The California BRN grants legal authority to practice, regulates, and issues separate certification to APRNs. APRNs are defined as NPs, CNMs, CRNAs, and CNSs. NPs function under "standardized procedures" or protocols when performing medical functions, which are collaboratively developed and approved by the NP, physician, and administration in the organized healthcare facility in which they work. The SOP of an NP is defined within their standardized procedures, not in statute or regulation. NPs and CNMs are statutorily recognized as "Primary Care Providers" in California's medical system. APRNs are not legally authorized to admit patients to the hospital; however, individual hospitals may grant hospital privileges to APRNs. NPs must have a master's degree to practice; however, California does not require national certification.

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Reimbursement

All nationally board-certified nurse practitioners are reimbursed independently by the medical system. Medical-covered services performed by NPs, CNMs, and CRNAs are reimbursed at 100% of the physician reimbursement rate. Blue Cross of CA Medical Provider Directory lists NPs as PCPs under their area specialty. There is no legal preclusion to third-party reimbursement of services; however, policies vary from payer to payer. Third-party payers are legally required, however, to reimburse BRN-listed psychiatric-mental health nurses for qualifying services. Participants in the state's managed-care programs for specified medical beneficiaries may select NPs and CNMs as their PCPs.

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Prescriptive authority

NPs and CNMs may furnish or "order" drugs or devices, including controlled substances II-V when the drugs or devices are furnished or ordered by an NP or CNM in accordance with a standardized procedure. The act of "furnishing" requires physician supervision of the NP and CNM; however, physical presence of the physician is not required. The act of "furnishing" is legally the same as the act of prescribing. Prescriptions are labeled with the NP's or CNM's name only. NPs and CNMs may request, receive, and dispense pharmaceutical samples and may dispense drugs, including controlled substances. NPs and CNMs must have authorization by the BRN to furnish controlled substances and must register for a DEA number. To obtain a BRN-issued furnishing number, NPs and CNMs must complete a 45-hour qualifying pharmacology course and 520 hours of physician-supervised experience postcertification.

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Colorado

http://www.dora.state.co.us/nursing

http://www.nurses-co.org/

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Legal authority

The State Board of Nursing grants APNs legal authority to practice and also regulates their practice. APNs included on the registry can maintain their APN authority as long as the underlying RN license is active and a minimum of a graduate degree is required to be added to the APN registry. Title protection is provided to APNs, defined as NPs, CNSs, CNMs, and CRNAs. Use of APN titles requires BON registration. APNs are deemed to be independent practitioners. Legislation to take effect on July 1, 2010 will remove the collaborative agreement requirement for prescriptive authority and introduce a mechanism for autonomous prescribing for APNs. At time of press, the rules regulating this transition, the graduated process for prescriptive authority, and articulated plan are in development. Colorado APNs are encouraged to consult the Colorado Board of Nursing website for updates and hearing information. APN SOP is founded on the relevant educational program and core curriculum as determined by accepted professional standards. Although a function may be within an APN's scope, the individual APN must have the requisite knowledge, judgment, and skill to safely and competently perform any undertaken function. APNs are not statutorily recognized as "PCPs"; however, they are not legally prohibited from being PCPs. Currently, APNs may hold hospital privileges, but hospital bylaws may be more restrictive. Current law states that an RN may be admitted onto the APN Registry upon successful completion of a nationally accredited education program for the preparation as an APN or a passing score on a certification exam of a nationally recognized accrediting agency. National board certification will be required for prescriptive authority after July 1, 2010.

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Reimbursement

Medicaid reimburses all advanced practice nurse services. Third-party reimbursement is available to any RN; billed services qualify for reimbursement only if the type of service has a history of being reimbursable to other healthcare providers. No statutes require insurance companies to credential, empanel, or reimburse APNs; however, some insurance companies reimburse for NP services, especially related to psychiatric APNs with prescriptive privileges. No statutes or rules prohibit or constrain APNs in managed care.

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Prescriptive authority

Colorado APNs enjoy full prescriptive authority including Schedules II-V controlled substances. For prescriptive authority eligibility, the prescribing nurse must be listed on the APN registry and have a graduate degree or higher as an APN that includes at least 45 contact hours in health assessment, pharmacology, and pathophysiology. The APN must have satisfactorily completed education in the use of controlled substances and prescription drugs, have postgraduate experience as an APN in a relevant clinical setting of no less than 1,800 hours (in the immediately preceding 5-year period), and have a written collaborative agreement with a physician whose medical education and active practice correspond with that of the APN. As of July 1, 2010, new prescriptive authority legislation and rules take effect. At press time, the Board of Nursing rules will be drafted. Updated information can be found on the Colorado Board of Nursing website. APN law states that nothing shall be construed to limit the ability of the APN with prescriptive authority to make independent judgments, require supervision by a physician, or require the use of formularies. APNs with prescriptive authority are legally authorized to request, receive, or dispense pharmaceutical samples.

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Connecticut

http://www.dph.state.ct.us/

http://www.ctaprns.org/

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Legal authority

The Connecticut NPA defines APRNs as NPs, CNSs, and CRNAs, and authorizes APRNs to work in collaborative relationships with physicians. R&R specific to this law have not been written. Connecticut law defines collaboration as a mutually agreed upon relationship between an APRN and a physician who is educated, trained, or has experience related to an APRN's work. Current law exempts CRNAs because their service is under the direction of a licensed physician. SOP for APRNs is defined in statute; however, CNM SOP is recognized under separate statute. The NPA specifically authorizes RNs to operate under an order issued by an APRN. APRNs are statutorily recognized as "PCPs," and are authorized to admit patients and hold hospital privileges. A master's degree in nursing or other related field and national board certification are required to enter into practice.

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Reimbursement

Medicaid regulations govern reimbursement to APRNs under the remaining Medicaid fee-for-service programs. NPs, psychiatric CNSs, 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 services that are reimbursed if provided by any other healthcare provider. The law further states that insurers cannot require supervision or signature by any other healthcare provider as a condition of reimbursement.

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Prescriptive authority

APRNs working in a collaborative relationship with a physician may prescribe, dispense, and administer medications, including Schedules II-V controlled substances that are expressly specified in the written collaborative agreement. If the APRN prescribes noncontrolled substances only, state-controlled substance registration or a federal DEA number is not required. If the APRN prescribes controlled substances in a hospital setting only and the hospital has granted subscript authority under the hospital DEA number, a state-controlled substance registration number is required but a federal DEA number is not. If the APRN prescribes controlled substances in any other setting, the state-controlled substance registration and the federal DEA number are required. CRNAs can only administer drugs during surgery when the physician, who is medically directing the prescriptive activity, is physically present in the institution, clinic, or other setting. APRNs are legally authorized to request, receive, and dispense pharmaceutical samples.

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Delaware

http://professionallicensing.state.de.us/boards/nursing/

http://www.delapn.org/links.php

http://denurses.org/apn_council.php

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Legal authority

The Delaware BON regulates APNs and grants APN authority to practice. APNs are defined as NPs, CNSs, CNMs, and CRNAs. If the APN's SOP does not include independent acts of diagnosis or prescribing, practice authority is governed solely by the BON. If the APN wishes to provide independent acts of diagnosis or prescribing, the APN must apply to the JPC (composed of APNs, MDs, a pharmacist, and one public member). The JPC is statutorily empowered, with BOMP approval, to grant independent practice and/or prescriptive authority to nurses who qualify. APNs must practice in a collaboratory relationship with physicians while performing theses services. The collaborative agreement is a written document that outlines the process for consultation or referral complementary to the APN's independent practice area. The collaborative agreement is defined as "a true collegial agreement between two parties where mutual goal-setting access, authority, and responsibility for actions belong to individual parties and there is a conviction to the belief that this collaborative agreement will continue to enhance patient outcomes, and a written document that outlines the process for consultation and referral between an APN and physician licensed in Delaware, dentist, podiatrist, or licensed health care delivery system." If the agreement is with a licensed healthcare delivery system, the document must clarify that the system will supply appropriate medical backup for purposes of consultation and referral. Requirements for physician supervision, chart review, or on-site physician visits do not exist. APN applicants must have a master's degree or postbasic certificate in a clinical nursing specialty, be nationally certified, submit a copy of their collaborative agreement, and show evidence of BON-specified relevant courses including advanced health assessment, diagnosis and management of problems within the clinical specialty, advanced pathophysiology and advanced pharmacology. If the APN has graduated from an approved program more than 2 years prior to application, the APN must document the equivalent of at least 30 hours continuing education in pharmacology and other areas.

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Reimbursement

Delaware has statutory provisions requiring health insurers, health service corporations, and HMOs to provide benefits for eligible services when rendered by APN acting within his SOP. APNs may be listed on provider panels; some providers are recognizing APNs on managed-care provider panels. CNMs have legislative authority under the Board of Health for third-party reimbursement. FNPs and PNPs also receive Medicaid reimbursement at 100% of physician payment.

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Prescriptive authority

JPC- and BOMP-approved APNs may prescribe, administer, and dispense legend drugs, including Schedules II-V controlled substances, parenteral medications, medical therapeutics, devices, and diagnostics. Authorized APNs are assigned a provider identifier number; APNs must register with the State Controlled Substance Agency and DEA, and use their number for prescribing controlled substances. Authorized APNs may request and issue professional samples of legend drugs, including Schedules II-V controlled substances and properly labeled over-the-counter drugs. The prescription order includes the APN's name and prescriber identification number and the prescriber's DEA number and signature when applicable.

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District of Columbia

http://hpla.doh.dc.gov/hpla/cwp/view,A,1195,Q,488526,hplaNav,%7C30661%7C,.asp

http://www.npadc.org/

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Legal authority

The Washington, D.C. Department of Health BON approves and regulates APNs. APNs are defined as APRNs or CNPs, CNMs, CRNAs, and CNSs. Current law authorizes APNs to practice independently without a physician collaborative agreement or protocols. CNP SOP is defined in statute, regulated by the BON, and without limitations. APNs may apply for admitting privileges to the hospital. Graduation from a postbasic NP program or national certification in a specialty area is required to enter into practice.

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Reimbursement

APNs receive direct reimbursement for providing drug abuse, alcohol abuse, and mental illness care; healthcare plans or institutions are prohibited from discriminating against APNs with clinical privileges. Legislative authority mandating APN reimbursement does not exist; however, private third-party payers reimburse for NP services. APNs are statutorily recognized as PCPs. NPs and CNMs receive Medicaid payment as PCPs.

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Prescriptive authority

The D.C. regulations provide for full prescriptive authority including Schedules II-V controlled substances. The law and R&R authorize prescribing Schedules II-V controlled substances and allow dispensing of all medications, including sample medication. APNs are authorized to request and receive pharmaceutical samples. The D.C. Pharmacy Board issues DEA number to providers with controlled substance authority. Prescriptions are labeled with the APN name.

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Florida

http://www.doh.state.fl.us/mqa/

http://www.floridanurse.org/

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Legal authority

The BON certifies and regulates ARNPs, who are defined as NPs, CNMs, and CRNAs. ARNP SOP is defined in statute and includes the performance of medical acts of diagnosis, treatment, and operation pursuant to protocols established between the ARNP and physician, DO, or dentist. Within the framework of established protocols, ARNPs may order diagnostic tests and physical and occupational therapy. The degree and method of supervision, determined by the ARNP and physician, DO, or dentist, is specifically identified in written protocols and shall be appropriate for prudent healthcare providers under similar circumstances. ARNPs must file protocols yearly with the BON, and the physicians working with the ARNP must send the statement required in the medical practice act to the BOM. BOM and BON rules define general supervision as the ability to communicate/contact by telephone; on-site presence of the supervising practitioner is not required. ARNPs are not statutorily recognized as PCPs. ARNPs are authorized to admit patients to the hospital and hold hospital privileges; however, this authority is dependent upon privileges granted by the institution. ARNP applicants must have a master's degree to qualify for initial certification and are required to hold national board certification to enter practice.

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Reimbursement

ARNPs receive Medicaid, Medicare, CHAMPUS, and third-party reimbursement; however, Medicaid reimburses ARNPs at 100% of the physician rate only if the on-site physician countersigns the chart within 24 hours. Medicaid reimburses ARNPs at 85% of the physician rate if the physician is not on-site and does not countersign. In 2008, Florida initiated a pilot program for Medicaid managed care. Providers must be on approved panels. Managed-care companies are prohibited from discriminating against the reimbursement of ARNPs if based on licensure. Private insurers must reimburse CNM services if the policy includes pregnancy care.

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Prescriptive authority

The BON/BOM joint committee allows prescriptive privileges for ARNPs; however, controlled substances are excluded. ARNPs prescribe under a protocol, which broadly lists the medical SOP and generic categories from which the ARNP can prescribe. ARNPs use their own prescription pad (containing name and license number); the pharmacist is required to put the prescriber's name on the drug label. ARNPs who dispense (distribute medication for reimbursement) must apply for dispensing privileges. ARNPs are authorized to request, receive, or dispense pharmaceutical samples.

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Georgia

http://www.sos.state.ga.us/plb/rn/http://www.georgianurses.org/

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Legal authority

APRNs are authorized to practice and regulated by the BON. APRNs are defined as NPs, CNMs, CRNAs, and CNSs in psychiatric/mental health. APRN practice is collaboratory in nature. An APRN is authorized to perform advanced nursing functions and certain medical acts that include, but are not limited to, ordering drugs, treatments, and diagnostic studies through a "nurse protocol." A "nurse protocol" is defined as a written document signed by the NP and physician in whom the physician delegates authority to the nurse to perform certain medical acts and provides for immediate consultation with the delegating physician under OCGA 43-34-26.1 or 26.3. APRNs may hold hospital privileges in limited situations, according to the Georgia Nurses Association. A master's degree or higher in nursing or other related field and national board certification is required for all APRNs at entry into practice except for CRNAs educated prior to 1999.

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Reimbursement

There are no statutes mandating third-party reimbursement for APRNs. FNPs, PNPs, OB/GYN NPs, CNMs, and CRNAs are eligible for Medicaid reimbursement from the Department of Community Health. Reimbursement rates vary: NPs and CRNAs are reimbursed at 90% of a physician's payment and CNMs are reimbursed at 95% of a physician's payment. Some private insurers reimburse APNs but are not required by law to do so.

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Prescriptive authority

APRNs practice under protocol as defined by O.C.G.A 43-34-26.3. A process exists that permits RNs (including APRNs) to administer, order, or dispense drugs under delegated medical authority, either as prescribed by a physician or as authorized by protocol. BON regulations governing protocols used by RNs require that the RN document preparation and performance specific to each medical act. "Medication orders" may be called into a pharmacy. APRNs are authorized to request and receive pharmaceutical samples.

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Hawaii

http://www.hawaii.gov/dcca/areas/pvl/boards/nursing

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Legal authority

The BON grants recognition of and regulates APRNs in Hawaii. APRNs are defined in the NPA as an NP, CNS, CNM, or CRNA and as of July 2009, APRNs have independent scope of practice and prescriptive authority. The minimum requirements to enter practice in Hawaii are a master's in nursing and national certification in the APRN's clinical specialty.

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Reimbursement

Current law provides direct reimbursement to all APRNs and now authorizes all insurers to legally recognize APRNs as PCPs. The reimbursement rate ranges from 85% to 100%. NPs and CNSs are also reimbursed through CHAMPUS. Medicaid expanded the types of APRNs they reimburse to include psychiatric CNSs and additional specialties of NPs. Medicaid reimburses at 75% of physician payment. Hawaii Health QUEST, a Medicaid waiver program, defines PNPs, FNPs, and CNMs as PCPs.

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Prescriptive authority

The BON regulates APRN prescriptive authority and APRNs have legal authority to prescribe prescription medications, including Schedules II-V controlled substances, independently. APRNs with prescriptive authority are legally authorized to request, receive, and dispense pharmaceutical samples. NP prescribers' prescriptions are labeled with the NP name.

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Idaho

http://www.idaho.gov/ibn

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Legal authority

The BON regulates and grants authority to practice for APPNs. APPNs are defined as NPs, CNMs, CNSs, and RNAs. APPN licensure requires RN licensure, completion of an approved APPN program, and national certification. NPs, CNMs, and CNSs must practice in collaboration with other health professionals. Revised NPA rules rely on the Decision-Making Model to determine an APPN's SOP. The APPN can determine if a specific function can be legally performed by determining if the act: (1) is expressly forbidden in the NPA Rules and Regulations; (2) was taught in the APPN curriculum and the APPN is clinically competent to perform it; (3) does not exceed employment policies; (4) is consistent with national specialty organization standards; and (5) is within the accepted standard of care for the APPN's geographic region and practice setting. APPNs are not statutorily recognized as PCPs; however, Idaho does have "any willing provider" language in statute. APPNs are legally authorized to admit patients to hospitals and hold hospital privileges in Idaho. Some facilities have granted APPNs privileges. State law requires a minimum of an associate's degree as entry into practice; however, the NPA also requires national board certification to enter practice, which requires a master's degree in nursing to enter into most specialties.

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Reimbursement

Listing APPNs on managed-care provider panels is neither specifically permitted nor prohibited and is considered by third-party payers on an individual basis. BC/BS credentials NPs as "preferred providers" within their program. NPs receive their own Medicaid provider number and may choose to file independently or with a group. Reimbursement rates are 85% of physician payment.

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Prescriptive authority

Prescriptive and dispensing authority is granted to APPNs who have completed 30 contact hours of pharmacology-specific formal instruction beyond basic RN education. Authorized APPNs may prescribe and dispense legend and Schedules II-V controlled substances appropriate to their defined SOP. Some dispensing restrictions apply to Schedule II substances. Authorized APPNs have their own DEA numbers and prescribe independently. APPNs are legally authorized to request, receive, and dispense pharmaceutical samples and NP prescriptions are labeled with the NP's name only.

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Illinois

http://www.idfpr.com/dpr/WHO/nurs.asp

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Legal authority

The Illinois Department of Professional Regulation's Board of Nursing grants authority and regulates the practice of APNs. APNs are defined as CNPs, CNSs, CNMs, and CRNAs. APNs must have a written collaborative agreement with a physician, except APNs who are credentialed and privileged in a hospital or ambulatory surgical treatment center (ASTC). Collaboration is defined in Section 65-35 (b) between an APN and a collaborating physician or podiatrist. APNs must meet in person with their collaborating physician once a month. APNs may provide services within a hospital or ASTC if clinical privileges have been granted by the facility. All new applicants must have a graduate degree in their APN specialty or a graduate degree in nursing and a certificate from a graduate level program in one of the APN specialty areas. Additionally, APNs must hold national certification to enter into practice.

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Reimbursement

The Illinois Department of Public Aid provides direct reimbursement at 100% of physician rates to certified PNPs and FNPs who enroll independently as Medicaid providers. PNPs and FNPs may alternately choose to bill under a physician and receive 100% reimbursement. Statutory prohibition for third-party reimbursement to APNs does not exist. APNs receive direct or indirect reimbursement from third-party payers in some cases.

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Prescriptive authority

Prescriptive authority is delegated by the physician as part of the written collaborative agreement or clinical privileges. To prescribe controlled substances, a midlevel controlled substance license must be obtained. An APN may prescribe schedules II-V without restrictions and may prescribe schedule II medications if all of the following conditions apply: no more than five Schedule II medications may be delegated; any delegation must be controlled substances that the physician prescribes; the prescription is limited to 30 days and the APN must discuss the condition of the patient with the delegating physician.

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Indiana

http://www.in.gov/pla/nursing.htm

http://www.indiananurses.org

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Legal authority

The Indiana State BON grants the authority to and regulates APNs. The NPA defines APNs as NPs, CNMs, or CNSs. The BON does not issue separate licenses to NPs or CNSs. CNMs must apply for "limited licensure" to practice. APNs without prescriptive authority may function independently in their advanced practice; however, a Written Collaborative Practice Agreement (WCPA) is necessary if the APN seeks prescriptive authority. APN SOP is defined in regulation. If the NP holds a baccalaureate degree, national certification is required to obtain prescriptive authority. NPs with a graduate degree do not need to be nationally certified for prescriptive authority to be granted.

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Reimbursement

Indiana is considered an "any willing provider" state backed by current law. APNs may receive third-party reimbursement as determined by payers. NPs receive Medicaid reimbursement at 85% of a physician's payment. Medicaid for children, however, does not allow for NP reimbursement under current managed-care arrangements.

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Prescriptive authority

The BON has legal authority to establish rules, and, with the approval of the BOM, to permit prescriptive authority for APNs. The BON may issue authorization to prescribe legend drugs and controlled substances if the qualified APN submits proof of successful completion of a graduate-level pharmacology course, consisting of at least two accredited semester hours. Additionally, the APN must submit proof of collaboration with a "licensed practitioner" (licensed physician, dentist, podiatrist, or osteopath) in the form of a WCPA. WCPAs must be approved by the BON and include (1) the manner in which the APN and licensed physician will cooperate, coordinate, and consult with each other in the provision of healthcare, and (2) the specifics of the licensed physician's reasonable and timely review of the APN's Rx practices, including the provision for a minimum weekly review of 5% random chart sampling. The BON issues a prescriptive authority identification number; the authority limits APN prescribing to within the APN's and collaborating physician's SOP. APNs requesting authority to prescribe controlled substances must apply for and obtain Indiana State Controlled Substances Registration before obtaining a federal DEA number. Prescriptions are labeled with the APN's name only. APNs are not permitted to prescribe Schedules III and IV controlled substances for the purpose of weight reduction or to control obesity, and must follow specific guidelines before prescribing a stimulant for attention deficit hyperactivity disorder. CRNAs are not required to obtain Rx authority to administer anesthesia.

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Iowa

http://www.state.ia.us/nursing/

http://www.iowanurses.org/

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Legal authority

The Iowa BON grants ARNPs authority to practice and regulates their practice through administrative rules. ARNPs are defined as NPs, CRNAs, CNMs, and CNSs. ARNPs are authorized to practice independently within their recognized nursing specialties, and collaborative practice agreements are not required by the BON. SOP is broadly defined. ARNPs are statutorily recognized as PCPs; however, state law does not contain "any willing provider" language. ARNPs may hold hospital clinical privileges. Registration as an ARNP requires current licensure as an RN and certification by a national certifying body. A master's degree in nursing is only required for clinical nurse specialists.

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Reimbursement

Iowa's Medicaid managed care and prepaid service programs reimburse ARNPs pursuant to legislation passed in 2003. Payment of necessary medical or surgical care and treatment is provided to an ARNP in third-party reimbursement if the policy or contract would pay for the care and treatment when provided by a physician or DO. Managed-care organizations are not mandated to offer ARNP coverage unless there is a contract or other agreement to provide the service. Under 2003 legislation, all ARNPs are approved as providers of healthcare services pursuant to managed care or prepaid service contracts under the medical assistance program.

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Prescriptive authority

Authorized ARNPs are granted full, independent Rx authority within their nursing specialty, including Schedules II-V controlled substance medications. ARNPs may prescribe, deliver, distribute, or dispense noncontrolled and controlled drugs, devices, and medical gasses, including pharmaceutical samples. ARNPs must register with the DEA, and prescriptions written by ARNPs must be labeled with their name.

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Kansas

http://www.ksbn.org

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Legal authority

The Kansas BON regulates the practice of ARNPs. The BON grants ARNP the authority to practice and defines them as NPs, nurse midwives (NMWs), NAs (CRNAs), and CNSs. ARNPs function in collaboratory relationships with physicians and other healthcare professionals in the delivery of primary healthcare services. ARNPs make independent decisions about the nursing needs of patients and interdependent decisions with physicians in carrying out health regimens for patients; however, the physical presence of a physician is not required when care is given by the ARNP. Any ARNP who interdependently develops and manages the medical plan of care for patients or clients is required to have a signed authorization for collaborative practice with a physician who is licensed in Kansas (60-11-010 (b)). Each authorization for collaborative practice shall include a cover page containing the names and telephone numbers of the ARNP and the physician, their signatures, and the date of review by the ARNP and the physician. Each authorization for collaborative practice shall be maintained in either hard copy or electronic format at the ARNP's principal place of practice. SOP is defined in statute and regulation; however, ARNPs are not recognized as "PCPs." No specific language in statute authorizes or prohibits hospital privileges. Admitting and hospital privileges are determined by individual institution policy and procedure. ARNP applicants in all categories, except NMWs, require a master's degree or higher in nursing; however, national board certification is not required to enter practice in Kansas.

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Reimbursement

Insurance companies are legally required to reimburse all ARNPs for covered services in health plans. Medicaid has expanded payment to include all covered services at 80% of physician payments (except for practitioners performing early periodic screening diagnosis and treatment, who receive 100%). NAs receive 85% of physician payments. Some insurance companies are paying 85% of physician payments to ARNPs.

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Prescriptive authority

ARNPs, with the exception of CRNAs, are legally authorized to prescribe medications, including Schedules II-V controlled substances pursuant to a collaborative practice agreement and written protocol that contains a precise and detailed medical plan of care for each classification of disease or injury for which the advanced registered nurse practitioner is authorized to prescribe and shall specify all drugs which may be prescribed by the ARNP. This can be published protocols or practice guidelines that have been agreed upon by both the ARNP and physician. The prescription order must be signed by the ARNP and include the name of the physician and ARNP. Prescription labels include both the ARNP and physician's name. ARNPs are authorized to request, receive, and dispense pharmaceutical samples, with the exception of controlled substances, if the drug is within their protocol.

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Kentucky

http://kbn.ky.gov

http://www.kcnpnm.org

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Legal authority

The Kentucky BON grants ARNPs authority to practice and regulates their practice. ARNPs are statutorily defined as NPs, CNSs, CNMs, and CRNAs. ARNPs practice in collaboration with a physician in Kentucky for prescriptive purposes only. ARNPs may practice autonomously within their relative SOPs; however, they must practice in accordance with the SOP of the national certifying organization as adopted by the BON in regulation. NP SOP is defined in Kentucky statute, KRS 314.011: "ARNPs shall seek consultation or referral in situations outside their scope of practice." ARNPs are recognized as "primary care providers" in regulation, and are legally authorized to admit patients to a hospital and hold hospital privileges; however, hospital regulations permit medical staff to set conditions. A master's degree in nursing and national board certification is required to enter practice in Kentucky.

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Reimbursement

The state medical assistance program reimburses ARNPs for services at 75% of physician rates in all state regions except Jefferson County. In the Jefferson County region, there is capitated managed care through a healthcare partnership, with reimbursement at physician rates. Kentucky is an "any willing provider" state. In April 2003, the United States Supreme Court upheld the Kentucky law providing that a health insurer may not discriminate against any provider who is located within the geographic coverage area of the health benefit plan and who is willing to meet the terms and conditions for participation established by the health insurer (including Medicaid programs).

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Prescriptive authority

ARNPs may prescribe Schedules II-V controlled substances and nonscheduled legend drugs pursuant to separate "Collaborative Agreement for Prescriptive Authority for Nonscheduled Drugs (CAPA-NS)," and "Collaborative Agreement for Prescriptive Authority for Controlled Substances (CAPA-CS). The CAPA-CS and NS defines ARNP scope of prescribing authority and is signed by the ARNP and physician. ARNPs may prescribe CS II medications for a 72-hour supply with additional authority for psychiatric/mental health clinicians. CS III medications for a 30-day supply have the following limitations: ARNPs may prescribe a 14-day supply of benzodiazepines and hydrocodone combination products without refills. ARNPs are still able to prescribe a 30-day supply of carisoprodol (Soma) without refills. Other Schedules IV and V may be prescribed with refills not to exceed a 6-month supply. CRNAs do not need CAPAs to deliver anesthesia care. The ARNP alone signs his or her name to the prescription pad when prescribing. ARNPs must complete 5 contact hours in Rx annually as part of their CE requirement. ARNPs are legally authorized to request and receive drug samples (noncontrolled legend medications only) and may dispense pharmaceutical samples. Dispensing is applicable to ARNPs working in health departments: ARNPs may dispense with a written agreement with a local pharmacist.

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Louisiana

http://www.lsbn.state.la.us

http://www.lanp.org/

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Legal authority

APRNs are licensed by the BON and are defined as NPs, CNMs, CRNAs or RNAs, and CNSs. APRNs perform certain acts of medical diagnosis in accordance with a "collaborative practice agreement," a formal written statement addressing the parameters of the collaborative practice that are mutually agreed upon by the APRN and physician(s) or dentist(s) including consultation or referral availability, clinical practice guidelines, and patient coverage. APRNs' SOP is limited to their BON-recognized category and area of specialization. The APRN SOP includes "certain acts of medical diagnosis or medical prescriptions of a therapeutic or corrective nature, prescribing assessment studies, legend and certain controlled drugs, therapeutic regimens, medical devices and appliances, receiving and distributing a therapeutic regimen of prepackaged drugs prepared and labeled by a pharmacist, and free samples supplied by a drug manufacturer." Louisiana State law includes "any willing provider" language pursuant to the passage of SB 135/Act 106, and APRNs are legally authorized to hold hospital privileges. APRNs must be licensed as an RN, possess a master's degree or higher, and be certified by a national certifying body recognized by the board or meet "commensurate requirements" if certification is not available.

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Reimbursement

The passage of SB 135/Act #106 in 2006 provides that any qualified plan shall not exclude direct reimbursement of healthcare services provided by an APRN as stated above. Medicaid managed care is required to reimburse FNPs and PNPs at a rate equal to that of physicians performing the same service. Medicaid recognizes FNPs and PNPs as primary care case managers/providers and will give assignment of NPs as the PCP or "Medical Home" under certain circumstances. APRNs are reimbursed at 80% of physician fees per Medicaid; all billing must be under the APRN license, essentially eliminating "incident to" billing.

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Prescriptive authority

APRNs have prescriptive authority in Louisiana, including Schedules II-V controlled substances. The BON has sole authority to develop, adapt, and revise R&R governing SOP, including Rx authority, the receipt and distribution of sample and prepackaged drugs, and prescribing of legend and controlled drugs. An APRN who is granted limited Rx authority may request approval to prescribe and distribute controlled substances as authorized by the APRN's collaborating physician if the patient population served by the collaborative practice has an identified need. Prescribing distributed controlled substances (Schedules II-V) must be consistent with the practice specialty of the collaborating physician and the APRN's licensed category and area of specialization. APRNs with authority to prescribe or distribute controlled substances may not prescribe controlled substances to treat chronic or intractable pain, or obesity, or themselves, or family.

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Maine

http://www.state.me.us/boardofnursing/

http://www.mnpa.us

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Legal authority

The Maine BON authorizes and regulates APRN practice. APRNs licensed by the BON are defined as CNPs, CNMs, CNSs, and CRNAs. A CNP who qualifies as an APRN must practice for at least 24 months under the supervision of a licensed physician, nurse practitioner, or must be employed by a clinic or hospital that has a medical director who is a licensed physician. The CNP must submit written evidence to the BON upon completion of the required clinical experience. After this 24-month period, the CNP can practice independently. CNSs practice independently. CRNAs are responsible and accountable to a physician or dentist. The APRN SOP, as defined in regulation, includes standards of the national certifying body and consultation with or referral to medical and other healthcare providers when required by client healthcare needs. CNPs and certified psychiatric CNSs may sign documents for emergency involuntary commitment through EDs. APRNs are statutorily defined as "PCPs," and may be credentialed as Allied Staff for hospital privileges. Admitting privileges are not granted in this authority. Workers' compensation forms recognize CNPs and allow issuance of license plates and cards for the physically disabled. Current law requires a master's degree in nursing (licensed after January 1, 2006) and national certification to enter into practice.

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Reimbursement

The 1999 Act to Increase Access to Primary Health Care Services (HP617) 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 separate provider identification numbers to CNPs and CNMs; and allows managed-care enrollees to designate CNPs as their PCP. However, managed-care organizations are not required to credential any physician or CNP if their "access standards" have been met. Reimbursement under indemnity plans is mandated for master's-prepared, certified psychiatric/mental health CNSs; no other third-party reimbursement for APRNs is required by law. Some insurance carriers, however, reimburse independent CNPs. Medicaid reimburses in full, on a fee-for-service basis, for services provided by certified family nurse practitioners, CPNPs, and CNMs.

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Prescriptive authority

CNPs and CNMs may prescribe and dispense drugs or devices, including Schedules II-V controlled substances, in accordance with rules adopted by the BON; approved CNPs and CNMs receive their own DEA numbers. BON rules require CNPs and CNMs to have a pharmacology course and prescribe from FDA-approved drugs related to the nurse's specialty. CNPs in independent practice and CNMs may prescribe Schedules II-V controlled substances and off-label drugs, according to common and established standards of practice. Dependency on other professionals for APRN prescriptive authority does not exist, except in the case of CNPs working pursuant to medical delegation by a physician (an employment practice required by a number of Maine hospitals). CNPs working pursuant to medical delegation may now prescribe controlled substance II medications after written request to the BoLM and their approval. APRNs may receive and distribute drug samples included in the formulary for Rx writing.

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Maryland

http://www.mbon.org

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Legal authority

The Maryland Board of Nursing and Board of Medicine jointly regulate APN practice. APNs are defined as NPs, Certified Registered Nurse Anesthetists (CRNAs), CRNMs, and APRNs/Psychiatric Mental Health Nurses. APNs are legally required to have a written agreement with a collaborating physician, which must be approved by an equally represented physician and NP joint committee. Once the agreement is approved, NPs may perform the functions of the agreement independently. SOP is defined in Code but the written agreement details the extent the NP can practice within that scope. Current law recognizes APNs as "PCPs." The minimum degree required to enter practice in the State of Maryland is a Masters degree; however, NPs with an associate degree who were practicing before the requirements took effect were grandfathered into practice. National board certification is required. In the 2008 legislative session, a clarifying bill was passed to facilitate NP patient care by changing 10 out of 12 of the requested privileges such as the ability to sign death and birth certificates and the ability to sign for handicapped tags.

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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 a managed-care organization; NPs (with the exception of neonatal and acute care) and CRNMs have been designated as PCPs and may apply to be placed on a provider panel. Medicaid reimburses at 100% of physician payment. Legislation allows due process for APNs listed on managed-care panels; APNs are not to be arbitrarily denied. Legislation passed in 2003 requires an HMO to permit an enrollee to select a certified NP as the enrollee's PCP if (1) the NP provides services at the same location as the NP's collaborating MD and (2) the collaborating MD provides the continuing medical management required. The law does not require that an HMO include NPs on the HMO panel as PCPs.

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Prescriptive authority

NPs and CNMs have full prescriptive authority, including Schedules II-V controlled substances. The scope of prescriptive authority is defined by the written agreement developed by the NP and collaborating physician. CNMs have statutory authority to prescribe based on a formulary mutually developed by the BON, BOM, and BOP. NPs and CNMs are authorized to obtain both federal and state DEA numbers. The Division of Drug Control lists newly authorized NP and CNM prescribers in their newsletter and sends a list of authorized NP and CNM prescribers to pharmacists. NPs and CNMs are legally allowed in most settings (those in which drug samples are state authorized to be distributed) to dispense medications. Prescription containers are labeled with the NP or CNM name.

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Massachusetts

http://www.state.ma.us/reg/boards/rn/

http://www.mcnpweb.org

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Legal authority

The Massachusetts BON grants APNs the authority to practice and regulates their practice. APNs are defined as NPs, NAs, psychiatric clinical nurse specialists (PCs) and NMs (Nurse Midwives). All APNs practice in accordance with written guidelines developed in collaboration with the nurse and supervising physician. In all cases, the written guidelines designate a physician who shall provide medical direction as is customarily accepted in the specialty area. If practicing in an institution, the nursing and medical administrative staff must approve the guidelines. If there is no nursing and medical administrative staff, the guidelines must be approved by the BON. Advanced practice R&Rs governing the ordering of tests, therapeutics, and prescribing are promulgated by the BON in conjunction with the BOM. All other areas of SOP are exclusively under the BON. SOP is defined both in statute and regulation. Massachusetts does not recognize APNs as PCPs and does not have "any willing provider" language in law. Credentialing for hospital privileges varies according to hospital policies. Although Massachusetts does not have a minimum degree requirement for entry into practice, national certification is required, which requires a minimum of a master's degree to obtain.

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Reimbursement

FNPs, PNPs, and adult NPs are reimbursed at 100% of physician payment rate for Medicaid unless the NP is employed by the hospital in a hospital-based practice. Massachusetts state law mandates reimbursement to NPs, PCs, NMs, and NAs in accordance with Chapter 302 of the Acts and Resolves of 1994. These include indemnity plans, nonprofit hospital corporations, medical service corporations, and HMOs. BC/BS, Fallon and Neighborhood Health Plan credential NPs in private practice settings to receive individual provider numbers. Effective January 2009, all health insurers are required to recognize NPs as PCPs and include them in provider directories for consumer choice.

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Prescriptive authority

Massachusetts state law provides for prescriptive authority for NPs, NMs, and PCs, including Schedule II controlled substances. Authorized APNs must apply to the Massachusetts Department of Public Health for state registration; then apply for a federal DEA number. Authorized APNs have (1) prescribing guidelines mutually developed and agreed on by the nurse, and supervising physician; guidelines do not need to be submitted to the BON unless requested. Guidelines pertaining to prescriptive practice shall include a defined mechanism to monitor prescribing practices, including review with the supervising physician at least every 3 months with the exception of initial prescription of Schedule II drugs, which requires review within 96 hours. Authorized APNs are allowed to request, receive, and dispense pharmaceutical samples. The prescription label and pad include the name of supervising physician and the APN; however, the authorized APN signs the prescription.

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Michigan

http://www.michigan.gov/mdch/0,1607,7-132-27417_27529_27542—,00.html

http://www.micnp.org/

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Legal authority

The BON authorizes advanced practice authority as a specialty certification; however, Michigan is one of the few states without a Nurse Practice Act or a definition of APRNs in statute. APRN nurse specialists are defined by the board as CNMs, CRNAs, and NPs. According to the Michigan Council of Nurse Practitioners, although no statute exists requiring supervision or collaboration to practice (with the exception of prescriptive authority), recently the state has interpreted NP practice as "supervised," due to their ability to "diagnose," which is defined as the practice of medicine. Under some HMOs and systems NPs are recognized as "PCPs." Michigan does not have "any willing provider language" in statute. Michigan statute does not specifically authorize nurse specialists to admit patients or hold hospital privileges; however, according to the state nursing association, this depends on the institution, but hospitals generally grant these privileges. Nurse specialists are required to have a master's degree in nursing and national board certification to enter into practice.

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Reimbursement

Medicaid directly reimburses all certified NPs at 100% of the reimbursement rate. CRNAs and CNMs are also recognized by Medicaid and directly reimbursed. BC/BS directly reimburses all NPs, CNMs, and CRNAs, however, the statute does not legally require insurance companies to credential, empanel, or recognize nurse specialists.

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Prescriptive authority

Under the Michigan Public Health Code, a prescriber is defined as "a licensed health professional acting under the delegation and supervision of and using, recording, or otherwise indicating the name of the delegating physician." NPs, CRNAs, and CNMs may prescribe noncontrolled substances as a delegated act of a physician. There is no requirement for a physician countersignature. Under BOM administrative rules, a physician may delegate prescriptive authority for Schedules III-V controlled substances to NPs and CNMs if "the delegating physician establishes a written authorization," containing names and license numbers of the physician and NP or CNM and the limitations or exceptions to the delegation. Written authorizations must be reviewed annually. The DEA requires NPs and CNMs to obtain DEA numbers for those prescribing controlled substances. Schedule II controlled substances may also be delegated if the physician and NP or CNM are practicing within a defined health facility (freestanding surgical outpatient facility, hospital, or hospice) and if, on discharge, the prescription does not exceed a 7-day period. A supervising physician may delegate in writing the ordering, receipt, and dispensing of complimentary starter dose drugs other than controlled substances. Prescription labels are labeled with the name of the physician.

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Minnesota

http://www.nursingboard.state.mn.us

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Legal authority

The Minnesota BON grants APRNs the authority to practice and regulates their practice. APRNs are defined as an RN certified by a national nursing certification organization acceptable by the BON to practice as a CNP, CNS, CNM, or CRNA. "The APRN must practice within a healthcare system that provides for consultation, collaborative management, and referral as indicated by the health status of the patient." Collaborative management is defined as a mutually agreed on plan between an APRN and physician(s) that designates the scope of collaboration necessary to manage the care of patients in which the APRN and physician(s) have experience in providing care to patients with the same or similar medical problems. SOP for CNPs is defined in statute and CNPs are legally recognized as PCPs. Minnesota state law does not contain "any willing provider" language, however. APRNs are legally authorized to admit patients to a hospital and hold hospital privileges as defined within their SOP. Minnesota does not identify a minimum degree requirement for entry into practice; however, the state does require national board certification to enter practice.

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Reimbursement

APRNs may enroll with Medicaid as a provider and bill for services. FNPs, PNPs, GNPs, WHNPs, and ANPs are reimbursed by Medicaid at 90% of the physician rate. CNPs, CNMs, CRNAs, and CNSs in psychiatric health have legal authority for private insurance reimbursement. Minnesota law prohibits HMOs and private insurers from requiring a physician's cosignature when an APRN orders a lab test, X-ray, or diagnostic test.

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Prescriptive authority

APRNs who meet statutory requirements may prescribe, receive, dispense, and administer drugs including Schedules II-V controlled substances within the scope of their written agreement with a physician and within the practice specialty. CNPs, CRNAs, and CNSs must have a written agreement with a physician that defines the delegated responsibilities related to prescribing drugs and devices. CNMs have independent Rx authority. The BON does not grant prescriptive authority; however, they do have the authority to discipline the APRN if the prescribing practices are unsafe, unethical, or illegal. An authorized APRN who chooses to prescribe controlled substances must apply to the DEA and verify compliance with Minnesota prescribing laws with the BON. APRNs have statutory authority to receive and dispense sample drugs within their authorized SOP.

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Mississippi

http://www.msbn.state.ms.us

http://www.msnurses.org

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Legal authority

The Mississippi BON grants APRNs the authority to practice and regulates their practice. APRNs are defined as NPs, CRNAs, and CNMs and CNSs. The R&Rs are now promulgated solely by the BON. NPs, CRNAs, and CNMs practice in a collaborative relationship with physicians in Mississippi. The collaborating physicians' practice must be compatible with the NP's practice. NPs must practice according to a BON-approved protocol agreed on by the NP and physician. NP applicants must submit official evidence of graduation from a graduate program with a concentration in the applicant's APN specialty. Practicing in a site not approved by the BON, with a physician not approved by the BON, or according to a protocol not approved by the BON is in violation of the NPA R&Rs. SOP is defined and regulated by the BON. NPs are statutorily recognized as "PCPs"; however, Mississippi law does not contain "any willing provider" language. APRNs are legally authorized to admit patients and hold hospital privileges. APNs are required to have a master's degree in nursing and be nationally certified to enter into practice.

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Reimbursement

Medicaid reimbursement is available to APNs at 90% of physician payment. Insurance law specifies that whenever an insurance policy, medical service plan, or hospital service contract provides for reimbursement for any service within the SOP of a NP working under the supervision of a physician, the insured shall be entitled to reimbursement whether the services are performed by the physician or NP.

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Prescriptive authority

NPs have full prescriptive authority, including Schedules II-V controlled substances, based on the standards and guidelines of the NP's national certification organization and a BON-approved protocol that has been mutually agreed on by the NP and qualified physician. The protocol must outline diagnostic and therapeutic procedures and categories of pharmaceutical agents that may be ordered, administered, dispensed, and/or prescribed for patients with diagnoses identified by the NP. NPs may receive and distribute prepackaged medications or samples of noncontrolled substances for which the NP has Rx authority. Controlled substances (II-V) may be prescribed pursuant to additional BON rules and regulations: the NP must have a DEA number, completed a BON-approved educational program, and submittal of a "controlled substance prescriptive authority protocol" to the BON. CNMs and CRNAs may order controlled substances within a licensed healthcare facility using BON-approved protocol or practice guidelines.

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Missouri

http://pr.mo.gov/nursing.asp

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Legal authority

The Missouri BON grants APRNs the authority to practice and regulates their practice. APRNs are defined as NPs, CNSs, CNMs, and CRNAs. APRNs practice in collaboration with physicians in Missouri. Collaborative practice includes written agreements, written protocols, or written standing orders. R&Rs define the Collaborative Practice Rule (CP). Three focus areas in the CP rule include: (1) geographic areas to be covered, (2) methods of treatment that may be covered by CP arrangements, and (3) requirements for review of services provided pursuant to a CP arrangement. A written CP arrangement with a physician is not needed when the APRN is performing nursing acts consistent with the APRN's skill, training, education, and competence. A CP arrangement may be indicated to perform physician-delegated medical acts within the mutual SOP of the physician and APRN and consistent with the APRN's skill, training, education, and competence. CRNAs practice under the direction of the surgeon, anesthesiologist, dentist, or podiatrist. Individuals are recognized by their specific clinical nursing specialty area as a CNS, NP, NM, or CRNA, which delineates their title and SOP as APRNs in R&Rs. When practicing outside their recognized clinical nursing specialty, individuals must practice and title as RNs only. Missouri law does not recognize APRNs as "PCPs" and does not contain "any willing provider" language. Additionally, APRNs are not legally authorized to admit patients or hold hospital privileges. NPs are required to hold a master's degree in nursing and national certification to enter into practice in Missouri.

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Reimbursement

Current law states "Any health insurer, nonprofit health service plan, or HMO shall reimburse a claim for services provided by an APRN, if such services are within the SOP of such a nurse." Medicaid reimbursement is made to APRNs enrolled as Missouri Medicaid fee-for-service providers and Medicaid-enrolled APRNs associated with a federally qualified healthcare or rural healthcare facility or both. Medicaid reimbursement is limited to services furnished by enrolled APRNs who are within the SOP allowed by federal and state laws and inpatient or outpatient hospital services or clinic services furnished to the extent permitted by the facility. Reimbursement for services provided by APRNs is at the same rate and subject to the same limitations as physicians.

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Prescriptive authority

Prescriptive authority for NPs, CNSs, and CNMs includes prescription drugs and devices and Schedules III-V controlled substances as delegated by a physician pursuant to a written CP arrangement (pending adoption of Rules & Regulations). CRNAs may not prescribe controlled substances. Schedule III prescriptions will be limited to 120-hour supply with no refills. Delivery of such APRN healthcare services shall be within the APRN's advanced clinical nursing specialty area and a mutual SOP with the physician, and be consistent with the individual's skill, training, education, and competence. APRNs may receive/dispense samples within their Rx authority. A state BNDD number and DEA number is required. Prescriptions written by an NP are labeled with both the collaborating physician's and NP's name.

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Montana

http://www.nurse.mt.gov

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Legal authority

The Montana BON grants APRNs the authority to practice and regulates their practice. APRNs are defined as NPs, CNSs, CNMs, and CRNAs. APRNs practice independently after completion of specific curriculum requirements and a national certifying exam by a BON-recognized national certifying body. According to the Montana BON, all APRNs involved in direct patient care must have an approved quality assurance program in place. NP SOP is defined in Rule ARM 24.159.1470. State law does not contain "any willing provider" language. APNs are legally authorized to admit patients and hold hospital privileges; however, this varies according to the rules and bylaws of each hospital. APRNs must have a master's degree in nursing and hold national certification to enter into practice. All APRNs must achieve mandatory continuing education hours for renewal every 2 years.

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Reimbursement

Medicaid reimburses APRNs at 85% of physician payment. Montana law requires indemnity plans to reimburse APRNs for all areas and services for which a policy would reimburse a physician; however, HMOs are not included in the indemnity insurers' law, mandatory coverage for APRNs does not apply to HMOs. APRNs receive 85% of the physician payment from BC/BS. Medicare reimbursement consistent with 1990 federal guidelines is in effect. APRNs are included as providers for workers' compensation.

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Prescriptive authority

APRNs who desire Rx authority must apply for recognition by the BON through the recommendation of the Prescriptive Authority Committee, consisting of BON members. APRNs with Rx authority are authorized to prescribe all medications, including Schedules II-V controlled substances using their own DEA number, and are permitted to receive and dispense drug samples. Authority to prescribe is not dependent on any other health professional. Prescribing APRNs must have a quality-assurance program in place, with a defined process of referral. The quality assurance method must be BON-approved before issuance of prescriptive authority and includes 15 charts or 5% of all APRN charts reviewed quarterly by an APRN or physician in the same specialty. Additional continuing education for prescriptive authority (additional to CE requirement for practice authority) is required for renewal every 2 years.

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Nebraska

http://www.hhs.state.ne.us/crl/nursing/Nursingindex.htm

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Legal authority

The Nebraska APRN Board grants APRNs the authority to practice and regulates their practice. APRNs are defined as NPs, CRNAs, CNMs, and CNSs. NPs and physicians practice collaboratively and have joint responsibility for patient care, based on the SOP of each practitioner. The collaborative agreement is contained within the integrated practice agreement (IPA). An IPA specifies, "The collaborating physician shall be responsible for supervision through ready availability for consultation and direction of the activities of the NP." If, after diligent effort, an NP is unable to obtain an IPA with a physician, the APRN Board may waive the requirement for an IPA if the NP has demonstrated proper course work, holds a master's degree or higher in nursing, has completed 2,000 hours under the supervision of a physician, and will practice in a geographic area where there is a shortage of healthcare services. NP SOP is defined in statute and includes illness prevention, diagnosis, treatment, and management of common health problems and chronic conditions. "PCP" status and "any willing provider" language was not reported in the survey. NPs without a master's or doctoral degree, and/or at least 2,000 hours of physician-supervised practice must also have jointly approved protocols. NPs licensed after 1996 must have a master's or doctoral degree to practice July 1, 2007, an NP in women's health and neonatal practice will also be required to have a masters or doctoral degree. Nebraska requires national board certification to enter practice.

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Reimbursement

State legislation mandating third-party reimbursement for NPs does not exist; consequently, some NPs have been refused recognition as a provider. In 2008, Blue Cross/Blue Shield began reimbursing APRNs at 85% of the physician rate of reimbursement. Medicaid reimburses NPs at 100% of physician payment.

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Prescriptive authority

Nebraska NPs are authorized full prescriptive authority including Schedules II-V medications, as defined in their statute. On July 14, 2006, the limitation of prescribing Schedule II controlled substance for pain control only up to 72 hours, was removed. NPs may request, receive, and dispense pharmaceutical samples if the samples are drugs within their prescribing authority. CRNAs prescribe within their specialty practice; authority is implied in the statute. Qualified CRNAs, NPs, and CNMs may receive DEA numbers.

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Nevada

http://www.nursingboard.state.nv.us

http://www.nvnurses.org/groups/apn/

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Legal authority

The Nevada BON grants APNs the authority to practice and regulates their practice. To qualify for APN certification, an application must have completed an education program to prepare an APN (NP, CNS, CNW, and nurse psychotherapist). If the applicant completed an APN program between July 1, 1992 and June 1, 2005, the applicant must hold a current national certification as an advanced practitioner of nursing or hold a bachelor's degree in nursing from an accredited school and must have worked 800 hours in APN practice during the 5 years immediately preceding the application or have completed a program designed to prepare an advanced practitioner of nursing in the preceding 2 years. If the applicant completed an APN program after June 1, 2005, the applicant must hold a master's degree in nursing or related health field. APNs in Nevada practice in collaboration with a physician. The APN must keep written protocols at every job site, together with a collaborative agreement signed by a BOME-approved physician. APN SOP is defined in regulation and includes performance of "designated acts of medical diagnosis, prescribe therapeutic or corrective measures, and prescribe controlled substances, poisons, dangerous drugs and devices." APNs are not recognized as "PCPs" under state law; however, APNs are legally authorized to admit patients to the hospital and hold hospital privileges.

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Reimbursement

APNs are recognized by insurance companies and receive third-party reimbursement. Reimbursement from private insurance is at the same rate as the physician payment; however, Medicaid reimbursement is available to all APNs at 85% of physician reimbursement.

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Prescriptive authority

BON-authorized APNs may prescribe controlled substances, including Schedules II-V controlled substances, poisons, and dangerous drugs and devices pursuant to a protocol approved by a collaborating physician: "A protocol must include that an APN shall not engage in any diagnosis, treatment, or other conduct which the APN is not qualified to perform." APNs may prescribe controlled substances, poisons, and dangerous drugs and devices if authorized by the BON, and if a certificate of registration is applied for and obtained from the BOP. APNs register for their own DEA numbers. APNs may pass a BON exam for dispensing and, after passing the exam with BON approval, apply to the BOP for a dispensing certificate. Samples are not considered "dispensing"; APNs with prescriptive authority may receive and distribute samples without having dispensing authority.

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New Hampshire

http://www.state.nh.us/nursing

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Legal authority

The New Hampshire BON grants APRNs the authority to practice and regulates their practice. Regulatory changes now recognize adult and PNPs, CRNAs, and CNMs. APRNs do not require physician collaboration or supervision. APRN SOP is defined in statute. APRNs are statutorily recognized as "PCPs" in NH; however, state law does not include "any willing provider" language. APRNs may admit patients and hold hospital privileges; however, this is institutionally driven. The minimum academic degree required to enter into practice is a master's degree in nursing and national certification by a BON-recognized certification agency is required.

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Reimbursement

All major insurance companies, hospital service corporations, medical service corporations, and nonprofit health service corporations must reimburse APRNs when the insurance policy provides for any service that may be legally performed by the APRN and such service is rendered. APRNs are recognized as PCPs by several HMOs in the state. Medicaid reimburses APRNs at 100% of physician payment.

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Prescriptive authority

BON-licensed APRNs have plenary authority to prescribe controlled and noncontrolled drugs. APRNs are assigned a DEA number on request and after licensure as an APRN and are authorized to request, receive, and dispense pharmaceutical samples. Prescription labels are labeled with the APRN name.

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New Jersey

http://www.state.nj.us/lps/ca/medical.htm

http://www.njsna.org

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Legal authority

The New Jersey BON grants APNs the authority to practice and regulates their practice. APNs are defined as NPs, CNSs, and CRNAs. APNs practice in collaboration with physicians and are required to have a Joint Protocol with the collaborating physician for prescribing drugs and devices only. SOP for APNs is defined in statute. APNs are recognized as "PCPs"; however, New Jersey does not have "any willing provider" language in statute. APNs are legally authorized to admit patients and hold hospital privileges; however, this is not defined by statute or regulation. Privileges are determined through the credentialing/privileging process of individual healthcare institutions. APN applicants must be masters prepared in nursing and national board certification is required to enter into practice in New Jersey.

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Reimbursement

Private health plans, including Medicaid-managed care plans, are permitted to credential APNs as "PCPs," but are not required to recognize or reimburse them. Once the APN has been credentialed by or obtained a provider number from these insurers, the APN is recognized as an Independently Licensed Practitioner/Provider (ILP) and can be directly reimbursed by: Medicare, NJ Medicaid, NJ FamilyCare, United Healthcare; Horizon-Mercy and other Medicaid HMOs, Cigna, Great West, Health Net, Amerigroup/Choice, QualCare, and Oxford. Aetna and Horizon BC/BS will only credential and reimburse APNs who work in physician practices, not as ILPs although there has been recent activity that suggests Aetna may be changing this policy; additionally, for many years, HBC/BS credentialed and directly reimbursed Psych. CNSs but have been intermittently reluctant to do so when clinicians self-identified as APNs. Note that direct reimbursement to APNs is also provided by the Civilian Health and Medical Program (uniformed services members and their families) and by the Federal Employee Health Benefit Plan (federal employees). Where APNs are credentialed and directly reimbursed by private insurers, it is generally at 85% of the physician rate, mirroring Medicare

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Prescriptive authority

APNs credentialed by the BON have full prescriptive authority, including Schedules II-V controlled substances in accordance with a joint protocol, which has been established by the APN and the collaborating physician. The joint protocol is required for prescribing drugs and devices only and is not a collaborative agreement for general practice. To prescribe controlled substances, APNs must have both a state controlled dangerous substance number and a federal DEA number, have modified the joint protocol to indicate whether or not prior consultation with the collaborating physician is necessary prior to initiating CDS prescriptions. All APNs in New Jersey must complete a one-time 6-hour course in controlled substance prescribing. APNs are authorized to request, receive, and dispense pharmaceutical samples.

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New Mexico

http://www.state.nm.us/nursing

http://www.nmnpc.org

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Legal authority

The New Mexico BON grants APRNs the authority to practice and regulates their practice. APRNs are defined as CNP, CRNA, and a CNS. CNPs practice independently without physician supervision or collaboration requirements. CNP SOP is defined in statute 61.3.23.2 of Chapter 61, Article 3 of the New Mexico Statutes. CNPs are statutorily recognized as "PCPs"; however, New Mexico does not have "any willing provider" language contained within the statutes. CNPs are legally authorized to hold admitting and hospital privileges. A master's degree in nursing or higher and national board certification is required to enter into practice as a CNP. The BON also regulates CRNAs and CNSs. CRNAs seeking initial licensure must be at the master's level or higher. CRNAs work in collaboration with a physician and have Rx authority including Schedules II-V controlled substances. CNSs must be master's prepared and certified by a national certifying nursing organization. CNSs "make independent decisions"; have "prescriptive authority," including Schedules II-V controlled substances; and can distribute prepackaged drugs. CNMs are regulated by the Department of Health. CNPs can serve as "acute, chronic, long-term, and end-of-life healthcare providers."

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Reimbursement

Statutory authority for third-party reimbursement for NPs and CNSs has been in effect since 1987; however, reimbursement is not legally mandated for CNP services, thus CNPs continue to meet resistance in being listed as PCPs with some companies. FNPs and PNPs receive Medicaid reimbursement at 85% of physician payment. All three of the managed-care groups contracted to provide Medicaid coverage have contracts with NPs.

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Prescriptive authority

CNPs have full, independent prescriptive authority, including Schedules II-V controlled substances. BON prerequisites to prescribe controlled substances include experience with Rx writing, a state-controlled substance license, and a DEA number. Each CNP must maintain a formulary. CNSs must have graduate-level pharmacology, pathophysiology, a physical assessment course, and prescribe in collaboration with a physician, CNP, or CNS with Rx authority during a 400-hour preceptorship before they can prescribe independently. CNMs have Rx authority; the Department of Health has rule-making authority. CRNAs who meet prescriptive authority requirements may collaborate independently and prescribe and administer therapeutic measures, including dangerous drugs and controlled substances within emergency procedures, perioperative care, or perinatal care environments. CNPs and CNSs with prescriptive authority may distribute dangerous drugs and Schedules II-V controlled substances that have been prepared, packaged, or prepackaged by a pharmacist or pharmaceutical company. Prescription labels are labeled with the CNP name, where appropriate.

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New York

http://www.op.nysed.gov/nurse.htm

http://www.thenpa.org/

http://www.nysna.org

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Legal authority

The New York State Education Department grants NPs authority to practice and regulates their practice pursuant to Title VIII, Article 139 of NYS Education Law. APNs are defined as NPs. NPs are licensed as RNs by the BON and certified by the State Education Department as NPs. NPs are legally required to practice in collaboration with physicians in accordance with a written practice agreement and written practice protocols. NP SOP is defined in statute. NPs are considered autonomous, independent practitioners who are authorized to diagnose, treat, and prescribe in accordance with collaborative practice. The written agreement must include a provision for dispute resolution between the NP and the physician and provisions for a review by the collaborating physician of a patient record sample at least every 3 months. NPs are legally authorized to hold admitting privileges. A master's degree in nursing is required to enter into practice; however, national board certification is not required.

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Reimbursement

NPs of all specialties may register as Medicaid providers, including mental health NPs and be reimbursed at 100% of the physician rate. Nurses continue to be qualified providers and NPs are specifically mentioned as qualified "primary care gatekeepers." A law regulates the practice of HMOs: Provisions are provider-neutral and apply equally to physician and nonphysician providers. Although there is no guarantee that APNs will have a role in managed care delivery, their rights are assured. The law also prohibits "gagging" healthcare providers, establishes due process for termination of provider contracts, allows for access to specialty providers, includes continuity of care provisions for ongoing care with providers outside of the plan, and requires the commissioner of health to determine that there are sufficient providers to meet the covered patients' needs. "Willing Provider" legislation has been proposed; the public health law would specify "No HMO shall discriminate against any provider who is located within the geographic coverage area of the health benefit plan and who is willing, capable, and can meet the terms and conditions for participation."

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Prescriptive authority

NPs have full prescriptive authority, including Schedules II-V controlled substances. NPs may order drugs, devices, immunizing agents, tests, and procedures in accordance with the practice agreement and practice protocols without cosignature. NPs may receive and dispense pharmaceutical samples if appropriately labeled and handed directly to the patient. Prescription labels are labeled with the NP's name. Midwives are authorized to prescribe and administer drugs, immunizing agents, diagnostic tests, and devices, and order lab tests limited to the practice of midwifery; they can dispense pharmaceutical samples.

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North Carolina

http://www.ncbon.com

http://www.ncnurses.org/practice_npcouncil_home.html

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Legal authority

The North Carolina BON and the North Carolina BOM jointly grant NPs the authority to practice and regulate their practice. CRNAs and CNSs are regulated by the BON only. APRNs are defined as NPs, CRNAs, CNSs, and CNMs. According to the North Carolina Nurses Association, NPs legally practice under a supervisory relationship with a physician; however, this is referred to as a collaborative practice. Collaborative practice must include a WCPA with a physician for continuous availability and ongoing supervision, consultation, collaboration, referral, and evaluation. After the first 6 months of NP practice, in which documented face-to-face meetings are required, NPs and physicians may meet by phone or electronically. The CPA also includes the drugs, devices, medical treatments, tests, and procedures that may be prescribed, ordered, and performed by the NP as well as a plan for emergency services. The supervising physician does not have to be on site. The NP shall be prepared to demonstrate to the BON or BOM the ability to perform medical acts as outlined in the CPA. NP SOP is defined in both statute and regulation (21 NCAC 36.0800.0814). NPs are not recognized as "PCPs" and North Carolina statutes do not contain "any willing provider" language. State law does not prohibit NPs from holding admitting and hospital privileges; however, these are granted on a facility-by-facility basis. New NPs must have a master's degree in nursing or in a field with primary focus on nursing and national board certification is required to enter into practice. CRNAs are regulated solely by the BON and do not have prescriptive authority. CNMs have their own separate statute and are regulated by a midwifery joint committee. CNS recognition and SOP is regulated by the BON, but does not include prescriptive authority. CNSs with master's degrees in psychology/mental health may independently practice psychotherapy. All APRNs are allowed to form corporations with physicians; however, CRNAs can only incorporate with anesthesiologists.

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Reimbursement

FNPs receive Medicaid reimbursement at 100% of the physician rate for primary care activities. NPs who are enrolled in mental health programs receive 85% of the physician rate. CHAMPUS also reimburses NPs. Statutory authority for third-party reimbursement for NPs provides direct reimbursement to NPs for services within their scope that are reimbursable to a nonnurse provider. "No Discrimination in the Selection of Providers," patients may choose services from a provider list that includes APRNs. The section, "Provider Directory Information," requires that every health benefit plan use a provider network directory that includes all types of participating providers, including APRNs, upon participating providers' written request.

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Prescriptive authority

NPs and CNMs have full prescriptive authority, including Schedules II-V controlled substances that are identified in their CPA. Dispensing may be done under specific conditions and if a dispensing license has been obtained. NPs may refill legend drugs up to 1 year and may write controlled substance prescriptions for 30 days; NPs may not refill any controlled substances. NPs with controlled substances in their collaborative practice agreements must obtain a DEA number (in addition to their prescribing number issued at the time of their approval as NPs). Prescription labels include the NP name only.

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North Dakota

http://www.ndbon.org

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Legal authority

The North Dakota BON grants APRNs the authority to practice and regulates their practice. APRNs are defined as NPs, CNSs, NMs, and NAs. NPs practice in collaboration with a physician in North Dakota for prescriptive authority only. The SOP for a NP is based upon the Decision-Making Model and as defined in specialty certification. NPs are required to submit a SOP statement for review by the BON to apply for and renew their APRN license. APRN applicants for initial licensure must have a master's degree with completion of an advanced practice track and national board certification.

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Reimbursement

FNPs, PNPs, and CNMs, receive Medicaid reimbursement at 75% of the physician rate and CNMs at 85% of physician rate. BCBSND reimburses CRNAs, CNMs, CNSs, and NPs based on the lesser of the (1) provider's billed charges or, (2) 75% of the BC/BS physician payment system in effect at the time the services are rendered. New legislation passed in 2009 grants an NP authority to be a PCP within the Medicaid system. Any certified NP is eligible for a Medicaid provider number. State law authorizes reimbursement for health services provided in the scope of licensure by nurses with advanced licensure and mental health in their SOP. APRNs are statutorily recognized as "PCPs." Providers practicing more than 20 miles from the following cities: Williston, Dickson, Minot, Bismark, Jamestown, Devils Lake, Grand Fords, Wahpeton, and Fargo shall be reimbursed the lesser of (1) provider's billed charges or, (2) 85% of the BCBSND physician payment system(s) in effect at the time services are rendered.

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Prescriptive authority

Authorized APRNs may prescribe legend drugs and Schedules II-V controlled substances. For prescriptive authority, the APRN must submit a statement to the BON addressing methods and frequency of the collaboration for prescriptive practices, which must occur as client needs dictate but no less than once every 2 months; documentation methods of the collaboration process regarding prescriptive practices; and alternative arrangements for collaboration regarding prescriptive practices in the absence of the physician. Communication between the APRN and physician must occur at least once every 2 months. An affidavit from the physician must be submitted, acknowledging the manner of review and approval of the planned prescriptive practices and that the APRN's SOP is "appropriately related" to the collaborating physician's specialty. The collaborative agreement requirement is solely for prescriptive authority. APRNs with prescriptive authority may apply for a DEA number.

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Ohio

http://www.nursing.ohio.gov

http://www.ohnurses.org/

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Legal authority

The Ohio BON grants APNs the authority to practice and regulates their authority. APNs are defined as CNPs, CRNAs, CNMs, and CNSs. Legal authority to practice requires a collaborative practice arrangement between a physician and a CNP, CNM, or CNS. These groups of nurses (except psychiatric /mental health CNSs) must develop a standard care arrangement (practice agreement) with the collaborating physician. CRNAs are required to practice with a supervising physician. The SOP for CNPs is defined in statute, ORC 4723.43. APNs are statutorily recognized as providing "primary care services"; however, they are not currently authorized to admit patients or hold hospital privileges. Currently, CNPs, CNSs, and CNMs do not have statutory authority to admit patients or hold hospital privileges. Applicants for licensure must have a master's degree in nursing or a related field that qualifies the individual to sit for the national certifying exam. Certification from a national certifying body is also required to enter into practice.

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Reimbursement

Ohio's Medicaid program recognizes CNPs certified in family, adult, acute care, geriatric, neonatal, pediatric, women's health, and OB/GYN, CNMs, CRNAs, and CNSs certified in gerontology, medical-surgical, and oncology nursing specialties. Managed-care organizations vary on empanelment. There are no legislative restrictions for an APN being listed on managed-care panels; however, insurance companies are statutorily mandated to reimburse CNMs. Workers' compensation continues to reimburse CNPs, CRNAs, and CNSs.

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Prescriptive authority

Ohio state law grants full prescriptive authority to qualified CNPs, CNMs, and CNSs on a voluntary basis, which includes Schedules II-V controlled substances under the following rules and in collaboration with a physician. A separate approval process is required to apply for prescriptive authority. APNs prescribe based upon a formulary developed and approved by the Interdisciplinary Committee on Prescriptive Governance. The formulary lists (1) permitted drugs, (2) drugs excluded from use, (3) physician-initiated drugs that can be renewed or adjusted, and (4) drugs with special parameters. APNs are not permitted to prescribe newly released drugs until the Committee has reviewed them, and those who wish to prescribe drugs for off-label use must include parameters for off-label use in the standard care arrangement. Schedule II controlled substances are limited to the care of terminally ill patients after physician-initiation and only for a 24-hour period. DEA registration is required. Pharmacists log the prescription by nurse prescriber, not by a physician. The BOP and BON agree that the nurse with Rx authority may request, receive, sign for, and distribute sample medications within their scope and within the formulary. According to the law, (1) no fee may be charged for a sample, (2) only a 72-hour supply (or smallest commercially available size) may be dispensed, and (3) samples of controlled substances may not be dispensed.

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Oklahoma

http://www.lsb.state.ok.us

http://www.ok.gov/nursing

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Legal authority

The Oklahoma BON grants APNs the authority to practice and regulates their practice. APNs are defined as ARNPs, CNMs, CNSs, and CRNAs. ARNPs function independently with the exception of prescriptive authority, which requires supervision by a physician. APNs practice within a SOP as defined by the NPA. The SOP for an ARNP is defined in regulation and is further identified in specialty categories that delineate the population served such as adult ARNP, family ARNP, and so forth. ARNPs are listed as "primary care managers" in the Oklahoma Medicaid system. Authorization to admit patients or hold hospital privileges was not reported in this survey. CNSs must hold a master's degree in nursing, and ARNPs and CNSs must be nationally board certified to enter into practice.

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Reimbursement

Oklahoma's Medicaid plan includes ARNPs as "primary care managers." State law does not mandate reimbursement of ARNPs; however, the Oklahoma State and Education Employees Insurance Company does recognize ARNPs as providers. Negotiation continues with other third-party insurers.

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Prescriptive authority

The BON regulates optional prescriptive authority for ARNPs, CNSs, and CNMs, which includes controlled substances Schedules III-V. Physician supervision is required for the prescriptive authority portion of advanced practice. Prescribing parameters include: (1) not be on the exclusionary formulary approved by the board, (2) must be within the ARNP, CNM, and CNS SOP, (3) include Schedules III-V controlled substances (30-day supply) if state narcotics and DEA registrations are obtained, and (4) include signing to receive drug samples. ARNPs, CNMs, and CNSs must have 45 contact hours or 3 academic hours of pharmacology in the 3 years immediately preceding the initial application for Rx authority and 15 contact hours or 1 academic hour every 2 years for renewal. CRNAs have authority to "order, select, obtain, and administer legend drugs, Schedules II-V controlled substances, devices, and medical gases, when engaged in pre-anesthetic preparation and evaluation, anesthesia induction, maintenance and emergence, and post-anesthesia care." Regulation is by the BON. The CRNA functions under the supervision of a medical physician, DO, podiatric physician, or dentist licensed in Oklahoma and under conditions in which timely on-site consultation by such medical physician, DO, podiatric physician, or dentist is available. CRNAs must obtain state narcotics and DEA registrations to order Schedules II-V controlled substances.

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Oregon

http://www.oregon.gov/OSBN

http://npo.oregonrn.org/

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Legal authority

The Oregon BON grants APNs the authority to practice and regulates their practice. APNs are defined as NPs (which includes CNMs), CNSs, and CRNAs. Nurses in all three categories of advanced practice must be credentialed with a certificate by the BON. APNs in Oregon are independent and are not required to have a collaboratory or supervisory relationship with a physician. SOP is defined in regulation, Division 50 of the Nurse Practice Act. Division 56 addresses prescriptive and dispensing authority for both NPs and CNSs. NPs are statutorily recognized as "PCPs" and permissive statutes allow for NP hospital privileges. NPs may, however, be refused privileges only on the same basis as other providers. A master's degree in nursing or doctoral degree in nursing is required for the CNS and the NP or CRNA educated after specific dates (see regulations for further information); however, national board certification is not required to enter into practice in Oregon.

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Reimbursement

NPs are entitled by law to reimbursement by third-party payers. APNs are designated as PCPs on several HMO and managed-care plans. Medicaid reimburses NPs for services within their SOP at the same rate as physicians. Numerous administrative rules and statutes include NPs, such as special education physical exams (Department of Education) and chronically ill and disabled motorist exams (Department of Motor Vehicles).

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Prescriptive authority

Regulation of Rx authority is under the sole authority of the BON. Oregon has legislated independent or plenary authority for NPs to prescribe, so NPs are able to obtain DEA numbers for Schedules II-V. NPs with prescription writing authority may receive and distribute prepackaged complimentary drug samples. NPs may apply to the BON for drug dispensing authority if the NP's patients have financial or geographic barriers to pharmacy services. NPs do not have authority to prescribe under the physician-assisted suicide law. Only physicians can authorize medical marijuana use.

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Pennsylvania

http://www.dos.state.pa.us/nurse

http://www.pacnp.org

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Legal authority

The Pennsylvania BON grants CRNPs authority to practice and regulates their practice. A CRNP performs the expanded role in collaboration with a medical or osteopathic physician. Collaboration is defined as a process in which a CRNP works with one or more physicians to deliver healthcare services within the scope of the CRNP's expertise. The CRNP's SOP is defined in statute and regulation. CRNPs are recognized as PCPs by DPW and many insurance companies but there are some managed-care companies who do not recognize CRNPs as PCP. The Pennsylvania Department of Health Regulations authorizes a hospital's governing body to grant and define the scope of clinical privileges to individuals, with advice of the medical staff. After February 5, 2005, CRNPs must have a master's degree and pass a national certification exam; CRNPs without a master's degree/certification are accepted if their CRNP was granted prior to the law's effective date. Regulations pertaining to the CNS have been published as proposed in June, pending for certification for the CNS. The BON does not track, monitor, or license CRNAs. The BOM licenses and regulates CNMs.

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Reimbursement

Third-party reimbursement is available for the CRNP, CRNA, certified enterostomal therapy nurse, certified community health nurse, certified psychiatric/mental health nurse, and certified CNS, provided the nurse is certified by a state or a national nursing organization recognized by the BON. Medicaid reimburses CRNPs and CNMs at 100% of physician payment for certain services. The State Department of Health allows HMOs to recognize CRNPs as primary care gatekeepers.

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Prescriptive authority

The BON confers prescriptive authority, including Schedules II-V controlled substances, to CRNPs with a collaborating physician. Regulations allow a CRNP to prescribe and dispense drugs if the CRNP has successfully completed a minimum of 45 hours of course work specific to advanced pharmacology and if the prescribing and dispensing is relevant to the CRNP's area of practice, documented in a collaborative agreement, and not from a prohibited drug category. The CRNP may write a prescription for a Schedule II controlled substance for up to a 72-hour dose if the CRNP notifies the collaborating physician within 24 hours. CRNPs may prescribe Schedules III-V medications for up to a 30-day supply, however, the physician must authorize a refill. CRNPs are authorized to request, receive, and dispense pharmaceutical sample medications. Prescription blanks must include the name and certification number of the CRNP and identify the collaborating physician. The collaborative agreement is a signed, written agreement between the CRNP and a collaborating physician and must identify the parties to the agreement; area of practice; specify the categories of drugs from which the CRNP may prescribe and dispense; specify conditions for prescribing a Schedule II controlled substance; and specify the circumstances and how often the collaborating physician will personally see the patient, be kept at the primary practice site, and be available for inspection.

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Rhode Island

http://www.healthri.org/hsr/professions/n_pract.htm

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Legal authority

The Rhode Island BON grants APNs the authority to practice and regulates their practice. APNs are defined as CRNPs, CRNAs, and Psychiatric and Mental Health Clinical Nurse Specialists (PCNSs). There are no requirements for physician collaboration to practice as a CRNP, with the exception of prescriptive authority. SOP is defined within the NPA. CRNPs are statutorily recognized as "PCPs" in Rhode Island by the Medicaid managed-care program. Nothing prohibits hospitals from granting admitting and hospital privileges to providers; however, privileging is granted by the facilities based upon individual policies. The minimum degree to enter into practice is a master's degree in nursing and national board certification is required. CNMs have a separate law and separate R&R that are not under the BON. BON R&R define CNSs.

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Reimbursement

State law allows for direct reimbursement of psychiatric CSs and CNMs. CRNPs and PCNSs practicing in collaboration with or employed by a physician, receive third-party reimbursement. United Healthcare has begun to empanel NPs. The RiteCare Program (managed-care program for persons eligible for Medicaid), allows CRNPs and CNMs to serve as PCPs. CRNAs receive third-party reimbursement for services under the supervision of anesthesiologists or dentists.

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Prescriptive authority

Rhode Island requires a collaborative practice agreement for prescriptive authority. CRNPs are authorized to apply for controlled substance registration for privileges to prescribe legend and Schedules II-V controlled substances. Prescriptive authority registration requires 30 hours of pharmacy CE within 3 years prior to application, Advisory Committee approval, and written collaborative guidelines with a physician. The CRNP and collaborating physician or medical director develop practice guidelines, which determine the drugs that will be prescribed from the formulary; the practice guidelines are kept at the practice site. PCNSs have authority to prescribe certain legend medications and controlled substances from Schedule II classified as stimulants and controlled substances from Schedule V that are described in regulations. PCNSs prescribe in accordance with annually updated practice guidelines, written in collaboration with the medical director or physician consultant of their individual establishments. Draft guidelines "provide guidance to licensed healthcare facilities relating to the proper storage, security, and dispensing of medications." The guidelines, referenced from state statutes, state that licensed practitioners with authority to prescribe medications may procure and dispense (including drug samples) legend medications and Schedules II-IV controlled substances if the practitioner has obtained the required state and federal registrations.

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South Carolina

http://www.llr.state.sc.us/pol/nursing/

http://www.scnurses.org/A_P_SIG/

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Legal authority

The South Carolina BON grants APRNs the authority to practice and regulates their practice. APRNs are defined as an NP, CNM, CNS, or CRNA. APRNs must have a collaborative relationship with a physician and may perform "delegated medical acts" in addition to nursing acts as defined by the BON. "Delegated medical acts" may be performed by APRNs pursuant to an approved written protocol between the nurse and physician, and are defined as "additional acts delegated by the physician that include formulating a medical diagnosis and initiating, continuing, and modifying therapies, including prescribing drug therapy under approved written protocols." NPs who manage delegated medical aspects of care must have a supervising physician who can be accessed by electronic/telephonic means, and operate within the "approved written protocols." APRNs are legally authorized to admit patients to a hospital and hold hospital privileges; however, this is left up to the individual agency. APRNs must hold a master's degree in nursing and national board certification in an advanced practice-nursing specialty to enter into practice.

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Reimbursement

All NPs, regardless of specialty, may apply for a Medicaid provider number (now the NPI number), are paid 85% of the physician payment rate, and are recognized as "PCPs." The State Health and Human Services finance commissioner requires that NPs have current, accurate, and detailed treatment plans. Approximately 23 payers recognize, enroll, and directly reimburse APRNs for services provided. Dr. Stephanie Burgess, the first APRN to sit on the advisory board for State Health and Human Services Board in SC—rest of Board are MDs.

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Prescriptive authority

APRNs have prescriptive authority, including Schedules III-V controlled substances, and prescribe according to practice agreement/ protocol within the specialty area of the APRN. The BOP has opined that, "The supervising physician is not the prescriber. The NP prescribes independently of the supervising physician, has their own DEA registration, and must have a state and federal ID number." The BON issues an ID number to the nurse authorized to prescribe. State law requires prescriptions by NPs be signed by the NP, contain the NP's BON-assigned prescriptive authority number and place of practice, and the physician's name and address preprinted on the prescription blank. APRNs with prescriptive authority may request, receive, and sign for professional samples, including Schedules III-V controlled substances.

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South Dakota

http://www.nursing.sd.gov

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Legal authority

The South Dakota BON and BOM jointly regulate the practice of CNPs and CNMs. APNs are defined as CNPs, CNMs, CRNAs, and CNSs. CNPs and CNMs practice in collaboration with a physician licensed in the state when performing overlapping functions between advanced practice nursing and medicine. On-site physician collaboration must occur no less than twice each month unless a modification request is approved to allow one of the twice-monthly meetings be held by telecommunication. CNSs are regulated by the BON and physician supervision is not required; however, prior to ordering durable medical equipment or therapeutic devices, CNSs must collaborate with a physician. CRNAs are regulated by the BON and perform acts of anesthesia in collaboration with a physician licensed in the state as a member of a physician-directed healthcare team. On-site supervision is not required. APNs are granted hospital privileges.

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Reimbursement

CNPs and CNMs receive Medicaid reimbursement at 90% of the physician payment rate. CRNAs are reimbursed at the physician rate for services provided under Medicaid. State insurance law is silent regarding CNSs; however, CNSs may be reimbursed under specific plans. Medicaid reimbursement is allowed only if billed through a physician's practice. CNPs and CNMs receive third-party reimbursement. State law mandates that CRNAs, CNPs, and CNMs must be reimbursed on the same basis as other medical providers, assuming that the service is covered under the policy; CRNAs, CNPs, and CNMs may receive reimbursement when the service is covered under the policy and they are acting within their SOP.

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Prescriptive authority

South Dakota's CNPs and CNMs may prescribe legend drugs and Schedules II-IV controlled substances as authorized by the collaborating physician agreement. CNPs and CNMs have two controlled substance registration options: (1) they may seek independent state registration and independent DEA registration in all Schedules as authorized by their collaborative agreement; or (2) they may act as an agent of an institution, using the institution's registration number to prescribe, provide, or administer controlled substances. Controlled substance authority is granted by separate application to the Department of Health following collaborative agreement approval by the BON and BOM. CNPs and CNMs may request and receive drug samples, provide drug samples, and provide a limited supply of labeled medications. Medications and sample drugs must be accompanied by written administration instructions and documentation entered in the patient's medical record. The provision of drug samples or a limited supply of medications is not restricted, with the exception of Schedule II controlled substances, which are limited to a one-time, 30-day supply. Therefore, the amount provided is at the professional discretion of the CNP or CNM and the collaborating physician. CNPs or CNMs who accept controlled substances, either trade packages or samples, must maintain a record of receipt and disposition. CRNAs and CNSs do not have Rx authority. CNSs may order and dispense durable medical equipment and therapeutic devices in collaboration with a physician.

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Tennessee

http://www.tnaonline.org

http://www2.state.tn.us/health/Boards/Nursing/

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Legal authority

The Tennessee BON grants APNs the authority to practice and regulates their practice. APNs are defined as NPs, CNMs, CRNAs, or CNSs. APNs meeting requirements for prescriptive authority are eligible for a certificate that is designated "with certificate to prescribe." APNs must hold a current RN license in Tennessee or a compact state if home state is a compact state. APNs who prescribe must have protocols that are jointly developed by the APN and the supervising physician. Medical Board rules that govern the supervising physician of the APN prescriber are jointly adopted by the BOME and BON. Physicians who supervise APN prescriber practices are not required to be on site, but must personally review and sign 20% of the charts within 30 days. CRNAs and CNMs are defined in the hospital licensure rules, which also provide that the medical staff may include CNMs; CNMs are not precluded from admitting a patient with the concurrence of a physician member of the staff. NPs have admitting and clinical privileges in Medicare critical access hospitals; however, privileges for NPs are not addressed in other hospital licensure rules and these privileges are inconsistent across the state.

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Reimbursement

Tennessee private insurance laws mandate reimbursement of APNs. A managed-care-antidiscrimination law prevents managed-care organization discrimination against APNs (specifically CNPs, CNSs, CNMs, and CRNAs) as a class of providers. However, not all organizations are, as of yet, credentialing and accepting APNs into their network. This is a major issue being addressed by TNA and private, APN practice owners. BC/BS credentials APNs in most of their programs and provides 100% reimbursement to primary care NPs in the TennCare program; BC/BS also reimburses CNMs and CRNAs. Other managed-care organizations participating in the TennCare program also credential APNs and assign an established patient panel upon individual review of specialty.

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Prescriptive authority

APNs that have a BON-issued certificate to prescribe may prescribe legend and Schedules II-V controlled substances with an active DEA registration number. A certificate to prescribe requires master's or doctorate in nursing, preparation in specialized practitioner skills at the master's, postmaster's, doctorate, or postdoctoral level, 3 academic quarter hours of pharmacology, or its equivalent, and current certification in the appropriate nursing specialty area. APNs meeting these qualifications may sign prescriptions and/or issue medications, including Schedules II-V controlled substance medications under protocols in any practice site. The APN's script pad must have the preprinted name and address of the supervising physician and of the APN; however, the name of the physician is no longer required on the signature line. NPs may request, receive and issue pharmaceutical samples.

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Texas

http://www.bon.state.tx.us.

http://www.cnaptexas.org

http://www.texasnp.org

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Legal authority

The BON is authorized by the NPA to regulate APRNs. RNs may practice on the basis of a multistate licensure privilege and the Texas Legislature enacted the APRN Compact in 2007, but the APRN Compact has not been implemented. All APNs must apply to the BON for licensure to practice as an NP, CNM, CRNA, or CNS. The APRN's SOP is based on advanced practice education, experience, and the accepted SOP of the particular specialty. Unless NPs receive a waiver, the BON will only recognize NPs educated in nine specialties for entry into practice: (1) adult acute care, (2) pediatric acute care, (3) adult, (4) family, (5) geriatric, (6) neonatal, (7) pediatric, (8) psychiatric/mental health, and (9) women's health. The APRN acts independently and/or in collaboration with the healthcare team. The authority to make a medical diagnosis and write Rx must be delegated by an MD or DO using written general delegation protocols or collaborative agreement. The rules refer to protocols as written authorization to provide medical aspects of care. Protocols should allow the APN to exercise professional judgment and are not required to outline specific steps the APN must take. Hospitals may extend privileges to APRNs but are not required to do so. Hospitals electing to extend clinical privileges to APRNs must use a standard application form, and afford due process rights in granting, modifying, or revoking those privileges.

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Reimbursement

All APRN categories are eligible for direct Medicaid reimbursement at 92% of physician payment. Under certain circumstances, physicians in the Texas Medicaid Program may bill for an APRN's services and receive 100%. Some programs such as Texas Health Steps reimburse all providers at the same rate. NPs can be PCPs in Texas Medicaid–managed-care plans. APRNs are listed in the Texas Insurance Code as practitioners that must be reimbursed by indemnity health insurance plans. All HMOs and PPOs in Texas must list an APRN on provider panels if the APRN's collaborating physician is on the panel and the physician requests that the APRN also be listed.

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Prescriptive authority

APRNs must obtain a prescriptive authorization number from the BON. To receive the number, the nurse must have full licensure to practice as an APRN in Texas and meet certain additional educational requirements. To use prescriptive authority, APRNs must practice in a qualifying site and a physician must delegate prescriptive authority in that site using general delegation protocols. Sites qualifying for prescriptive authority are as follows: (1) sites that serve medically underserved populations, (2) physician primary practice sites, (3) physician alternate practice sites, and (4) facility-based practices in hospitals or long-term-care facilities. The delegating physician must spend some time at each site with the APRN, but that time varies from once every 10 business days in a medically underserved population site to the majority of the time in a physician's primary practice site. The Texas Medical Board has authority to waive many of the supervisory and site requirements for physicians who delegate prescriptive authority. The BON is not part of this process. Physicians may delegate prescriptive authority for Schedules III-V controlled substances with the following limitations: (1) APNs may only Rx a maximum 90-day supply, (2) the APN must consult with the physician before authorizing a refill, (3) APNs may not Rx controlled substances to a child under 2 years without physician consultation, and (4) physician consultation must be noted in the chart. APNs that prescribe controlled substances must have a permit from the Texas Department of Public Safety and a DEA number. APNs with prescriptive authority may request, receive, possess, and distribute samples of drugs they are authorized to prescribe.

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Utah

http://www.dopl.utah.gov/nurse.html

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Legal authority

The Utah BON in collaboration with the Division of Occupational and Professional Licensing grants authority to practice via licensure with an "APRN" or "APRN-CRNA without prescriptive practice" license and regulates the practice of APRNs and CRNAs. Licensed APRN categories include NPs, CNSs, psychiatric/mental health nurses and CRNAs. CNMs are regulated by a separate practice act and CNM board. APRNs practice independently except for the act of prescribing Schedules II-III controlled substances, where a consultation and referral plan is required. The APRN SOP is defined by set standards from national professional specialty organizations, APRNs are not statutorily prohibited from admitting patients and holding hospital privileges; however, this is decided upon by the individual institution. All APRNs must hold a master's degree or higher and nationally certified to obtain licensure. During the 2004 legislative session, the Utah Legislature was the first legislature to adopt the APRN compact.

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Reimbursement

The state insurance code has a nondiscrimination code; nothing prohibits reimbursement. CNMs, APRNs, and CRNAs, are reimbursed by most insurance companies. Board-certified PNPs and FNPs are reimbursed by Medicaid at 100% of the physician rate. CNMs are reimbursed at 65% by Medicare, whereas other APRNs receive reimbursement at 80% of the physician rate.

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Prescriptive authority

APRNs and CNMs have prescriptive authority for all legend drugs and devices, including Schedules IV-V controlled substances, within their SOP. A consultation and referral plan is only needed if prescribing Schedules II or III controlled substances. APRN-CRNAs do not require a consultation or referral plan for their practice. CRNAs may order and administer drugs, including Schedules II-V controlled substances, in a hospital or ambulatory care setting; they may not provide prescriptions to be filled outside the hospital. APRNs, CRNAs, and CNMs receive a DEA number after passing a controlled substance exam and obtaining a state-controlled substance license. APRNs and CNMs may sign for and dispense drug samples, and the NP name is listed on the prescription label.

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Vermont

http://www.vtprofessionals.org/nurses/

http://www.vtnpa.org/

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Legal authority

The Vermont BON grants APRNs authority to practice and regulates their practice. APRNs include, but are not limited to, NPs in adult, pediatrics, family and women's health, CNMs, CRNAs, and CNSs in psychiatric health. The BON endorses other CNSs under certain circumstances. The APRN performs medical and nursing acts independently, within a written collaborative practice with a physician, under practice guidelines that are mutually agreed on between the APRN and collaborating physician. The practice guidelines must be reviewed and signed annually and filed at the workplace. APRN SOP is defined in statute and legally recognized as "PCPs," are endorsed by the BON to perform acts of medical and nursing diagnosis and to prescribe nursing, medical, therapeutic, or corrective measures under the R&R. CNSs in psychiatric health do not need a collaborative physician if they do not have prescriptive privileges. APRNs are authorized to admit patients to a hospital and hold hospital privileges, according to agency protocols. APRNs are required to have a master's degree in nursing and hold national board certification to enter into practice.

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Reimbursement

BC/BS reimburses psychiatric NPs using a provider number. All NPs receive Medicaid reimbursement at 100% of physician payment. The state Medicaid program provides enhanced reimbursement to physicians who care for patients covered by both Medicare and Medicaid. The medical case management fee rules do not include NPs as eligible PCPs. Although legislation requiring or prohibiting third-party reimbursement does not exist, insurance companies may reimburse NPs depending on policies.

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Prescriptive authority

APRNs have full prescriptive authority, including Schedules II-V controlled substances within their practice guidelines. APRNs have the same privileges dispensing and administering drugs as physicians. NPs register for their own receive DEA numbers and are authorized to request, receive and/or dispense pharmaceutical samples. Prescriptions are labeled with the APRN's name.

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Virginia

http://www.dhp.virginia.govhttp://www.vcnp.net/

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Legal authority

The Virginia BON and BOM have joint statutory authority to regulate licensed nurse practitioners (LNPs). LNPs are defined as NPs, CNMs, and CRNAs. CNSs are registered solely with the BON. The presidents of the BON and BOM each appoint three board members to the Committee of the Joint Boards of Nursing and Medicine to administer LNP regulations. LNPs must be nationally certified to apply for state authorization. LNPs licensed in a category other than CNMs must practice under the medical direction and supervision of a physician. CNMs practice in collaboration and consultation with a licensed physician except for prescriptive authority, which still carries a statutory requirement for supervision. NP practice is based on education and a written protocol. An NP may practice within the parameters of a written protocol with a supervising physician, as defined in regulation. According to the Virginia BON, NPs are not statutorily prevented from being "PCPs" and no law or regulation prevents them from admitting patients to the hospital and holding hospital privileges. Virginia state law does not include NPs in its "any willing provider" language. A master's degree in nursing and national board certification is required to enter into practice in Virginia. In 2004, legislative changes were made to Virginia Code that now include NPs whenever any law or regulation requires a signature, certification, stamp, verification, affidavit, or endorsement by a physician. Among other things, NPs are also authorized to certify medical necessity of durable medical equipment that is to be reimbursed by Medicaid.

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Reimbursement

Pediatric, adult, family, women's Health, geriatric, acute care, and neonatal nurse practitioners, and CNMs are reimbursed by Medicaid at 100% of the physician rate. Psychiatric NPs are paid the same rate for psychiatric diagnosis, evaluation and psychotherapy services as a psychiatric clinical nurse specialist, which is 67% of the rate currently paid to Medicaid enrolled psychiatrists. For other procedures, such as physical examinations, psychiatric NPs will be reimbursed at the same rate as other NPs. NPs can independently bill insurers; however, payment is dependent upon individual company policy. Virginia does have an "any willing provider" law, but it applies only to mandated providers and, among APNs, only psychiatric CNSs and CNMs are mandated providers. CNMs and CNSs in psychiatric health receive third-party reimbursement.

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Prescriptive authority

Authorized LNPs may prescribe all legend drugs, including Schedules II-V controlled substances as defined in the LNP's Practice Agreement. A Practice Agreement, developed between the NP and the supervising physician and submitted to the Joint Boards of Nursing and Medicine, lists the drug categories the NP will prescribe. NPs may only prescribe legend drugs if "such prescription is authorized by the written agreement between the NP and physician." The prescription must include the NP's name and prescriptive authority number, and the patient must be informed in writing of the name and address of the supervising physician. Supervision means the physician documents being readily available for medical consultation by the LNP or the patient, with the physician maintaining ultimate responsibility for the agreed-upon course of treatment and medications prescribed. Physicians who enter into a Practice Agreement may only supervise four NPs with prescriptive authority. Physicians who supervise NPs must make periodic site visits, regularly practice in any location where the NP exercises prescriptive authority, and conduct monthly, random review of patient charts on which the NP has entered a prescription for an approved drug or device. The joint regulations of the BON and BOM include requirements for continued NP competency including eight hours of continuing education in pharmacology or pharmacotherapeutics for each biennium. LNPs may receive and dispense drug samples under an exemption to the state Drug Control Act, which states that the act "shall not interfere with any LNP with prescriptive authority receiving and dispensing to his own patients manufacturer's samples of controlled substances and devices that he is authorized to prescribe according to his practice setting and a written agreement with a physician.

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Washington

http://www.doh.wa.gov/nursing/

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Legal authority

The Nursing Care Quality Assurance Commission grants APNs the authority to practice and regulates their practice. APNs are designated as ARNPs. This includes NPs, CNMs, and CRNAs. ARNP practice is independent and ARNPs assume primary responsibility for continuous and comprehensive management of a broad range of patient care, concerns, and problems. The SOP for ARNPs is defined in statute and regulation. ARNPs are statutorily defined as "PCPs" and are legally authorized to admit patients to a hospital and hold hospital privileges. However, hospitals and medical staff have the right to make the decision on credentialing. A graduate degree and national certification is required to obtain licensure as an ARNP in Washington.

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Reimbursement

Medicaid reimbursement is available to ARNPs at 100% of physician payment. Washington insurance code bans discrimination against RNs, podiatrists, chiropractors, and certain mental health professionals. Rules governing payment to, and inclusion of, nurses prohibit artificial reductions in the level of an indemnification benefit based on a patient's choice of nursing services rather than those of other healthcare providers. A difference in payment between a physician and a nurse who provide the same services must result from the "disparity of fees actually charged by medical doctors and RNs rather than from an arbitrary formula based on assumptions concerning the relative worth of physician-provided services versus nurse-provided services." The law pertains to private insurers and healthcare service contractors. The Women's Health Care Law allows women to directly access a women's healthcare practitioner of their choice, without referral from another provider. The law applies to all insurance carriers regulated by the insurance commissioner and includes ARNP specialists in women's health and midwifery.

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Prescriptive authority

All ARNPs who qualify to receive prescriptive authority have independent authority to prescribe legend and Schedules II-V controlled substances. Independent prescriptive authority requires an initial 30 hours of pharmacotherapeutic education within the area of practice obtained within the 2-year period immediately prior to application. For new graduates, if a pharmacokinetic principles course occurred in a graduate program and the program of study occurred within the last 2 years that qualifies for licensure. Renewal of Rx authority every 2 years requires 15 hours of pharmacotherapeutic education within the area of practice. ARNPs are legally authorized to request, receive, and dispense pharmaceutical samples. Prescriptions are labeled with the ARNP's name.

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West Virginia

http://www.wvrnboard.com

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Legal authority

The West Virginia BON grants authority to practice and regulates the practice of ANP. R&R define advanced practice for RNs. ANP includes NPs, CNSs, CNMs, and CRNAs. ANP SOP includes the ability to assess, conceptualize, diagnose, analyze, plan, implement, and evaluate complex problems related to health. The ANP SOP does not require collaboration with a physician unless the ANP is prescribing. The CNM is required to practice in a collaborative relationship with a physician. CRNAs administer anesthesia in the presence and under the supervision of a physician or DDS. Hospital credentialing for ANPs is dependent upon individual hospital policy. All ANPs must have a master's degree in nursing and hold national board certification to enter into practice.

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Reimbursement

Family and pediatric NPs receive Medicaid reimbursement at 100% of the physician rate. State law requires insurance companies to reimburse nurses for nursing services, if such services are commonly reimbursed for other providers; however, rules and regulations have not been promulgated. NPs and CNMs are defined as "PCPs" ("a person who may be chosen or designated in lieu of a primary care physician who will be responsible for coordinating the healthcare of the subscriber."). The only restriction is that the NP or CNM must have a written association with a physician listed by the managed care panel; there is no requirement for employment or supervision by the physician. The Woman's Access to Health Care Bill provided for direct access, at least annually, to a woman's healthcare provider for a well-woman examination; providers include ANPs (CNMs, FNPs, WHNPs, Adult NPs, GNPs, or PNPs).

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Prescriptive authority

Qualified ANPs and CNMs have prescriptive authority, including Schedule III-V controlled substances when working in collaboration with a physician with some restrictions. Rules and regulations specify that the ANP or CNM must meet specified pharmacology education requirements and certify that they have a written collaborating agreement with a physician or osteopath. The written collaborative agreement must include guidelines or protocols describing the individual versus shared responsibility between the ANPor CNM and physician, with periodic joint evaluation of the practice and review and updating of the written guidelines or protocols. No supervision requirement exists; ANPs are not required to be employed by a collaborating physician. The ANP and CNM works from an exclusionary formulary. Schedules I and II, anticoagulants, antineoplastics, radiopharmaceuticals, and general anesthetics are prohibited. MAO Inhibitors are excluded, except when in a collaborative agreement with a psychiatrist. Additional changes include the increase in amount of CS VI and V medications that may be prescribed. A DEA number is issued directly to an ANP or CNM by the DEA and ANPs are authorized to sign for and provide drug samples.

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Wisconsin

http://drl.wi.gov/boards/nur/

http://www.wisconsinnurses.org/content.asp?id=134

http://www.legis.state.wi.us/statutes/Stat0441.pdf

http://www.legis.state.wi.us/rsb/code/n/n008.pdf

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Legal authority

The Wisconsin BON grants advanced practice nurse prescribers (APNPs) the authority to practice and regulates their practice. APNPs are defined as NPs, CNSs, CNMs, and CRNAs. NPs function under the NPA with a broad description of nursing practice. SOP is defined in statute and regulations that cover the performance of both delegated medical acts by an RN and also the expanded role practiced by APNPs by virtue of the education, training, experience, and certification. Advanced practice nurses are educated to exercise a high degree of independent judgment, complex decision making, and skill in managing organizations and health care environments. They are educated to provide services that include but are not limited to physical assessment, diagnosis, prescription of medication, and selection and performance of appropriate diagnostic and therapeutic regimens. Current state statute allows the Wisconsin Board of Nursing to promote public safety while encouraging professional nurses to practice at the full level of their educational preparation, training and experience (The Contemporary Scope of Practice for Professional Nursing in Wisconsin, 1998). Hospital privilege laws are permissive, not prescriptive; therefore, some hospitals extend full admitting privileges to APNPs, others do not. An RN must have a master's degree in nursing, national APN board certification, malpractice insurance (1 million/3 million), and 45 required clinical pharmacology hours to enter into practice in Wisconsin. APNPs collaborate with other healthcare providers, at least one of whom needs to be a physician.

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Reimbursement

Medicaid reimbursement of 100% exists for specified reimbursable billing codes as submitted by all master's degree prepared NPs or NPs certified by ANCC, NAPNAP, or NAACOG. Reimbursement is up to the maximum allowed for physicians billing for the same service. Qualified NPs are paid directly regardless of their employment site or arrangement. There are Medicaid bonuses for NPs working in certain areas or for certain pediatric visits. CHAMPUS reimburses NPs; home health RNs bill under their own provider number. Third-party reimbursement has not been addressed legislatively. Some managed-care panels are open to NPs, but few allow NPs to be the PCP of record.

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Prescriptive authority

RNs may prescribe legend drugs and controlled substances as a delegated medical act under the NPA. APRNs may receive "Advanced Practice Nurse Prescriber" certification from the BON for independent prescriptive authority. Eligible APRNs must be certified by a board-approved APRN national certifying body, have completed 45 contact hours in clinical pharmacology/therapeutics within the 3 years preceding application, pass an APNP jurisprudence exam, and hold a master's degree in nursing or a health-related field. DEA numbers are issued to APNPs. The APNP may prescribe Schedules II-V controlled substances and must comply with restrictions regarding prescribing amphetamines and anabolic steroids. Schedule II substances may only be prescribed as an adjunct to opioid analgesic compounds for the treatment of cancer-related pain, narcolepsy, hyperkinesis, drug-induced brain dysfunction, epilepsy, and depression refractory to other modalities, according to the BON. Drug samples may be dispensed if the APRN is certified to prescribe; prepackaged doses may be dispensed independently if the nearest pharmacy is more than 30 miles away.

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Wyoming

http://nursing.state.wy.us/

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Legal authority

The Wyoming BON grants APRNs the authority to practice and regulates their practice. APRNs are defined as NPs, CNMs, CRNAs, and CNSs. APRNs are not required to have a collaborative or supervisory relationship with a physician. The SOP of an APRN is defined in statute, within the Nurse Practice Act, and includes prescriptive authority and management of patients. APRNs are statutorily defined as "PCPs" and are legally authorized to admit patients to a hospital and hold hospital privileges. A master's degree in nursing and national board certification is required to enter into practice as an APRN in Wyoming.

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Reimbursement

APRNs are authorized to receive Medicaid payments at 100% of physician payment. All PCPs may receive third-party payment; however, policies differ among third-party payers.

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Prescriptive authority

BON-approved APRNs may independently prescribe legend and Schedules II-V controlled substances. APRNs are considered independent providers and register for their own DEA numbers. Additionally, APRNs who have prescriptive authority are legally authorized to request, receive, and dispense pharmaceutical samples. Prescriptions are labeled with the APRN name according to the Wyoming Board of Nursing.

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