This year's review and annual advanced practice registered nurse (APRN) legislative update heralds significant state legislative accomplishments in the areas of APRN practice authority, reimbursement, and prescriptive authority. During the past year, exceptional progress continued through strong and successful partnerships made possible by APRN professional associations, Boards of Nursing (BON), and the Future of Nursing: Campaign for Action (www.campaignforaction.org/campaign-progress). Many individuals and groups have come together in every state to remove scope of practice (SOP) barriers with the ultimate goal to improve access and care delivery to the nation's residents; among them are: APRN activists and associations, state and national nursing associations, healthcare provider groups, consumer groups, and business and industry stakeholders. The result continues to be a strong momentum toward alignment with the recommendations of the Institute of Medicine (IOM) Report: The Future of Nursing: Leading Change, Advancing Health (http://iom.nationalacademies.org/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx) and the Consensus Model for APRN Regulations: Licensure, Accreditation, Certification, and Education (www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf).
In 2015, three states eliminated collaborative and/or supervisory models of practice following completion of a collaborative and/or supervisory period following licensure and certification through passage of legislation; three states have reported improvement in reimbursement practices; and one state significantly improved a burdensome preceptorship/mentorship model of prescriptive practice, allowing full practice authority following a new, less onerous mentorship period. This overview provides a snapshot of legislative and regulatory activity reported by state BONs and nursing organizations representing APRNs.
Updates to APRN practice authority
This year, we would like to welcome the Commonwealth of the Northern Mariana Islands to the Annual Legislative Update. Over the next few years, the Update will include U.S. Territories where APRNs are actively licensed and practicing. The update focuses on the practice of NPs; however, statutory and regulatory changes in the practice of other APRN roles are noted as reported through the surveys of states' BON and professional associations. The following summarizes successful legislative efforts of state attempts to improve the practice of all APRNs.
Delaware, Maryland, and Nebraska are highlighted in this Update as states that have made significant progress toward full practice authority as defined by the American Association of Nurse Practitioners. Delaware's governor signed Chapters 171 and 172, statutorily defining the terms APRN, full practice authority, and independent practice, as well as authorizing the BON to administer a new APRN Committee, which will serve as advisory to the Board. This new law, effective January 2016, eliminates joint regulatory authority with the Board of Medicine (BOM), providing sole BON regulatory authority over APRNs. Delaware is the first state to define full practice authority and independent practice separately, which can be found under Delaware's state update.
APRNs may apply for independent practice after successfully practicing under a collaborative agreement within a hospital or integrated clinical setting (between a physician, podiatrist, or licensed Delaware healthcare delivery system and an APRN) for at least 2 years and a minimum of 4,000 full-time hours. Maryland also passed significant legislation, Chapter 468, removing the previously required attestation of collaboration for NP practice. A new 18-month collaboration period with a certified nurse practitioner (CNP) or physician mentor is required for NPs who have not been certified as NPs by the Maryland BON or any other board of nursing. The passage of Legislative Bill 107 in Nebraska eliminates their Integrated Practice Agreement (IPA), replacing it with a 2,000-hour transition to practice agreement that provides for collaborative practice for new graduates with a physician or NP with 10,000 hours of experience in the same specialty.
The Alabama BON reported substantive changes to certified registered nurse practitioner (CRNP) and certified nurse midwife (CNM) regulations, Chapter 610-X-5, including an increase in the physician's limit on CRNP and CNM collaboration and physician assistant (PA) supervision to a total of four full-time equivalent (FTE) employees and provides for additional allowance for the purpose of orientation of an incoming CRNP; reduction in provisional approval of CRNP and CNM practice; amendment of the requirements for collaborative practice by physicians and CRNPs or CNMs; and addition of rules pertaining to off-label and non-FDA approved drug prescribing.
Arkansas reported the passage of legislation increasing the number of APRN members to the board from 1 member to 2 (Act 997: one educator and one prescribing APRN), thereby increasing the presence of APRNs on the board. Several pieces of legislation were passed in Arizona, including authorization for NPs to provide orders for naloxone to emergency medical technicians and peace officers (HB 2489); elimination of the term “midlevel provider,” substituting “advanced practice clinician” in statutes pertaining to student loan debt (SB 1194 and HB 2495); and inclusion of provider-neutral language in a bill to permit consumers to obtain lab testing without an order (HB 2645).
California enacted Chapter 217 authorizing NPs and PAs who practice under the supervision of a physician to sign Physician Orders for Life Sustaining Treatment forms. Connecticut enacted Public Act No. 15-242 requiring APRNs and other providers to include a minimum of 2 contact hours of training on the topic of mental health conditions common to veterans and family members of veterans that must include screening for and prevention of suicide, among other provisions. This requirement must be met at least once every 6 years. Colorado passed SB 15-197 defining APNs as advanced practice registered nurses consistent with the Consensus Model. Other provisions of this bill are reported in the Updates to APRN Prescriptive Authority below.
Florida was successful in enacting Chapter No. 2015-111, defining “psychiatric nurse” as an advanced registered nurse practitioner (ARNP) who holds a master's or doctoral degree in psychiatric nursing and national certification as a Psychiatric Mental Health (PMH) advanced practice nurse. This bill also authorizes a psychiatric ARNP to approve emergency treatment of patients and release of individuals following involuntary examination under certain circumstances. Additionally, Chapter No. 2015-25 was enacted creating new statutes related to transitional living facilities and includes authorization for NPs to admit, develop a comprehensive treatment plan, manage and discharge patients, as well as authorization to order physical and/or chemical restraints in this setting. Georgia reported the passage of the Consumer Information and Awareness Act, which requires APRNs, among others, to provide identification of license and/or educational degree on personal identification during patient encounters, with some exceptions.
Hawaii's legislative efforts realized the passage of five separate acts pertaining to APRN practice, including the passage of Act 214, which adds APRNs to various statutes who may provide written certification authorizing a student to provide self-care for diabetes mellitus, asthma, anaphylaxis, or other life-threatening illnesses; Act 036, which provides for the expansion of pharmacists' ability to administer all vaccines to 14- to 17-year olds as authorized by the patient's APRN or physician; Act 027, which provides for the clarification of the APRN role in various sections of the Hawaii Revised Statutes relating to emergency hospital admission and involuntary hospitalization, including authorizing APRNs to determine mental health status and ability to provide for involuntary admission, or to authorize discharge; and Act 035, which provides for the clarification of licensure of APRNs in several statutes.
Public Act 99-0173 was passed in Illinois, clarifying that APNs working in hospital affiliates do not need written collaborative agreements if their practice and prescriptive authority are delineated in clinical privileges authorized by the hospital affiliate. Iowa's governor signed Senate File 203, revising several references to ARNPs throughout the Iowa Code, replacing the term “registered” with “licensed” in reference to BON registration. The Act also adds the ARNP role to the “practice of nursing” definition and authorizes RNs and LPNs to report pronouncements of death to an ARNP or PA in addition to a physician.
Mississippi reported the governor's signature on HB 204, which prevents having to participate in an insurance plan as a condition for licensure for APRNs, PAs, physicians, dentists, optometrists, and chiropractors. The Missouri BON reported updates to regulations to cover APRN practice and telehealth (20 CSR 2200-4.200(2)(B); (3)(H), and (4)(F)). New Jersey reported the passage of legislation authorizing attending APRNs to determine cause of death and the authority to sign death certificates for their patients.
The enactment of SB 299 in New Mexico authorizes APRNs, CNMs, or PAs working within their respective SOP to verify and sign documents, including a certificate of disability and proof for parking placards, issuance of statements for school employees who are free from communicable disease, and certificates for health status exemptions for childhood vaccines. The Act also expands certain provisions of the Uniform Health-Care Decisions Act to include all primary care providers, not only physicians, and assures provider-neutral language on advance directives forms and statutes, among other provisions.
North Dakota reported passage of several bills, including HB 1038 relating to telemedicine, which includes NPs and RNs in the definition of “healthcare providers”; HB 1040 and SB 2047, which update the definition of a “mental health professional” to an “APRN who has completed requirements for a minimum of a master's degree in psychiatric and mental health nursing”; authorization of APRNs to certify appropriateness of treatment in an involuntary treatment court hearing, issue orders requesting the restriction of patient's rights, and authority to initiate emergency treatment and detention procedures. Finally, provider-neutral language is used for the newborn genetic screening programs in SB 2334.
The North Carolina BON reported new clinical nurse specialist (CNS) regulations effective July 2015, which require all CNSs to be recognized by the board in order to practice in NC. CNS national board certification is required. The CNS must meet other board requirements if no certification is available in a CNS specialty (21 NCAC 36.0228).
The Oklahoma BON reported the adoption of several regulations, including the authorization of temporary licensure and prescriptive authority for APRNs endorsing into OK when certain conditions are met (OAC 485: 10-15 and 10-16). Oregon reported the passage of legislation authorizing NPs to sign state seat belt exemptions (HB 2837). Of special interest in South Dakota is passage of a ballot initiative (Initiated Measure 17) requiring insurance plans to list “any willing provider” in their directories; however, implementation will require participation and monitoring by state and national APRN organizations to ensure APRN providers are included appropriately.
Act No. 32 was signed by the Governor of South Carolina amending current law pertaining to Rights of Mental Health Patients to include APRNs and PAs in the definition of “Authorized Health Care Provider” as those who may examine a patient within 6 hours of admission to a residential facility operated by the State Department of Mental Health, order medications and therapeutic measures in these facilities, and overrule patient consent provisions in emergencies. This act maintains current law requiring physician formulation of a care plan within 14 days with a multidisciplinary team.
The Utah BON adopted regulations clarifying rules related to the minimum supervised clinical practice hour requirements in mental health therapy and psychiatric and mental health nursing for licensure as an APRN specializing in PMH nursing. Supervisors may include a PMH APRN or a licensed mental health therapist as delegated by the supervising APRN.
Vermont reported signature of Act 21, authorizing psychiatrists, APRNs licensed in psychiatric nursing, and PAs supervised by a psychiatrist to order emergency involuntary medication following personal observation of a patient in need or following observation of a patient by an RN or PA when the psychiatrist or APRN who writes the order does not directly observe the patient. Chapter 107 was signed by the Governor of Virginia authorizing NPs working in collaboration with a physician to serve as county medical examiners. Additional legislation was passed authorizing NPs to serve as expert witnesses when the case is within their SOP. The state of Washington reported the passage of HB 1259, authorizing ARNP global signature and attestation authority to any required documentation that a physician may legally sign and that is within the ARNP's SOP.
Updates to APRN reimbursement
Connecticut reported enactment of Public Act No. 15-88, listing APRNs as “telehealth providers” and providing for reimbursement of those services. In Colorado, SB 15-228 adds an APN to the existing review committee for Medicaid Provider Rate Review. Oregon's passage of SB 153 ensures NPs receive the full reimbursement rate for their services regardless of billing under the NP name or clinic name. During implementation of Oregon's Payment Parity Law, as reported in a previous update, it was discovered that some insurers were processing claims in a manner that prevented NPs from receiving full reimbursement for their services. This bill eliminates the loophole that contributed to the lower reimbursement.
Updates to APRN prescriptive authority
In Arkansas, Act 529 authorizes APRNs to prescribe hydrocodone combination products reclassified to controlled substance Schedule II in October 2014 when expressly authorized in their collaborative practice agreement. Act 1208 requires all clinicians authorized to prescribe controlled substances after December 31, 2015, to obtain a minimum of 2 hours of continuing education about controlled substances; physician evaluation of any patient treated with controlled substances for chronic nonmalignant pain every 6 months; and review of the patient's prescriptive history by prescribers on the Prescription Drug Monitoring Program (PDMP) at least every 6 months and have a signed pain contract with the patient, with some exceptions. The passage of SB 1370 to amend the Controlled Substance Monitoring Program has improved the reporting process and provided for the inclusion of provider-neutral language in Arizona.
In Colorado, SB 15-197 was signed into law significantly improving full prescriptive authority for APNs. This bill removes the 1,800 hours of prescribing in a preceptorship and 1,800 hours of prescribing in a mentorship with a physician or physician and APN prior to full prescriptive authority, replacing the provision with a 1,000-hour mentorship with a physician or APN. Attestation of completion of at least 3 years of combined clinical work experience as a professional nurse or as an APN and inclusion on an advanced practice registry are required for provisional prescriptive authority while completing the 1,000-hour mentorship. Following the 1,000-hour mentorship, Colorado APNs have full prescriptive authority with no physician involvement.
Connecticut passed Public Act No. 15-198, establishing a PDMP and requiring all prescribers to check the PDMP before prescribing more than a 72-hour supply of a controlled substance and no less than every 90 days when a controlled substance is prescribed on an ongoing basis. Regulations are pending. Chapter 26 passed in Idaho authorizing prescribers to write prescriptions in certain instances where no provider-prescriber relationship exists in certain circumstances, including, but not limited to: writing a prescription for a patient of another prescriber for whom the prescriber is taking call; in emergency situations; for epinephrine autoinjectors in the name of a school; or for partners of those with sexually transmitted infections. Other amendments authorize e-prescribing and verbal or fax submission.
Illinois passed Public Act 99-0173 eliminating the requirement for monthly physician consultation as specified in the APN's collaborative agreement with the exception of renewal of Schedule II controlled substance prescriptions. Indiana passed House Enrolled Act No. 1183 authorizing APNs to prescribe Schedules III-V controlled substances for the purposes of weight loss or obesity when certain conditions are met. Prior law prohibited APNs from prescribing Schedules III-V controlled substances for this purpose.
Missouri reported the passage of HB 709 authorizing APRNs with a collaborative practice agreement and controlled substance prescriptive authority “restricted Schedule II authority” for the purposes of prescribing hydrocodone-containing medications. This new authority limits these prescriptions to a 120-day supply. Public Law 2015, c.74 was approved in New Jersey requiring all prescribers to access the PDMP when prescribing a controlled substance to a patient for the first time and at least quarterly thereafter when long-term treatment is required, with several exemptions. Some of the exemptions include instances of substance abuse treatment, when directly administering a controlled substance to a patient, when sending to an institutional pharmacy, and when prescribing a 5-day or less supply in the ED, and for hospice patients.
The passage of HB 341 in Ohio mandates prescribers who hold Drug Enforcement Administration registration and prescribe opioid analgesics or benzodiazepines register with the Ohio Automated Rx Reporting System (OARRS). Additionally, the prescriber must request patient information from OARRS that covers the previous 12 months before initially prescribing an opioid or benzodiazepine, with certain exceptions.
The update would like to thank the State Board of Nursing representatives and APRN association representatives who contributed to this update through submission of the annual survey. All efforts are made to ensure the information provided to readers is accurate and up-to-date.
APRNs are defined as advanced practice nurses (APNs) in Alabama and include CNP (CRNP in statute), CNS, CNM, and CRNA roles. Although the BON has sole authority to establish the qualifications and certification requirements of APNs through R&Rs, the BON and BOME regulate the collaborative practice of physicians with CRNPs and CNMs, requiring them to practice with BON- and BOME-collaborative practice agreements. The collaborating physician and CRNP or CNM must sign written protocols. The term “collaboration” does not require direct, on-site supervision by the collaborating physician. The term does, however, 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 or CNM is scheduled 30 or more hours per week) and a minimum of 10% on a quarterly basis (if scheduled less than 30 hours per week). “Remote practice site” is defined in rule, and the collaborating physician must visit each remote site at least quarterly. CRNP SOP is defined in statute and regulation; APNs practice in accordance with national standards and functions identified by the appropriate specialty-certifying agency in congruence with Alabama law.
Alabama does not recognize APNs as PCPs and does not have “any willing provider” language in statute. CRNPs are required to hold 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 before 1996 in a post-BSN NP program or graduation before 1984 from a non-BSN program preparing NPs. CRNAs must at minimum hold a master's degree from an accredited nurse anesthesia graduate program and be currently certified as a CRNA; CRNAs who graduated before December 31, 2003, are exempt from the master's degree requirement. CNS approval requires a master's degree or higher in advanced practice nursing as a CNS and national certification.
There are no legislative restrictions for APNs on managed-care panels. The Alabama Medicaid Program enrolls and reimburses CRNPs independently pursuant to supervision rules; however, a CRNP who is employed and reimbursed by a facility that receives reimbursement from the Alabama Medicaid Program for services provided by the CRNP may not enroll. CRNPs 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.
CRNPs and CNMs may prescribe, administer, and provide therapeutic tests and drugs within a BON- and BOME-approved formulary. CRNPs and CNMs in collaborative practice with a physician may prescribe controlled substances in Schedules III, IV, and V pursuant to the Rules of the Alabama BOME Chapter 540-X-18. CRNPs and CNMs are required to complete 12 continuing medical education contact hours in advanced pharmacology and prescribing trends and 4 additional contact hours every 2 years for renewal of the Qualified Alabama Controlled Substances Certificate under current regulation for Schedule III-V controlled substance authority.
A BON and BOME joint committee recommends R&R governing the collaborative relationship between physicians, CRNPs, CNMs, and the prescription 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. Prescription pads must include the physician's name and address, the CRNP's or CNM's 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. CNSs and CRNAs are not regulated by the joint committee (BON and BOME) and are not eligible for prescriptive authority.
APRNs are defined as ANPs and are regulated by the Alaska BON. ANPs include CNP (NP in regulation), CNM, and as of 2014, CNS roles. ANPs are further defined as RNs who, due to specialized education and experience, are 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. Entry into NP practice requires a graduate degree in nursing and national board certification. Continuing education (CE) requirements for ANPs are 30 CE units; 12 of these must be advanced pharmacotherapeutics and 12 hours of CE in clinical management of patients every 2 years. CRNAs practice under separate BON rules, and regulations and are not currently defined as ANPs/APRNs in Alaska.
All healthcare in Alaska is provided on a fee-for-service basis, and 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; Alaska legally requires insurance companies to credential, empanel, and/or recognize ANPs. Alaska does not have “any willing provider” language in current law.
Authorized ANPs 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 ANP's name only. To renew prescriptive authority, ANPs and CRNAs must complete 12 contact hours of CE in advanced pharmacotherapeutics and 12 contact hours of CE in clinical management of patients every 2-year renewal cycle.
The Arizona State Legislature grants APRNs authority, and the BON alone regulates their practice. APRNs include RNP (inclusive of the CNP and CNM roles), CRNA, and CNS roles. According to the BON, an RNP will refer a patient to another healthcare provider if a situation or condition occurs with a patient that is beyond the RNP's knowledge and experience. No formal collaboration agreement is required. RNP SOP is defined in the Arizona Administrative Code R4-19-508. In the SOP, RNPs are authorized to admit patients to healthcare facilities, manage the care of patients admitted, and discharge patients.
However, the Arizona Department of Health regulations require that patients admitted to an acute care facility must have an attending physician. Acute care facilities apply this citation as the basis to deny independent admitting and hospital privileges to NPs. RNPs and CNSs must have a graduate degree in nursing and national board certification in their focus area to enter into practice. CRNAs must have a graduate degree associated with an accredited CRNA program and hold national certification to enter into practice.
RNPs and other APRNs may receive third-party reimbursement, enabled by the Department of Insurance statutes. RNP reimbursement varies depending on the health insurance plan.
RNPs have full prescriptive and dispensing authority, including controlled substances Schedules II-V, on application, and fulfillment of BON-established criteria. RNPs' prescriptive and dispensing authority is linked to the RNP's area of population focus and certification. For example, women's health RNPs are not authorized to prescribe medication to males except in cases of partner therapy for sexually transmitted infections. Prescribing without documenting an assessment is a violation of the NPA. An RNP with prescriptive and dispensing authority who wishes to prescribe a controlled substance must apply to the DEA for a registration number and submit this number to the BON and the BOP. Drugs, other than controlled substances, may be refilled up to 1 year. CRNAs may administer anesthetics and issue medication orders for medications to be administered by a licensed, certified, or registered healthcare provider preoperatively, postoperatively, or as part of a procedure; CRNAs are not authorized to prescribe or dispense medications. CNSs do not have prescriptive authority in Arizona.
The BON grants APRNs authority to practice per an additional license separate from RN licensure. APRNs include CNP, CNM, CNS, and CRNA roles. APRNs practice independently with the exception of RNPs (NPs who do not hold national certification). In this instance, RNPs must practice under physician direction/protocol and may only transcribe orders from a protocol. The BON ceased issuing new RNP licenses in 1996. All NPs licensed after 1996 hold CNP licensure. Hospital privileges for APRNs are determined on a hospital-to-hospital basis according to the credentialing committee of each hospital. Graduate or postgraduate-level APRN education and national board certification are required for initial APRN licensure. Current national certification must be maintained to continue to hold an APRN license.
The NPA mandates direct Medicaid reimbursement to APRNs and RNPs. Medicaid reimbursement is 80% of a physician's rate. APRNs are not recognized as PCPs for Medicaid. A statutory provision exists for third-party reimbursement for CRNAs.
The NPA authorizes the BON to provide a certificate of prescriptive authority to qualified APRNs. A collaborative practice agreement with a practicing physician who has training in scope, specialty, or expertise to that of the APRN, and use of prescriptive protocols are required. APRNs with prescriptive authority may apply for and hold a DEA number. The NPA limits the prescribing of controlled substances to Schedules III-V and hydrocodone-combination products from Schedule II of the Controlled Substance Act (with authorization from the physician on the collaborative practice agreement). Neither protocols nor collaborative practice agreements with a physician are required unless the APRN has prescriptive authority.
Under the Chapter 4 Rules, an initial applicant for prescriptive authority must hold an active APRN license with completion of pharmacology course work of 3 graduate credit hours or 45 contact hours in a competency-tested pharmacology course; have 300 hours of precepted prescribing experience; and include a collaborative practice agreement with a physician. Endorsement applicants must provide prescribing evidence of at least 500 hours in the last year and have a clear DEA history. APRNs who have fulfilled requirements for prescriptive authority may receive pharmaceutical samples and therapeutic devices appropriate to their area of practice. APRNs with prescriptive authority have implied authority to give prescriptive drug samples to patients.
The California BRN grants legal authority to practice, regulate, and issue separate certifications to APRNs. Defined in statute, APRN includes CNP (NP in statute), CNM, CRNA, and CNS roles. NPs function under “standardized procedures” or protocols when performing medical functions, collaboratively developed and approved by the NP, physician, and administration in the organized healthcare facility in which they work. SOP of an NP is defined within the standardized procedures, not in statute or regulation. CNPs and CNMs are statutorily recognized as “PCPs” in California's Medi-Cal system (Medicaid). APRNs are not legally authorized to admit patients to the hospital; however, individual hospitals may grant APRNs hospital privileges. CNPs and CNSs must hold a minimum of a master's degree in nursing or health-related field to practice; however, California does not require national certification to enter into practice. CRNAs are required to hold national certification to practice in the state of California.
All nationally board-certified CNPs are reimbursed independently by the Medi-Cal system. Medi-Cal-covered services performed by CNPs, CNMs, and CRNAs are reimbursed at 100% of the physician reimbursement rate. Blue Cross of CA Medi-Cal Provider Directory lists CNPs as PCPs under their 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 CNMs and BRN-listed psychiatric-mental health nurses for qualifying services. Participants in the state's managed-care programs for specified Medi-Cal beneficiaries may select CNPs and CNMs as their PCPs.
CNPs and CNMs may “furnish” or order drugs or devices, including controlled substances II-V when the drugs or devices are furnished by a CNP or CNM in accordance with a standardized procedure and when separate authorization is granted by the BRN. The act of “furnishing” requires physician supervision of the CNP 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 CNP's or CNM's name only. CNPs and CNMs may request, receive, and dispense pharmaceutical samples and may dispense drugs, including controlled substances. CNSs and CRNAs do not have prescriptive authority in California.
The State BON grants advanced practice authority to RNs who meet the criteria set forth in the Colorado NPA and the Board R&Rs for inclusion on the Advanced Practice Registry (APR), regulates the practice of APRNs, and affords title protection. APRNs are defined as “APN” in the State of Colorado and include CNP (NP in statute), CNS, CNM, and CRNA roles. APNs are deemed to be independent practitioners. National certification in a role and population focus is required of all APR applicants. APNs listed on the registry prior to July 1, 2010, may retain their listing on the APR without certification so long as the APN does not allow his or her advanced practice authority to lapse or expire. APNs engaged in an independent practice must be covered by professional liability insurance.
The scope of advanced practice nursing is based on the professional nurse's SOP within the APN role and population focus, which may include, but is not limited to, performing acts of advanced assessment, diagnosing, treating, prescribing, ordering, selecting, administering, and dispensing diagnostic and therapeutic measures. The NPA and Board Rules do not address and, therefore, do not prohibit APNs from being designated as PCPs or being granted hospital privileges; however, APNs are not currently recognized as PCPs in statutes and regulations under the jurisdiction of state agencies regulating healthcare.
Medicaid reimburses APN services; however, some managed-care Medicaid companies restrict independent APNs from joining networks. Third-party reimbursement is available to APNs, but third-party payers are not mandated to credential, empanel, or reimburse APNs.
New legislation passed in May 2015 granting Colorado APNs full prescriptive authority by the Board within their recognized role and population focus, including Schedule II-V controlled substances following a 1,000-hour documented prescribing mentorship period and registration with the DEA. This legislation amends the outdated 1,800-hour preceptorship + 1,800-hour mentorship requirement previously required and now authorizes either a physician or an APN to provide the mentorship services.
A one-time attestation signature is required following completion of the mentorship for verification and the existence of an articulated plan for safe prescribing. The attestation form is kept on a file at the BON. The APN is responsible for reviewing his or her articulated plan on an annual basis, and articulated plans may be audited by the BON. Board Rules authorize APNs with prescriptive authority to receive and distribute a therapeutic regimen of prepackaged and labeled drugs, including free samples.
Commonwealth of the Northern Mariana Islands
APRNs are defined in statute and regulated by the Commonwealth Board of Nurse Examiners and include CNP, CNS, CNM, and CRNA roles. Since 2009, APRNs enjoy full practice authority within their defined scope of practice. Initial licensure requires a minimum of a master's degree in nursing and passage of the appropriate APRN national certification exam. CNP scope of practice includes PCP status. According to the BON, NPs are authorized to order durable medical equipment and refer patients to other health care professionals. Hospital privileges are granted if the NP works for the government hospital.
This section is under development. In general, NPs are reimbursed at 80% of physician reimbursement
The Board grants prescribing and ordering authority to Commonwealth of the Northern Mariana Islands (CNMI)-licensed CNPs, CRNAs, and CNMs. The Board may grant prescribing and ordering authority to CNSs on a case-by-case basis. A CNMI-licensed NP, CRNA, CNM, or CNS may prescribe, procure, administer, and dispense over-the-counter, legend, and Schedules II-V controlled substances, pursuant to applicable state and federal laws and the Board's regulatory authority. These licensees may also plan and initiate a therapeutic regimen that includes ordering and prescribing medical devices and equipment, nutrition, diagnostic, and supportive services including, but not limited to, home healthcare, hospice, physical, and occupational therapy. NPs, CRNAs, and CNMs may receive, sign for, record, and distribute samples to patients in accordance with state law and federal laws, regulations, and guidelines.
APRNs are defined in the NPA, regulated by the Connecticut State Board of Examiners for Nursing, and include CNP (NP in statute), CNS, and CRNA roles. APRNs are granted full practice authority following not less than 3 years and for not less than 2,000 hours of APRN practice in collaboration with a physician. APRN SOP, independent practice, and collaborative practice are defined in statute by the BON. Additionally, 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 graduate degree in nursing (or other related field) and national board certification are required to enter into practice. CNM authority is regulated by the Department of Public Health, and SOP is recognized under a separate statute (Chapter 377, Midwifery).
Medicaid regulations govern reimbursement to APRNs under the remaining Medicaid fee-for-service programs. NPs, psychiatric CNSs (PCNSs), and CNMs are reimbursed for services under state insurance statutes, which affect only private insurers. Reimbursable services must be within the individual's SOP and must be 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.
Following the passage of Public Act No. 14-12 in 2014, APRNs may independently prescribe, dispense, and administer medications autonomously, including Schedules II-V controlled substances following not less than 3 years and not less than a 2,000-hour transition to practice period. APRNs and CNMs are legally authorized to request, receive, and dispense pharmaceutical samples.
APRNs are defined as advanced practice registered nurses and are licensed and regulated by the Delaware BON. APRNs include CNP, CNS, CNM, and CRNA roles. Beginning January 2016, APRNs enjoy full practice authority (FPA) as defined in section 1935 of the Delaware Nurse Practice Act; however, the statute is clear that FPA does not equate to the granting of independent practice. Passage of legislation in 2015 authorizes the BON to grant APRNs “independent practice” following recommendation of a newly developed APRN Committee. Independent practice is defined as practice and prescribing by an APRN who is not subject to a collaborative agreement and works outside the employment of an established healthcare organization, healthcare delivery system, physician, podiatrist, or practice group owned by a physician or podiatrist.
Independent practice may be granted when an APRN has submitted written evidence of practice under a collaborative agreement with a hospital or integrated clinical setting for at least 2 years and a minimum of 4,000 full-time hours when the practice is substantially related to the population and focus area of the APRN. This new legislation also grants APRNs authority to serve as a PCP by an insurer or healthcare services corporation. APRNs must graduate from or complete a graduate-level APRN program accredited by a national accrediting body and current certification by a national certifying body in the appropriate role and population focus area to be licensed in Delaware.
Delaware has statutory provisions requiring health insurers, health service corporations, and HMOs to provide benefits for eligible services when rendered by an APRN acting within his or her SOP. APRNs may be listed on provider panels, and 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 the physician payment.
APRNs licensed by the Board may prescribe, order, procure, administer, store, dispense, and furnish over-the-counter, legend, and controlled substances pursuant to applicable state and federal laws and within the APRN's role and population focus. APRNs may receive, sign for, record, and distribute sample medications to patients in accordance with state law and DEA laws, regulations, and guidelines.
District of Columbia
The Washington D.C. Department of Health BON approves and regulates APRNs. APRNs include CNP (NP title in D.C.), CNS, CNM, and CRNA roles. Current law authorizes APRNs to practice independently without a physician collaborative agreement or protocols. ARPN SOP is defined in statute, regulated by the BON, and without limitations. APRNs may apply for hospital admitting privileges. National certification in a specialty area is required to enter into practice.
ARPNs receive direct reimbursement for providing drug abuse, alcohol abuse, and mental illness care; healthcare plans or institutions are prohibited from discriminating against ARPNs with clinical privileges. Legislative authority mandating ARPN reimbursement does not exist; however, private third-party payers reimburse for NP services. APRNs are statutorily recognized as PCPs. NPs and CNMs receive Medicaid payment as PCPs.
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. ARPNs are authorized to request and receive pharmaceutical samples. The D.C. Pharmacy Board issues a Controlled Substance Registration to providers with controlled substance authority; however, APRNs must also hold DEA registration. Prescriptions are labeled with the ARPN's name.
APRNs are defined as advanced registered nurse practitioners (ARNPs) and include CNP (NP in statute), CNM, and CRNA roles. The CNS role is defined in statute; however, CNSs do not have advanced practice authority. The BON certifies and regulates ARNPs and CNSs. 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 an MD, DO, or dentist. Within the framework of established protocols, ARNPs may order diagnostic tests, physical therapy, and occupational therapy. The degree and method of supervision, determined by the ARNP and MD, DO, or dentist are specifically identified in written protocols and shall be appropriate for prudent healthcare providers under similar circumstances.
ARNPs must file protocols with the BON when renewing their licenses, and when there are changes to the protocol, 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; the supervising practitioner's on-site presence is not required. ARNPs are authorized to admit patients to a hospital and hold hospital privileges; however, this authority is dependent upon privileges granted by the institution and the supervising physician. ARNP applicants must have a master's degree to qualify for initial certification and are required to hold national board certification to enter practice. CNSs must hold a master's degree in a clinical nursing specialty and either national certification in a CNS specialty or proof of having completed clinical experience in a CNS specialty for which there is no available national certification.
ARNPs receive Medicaid, Medicare, Civilian Health and Medical Program of the Uniformed Service (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 in which 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.
The BON/BOM joint committee allows prescriptive privileges for ARNPs, authorizing initiation and alteration of drug therapies; however, prescribing of controlled substances is 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 include 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. CNSs do not have prescriptive authority in Florida.
APRNs are defined in statute and include CNP (NP in statute), CNM, CRNA, and CNS roles. 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 (exception: CRNAs educated prior to 1999). An APRN's authority to practice is granted through one of two statutes: OCGA 43-34-25 and OCGA 43-34-23. APRNs authorized to practice under 43-34-23 are regulated by the BON. 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 which the physician delegates authority to the nurse to perform certain medical acts and provides for immediate consultation with the delegating physician. The issuance of a written prescription is prohibited. APRNs practicing under OCGA 43-34-25 have prescriptive authority. There is joint regulation by the BON and BOM in that APRNs requesting prescriptive authority are required to submit, under BOM rules, a Nurse Protocol Agreement that must be approved by the Board of Medicine.
Practice under 43-34-25 prohibits APRNs from ordering certain radiographic imaging tests, such as MRIs and CT scans, unless there are “life-threatening situations.” There is a universal requirement for periodic review of a sampling of patient records as well as a requirement for patient evaluation and exam by the delegating physician in certain circumstances. Practice is delegated supervisory in nature. APRNs may hold hospital privileges in certain situations.
There are no statutes mandating the third-party reimbursement for APRNs. FNPs, PNPs, women's health 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 100% of a physician's payment. Some private insurers reimburse APRNs but are not required by law to do so.
APRNs practicing under a nurse protocol as defined by OCGA 43-34-23 defines a process that permits RNs (including APRNs) to administer, order, or dispense drugs under delegated medical authority as either prescribed by a physician or authorized by protocol. APRNs practicing under a Nurse Protocol Agreement defined and approved by the BOM as authorized by OCGA 43-34-25 may issue a written drug order, including the authority to prescribe Schedules III-V controlled substances, and request, receive, sign for, and distribute pharmaceutical samples. 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.
The BON licenses and regulates APRNs in Hawaii consistent with the National Council of State Boards of Nursing APRN Consensus Model. APRNs include CNP (NP in regulation), CNS, CNM, and CRNA roles and have independent SOP and prescriptive authority. APRN SOP is defined in statute and regulation and conforms to the NCSBN Model Nurse Practice Act for APRNs. Recent legislation passed enabling hospitals licensed in Hawaii to recognize APRNs, allow them to function with full SOP, and to act as a PCP in their institutions. The minimum requirements to enter practice in Hawaii include completion of an accredited, graduate-level education program preparing the nurse for one of the four recognized APRN roles and national certification in the APRN's clinical specialty.
Current law provides direct reimbursement to all APRNs and 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 PCNSs and additional NP specialties. Medicaid reimburses at 75% of the physician payment. Hawaii Health QUEST, a Medicaid waiver program, defines PNPs, FNPs, and CNMs as PCPs.
The BON regulates APRN prescriptive authority, and APRNs have legal authority to prescribe medications, including Schedules II-V controlled substances, independently. APRNs with prescriptive authority are legally authorized to request, receive, and dispense manufacturer's prepackaged pharmaceutical samples. APRNs may not request, receive, or sign for controlled substance samples; however, they may prescribe, order, and dispense medical devices and equipment. APRN prescribers' prescriptions are labeled with the APRN's name.
The BON regulates and grants FPA to APRNs. APRNs include CNP, CNS, CNM, and CRNA roles. APRN licensure requires RN licensure, completion of an approved APRN program, and national certification. NPA rules rely on the Decision-Making Model to determine an APRN's SOP. The APRN can determine if a specific function can be legally performed by determining the following: if the act is expressly forbidden in the NPA Rules and Regulations, was taught in the APRN curriculum, acquired through additional education, whether the APRN is clinically competent to perform it, does not exceed employment policies, is consistent with national specialty organization standards, and is within the accepted standard of care for the APRN's geographic region and practice setting.
APRNs are not statutorily recognized as PCPs; however, Idaho has an “any willing provider” language in statute. APRNs are legally authorized to admit patients to hospitals and hold hospital privileges in Idaho. Some facilities have granted APRNs privileges. State law requires a minimum of a graduate/postgraduate degree as entry into practice; however, APRNs educated prior to January 1, 2016, are exempt from the requirement for a graduate/postgraduate degree; the NPA has previously required national board certification to enter practice, which requires a master's degree in nursing to enter into most specialties.
Listing APRNs on managed-care provider panels is neither permitted nor prohibited and is considered by third-party payers on an individual basis. BC/BS credentials CNPs as “preferred providers” within their program. CNPs receive their own Medicaid provider number and may choose to file independently or with a group. Reimbursement rates are 85% of the physician payment.
Prescriptive and dispensing authority is granted to APRNs who have completed 30 contact hours of pharmacology-specific formal instruction beyond basic RN education. Authorized APRNs may prescribe and dispense legend and Schedules II-V controlled substances appropriate to their defined SOP. Authorized APRNs have their own DEA numbers and prescribe independently. APRNs are legally authorized to request, receive, and dispense pharmaceutical samples, and APRN prescriptions are labeled with the APRN's name only.
APRNs are defined as APNs in the State of Illinois and include CNPs, CNSs, CRNAs, and CNMs. The Illinois Department of Financial and Professional Regulation (IDFPR) grants authority and regulates APN practice. APNs must have a written collaborative agreement with a physician, podiatrist, or dentist, except for APNs who provide services in a hospital, hospital affiliate, or ambulatory surgical treatment center (ASTC) and have been granted clinical privileges by that facility. The requirement to consult every month with a physician was eliminated when HB 421 was signed into law July 29, 2015, except in the situation of the APN's prescribing Schedule II medications.
Communication methods (in person or electronic) with the collaborating physician or podiatric physician must be stipulated in the written agreement. New APN applicants must have a graduate degree or a postmaster's certificate from a graduate-level program appropriate for national certification in a clinical advanced practice nursing specialty. Additionally, the APN must hold current RN licensure and national certification as a CNP, CNS, CNM, or CRNA from the appropriate national certifying body as determined by rule of IDFPR. All APNs may practice only in accordance with their national certification.
There is an exception to the graduate degree requirement for CRNAs who completed their CRNA program prior to January 1, 1999, and have kept their certification current. This exception will expire on June 30, 2018. If a collaborative agreement with a physician or podiatrist is terminated, the APN is authorized to continue to practice up to 90 days after the termination of the agreement, provided the APN seeks any needed collaboration at a local hospital and refers patients who require services beyond the training and experience of the APN to a physician or other healthcare provider.
The Illinois Department of Healthcare and Family Services (HFS) administers the Illinois Medicaid program. APNs who enroll as providers in the department's medical programs are reimbursed at 100% of the physician rate. Medicaid recipients are being transitioned to Medicaid managed-care organizations (MCOs); therefore, in addition to enrolling as HFS providers, APNs must also enroll as providers for each Medicaid MCO for which any of their patients are members. Statutory prohibition for third-party reimbursement to APNs does not exist. APNs receive direct or indirect reimbursement from some third-party payers.
Prescriptive authority, including prescribing Schedules II-V controlled substances, may be delegated to an APN by a physician or podiatrist as a part of the written collaborative agreement or may be authorized by clinical privileges in a hospital, hospital affiliate, or ASTC. Delegation to prescribe controlled substances must be noted in the written collaborative agreement or otherwise authorized by the hospital, hospital affiliate, or ASTC. If delegated to prescribe controlled substances, an APN shall apply for a Mid-Level Practitioner Illinois Controlled Substances License and a Federal DEA number. In the case of Schedule II substances, APNs can prescribe such medications in only oral, transdermal, or topical forms.
For APNs prescribing controlled substances under a written collaborative agreement, the collaborating physician or podiatric physician must have a valid, current Illinois controlled substance license and federal registration. In the case of prescribing Schedule II controlled substances, such delegation whether by written collaborative agreement or by privileging by a hospital, hospital affiliate, or ASTC must identify the specific Schedule II controlled substances by either brand name or generic name. Medication orders shall be reviewed periodically by the collaborating physician or podiatric physician or appropriate hospital affiliate physicians committee or its physician designee. Any prescription for a Schedule II substance must be limited to no more than a 30-day supply.
Prior to renewal of a prescription of a Schedule II controlled substance, the APN must discuss the patient's condition monthly with the collaborating physician or appropriate physician committee of the hospital affiliate or its physician designee. As noted in the Illinois Controlled Substances Act, APNs who prescribe Schedule II controlled substances must have completed at least 45 graduate contact hours in pharmacology for any new Controlled Substance License issued with Schedule II authority and must annually complete 5 hours of continuing education in pharmacology for license renewal.
APRNs are defined as APNs in the State of Indiana and include CNP (NP in regulation), CNM, CNS, and CRNA roles. The Indiana State BON grants the authority to and regulates APNs. The BON does not issue additional, separate licenses or certification to NPs or CNSs; however, 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. SOP is defined in regulation. National certification is required to obtain prescriptive authority if the APN holds a baccalaureate degree. APNs with a graduate degree do not need to be nationally certified for prescriptive authority to be granted. CNSs are required to hold a minimum of a master's degree to practice.
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.
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 2 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 the following: the manner in which the APN and licensed physician will cooperate, coordinate, and consult with each other in the provision of healthcare and 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 ID 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.
Effective July 1, 2015, APNs with prescriptive authority may prescribe Schedules III and IV controlled substances for the purpose of weight reduction or to control obesity (Indiana Code 35-48-3-11) after certain conditions are met, which was previously prohibited under this code. Additionally, IC 25-1-9-6.8 requires practitioners to follow the most recent guidelines adopted by the AAP or American Academy of Child and Adolescent Psychiatry when prescribing stimulant medications for ADD or ADHD. CRNAs are not required to obtain Rx authority to administer anesthesia.
APRNs are defined as ARNPs in the state of Iowa and include CNP, CNS, CNM, and CRNA roles. The BON grants ARNPs authority to practice and regulates their practice through administrative rules. 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. Licensure 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 CNSs.
Iowa's Medicaid managed-care and prepaid-service programs reimburse ARNPs. Payment of necessary medical or surgical care and treatment is provided to an ARNP in third-party reimbursement if the policy or contract would pay for the care and treatment when provided by a physician or DO. MCOs are not mandated to offer ARNP coverage unless there is a contract or other agreement to provide the service. All ARNPs are approved as providers of healthcare services pursuant to managed-care or prepaid-service contracts under the medical assistance program.
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 gases, including pharmaceutical samples. ARNPs must register with the DEA, and prescriptions written by ARNPs must be labeled with their name.
The Kansas BON grants authority to APRNs and regulates the practice, issuing a separate license. Recognized APRN roles include CNP (NP in regulation), CNS, CNM (NM in regulation), and CRNA (RNA in statute). APRNs function in collaborative relationships with physicians and other healthcare professionals in the delivery of primary healthcare services. APRNs 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 APRN.
Any APRN 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 APRN 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 APRN's principal place of practice.
SOP is defined in statute and regulation; however, APRNs 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. APRN applicants in all categories require a master's degree or higher in nursing, and national board certification is not required to enter practice in Kansas (except for RNAs).
Insurance companies are legally required to reimburse all APRNs for covered services in health plans. Medicaid has expanded payment to include all covered services at 80% of the physician payments (except for practitioners performing early periodic screening diagnosis and treatment who receive 100%). NAs receive 85% of the physician payments. Some insurance companies are paying 85% of the physician payments to APRNs.
APRNs, 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 APRN is authorized to prescribe and shall specify all drugs, which may be prescribed by the APRN. These can be published protocols or practice guidelines that have been agreed upon by both the APRN and physician. The prescription order must be signed by the APRN and include the name of the physician and APRN. The APRN must register with the DEA and the BON if they prescribe controlled substances. Prescription labels include both the APRN's and physician's name. APRNs are authorized to request, receive, and distribute pharmaceutical samples–with the exception of controlled substances–if the drug is within their protocol.
The Kentucky BON grants APRNs authority to practice and regulates their practice. APRNs are statutorily defined as CNPs, CNSs, CNMs, and CRNAs. APRNs practice autonomously within their relative SOPs; however, they must practice in accordance with the SOP of the national certifying organization as adopted by the BON in regulation (collaborative agreement is required for certain prescriptive authority–see detail below). CNP SOP is defined in Kentucky statute KRS 314.011: “APRNs shall seek consultation or referral in situations outside their SOP.” APRNs are recognized as “PCPs” in regulation, 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, doctorate, or postmaster's certificate as an APRN and national board certification are required to enter practice in Kentucky.
The state medical assistance program reimburses APRNs for services at 75% of the 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 U.S. 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.
APRNs have autonomous prescriptive authority for nonscheduled legend drugs following 4 years of prescribing experience under a Collaborative Agreement for Prescriptive Authority for Nonscheduled Drugs (CAPA-NS) with a physician licensed in Kentucky. Prescribing of Schedules II-V controlled substances is authorized pursuant to a permanent Collaborative Agreement for Prescriptive Authority for Controlled Substances (CAPA-CS). The CAPA-CS and -NS define an APRN's scope of prescribing authority and are signed by the APRN and the physician. Recent 2014 legislation removed the CAPA-NS requirement following 4 years of experience; however, the CAPA-CS is still required.
APRNs may prescribe scheduled medications with the following limitations: Schedule II controlled substances for a 72-hour supply with additional authority for psychiatric/mental health clinicians; Schedule III controlled substances may be prescribed for a 30-day supply without refills; Schedules IV and V controlled substances may be prescribed with refills not to exceed a 6-month supply with the following limitations: diazepam, clonazepam, lorazepam, alprazolam, and carisoprodol may be prescribed for 30 days without refills. CRNAs do not need CAPAs to deliver anesthesia care.
The APRN alone signs his or her name to the prescription pad when prescribing. APRNs must complete 5 contact Rx hours annually as part of their CE requirement (as of 2012, all APRNs with a CAPA-CS must include 1.5 of the 5 contact hours related to the use of the prescription monitoring system [KASPER], pain management, or addiction disorders). APRNs are legally authorized to request and receive as well as dispense noncontrolled legend pharmaceutical samples. Dispensing is applicable to APRNs working in health departments: APRNs may dispense with a written agreement with a local pharmacist.
APRNs are licensed by the BON and include CNP (NP in statute), CNM, CRNA, and CNS roles. 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, physician(s), or dentist(s), including consultation or referral availability, clinical practice guidelines, and patient coverage.
APRNs' SOP is addressed in regulation in that “patient services provided by an APRN must be in accord with the educational preparation of that APRN.” The APRN SOP includes the following: 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.
APRNs may not receive samples of controlled substances. Louisiana State law includes “any willing provider” language, 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.
Prior legislation prohibits qualified plans from excluding direct reimbursement of healthcare services provided by an APRN. Medicaid recognizes NPs, CNSs, and CNMs as PCPs and will recognize those APRNs as the PCP or “medical home” under certain circumstances. APRNs are reimbursed at 80% of the physician fees per Medicaid; some immunizations and certain screening services for children are reimbursed at 100%. All billing must be under the APRN's provider number, essentially eliminating “incident to” billing, though that option is available under certain conditions.
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 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 is served by the collaborative practice.
The Maine BON authorizes and regulates APRN practice. APRNs licensed by the BON are defined as CNPs, CNMs, CNSs, and CRNAs. CNSs practice in an independent role; however, a CNP who qualifies as an APRN must practice for at least 24 months under the supervision of a licensed physician, NP, 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. Following this period, the CNP practices 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.” Psychiatric and mental health CNPs and certified PCNSs 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 and national certification to enter into practice.
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 ID numbers to CNPs and CNMs; and allows managed-care enrollees to designate CNPs as their PCP. However, MCOs 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 NPs, CPNPs, and CNMs.
CNPs and CNMs may prescribe and dispense drugs or devices, including Schedule 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 and CNMs may prescribe Schedule II-V controlled substances and drugs off-label, according to common and established standards of practice. In the 2014 legislative session, CNPs were granted authority to certify patients to receive therapeutic or palliative benefit from medical use of marijuana. CNPs and CNMs may receive and distribute drug samples included in the formulary for Rx writing.
The Maryland Board of Nursing regulates APRN practice. APRNs include CNP (NP or CRNP in statute), CRNA, CNM, and CNS roles. Maryland also recognizes nurse psychotherapists as APRNs (APRN/PMH). NP SOP is independent, defined in statute and regulations, and is in accordance with the Standards of Practice of the American Association of Nurse Practitioners or any other national certifying body recognized by the board. Scope and standards of independent practice for NPs are defined in statute and regulations. CRNAs maintain an affirmation of collaboration with the BON containing the name and license number of an anesthesiologist, physician, or dentist; as of 2015, CNPs, CNMs, and CNSs practice independently without a collaborative practice agreement. A master's degree is the minimum required degree to enter practice in Maryland in addition to national board certification.
All nurses are entitled to private third-party and Medicaid reimbursement for services if they are practicing within their legal SOP. All Medicaid recipients have been assigned to an MCO; CNPs (with the exception of neonatal and acute care) and CNMs 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; APRNs are not to be arbitrarily denied. The law does not require, however, that an HMO include CNPs on the HMO panel as PCPs. Several commercial insurers reimburse NPs directly, however, at a rate of 75% to 85% of a physician's fee schedule.
CNPs and CNMs have full prescriptive authority, including Schedule II-V controlled substances. The scope of prescriptive authority is defined in statute. CNPs and CNMs are authorized to obtain both federal and state DEA numbers. CNPs are legally authorized to dispense medications in public health settings and student health clinics. Prescription containers are labeled with the CNP or CNM name.
The Massachusetts BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CRNA, PCNS, CNS, and CNM roles. APRNs eligible for prescriptive practice must establish written guidelines developed in collaboration with the nurse and supervising physician with the exception of CNMs who no longer require written guidelines or a supervising physician. In all cases, the written guidelines designate a physician who shall provide medical direction for prescriptive practice as is customarily accepted in the specialty area.
Advanced practice R&Rs governing the ordering of tests, therapeutics, and prescribing are promulgated by the BON with concurrence from the BOM; all other areas of SOP are exclusively under the BON. SOP is defined both in statute and regulation. Massachusetts recognizes APRNs as PCPs; however, state law does not contain “any willing provider” language. Credentialing for hospital privileges varies according to hospital policies. Massachusetts mandates a minimum of a graduate degree for initial (not reciprocal) APRN authorization. National certification is required to enter into and remain in practice.
FNPs, PNPs, and adult NPs are reimbursed at 100% of the 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, PCNSs, 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.
Massachusetts state law provides for prescriptive authority for CNPs, CNMs, CRNAs, and PCNSs, including Schedule II controlled substances. Authorized APRNs must apply to the Massachusetts Department of Public Health for state registration and then apply for a federal DEA number. Authorized APRNs have guidelines for prescriptive practice mutually developed and agreed on by the nurse and supervising physician that include a defined mechanism to monitor prescribing practices with the exception of CNMs who no longer require written guidelines or a supervising physician. Initial prescription of Schedule II drugs requires review within 96 hours. Authorized APRNs are allowed to request, receive, and dispense pharmaceutical samples. The prescription pad of the CNP, CRNA, and PCNS includes the name of the supervising physician and the APRN; however, the authorized APRN signs the prescription.
The BON authorizes advanced practice authority as a specialty certification; however, Michigan is one of the few states without an NPA or a definition of APRNs in statute. Nurse specialists are defined by the board as NPs, NMs, and NAs. According to the Michigan Council of Nurse Practitioners (although no statute exists requiring supervision or collaboration to practice with the exception of prescriptive authority), the state has recently interpreted NP practice as “supervised” due to their ability to “diagnose,” which is defined as the practice of medicine. Clarification by the BON, “The advanced practice nurses are authorized to practice through the certification issued to them as a registered nurse. The certification recognizes the additional training and completion of a certification program that enables the registered nurse to handle tasks of a more specialized nature that are delegated to him or her...without the benefit of a defined scope of practice, we are left with the scope indicated for a registered nurse and what tasks can be delegated by another licensee, which is typically a physician.”
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, this is dependent on the institution, and 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.
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.
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, NAs, and NMs may prescribe noncontrolled substances as a delegated act of a physician. There is no requirement for a physician's countersignature. Under BOM administrative rules, a physician may delegate prescriptive authority for Schedules III-V controlled substances to NPs and NMs if “the delegating physician establishes a written authorization,” containing names and license numbers of the physician, NP, or NM, and the limitations or exceptions to the delegation.
Written authorizations must be reviewed annually. The DEA requires NPs and NMs to obtain DEA numbers for those prescribing controlled substances. Schedule II controlled substances may also be delegated if the physician, NP, or NM is 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 complementary starter dose drugs other than controlled substances. Prescription labels have the name of the physician.
The Minnesota Board of Nursing grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. Effective January 2015, APRNs have independent practice in Minnesota. CNPs and CNSs are required to complete a “postgraduate practice” period of at least 2,080 hours within the context of a collaborative agreement with a physician or APRN, within a hospital or integrated clinical setting where APRNSs and physicians work together to provide patient care. CRNAs and CNMs do not have a postgraduate practice requirement. APRN SOP is defined in statute and must be consistent with their education and certification. APRNs are not statutorily prohibited from admitting patients and holding hospital privileges. Minnesota APRNs are licensed by the BON following completion of an accredited graduate-level APRN program and national certification by a recognized APRN certifying organization.
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 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.
APRNs may prescribe, receive, dispense, and administer drugs, including Schedules II-V controlled substances independently following the recent 2015 legislative success. CRNAs must hold a written prescribing agreement with a physician when providing nonsurgical pain therapies for chronic pain symptoms. APRNs must register with the DEA, and they have statutory authority to request, receive, and dispense sample medications.
The Mississippi BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. CNPs, CRNAs, and CNMs practice in a collaborative relationship with physicians in Mississippi. The collaborating physicians' practice must be compatible with the CNP's practice. APRNs must practice according to a BON-approved protocol agreed on by the APRN and physician. 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. CNPs 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. APRNs are required to have a master's degree or higher in nursing, nurse anesthesia, or midwifery, and must be nationally certified to enter into practice.
Medicaid reimbursement is available to APRNs at 90% of the 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 CNP working under the supervision of a physician, the insured shall be entitled to reimbursement whether the services are performed by the physician or NP. Reimbursement is increased to 100% for CNPs who provide healthcare services after 5 p.m.
CNPs and CNMs have full prescriptive authority, including Schedules II-V controlled substances, based on the standards and guidelines of the CNP or CNM's national certification organization and a BON-approved protocol that has been mutually agreed on by the CNP or CNM and qualified physician. The protocol must outline diagnostic/therapeutic procedures and categories of pharmaceutical agents that may be ordered, administered, dispensed, and/or prescribed for patients with diagnoses identified by the CNP.
CNPs may receive and distribute prepackaged medications or samples of noncontrolled substances for which the NP has Rx authority. Controlled substances (Schedules 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 submitted 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.
The Missouri BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. 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 (CP) Rule. Three focus areas in the CP rule include geographic areas to be covered, methods of treatment that may be covered by CP arrangements, and 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 CNP, CNS, CNM, 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 graduate degree in nursing and national certification to enter into practice in Missouri.
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/clinical 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.
Prescriptive authority for CNPs, CNSs, and CNMs includes prescription drugs/devices and Schedules III-V controlled substances as delegated by a physician pursuant to a written CP arrangement. Recent 2015 legislation authorizes APRNs with a CP arrangement and controlled substance prescriptive authority to prescribe hydrocodone-containing compounds from Schedule II. CNPs, CNSs, and CNMs must complete 1,000 hours of postgraduate clinical experience in the APRN role prior to application for controlled substance authority. CRNAs have prescriptive authority but are prohibited from prescribing controlled substances. Hydrocodone-containing Schedule II & all Schedule III prescriptions will be limited to a 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 in addition to being consistent with the individual's skill, training, education, and competence. APRNs may receive/dispense samples within their Rx authority. A state Bureau of Narcotics and Dangerous Drugs number, as well as a DEA number, are required. Prescriptions written by an NP are labeled with both the collaborating physician's and NP's names.
The Montana BON grants APRNs authority to practice and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. APRNs practice independently after completing specific curriculum requirements and a national certifying exam by a BON-recognized national certifying body. According to the Montana BON, all APRNs are expected to engage in ongoing competence development per Rule ARM 24.159.1469. APRN SOP is defined in Rule ARM 24.159.1406 and 24.159.406. APRNs are legally authorized to admit patients and hold hospital privileges; however, this varies according to the rules and bylaws of each hospital.
APRNs licensed after 2008 must have a master's degree or postgraduate certificate from an accredited APRN program and hold national certification to enter into practice unless the APRN enters Montana from an endorsement as an APRN in another state. All APRNs must maintain a quality assurance plan as part of the APRN Competence Development as defined.
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, and 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.
APRNs who desire Rx authority must apply for recognition by the BON. APRNs with Rx authority are independently authorized to prescribe all medications, including Schedules II-V controlled substances using their own DEA number and are permitted to request, receive, and dispense drug samples. Additional CE for prescriptive authority is required for renewal every 2 years.
The Nebraska APRN Board grants APRNs the authority to practice and regulates their practice. APRNs include CNP (NP in statute), CNS, CNM, and CRNA roles. NPs now enjoy FPA following a 2,000-hour transition to practice period supervised by an experienced physician or NP, as defined, following passage of 2015 legislation. An NP's SOP is defined in statute and includes illness prevention, diagnosis, treatment, and management of common health problems and acute and chronic conditions. “PCP” status and “any willing provider” language were not reported in the survey. CNMs continue to practice in collaboration with physicians as specified within the integrated practice agreement (IPA).
CRNAs are authorized to determine and administer total anesthesia care as described in consultation and collaboration and consent of a licensed physician or osteopathic physician. An IPA is not required for CRNA practice. CNS scope of practice is defined in statute and includes health promotion and supervision, illness prevention, and disease management within a selected clinical specialty. Nebraska requires a master's or doctorate degree in nursing, proof of professional liability insurance, and national board certification to enter practice.
State legislation mandating third-party reimbursement for NPs does not exist; consequently, some NPs have been refused recognition as providers. In 2008, BC/BS began reimbursing APRNs at 85% of the physician rate of reimbursement. Medicaid reimburses NPs at 100% of the physician payment.
Nebraska NPs are authorized full prescriptive authority, including Schedules II-V medications as defined in their statute. NPs may request, receive, and dispense pharmaceutical samples if the samples are drugs within their prescribing authority. CRNAs prescribe within their specialty practice, and authority is implied in the statute. Qualified CRNAs, NPs, and CNMs may register for a DEA number. CNSs do not have prescriptive authority in Nebraska.
The Nevada BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP (NP in statute), CNS, CNM, and CRNA roles. APRNs that have been practicing for 2 years (or 2,000 hours) are granted FPA. New graduates or those practicing for less than 2 years (or 2,000 hours) are required to complete a transition to practice period, which includes a formal, written collaborative agreement with a physician with written protocols only if Schedule II controlled substances are prescribed.
APRN SOP is defined in the NPA and applicable regulations and includes the nationally established scope and standards for the APRN role. APRNs are not recognized as PCPs under state law; however, they are legally authorized to admit patients to the hospital and hold hospital privileges. If the applicant completed an APRN program after June 1, 2005, the applicant must hold a master's degree in nursing or related health field. Applicants requesting APRN licensure after July 14, 2014, must hold national certification.
APRNs 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 APRNs at 85% of the physician reimbursement.
BON-authorized APRNs may prescribe controlled substances (Schedules II-V), 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). A collaborative agreement and protocols with a physician are only required for APRNs with less than 2 years or 2,000 hours of experience and only if prescribing Schedule II controlled substances. APRNs register for their own DEA numbers. APRNs 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,” and APRNs with prescriptive authority may receive and distribute samples without having dispensing authority.
The New Hampshire BON grants APRNs authority to practice and regulates their practice. APRNs include the CNP, CNM, and CRNA roles. APRNs have FPA with their SOP defined in statute and do not require physician collaboration or supervision. APRNs are statutorily recognized as “PCPs” in New Hemisphere; 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.
All major insurance companies, hospital service corporations, medical service corporations, and nonprofit health service corporations must reimburse APRNs when the insurance policy provides any service that may be legally performed by the APRN and such service is rendered. APRNs are recognized as PCPs by all HMOs in the state. Medicaid reimburses APRNs at 100% of physician payment.
BON-licensed APRNs have plenary authority to possess, compound, prescribe, administer, dispense, and distribute controlled and noncontrolled medications within the scope of the APRN's practice. APRNs are assigned a DEA number on request and are authorized to request, receive, and dispense pharmaceutical samples. Prescription labels are marked with the APRN's name.
The New Jersey BON grants ARPNs authority to practice and regulates their practice. APRNs are defined as APNs in the state of New Jersey and include CNP, CNS, and CRNA roles. 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, but 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.
Private health plans, including Medicaid managed-care plans, are permitted to credential APNs as “PCPs” but not required to recognize or reimburse them. Once the APN has been credentialed by or has 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, New Jersey Medicaid, New Jersey FamilyCare, United Healthcare, and other Medicaid HMOs, including Cigna, Great West, Health Net, Amerigroup/Choice, QualCare, and Oxford.
Aetna and Horizon BC/BS and some other Horizon MCOs will only credential and reimburse APNs who work in physician practices, not as ILPs providing primary care. Both Horizon and Aetna have fairly consistently credentialed and directly reimbursed psychiatric APNs. Note that direct reimbursement to APNs is also provided by the Civilian Health and Medical Program (uniformed service members and their families). Where APNs are credentialed and directly reimbursed by private insurers, it is generally at 85% of the physician rate, mirroring Medicare.
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 (CDS) number/federal DEA number and have modified the joint protocol to indicate whether or not prior consultation with the collaborating physician is necessary before 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.
The New Mexico BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNS, and CRNA roles. CNPs practice independently without physician supervision or collaboration requirements. CNP SOP is defined in statute 18.104.22.168 of Chapter 61, Article 3 of the New Mexico Statutes. APRNs are statutorily recognized as PCPs when providing care within their scope of practice in several areas of NM law; however, New Mexico does not have “any willing provider” language contained within the statutes. CNPs are legally authorized to hold admitting and hospital privileges and can serve as “acute, chronic, long-term, and end-of-life healthcare providers.” A master's degree in nursing or higher and national board certification are required to enter into practice as a CNP.
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 masters' 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 and are recognized as PCPs in statute.
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, and CNPs continue to meet resistance in being listed as PCPs with some companies. FNPs and PNPs receive Medicaid reimbursement at 85% of the physician payment. All three of the managed-care groups contracted to provide Medicaid coverage have contracts with NPs.
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/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 marked with the APRN's name where appropriate.
The New York State Education Department grants CNP (NP in statute) authority to practice and regulates their practice pursuant to Title VIII, Article 139 of NYS Education Law. The term “advanced practice registered nurse” is not defined in New York statutes or regulation. NPs and CNSs are licensed as RNs by the BON and certified by the State Education Department. Effective January 2015, NPs who have practiced more than 3,600 hours are no longer required to hold a collaborative practice agreement with a physician; however, NPs with greater than 3,600 hours of practice must attest to a collaborative relationship with a physician. NPs who have not practiced a minimum of 3,600 hours are legally required to practice in collaboration with physicians in accordance with a written practice agreement and written practice protocols until they complete this transition to practice period.
The written practice 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. CNMs are not regulated or recognized by the BON but must complete a master's or higher degree program in midwifery or a related field that is accredited by the American College of Nurse Midwives Division of Accreditation.
NPs of all specialties may register as Medicaid providers so long as the collaborating physician is also a Medicaid provider (including mental health NPs) and be reimbursed at 100% of the physician rate when billed under the physician provider, and 85% of the physician rate when billed directly as an NP provider. 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.” NPs are included in the NYSHIP Empire Plan (insures 122,000 NYS Employees and their families) offered by the two largest state employees unions.
NPs are eligible for full prescriptive authority, including Schedules II-V controlled substances following completion of required coursework in pharmacotherapeutics, prescription writing, and record keeping. NPs may order drugs, devices, immunizing agents, tests, and procedures either independently if they have completed a minimum of 3,600 hours of practice or in accordance with the written practice agreement and practice protocols during the transition to practice period without physician 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, devices, and order lab tests limited to the practice of midwifery; they can dispense pharmaceutical samples.
A Joint Subcommittee of the North Carolina BON and the North Carolina Medical Board grant CNPs the authority to practice and regulate their practice. CRNAs and CNSs are regulated solely by the BON, and CNMs are regulated by the Midwifery Joint Committee. APRNs include the CNP (NP in statute), CRNA, CNS, and CNM roles, and all APRNs are required to maintain a current unencumbered RN license. NPs legally practice under a supervisory relationship with a physician; however, this is referred to as a collaborative practice agreement. Collaborative practice must include a WCPA with a physician for continuous availability, not necessarily on-site, and ongoing supervision, consultation, collaboration, referral, and evaluation.
During the first 6 months of NP practice with a new primary care physician, monthly meetings are required (for the first 6 months), then every 6 months thereafter. These meetings must be documented with NP and physician signatures. 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.
State law does not prohibit NPs from having admitting privileges and hospital privileges; however, these are granted on a facility-by-facility basis. CNPs, CRNAs, and CNMs are required to hold a minimum of a master's degree in nursing (or related field depending on the role) and must be nationally certified to enter into practice. Effective July 1, 2015, CNSs must be recognized as such by the BON, although national certification is not required at this time. APRNs are authorized to form corporations with physicians; however, CRNAs can only incorporate with anesthesiologists.
NPs/CNMs receive Medicaid reimbursement at 100% of the physician rate for primary care activities. NPs who are enrolled as psychiatric/mental health providers receive 85% of the physician rate. Statutory authority for third-party reimbursement for NPs provides direct reimbursement to NPs for services within their scope. Psychiatric/mental health CNS services are reimbursable by insurance. CRNA services are reimbursable by insurance.
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/CNMs may now prescribe up to 5 refills for Schedule III and IIIN controlled substances, and the dosage units continue to be limited to a 30-day supply for each refill. Schedule II and IIN controlled substances continue to be limited to a 30-day supply without refills; however, multiple prescriptions for Schedule II controlled substances that result in a 90-day supply are authorized under defined conditions (21 CFR 1306.12).
NPs/CNMs with controlled substances in their collaborative practice agreements must obtain DEA registration (in addition to their approval number issued at the time of their approval as NPs/CNMs). NPs are authorized to hand out, free of any charge, starter doses or packets of prescription drug samples received from a prescription drug manufacturer in compliance with the Prescription Drug Marketing Act. CRNAs and CNSs do not have prescriptive authority in North Carolina.
The North Dakota BON grants APRNs the authority to practice and regulates their practice. Individuals are licensed as APRNs in one of four roles: CNP, CNS, CNM, or CRNA. APRNs practice independently in North Dakota, and their SOP is defined in regulation and must be consistent with their nursing education and certification. APRN applicants for initial licensure must have a graduate degree with a nursing focus or have completed educational requirements in effect when the applicant was initially licensed as well as hold national certification in an advanced nursing role.
FNPs, PNPs, and CNMs receive Medicaid reimbursement at 75% of the physician rate and CNMs at 85% of the physician rate. BCBSND reimburses CRNAs, CNMs, CNSs, and NPs based on the lesser of the provider's billed charges or 75% of the BC/BS physician payment system in effect at the time the services are rendered. Legislation passed in 2009 granted 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 Williston, Dickson, Minot, Bismarck, Jamestown, Devils Lake, Grand Forks, Wahpeton, and Fargo shall be reimbursed the lesser of provider's billed charges or 85% of the BCBSND physician payment system(s) in effect at the time services are rendered.
Authorized APRNs may prescribe, administer, sign for, and dispense over-the-counter, legend, and controlled substances and procure pharmaceuticals, including sample legend drugs and Schedules II-V controlled substances. For prescriptive authority, the APRN must submit an application to the BON and meet the requirements outlined in NDAC section 54-05-03.1-09. APRNs with prescriptive authority may apply for a DEA number.
The Ohio BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CRNA, CNM, and CNS roles. Legal authority to practice requires a CP arrangement between a physician and a CNP, CNM, or CNS in the form of a standard care arrangement (practice agreement). CRNAs are required to practice with a supervising physician. The SOP for CNPs is defined in statute ORC 4723.43. CNPs are statutorily recognized as providing preventive and primary care services, services for acute illnesses, and evaluation and promotion of patient wellness.
Following passage of 2014 legislation, APRNs are authorized to admit patients to a hospital if the APRN has a standard care arrangement with a collaborating physician who is a member of the medical staff of the hospital. 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 and hold national certification to enter into practice.
Ohio's Medicaid program recognizes CNPs certified in family, adult, acute care, geriatric, neonatal, pediatric, and women's health/OB. It also recognizes CNMs, CRNAs, and CNSs certified in gerontology, medical-surgical, and oncology nursing specialties. MCOs vary on empanelment. There are no legislative restrictions for an APN to be listed on managed-care panels; insurance companies are statutorily mandated to reimburse CNMs. Workers' compensation continues to reimburse CNPs, CRNAs, and CNSs.
Ohio state law grants full prescriptive authority to qualified CNPs, CNMs, and CNSs on a voluntary basis, including Schedules II-V controlled substances under rules and in collaboration with a physician. APRNs with prescriptive authority are required to register with the Ohio Automated TX Reporting System (OARRS) and access the database information as required. A separate approval process is required to apply for prescriptive authority following a 1,500-hour externship period after graduation from an APRN program. APRNs with prescriptive authority in another state who meet Ohio's BON requirements may need to complete a limited externship or none at all, depending on the prior prescribing practices.
APRNs prescribe based upon a formulary developed and approved by the Interdisciplinary Committee on Prescriptive Governance. APRNs 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. The prescribing of Schedule II controlled substances is limited to those prescriptions issued through specific institutions and programs recognized in Ohio nursing law, and as consistent with the APRN's standard care arrangement.
APRNs who are not practicing in an institution or program recognized in law are limited in their Schedule II controlled substance prescribing to the care of terminally ill patients after physician initiation and only for a 24-hour period. DEA registration is required. Prescriptions are labeled with the name of the prescriber. APRNs with Rx authority may request, receive, sign for, and distribute sample medications that are not controlled substances in a 72-hour supply except when minimum available quantity of the sample is packaged in an amount greater than a 72-hour supply. All samples provided must be consistent with the APRN's scope and within the formulary.
The Oklahoma BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. CNPs function independently with the exception of prescriptive authority, which requires supervision by a physician. APRNs practice within an SOP as defined by the NPA. The SOP for a CNP is further identified in specialty categories that delineate the population served, such as adult gerontology, family/individual across the lifespan, and so forth. CNSs must hold a master's degree in nursing, and CNPs/CNSs must be nationally board certified to enter into practice.
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. Effective January 1, 2016, the APRN applicants shall have completed an accredited graduate-level APRN education program in at least one of the following population foci: family/individual across the lifespan, adult gerontology, neonatal, pediatrics, women's health/gender-related, or psychiatric/mental health.
Oklahoma's Medicaid plan includes CNPs as “primary care managers.” State law does not mandate reimbursement of CNPs; however, the Oklahoma State and Education Employees Insurance Company recognizes CNPs as providers. Negotiation continues with other third-party insurers.
The BON regulates optional prescriptive authority for CNPs, CNSs, and CNMs, which includes\Schedules III-V controlled substances. Physician supervision is required for the prescriptive authority portion of advanced practice. Prescribing parameters include the following: must not be on the exclusionary formulary approved by the board; must be within the CNP, CNM, and CNS SOP; include Schedules III-V controlled substances (30-day supply) if state Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) and DEA registrations are obtained; and include signing to receive drug samples. A CRNA, regulated by the BON, may order, select, obtain, and administer drugs only during the perioperative or periobstetrical period. CRNAs must obtain state OBNDD and DEA registrations to order Schedules II-V controlled substances.
The Oregon BON grants FPA to and regulates CNPs (NP title in regulation; CNMs are a category of NP), CNSs, and CRNAs. Nurses in all three categories of advanced practice must be credentialed with a certificate by the BON. “APRN” is not a protected title in the Oregon NPA. SOP is defined in regulation, Division 50, 52, and 54 of the NPA and 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 a doctoral degree in nursing is required for the CNS entry into practice and is also required for the NP or CRNA educated after specific dates (see regulations for further information). Since 2011, national board certification has been required to enter into practice.
NPs are entitled by law to reimbursement by third-party payers. APRNs 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. Statutory authority provides payment parity from private insurers for NPs in independent practice; however, SB 153's recent passage ensures NPs receive full reimbursement regardless of whether the NP bills through a clinic/practice or independently. 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).
Regulation of Rx authority is under the sole authority of the BON. Oregon has legislated independent or plenary authority for NPs and CNSs to prescribe, so NPs and CNSs are able to obtain DEA numbers for Schedules II-V controlled substances. NPs and CNSs with prescription-writing authority may receive and distribute prepackaged complementary drug samples. NPs and CNSs may apply to the BON for unencumbered drug-dispensing authority. NPs do not have authority to prescribe under the physician-assisted suicide law. Only physicians can authorize medical marijuana use. Division 52 addresses prescriptive authority for CRNAs, effective 2013.
The Pennsylvania BON grants CRNPs and CNSs authority to practice and regulates their practice. APRN is not defined in statute or regulation. A CRNP performs the expanded role in collaboration with a physician, which 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 that do not recognize CRNPs as PCPs. 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. The BON does not track, monitor, or license CRNAs; the BOM licenses and regulates CNMs.
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 the physician payment for certain services. The State Department of Health allows HMOs to recognize CRNPs as primary care gatekeepers.
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 and conforms with regulations.
The CRNP may write a prescription for a Schedule II controlled substance for up to a 30-day supply.
CRNPs may prescribe Schedules III-IV controlled substances for up to a 90-day supply; Schedule V is not restricted. CRNPs are authorized to request, receive, and dispense pharmaceutical sample medications. Prescription blanks must include the name, title, and Pennsylvania certification number of the CRNP. The collaborative agreement is a signed, written agreement between the CRNP and a collaborating physician in which they agree to the details of their collaboration, including the elements in the definition of collaboration.
The Rhode Island BON grants ARPNs FPA and regulates their practice. APRNs include CNP, CNS, and CRNA roles. CNMs are licensed and regulated under separate R&Rs not regulated by the BON. SOP is defined within the NPA. CNPs 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. APRNs are considered licensed independent practitioners in this state. The minimum degree to enter into practice for all APRNs is completion of a graduate or postgraduate-level APRN program and national board certification (certain exceptions apply).
State law allows for direct reimbursement of PCNSs and CNMs. CNPs 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 CNPs and CNMs to serve as PCPs. CRNAs receive third-party reimbursement for services under the supervision of anesthesiologists or dentists.
With the passage of S614 in 2013, APRNs are granted independent prescriptive authority, including authority to prescribe, order, procure, administer, dispense, and furnish over-the-counter, legend, and controlled substances (General Laws in Chapter 5-34, Section 5-34-49) within their APRN role and population focus. CNPs may also be authorized to apply for Schedules II-V controlled substances and may be certified to prescribe controlled substances from Schedule I. CRNA, CNS, and APRNs in mental health prescribe pursuant to Chapter 5-34, Section 5-34-49 (e) (f) and (g).
The South Carolina BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. 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 NPs, CNSs, and CNMs 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, CNSs, and CNMs 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 doctorate, postmaster's certificate, or a minimum of a master's degree in nursing and national board certification in an advanced practice nursing specialty to enter into practice.
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 is the first APRN to sit on the advisory board for State Health and Human Services Board in South Carolina, while the rest of the Board consists of MDs.
NPs, CNSs, and CNMs have prescriptive authority, including Schedule III-V controlled substances, and prescribe according to practice agreement/protocol within the specialty area of the APRN. CRNAs are not required to obtain prescriptive authority to deliver anesthesia care; however, CRNAs practice pursuant to approved written guidelines with a supervising physician, dentist, or medical staff. 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 Schedule III-V controlled substances.
The South Dakota BON and BOM jointly regulate the practice of CNPs and CNMs. APRNs include CNP, CNS, CNM, and CRNA roles. 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 occurs no less than twice each month unless a modification request is approved to allow one of the twice-monthly meetings held by the telecommunication. CNSs are regulated by the BON, and physician supervision is not required; however, before 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, and APNs are granted hospital privileges. CNPs and CNMs must hold a graduate degree in nursing and national certification to enter into practice. CRNAs and CNSs must complete an approved program of nurse anesthesia or graduate program in nursing and hold national certification unless exempted as specified.
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.
South Dakota's CNPs and CNMs may prescribe legend drugs and Schedule II-IV controlled substances as authorized by the collaborating physician agreement. CNPs and CNMs have two controlled substance registration options: They may seek independent state registration and independent DEA registration in all schedules as authorized by their collaborative agreement, or 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, 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; however, CNSs may order and dispense durable medical equipment and therapeutic devices in collaboration with a physician.
The Tennessee BON grants ARPNs authority to practice and regulates their practice. ARPNs are defined as APNs in regulation and include CNP (NP in regulation), CNS, CNM, and CRNA roles. 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. APNs are required to hold a master's degree or higher in a nursing specialty and national certification to enter into practice in this state.
Tennessee's private insurance laws mandate reimbursement of APNs. A managed-care antidiscrimination law prevents MCO 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 Tennessee Nurses Association (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 MCOs participating in the TennCare program also credential APNs and assign an established patient panel upon individual review of specialty.
APNs who have a BON-issued certificate to prescribe may prescribe legend and Schedule II-V controlled substances pursuant to protocols. Preauthorization is required for off-formulary medications and for Schedule II or III opioid prescriptions of more than 30-day supply. Prescribers must also now confer with the controlled substance database prior to issuing a prescription for opioids or benzodiazepines as a new course of treatment that will last more than 7 days and at least annually when the controlled substance medication remains part of ongoing treatment. Both the supervising physician's name and address must be printed on the prescription blank; however, the APN may sign the prescription. NPs may request, receive, and issue pharmaceutical samples.
The BON is authorized by the NPA to regulate APRNs. APRNs are licensed in one or more of the following recognized roles: NP, CNS, CNM, or CRNA. The APRN's SOP is based on advanced practice education, experience, and the accepted SOP of the associated population focus area. 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 delegation protocols or other written authorization in addition to a prescriptive authority agreement detailing those drugs and devices, which may be ordered or prescribed by the APRN. These two documents may be combined into a comprehensive document providing authority for both diagnosing and prescribing or ordering.
The rules define protocols as written authorization to provide medical aspects of care. Protocols should allow the APRN to exercise professional judgment and are not required to outline specific steps the APRN must take, but they are required to contain certain elements regarding prescriptive authority. 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.
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 who 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.
APRNs may be delegated prescriptive authority by a physician, which includes nonprescription, legend, and Schedules II-V controlled substances under certain circumstances contained within 22 Texas Administrative Code §222. Schedules III-V controled substances authority may be delegated with the following limitations: APRNs may only Rx a maximum 90-day supply; the APRN must consult with the physician before authorizing a refill; and ARPNs may not Rx controlled substances to a child less than 2 years without physician consultation, which must be noted in the chart.
Schedule II controlled substance authority may be delegated to an APRN when prescribing in a hospital-based facility to a patient who has been admitted for a period of 24 hours or greater; is receiving services in the ED; or as part of the plan of care for treatment of a patient receiving hospice care. The ratio of supervision has been increased to 1:7 FTEs (physician to APRNs and/or PAs); however, the supervision ratio does not apply to the prescriptive authority agreement when prescriptive authority is delegated in a medically underserved area or a hospital-based facility. APRNs with prescriptive authority may request, receive, possess, and distribute samples of drugs they are authorized to prescribe.
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, pursuant to the Utah Nurse Practice Act, Part 3, 58-31b-301. Licensed APRN roles include the CNP, CNS, psychiatric/mental health nurse, CNM, and CRNA. CNMs are regulated by a separate practice act and CNM board. APRNs practice independently without physician supervision or collaboration with the exception of Schedules II-III controlled substance authority as described below under prescriptive authority.
The APRN SOP is defined by set standards from national, professional, and 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 prepared or higher and nationally certified to obtain licensure. Utah Legislature was the first to adopt the APRN compact in 2004.
The state insurance code has a nondiscrimination code; nothing prohibits reimbursement. APRNs are reimbursed by most insurance companies. As of April 2014, Medicaid empanels and reimbursed all board-certified NP specialties (previously FNP and PNP only) at 100% of the physician rate. CNMs are reimbursed by Medicare and Medicaid at 100% of the physician rate, whereas other APRN roles receive reimbursement at 80% of the physician rate.
APRNs including 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 required by the NPA 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 including CNMs and CRNAs receive a DEA number after passing a controlled substance exam and obtaining a state-controlled substance license; CRNAs may use facility DEA numbers under certain conditions. APRNs and CNMs may sign for and dispense drug samples.
The Vermont BON grants APRNs the authority to practice and regulates their practice. APRNs include the CNP (NP in regulation), CNS in psychiatric and mental health nursing, CNM, and CRNA roles. APRNs are independent providers after a transition to practice requirement is met (2,400 hours and 2 years) with a SOP defined in statute and regulations. According to agency protocols, APRNs are authorized to admit patients to a hospital and hold hospital privileges. APRNs are required to have a master's degree in nursing and hold national board certification to enter into practice.
BC/BS reimburses psychiatric NPs using a provider number. Although legislation requiring or prohibiting third-party reimbursement does not exist, insurance companies may reimburse NPs depending on policies.
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.
The Virginia BON and BOM have joint statutory authority to regulate licensed NPs (LNPs). LNPs are defined as APRNs and include the NP, CNM, and CRNA roles. CNSs are registered solely with the BON and are not defined as APRNs. LNPs licensed in a category other than CRNA practice in collaboration and consultation with a patient-care team physician as part of a patient-care team. CRNA practice remains under the supervision of a physician. NP practice is based on education, certification, and a written practice agreement, and NPs are included in the list of professions authorized to perform surgery.
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. NPs are also authorized to certify medical necessity of durable medical equipment that is to be reimbursed by Medicaid.
Board-certified NPs 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 PCNS, which is 67% of the rate currently paid to Medicaid-enrolled psychiatrists. For other procedures, such as physical exams, 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 has an “any willing provider” law, but it applies only to mandated providers and, among APNs, only PCNSs and CNMs are mandated providers. CNMs and CNSs in psychiatric health receive third-party reimbursement.
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 patient-care team physician and maintained by the NP (which is to be provided to the Joint Boards of Nursing and Medicine upon request), lists the drug categories the NP will prescribe. NPs may only prescribe legend drugs if “such prescription is authorized by the practice agreement between the NP and physician.” The prescription must include the NP's name and prescriptive authority number.
The name and contact information of the collaborating physician shall be provided to the patient upon request. Physicians who enter into a practice agreement with an LNP may only collaborate at any one time, with up to six NPs with prescriptive authority. Periodic electronic or chart review is required, and physician collaboration and consultation may be satisfied via telemedicine. The collaborating physician is not required to regularly practice at the same site as the NP with Rx authority. A separate practice site may be established.
The joint regulations of the BON and BOM include requirements for continued NP competency, including 8 hours of CE 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.”
The Nursing Care Quality Assurance Commission grants APRNs the authority to practice and regulates their practice; APRNs are designated as “ARNPs” in statute and regulation, which include NP, CNM, and CRNA roles. ARNP practice is independent, and ARNPs assume primary responsibility for continuous and comprehensive management of a broad range of patient care, concerns, and problems. ARNP SOP 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 are required to obtain licensure as an ARNP in Washington.
Medicaid reimbursement is available to ARNPs at 100% of the physician payment. Labor and Industries reimbursement is at 90% of the physician payment. The Healthcare Service Contracts Act (RCW 48.44.290) makes it illegal to deny a healthcare service performed by an RN or ARNP within the person's SOP if the healthcare contract would have approved the same service performed by a physician. A court ruled that the law's use of the term “healthcare service contract” referred to contracts between the health plan and the insured individual and did not extend to the healthcare provider. The court ruled that the law did not have legal force in addressing reimbursement parity for ARNPs because it only applied to the agreement between the health plan and the patient. Consequently, many private insurance companies reimburse ARNPs at a lower rate than a physician for the same service.
All ARNPs who receive prescriptive authority may independently prescribe legend drugs and Schedules II-V controlled substances. Independent prescriptive authority requires an initial 30 contact hours of education in pharmacotherapeutics (within the applicant's SOP) obtained within the 2-year period immediately prior to application. An advanced pharmacology course, taken as a part of the graduate program, meets the requirement if the application is made within 2 years of graduation. 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, and prescriptions are labeled with the ARNP's name.
The West Virginia BON grants authority to practice and regulates the practice of APRNs; law defines advanced practice for RNs. APRNs include NP, CNS, CNM, and CRNA roles. APRN SOP includes the ability to: assess, conceptualize, diagnose, analyze, plan, implement, and evaluate complex problems related to health. The APRN SOP does not require collaboration with a physician unless the APRN is prescribing, with the exception of CNMs who are required to practice in a collaborative relationship with a physician with or without prescriptive authority. CRNAs administer anesthesia in the presence and under the supervision of a physician or Doctor of Dental Surgery. Hospital credentialing for APRNs is dependent upon individual hospital policy. APRNs must have graduated from an accredited graduate program and be nationally board certified to enter into practice in the State of West Virginia.
Family, pediatric, gerontologic, adult, women's health, and psychiatric NPs receive Medicaid reimbursement at 100% of the physician rate. State law requires insurance companies to reimburse nurses for their 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 Women's Access to Healthcare Bill provided for direct access, at least annually, to a woman's healthcare provider for a well-woman exam. Providers include APRNs, NPs, CNMs, FNPs, WHNPs, adult NPs, GNPs, or PNPs.
Qualified APRNs have prescriptive authority requiring a collaborative relationship with a licensed physician. Prescriptive authority includes Schedule III-V controlled substances with some restrictions. Rules and regulations specify that the APRNs 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 and shared responsibility between the APRN and physician with periodic joint evaluation of the practice and review/updating of the written guidelines or protocols. No supervision requirement exists; APRNs are not required to be employed by a collaborating physician. The APRN works from an exclusionary formulary.
Schedules I and II, antineoplastics, radiopharmaceuticals, and general anesthetics are prohibited. Monoamine oxidase inhibitors are excluded except when in a collaborative agreement with a psychiatrist. Additional changes include the increase in amount of Schedule IV and V controlled substances that may be prescribed. Prior to the initial provision of pain-relieving controlled substance, the APRN must access the West Virginia Controlled Substances Monitoring Program repository and database to determine if the patient has obtained any controlled substance from another prescriber within the 12-month period preceding the current visit. This must be documented and must be accessed by the current prescriber at least annually when treating a chronic pain condition. A DEA number is issued directly to APRNs by the DEA, and APRNs are authorized to sign for and provide drug samples.
The Wisconsin BON regulates the practice of APRNs defined as Advanced Practice Nurse Prescribers (APNPs) and includes CNP, CNS, CNM, and CRNA roles. SOP is not defined in statute for NPs, CNSs, or CRNAs with the exception of reference to prescriptive authority (Wisconsin Rule §N 8.10); however, SOP is defined in statute and rules for CNMs (Wisconsin Stat. §441.15(1)(b) and Wisconsin Administrative Rule § N4.06). APNPs must practice in a collaborative relationship with a physician.
There are no statutory requirements for hospitals to grant staff privileges, and few have done so. Regulations require all patients to be “under the care of a physician, dentist, or podiatrist.” An APNP must have a master's degree in nursing or related field, national board certification, malpractice insurance ($1 million/$3 million), and 45 required, clinical pharmacology hours to enter into practice in Wisconsin.
Specified, reimbursable billing codes have Medicaid reimbursement of 100% as submitted by all master's degree-prepared NPs or NPs who are certified. 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, and 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.
Eligible APNPs may prescribe legend drugs and Schedules II-V controlled substances as a delegated medical act under the NPA. Wisconsin Administrative Rule §N 8.06 describes limitations on prescriptive authority for Schedule II controlled substances. APNPs may dispense complementary pharmaceutical samples; the APNP may also dispense drugs to a patient if the treatment facility is located at least 30 miles from the nearest pharmacy.
The Wyoming BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. 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 commensurate with national organizations and accrediting agencies. “APRNs are statutorily defined as ‘PCPs’ and may be permitted to admit patients to a hospital and hold hospital privileges, depending on individual hospital policies.” A master's degree in nursing in a specific APRN role and national board certification in that role are required to enter into practice as an APRN in Wyoming.
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. Wyoming State BON has no say in reimbursement policies.
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, and prescriptions are labeled with the APRN name.