This article has been corrected on page 29 to clarify the new Health Care Authority rules for home health services and medical equipment effective in Washington state.
Advocates for improving patient safety and access to high-quality healthcare were exceedingly active in the 2018-2019 legislative sessions, enacting new or amended laws and adopting regulations pertaining to APRN practice authority, reimbursement, and prescriptive authority in 25 states. This year, states have again placed an emphasis on enacting policy focused on the national opioid crisis. APRNs in greater numbers participate in state prescription drug monitoring programs and opioid prescribing programs to improve access to safe and effective care for patients with chronic pain.
In addition to legislative and regulatory updates to practice authority, reimbursement, and prescriptive authority, highlights of the 2020 Annual APRN Legislative Update include telehealth policy adoption, home health challenges, transition-to-practice struggles, and an increasing number of states proposing or enacting laws pertaining to tax incentives for APRN preceptors.
Telehealth. Five states adopted telehealth services policy, improving access to vital healthcare services for their residents. Alaska adopted new regulations regarding standards of practice for APRNs delivering telehealth services. The new standards address follow-up care, communication with the primary care physician, prescriptive authority requirements, and documentation (12 Alaska Administrative Code 44.925). Kentucky adopted regulations pertaining to Medicaid reimbursement for telehealth services. New regulations require Medicaid to reimburse APRNs for telehealth consultation at the same amount paid for a comparable in-person service (907 KAR 3:170E). Missouri enacted SB 514, modifying telehealth statute, among other provisions. Effective July 11, 2019, SB 514 removes a sunset provision on the use of telehealth for APRNs in rural areas of need. Previously, APRNs were restricted to delivery of telehealth services within a 75-mile limit. Nebraska enacted Slip Law LB29, 2019, amending the Uniform Credentialing Act authorizing APRNs among other healthcare providers to offer healthcare services, including prescriptive authority, through telehealth without an initial face-to-face visit. South Dakota enacted Chapter 211 on March 27, 2019, amending South Dakota Codified Laws Chapter 58-17 Health Insurance Policies to define the term telehealth and provide for the payment of health insurance claims for covered services provided via telehealth. APRNs are included in the definition of “health care professional” as defined.
Tax credits. Securing clinical training preceptors is challenging given the number of healthcare provider student learners across the country. In 2019, four states proposed tax credit legislation for clinician preceptors; however, only one state was successful in enacting such policy. South Carolina's Act No. 45, effective May 16, 2019, authorizes income tax credit for each clinical rotation provided by an APRN, physician, or physician assistant preceptor. The new statute defines hourly requirements for precepting and practice payer mix percentage (Medicaid, Medicare, self-pay), and rotations are limited to family medicine, internal medicine, pediatrics, OB/GYN, emergency medicine, psychiatry, and general surgery.
Transition-to-practice adoption. State BONs and NP associations were surveyed to identify regulatory implementation challenges of newly enacted APRN transition-to-practice statutes. The South Dakota BON identified challenges with licensure of new NPs and CNMs. South Dakota law requires the new NP or CNM applicant to provide a signed collaborative practice agreement as a condition of licensure. As the law is written, the BON is unable to license NP and CNM applicants until they secure their initial position and obtain a collaborative practice agreement, which in many cases has resulted in a delay in licensure. For states considering transition-to-practice requirements for full practice authority, the South Dakota BON recommends avoiding tying licensure to the transition-to-practice language. Additional challenges to licensure have developed with new graduate NPs or CNMs who serve in the military or are federally employed within Veterans Affairs or Indian Health Services. Given that SD law requires new CNPs and CNMs to obtain a collaborative practice agreement with a SD-licnsed physician, CNP, or CNM as a condition of initial licensure, this poses a challenge in federal agencies that do not require such agreements to practice under federal law.
Home health services. ARNPs United of Washington State reported Health Care Authority (HCA) adopted the rules for home health services (Chapter 182-551 WAC, Subchapter II) and medical equipment (Chapter 182-543 WAC). Effective January 1, 2019, ARNPs and PAs ordering home health services or medical equipment for Medicaid recipients are required to obtain a physician's signature for the order. As a full practice authority state, APRNs do not require physician collaboration, supervision, or consultation. Implementation of these rules greatly reduces access to services needed by the state's most vulnerable residents. ARNPs United AUWS is working with state and national organizations to have the HCA rescind the rules.
Twelve states enacted legislation pertaining to APRN practice authority, including collaborative practice agreements, scope of practice improvements and clarification, BON regulatory authority, healthcare agency credentialing and privileging, and APRN education requirements.
Collaborative practice agreements. Arkansas enacted Act 308 (effective March 5, 2019) amending Arkansas Code § 17-87-310 (a) (2) authorizing a licensed podiatrist, in addition to a licensed physician, to engage in a collaborative practice agreement with an APRN.
Scope of practice improvements and clarification including signature authority. Seven states have enacted legislation improving or clarifying APRN scope of practice. Public Act No. 19-98 was signed by the Governor of Connecticut, effective October 1, 2019. The Act adds APRNs to numerous statutes pertaining to behavioral health, workers' compensation, health insurance, healthcare facility admissions, medical and vital records, Department of Public Health, prescriptive authority and collaborative agreements with pharmacists, and medical malpractice liability. These statutes previously referenced only physicians or other healthcare providers. Montana enacted Chapter Number 20 (effective October 1, 2019), amending Section 53-24-301, MCA to include APRNs as an authorized healthcare professional who may confirm the chemical dependency of an applicant for admission as a medically monitored or managed inpatient at an approved treatment facility. In addition to Chapter 20, Montana enacted Chapter Number 52 (SB 94), granting global signature authority to APRNs, effective October 1, 2019. Section 37-8-410 was added to Montana Code Annotated 2019 Title 37 Chapter 8, Part 4.
Nevada enacted Chapter 26, effective July 1, 2019, amending several statutes clarifying APRN authority to perform certain services and complete documentation related to medical clearance of children sustaining a head injury; self-administration of medication by pupils enrolled in a private school while on school grounds or participating in a school activity; and ordering home health services. North Dakota enacted SB 2138 amending subsection 10 of section 20.1-02-05 of the North Dakota Century Code. The amended law authorizes APRNs to verify physical conditions necessary to obtain special hunting permits to individuals who are unable to walk or who have lost the use of an arm at or below the elbow. Effective November 1, 2019, Oklahoma-licensed APRNs are authorized to refer patients for physical therapy services. Oklahoma enacted Chapter 224 on April 29, 2019, amending 59 O.S. 2011, Section 887.17 adding APRNs to the current list of healthcare providers authorized to refer for physical therapy services. Current law authorizes direct patient access to physical therapy services for 30 days; healthcare provider referral is required for treatment beyond the 30-day period.
South Carolina enacted Act 87 of 2019 (effective July 23, 2019)–cited as the “Advanced Practice Registered Nurse Act”–amending current law and authorizing APRNs to perform certain additional medical acts unless otherwise provided in their practice agreement. New provisions include authorization to pronounce, certify manner and cause of death, sign death certificates, and execute “do-not-resuscitate” orders. Additional provisions for prescriptive authority are noted below. Effective September 1, 2019, Texas APRNs are authorized to complete and sign a work status report regarding an injured worker's ability to return to work. Acts 2019 Chapter 723 amends Section 408.025 (a-1) of the Texas Labor Code to include APRNs.
BON regulatory authority. The enactment of Kentucky Acts Ch. 104 now authorizes the Kentucky BON to license and regulate the practice of certified professional midwifery. The legislation adds new sections to KRS Chapter 314, the nurse practice act, pertaining to APRNs. The new sections define “APRN-designated certified nurse-midwife” and “licensed certified professional midwife” as separate midwifery professionals.
Healthcare agency medical staff membership and credentialing and privileging. Three states have enacted legislation authorizing medical staff. Nevada enacted Chapter 246 on May 30, 2019 (SB 456), authorizing admission of APRNs to hospital medical staff membership, including provisions to prohibit automatic admission or denial of membership based on the APRN's professional licensure. New Mexico and Washington enacted similar laws pertaining to credentialing and clinical privileging APRNs. New Mexico enacted Chapter 129 (HB 280) granting parity between physician and CNP, CNM, and CNS privileging. Effective July 1, 2020, health facilities must use the same criteria to credential and privilege APRN providers, grant eligibility to serve on the medical staff, and conduct peer review of their professional colleagues. In Washington, Chapter 104 was enacted effective July 28, 2019, requiring hospitals to utilize the same process for granting or renewing clinical privileges to ARNPs as used for physicians.
APRN education requirements. The North Carolina BON reported adoption of updated CNS Education rules (21 BCAC 36.0228). The updated rules clarify the educational degree required to be recognized as a CNS in North Carolina, which now include a master's or doctoral degree or a postmaster's certificate for licensure.
In addition to regulatory success in Kentucky pertaining to Medicaid reimbursement for telehealth services described above, two additional states have reported improvement in reimbursement policies for healthcare services provided by APRNs. Colorado enacted Chapter Number 77 “Nurse Practitioner Workers' Compensation” (HB 19-1105), granting the ability of advanced practice nurses with prescriptive authority to receive Level 1 accreditation for the purposes of receiving 100% reimbursement under the “Workers Compensation Act of Colorado.” This provision was effective August 2, 2019. Effective October 1, 2019, Virginia enacted Chapters 332 (H1640) and 333 (S1178) amending current law to include NPs as authorized providers of service for the purposes of reimbursement by accident and sickness insurance and health services plans.
Ten states enacted a variety of legislation pertaining to APRN prescribing. Themes include CS and opioid prescribing, continuing education, prescription drug monitoring programs, prescriptive authority agreements, and consultation and referral plans.
Controlled Substances/Opioid Prescribing. Arkansas advanced APRN prescriptive authority in the state by amending current statute to include CS II authority under certain conditions. Act 593 (H 1267), effective March 29, 2019, APRNs are authorized to prescribe CS II medications with the following provisions: 1) the CS II opioid RX is limited to treatment for a 5-day period or less; 2) the stimulant prescription was initially prescribed by a physician, the patient has seen the physician within the previous 6 months, and the APRN is prescribing for the same use or condition. Florida enacted Chapter No. 2019-123 (effective July 1, 2019) pertaining to alternative treatment of pain with nonopioid therapies. Except in the provision of emergency care and prior to providing anesthesia, prescribing, ordering, dispensing, or administering an opioid medication listed as a schedule II CS, the new law requires healthcare providers to: inform a patient about available nonopioid alternatives for the treatment of pain including complementary and alternative therapies as defined; discuss advantages and disadvantages of the use of nonopioid alternatives as defined; and provide an educational pamphlet developed by the Department of Public Health.
South Carolina enacted Act 87 of 2019 (effective July 23, 2019), advancing Schedule II CSs prescriptive authority in their state by amending current statute to include additional conditions for prescribing CS II narcotic medications outside the current 5-day treatment limitation. Exceptions currently include written agreement of the physician with whom the APRN has a practice agreement, and prescriptions for patients within hospice or palliative care. The newly amended statute adds prescriptions for patients residing in long-term-care facilities. Wyoming enacted Chapter Number 103 effective February 26, 2019, limiting all prescribers to a 7-day treatment supply in a 7-day period of any opioid or combination of opioids for acute pain in an opioid-naive patient. Exceptions include chronic pain, cancer treatment, palliative care, and other clinically appropriate conditions as defined.
Continuing education requirements. The BON of Delaware reported adoption of amended regulations removing the redundant 10 hours of pharmacology CE required for APRN prescriptive authority renewal. Current regulations pertaining to licensure renewal require the APRN to meet the requirements for recertification as established by the [national] certifying agency, which have established CE requirements (24 DE Admin Code 1900). Oklahoma enacted SB 848 amending the NPA pertaining to requirements for renewal of prescriptive authority and pertaining to disciplinary action related to prescribing, dispensing, or administering opioid drugs in excess of maximum limits authorized by law (63 O.S. § 2-309I). Effective May 19, 2019, in addition to 15 contact hours or 1 academic credit of education in pharmacotherapeutics, clinical application, and use of pharmacologic agents, APRNs must complete 2 hours of education in pain management or opioid use or addiction (59 O.S. § 567.4a).
Prescription drug monitoring programs (PDMPs). Iowa's BON adopted updated regulations effective March 20, 2019. Among other provisions, updated regulations include ARNP standards of practice for CSs and use of the prescription monitoring program (655 IAC Chapter 7). Wyoming enacted Chapter No. 153 (effective July 1, 2019) pertaining to review of the PDMP prior to issuing a prescription for a schedule II, III, or IV CSs and schedule V CSs (opioid only). Prescribers must query the PDMP every 3 months thereafter while the CS is part of the treatment plan.
Prescriptive authority agreements/consultation and referral plans/new prescriptive authority. Texas has enacted HB 278 relating to the frequency and location of meetings required by a prescriptive authority agreement, a physician, and an APRN. Effective September 1, 2019, the amendments eliminate the requirement for “face-to-face” meetings between the physician and APRN [or PA], defining the meeting forum as “in a manner to be determined by the physician and APRN (or PA)” (TX Occupations Code Sections 157.0512(e) and (f)). Utah enacted Chapter 233, 2019 effective May 14, 2019, which eliminated APRN consultation and referral plan requirements for prescribing or administering Schedule II CSs, except under certain circumstances as defined. APRNs are not authorized to prescribe or administer Schedule II CSs without a consultation and referral plan when the APRN is engaged in solo practice and has been licensed for less than 1 year, or has less than 2,000 hours of experience as an APRN, or owns or operates a pain clinic. APRNs with at least 3 years of experience may supervise a consultation and referral plan for another APRN (Utah Code Section 58-31b-803). North Carolina enacted SL 2019-175 effective October 1, 2019, authorizing CNPs to prescribe hyperbaric oxygen therapy treatment to a veteran for the treatment of traumatic brain injury or posttraumatic stress disorder.
APRNs are defined as APNs in Alabama and include the roles of CNP (CRNP in statute), CNS, CNM, and CRNA. Although the BON has sole regulatory authority to establish the qualifications and certification requirements of APNs, the BON and BOME regulate the collaborative practice of physicians with CRNPs and CNMs requiring BON- and BOME-approved written collaborative practice agreement protocols. Collaboration does not require direct, on-site supervision by the collaborating physician. It does, however, require such professional oversight and direction as may be required by the R&R of the BON and BOME.
The CRNP or CNM and collaborating physician must be present in any approved practice site for a minimum of 10% of the CRNP/CNM's scheduled hours if the CRNP or CNM has fewer than 2 years of collaborative practice experience. Remote practice site is defined in rule, and the collaborating physician must visit each remote site at least twice annually. CRNP SOP is defined in statute and regulation; APNs practice in accordance with national standards and functions identified by the appropriate specialty-certifying agency, congruent with Alabama law.
CRNPs must hold a master's or higher degree in advanced practice nursing and hold and maintain national board certification, with a few exceptions, pursuant to Alabama Board of Nursing Administrative Code Chapter 610-X-5-.03.
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. 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 protocol and formulary. CRNPs and CNMs in collaborative practice with a physician may prescribe Schedules III, IV, and V CSs, pursuant to the rules of Alabama BOME Chapter 540-X-18, and, under limited circumstances, may prescribe Schedule II CSs, pursuant to BOME Administrative Code Chapter 540-X-20. 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 Schedules III–V CS authority.
APRNs are regulated by the Alaska BON, defined in statute, and include CNP, CNS, CNM, and CRNA roles. APRNs 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 APRN have a plan for patient consultation and referral, but a physician relationship is not required.
APRN SOP is directly defined under regulation 12 AAC 44.430. The Board recognizes advanced and specialized acts of nursing practice as those described in the scope of practice statements published by national professional nursing associations recognized by the Board for APRNs certified by the national certification bodies recognized by the Board (AS 08.68.100). APRNs in Alaska are statutorily recognized as PCPs. Nothing in the law precludes admitting privileges for APRNs. Entry into APRN practice requires a graduate degree in nursing and national board certification. Continuing education (CE) requirements for APRNs are to maintain current national certification. All CNPs, CNSs, CNMs, and CRNAs have been incorporated under the same set of regulations.
All healthcare in Alaska is provided on a fee-for-service basis, and managed care does not exist. FNPs, PNPs, PMHNPs, CNMs, and CRNAs are authorized by law to receive Medicaid reimbursement; NPs receive 85% of the physician payment. A nondiscriminatory clause in the insurance law allows for third-party reimbursement to NPs; Alaska legally requires insurance companies to credential, empanel, and/or recognize APRNs. Alaska does not have “any willing provider” language in current law.
Authorized APRNs have independent prescriptive authority, including Schedules II–V CSs, and hold DEA registration. APRNs are legally required to review the Prescription Drug Monitoring Program database prior to prescribing CSs and must complete 2 CE hours in pain management and opioid use and addiction each 2-year license renewal cycle. They are legally authorized to request, receive, and dispense pharmaceutical samples in Alaska. To renew prescriptive authority, APRNs must maintain national certification and complete the opioid CE requirement.
Opioid prescribing limitations enacted in 2017 (Chapter 2 SSSLA 17) provide restrictions on number of therapy days when prescribed by an APRN, including 7 days for initial prescriptions for adults and any prescription for a minor. Exceptions include chronic pain, cancer, palliative care, and patient travel or logistical barrier.
The Arizona State Legislature grants APRNs authority, and the BON alone regulates their practice. APRNs include CNPs (RNPs in statute), CNSs, CNMs, and CRNA roles. According to Arizona Revised Statutes Title 32, Chapter 15 32-1601; 20 (vi), the following language was added to both the RNP and the CNM definition:
“...recognizing the limits of the nurse's knowledge and experience by consulting with or referring patients to other appropriate healthcare professionals if a situation or condition occurs that is beyond the knowledge and experience of the nurse or if the referral will protect the health and welfare of the patient.”
No formal collaboration agreement is required. RNP SOP is defined in Arizona Administrative Code R4-19-508. In the SOP, RNPs are authorized to admit patients to healthcare facilities, manage the care of admitted patients, and discharge patients. However, Arizona Department of Health regulations require an attending physician for patients admitted to an acute care facility. Acute care facilities apply this citation as the basis to deny independent admitting and hospital privileges to RNPs.
RNPs, CNMs, and CNSs must have a graduate degree in nursing and national board certification in their focus area to begin practice. CRNAs must have a graduate degree associated with an accredited CRNA program and hold national certification to begin practice. CRNAs are responsible for their own practice; physicians and surgeons are not liable for any act or omission of a CRNA who orders or administers anesthetics.
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 prescribing and dispensing authority, including CSs Schedules II–V, on application, and fulfillment of BON-established criteria. RNP prescribing and dispensing authority is linked to the RNP's area of population focus and certification.
An RNP with prescribing and dispensing authority who wishes to prescribe a CS must apply to the DEA for a registration number and submit this number to the BON and the BOP. Drugs (other than CSs) may be refilled for up to 1 year. The passage of ARS 36-2606 requires RNPs who intend to hold or already hold a DEA registration number to also hold Controlled Substances Prescription Monitoring Program (CSPMP) registration issued by the BOP.
Effective October 1, 2017, prescribers must obtain a patient utilization report from the CSPMP's central database prior to prescribing an opioid analgesic or benzodiazepine CSs in Schedules II, III, or IV, with certain exceptions. Language has been added to the SOP for CRNAs to clarify that CRNAs may administer anesthetics and issue medication orders for medications, including CSs, 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 for patients to use outside of the CRNA's practice setting. 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, who practice independently, with the exception of RNPs (NPs who do not hold national certification). A collaborative practice agreement with a physician and prescribing protocols are required for prescriptive authority. APRNs practice within scope and standards defined in Chapter 4, Section VI of the Arkansas State Board of Nursing Rules as well as standards established by the national certifying body from which the APRN holds his or her certification required for licensure.
Hospital privileges for APRNs are determined on a hospital-to-hospital basis according to the credentialing committee of each hospital. Initial APRN licensure is granted to applicants who have completed 2,000 hours of active practice as an RN, have completed graduate- or postgraduate-level APRN education, and hold national board certification. National certification must be maintained to continue active APRN licensure.
The NPA mandates direct Medicaid reimbursement to APRNs and RNPs. Medicaid reimbursement is 80% of the physician 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 practicing in collaboration with a licensed practicing physician or podiatrist who has training in scope, specialty, or expertise to that of the APRN as well as the use of prescriptive protocols. Initial and CRNAs are not required to have prescriptive authority to provide anesthesia care, including the administration of drugs or medication necessary for such care. Prescriptive authority includes legend drugs, therapeutic devices, and Schedules III–V CSs, and if expressly authorized by the collaborative practice agreement, Schedule II hydrocodone-combination products limited to 7 days for acute pain. All prescribers are required to review the PDMP prior to prescribing an opioid from Schedule II or III CSs and benzodiazepines when prescribing to a patient for the first time and every 6 months after. PDMP review exceptions are described under Arkansas State Board of Nursing Rules Chapter 4, Section VIII (K).
Newly enacted legislation in 2019 extends APRN prescriptive authority to drugs listed in Schedule II under the following conditions: opioids are prescribed for a 5-day period or less; or stimulants, initially prescribed by a physician, may be prescribed by an APRN if the patient has been evaluated by the physician within the previous 6 months and the APRN is prescribing for the same condition or use.
APRNs who have fulfilled requirements for prescriptive authority may receive and dispense pharmaceutical samples and therapeutic devices appropriate to their area of practice.
The California BRN grants legal authority to practice and regulates/issues separate certification 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.
NP SOP is defined within the standardized procedure commensurate with the NP's education and training, 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 a health-related field to practice; however, California does not require national certification to practice. CRNAs are required to hold national certification to practice in 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. The Blue Cross of CA Medi-Cal Provider Directory lists CNPs as PCPs under their specialty. There is no legal preclusion to third-party reimbursement of services, and policies vary from payer to payer; however, third-party payers are legally required to reimburse CNMs and BRN-listed psychiatric-mental health nurses for qualifying services. 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 Schedules II–V CSs, 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. Legislation passed in 2017 codifies in California law federal authority for NPs to furnish or order buprenorphine when done in compliance with the provisions of the Comprehensive Addiction Recovery Act (Public Law 114-198).
Effective October 2, 2018, all prescribers are mandated to consult the Controlled Substance Utilization Review and Evaluation System the first time a patient is prescribed, ordered, administered, or furnished a CS (with some exemptions) and at least once every 4 months if the CS remains part of the patient's treatment plan (with some exemptions).
The act of furnishing is legally the same as prescribing and requires physician supervision of the CNP and CNM; however, the physician's physical presence is not required. CNPs and CNMs may request, receive, and dispense pharmaceutical samples and may dispense drugs, including CSs. 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 BON R&Rs for inclusion on the Advanced Practice Registry (APR), regulates the practice of APRNs, and affords title protection. APRNs are defined as APNs in the State of Colorado and include CNP (NP in statute), CNS, CNM, and CRNA roles. APNs are considered independent practitioners. National certification in a role and, if applicable, 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 as 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 BON rules do not address, and therefore do not prohibit, APNs 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. CNMs are now a recognized provider type for Colorado's Medicaid program, which is known as Health First Colorado.
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. Legislation passed in April 2019 authorizes APNs with prescriptive authority to receive Level I accreditation for purposes of receiving 100% reimbursement under the medical fee schedule within the Workers' Compensation Act of Colorado.
APNs have full prescriptive authority authorized by the BON within their recognized role and population focus, including Schedules II–V CSs. APNs applying for original prescriptive authority must have 3 years of clinical work experience as an RN to be eligible to apply for provisional prescriptive authority (RXN-P) per CRS 12-38-111.6(4.5)(a)(VII). The RXN-P must complete a 1,000-hour documented prescribing mentorship period with a physician or an APN who has full prescriptive authority and registration with the DEA. APNs who have active prescriptive authority in another state and more than 1,000 hours of safe prescribing experience in that state are not required to complete the mentorship period.
An articulated plan for safe prescribing and one-time attestation signature is required following completion of the mentorship or upon prescribing in Colorado with full prescriptive authority by endorsement, for verification, and the existence of an articulated plan for safe prescribing. The APN is responsible for reviewing his or her articulated plan on an annual basis, and articulated plans may be audited by the BON.
In May 2019, the Substance Use Disorders Prevention Act became law, requiring the BON and other healthcare provider boards to adopt rules on substance use disorder training for prescribers. Training must consist of up to 4 credit hours per licensing cycle related to best practices of opioid prescribing, recognition of substance use disorders, referral for and treatment of substance use disorders, and use of the PDMP. This new law restricts APNs among other prescribers from accepting direct or indirect benefits for prescribing specific medication.
BON rules authorize APNs with prescriptive authority to receive and distribute a therapeutic regimen of prepackaged and labeled drugs, including free samples.
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 FPA following no less than 3 years and no fewer 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. The passage of Public Act No. 19-98 in 2019 further acquired global signature authority, including worker's compensation, pharmacy collaborative drug management agreement, and psychiatric statute changes. This adds to the previously authorized signature authority including certification for medical marijuana use (except for glaucoma) in 2016.
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 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, 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.
APRNs may independently prescribe, dispense, and administer medications autonomously, including Schedules II–V CSs following no 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.
Opioid prescribing limitations for acute pain were enacted in 2016 and 2017. Initial prescription for acute pain in adults is limited to 7 days. Prescribing limitations for any opioid prescribing for minors are limited to 5 days. Exceptions to the limitations include chronic pain, cancer pain, palliative care, provider judgment, and substance abuse disorder or medication-assisted treatment (MAT).
APRNs are licensed and regulated by the Delaware BON and include CNP, CNS, CNM, and CRNA roles. APRNs enjoy FPA as defined in section 1935 of the Delaware NPA; however, the statute is clear that FPA does not equate to the granting of independent practice. The BON may grant APRNs independent practice following review and recommendation of the 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.
APRNs have authority to serve as PCPs 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 BON may prescribe, order, procure, administer, store, dispense, and furnish over-the-counter (OTC), legend, and CSs 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. APRN SOP is defined in statute, regulated by the BON, and is without limitations. APRNs may apply for hospital admitting privileges. National certification in a specialty area is required to begin practice.
APRNs receive direct reimbursement for providing drug abuse, alcohol abuse, and mental illness care; healthcare plans or institutions are prohibited from discriminating against APRNs with clinical privileges. Legislative authority mandating APRN 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 CSs. The law and R&R authorize prescribing Schedules II–V CSs and allow dispensing of all medications, including sample medication. APRNs are authorized to request and receive pharmaceutical samples. The D.C. Pharmacy Board issues a CS registration to providers with CS authority; however, APRNs must also hold DEA registration. Prescriptions are labeled with the APRN's name.
Effective October 2018, APNs in Florida are now licensed and defined as APRNs and include CNP, CNS, CNM, and CRNA roles. APRN SOP is defined in statute and includes the performance of medical acts of diagnosis, treatment, and operation pursuant to protocols established between the APRN and an MD, DO, or dentist.
Within the framework of established protocols, APRNs may order diagnostic tests, physical therapy, and occupational therapy. The degree and method of supervision (determined by the APRN and MD, DO, or dentist) are specifically identified in written protocols and shall be appropriate for prudent healthcare providers under similar circumstances. Supervision is defined as the ability to communicate or establish contact by telephone; the supervising practitioner's on-site presence is not required.
APRNs are authorized to admit patients to a hospital and hold hospital privileges; however, this authority is dependent on privileges granted by the institution and the supervising physician. APRN applicants must have a master's degree to qualify for initial certification and are required to hold national board certification practice. CNSs must hold a master's degree in a clinical nursing specialty and either national certification in a CNS specialty or proof of completed clinical experience in a CNS specialty for which there is no national certification.
APRNs receive Medicaid, Medicare, CHAMPUS, and third-party reimbursement; however, Medicaid reimburses APRNs at 100% of the physician rate only if the on-site physician countersigns the chart within 24 hours. Medicaid reimburses APRNs at 85% of the physician rate if the physician is not onsite and does not countersign. Managed-care companies are prohibited from discriminating against the reimbursement of APRNs based on licensure. Private insurers must reimburse CNM services if the policy includes pregnancy care.
APRNs are authorized by supervisory protocol to prescribe, dispense, administer, or order any drug, including Schedules II–V CSs as authorized in a BON-adopted CSs formulary with certain exceptions. Additionally, psychiatric mental health board-certified APRNs may prescribe psychotropic CSs.
APRNs prescribe under a protocol, which broadly lists the medical SOP and generic categories from which the APRN can prescribe, and the CSs formulary describes limitations and restrictions based on specialty certification, approved uses of CSs, and other restrictions the committee finds necessary to protect the health, safety, and welfare of the public. APRNs are authorized to request, receive, or dispense pharmaceutical samples.
Opioid prescribing restrictions signed in 2018 limit opioid prescribing for acute pain to 3 days; exceptions in dispensing previsions allow for MAT. A 7-day supply is permitted if medically necessary based on professional judgment. The term acute pain excludes cancer, terminal conditions, traumatic injury, and palliative care. Legislation enacted in 2019 requires APRNs and other prescribers to inform a patient of nonopioid alternatives including advantages and disadvantages of use and complementary and alternative therapies, prior to providing anesthesia or prescribing, ordering, dispensing, or administering an opioid listed as a schedule II CS to treat pain.
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 another related field and national board certification are required for all APRNs at entry into practice, except for CRNAs educated prior to 1999. APRN practice authority 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 BOM.
Practice under 43-34-25 prohibits APRNs from ordering certain radiographic imaging tests, such as MRI and computed tomography 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.
No statutes mandate the third-party reimbursement for APRNs. FNPs, PNPs, WHNPs, 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 the physician payment, and CNMs are reimbursed at 100% of the physician payment. Some private insurers reimburse APRNs but are not required by law to do so.
APRNs practice under a nurse protocol as defined by OCGA 43-34-23, which describes 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 Schedules III, IV, and V CSs, and request, receive, sign for, and distribute pharmaceutical samples. BON regulations governing protocols used by RNs require the RN to document preparation and performance specific to each medical act. Medication orders may be called in to a pharmacy.
The BON licenses and regulates APRNs in Hawaii consistent with the NCSBN APRN Consensus Model. APRNs include CNP (NP in regulation), CNS, CNM, and CRNA roles and have independent SOP and prescriptive authority. The APRN SOP is defined in statute and regulation and conforms to the NCSBN Model Act. Legislation passed in 2016 authorizes APRNs to certify patients for medical marijuana use.
Hospitals licensed in Hawaii recognize APRNs, allow them to function with full SOP, and authorize APRNs to act as a PCP in their institutions. 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 it reimburses to include PCNSs and additional NP specialties. Medicaid reimburses at 75% of the physician payment. Med-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 CSs independently pursuant to an exclusionary formulary established by the BON. APRNs with prescriptive authority are legally authorized to request, receive, and dispense manufacturers' prepackaged pharmaceutical samples. APRNs may not request, receive, or sign for CS samples; however, they may prescribe, order, and dispense medical devices and equipment.
Opioid prescribing restrictions were enacted in 2017 (Act 066/Chapter 39, Hawaii Revised Statutes, Subsection 329-38) restricting initial concurrent prescriptions of opioids and benzodiazepines to 7 days. Exceptions include chronic pain, cancer pain, palliative care, hospice care, substance use disorder or MAT, and postoperative care.
The BON regulates and grants FPA to APRNs. APRNs include CNP, CNS, CNM, and CRNA roles. APRN scope and standards of practice is defined in regulation (IDAPA 23.01.01.280) and is consistent with the NCSBN. APRNs are not statutorily recognized as PCPs; however, Idaho has “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 current RN licensure in Idaho, successful completion of an approved graduate or postgraduate APRN program accredited by a national organization recognized by the Board, and current national certification by an organization recognized by the Board for the specified role. Idaho is a member of the APRN Compact.
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.
Prescribing and dispensing authority is granted to APRNs who have completed 30 contact hours of pharmacology-specific formal instruction beyond basic RN education or who graduated from an APRN education program after December 31, 2015. Authorized APRNs may prescribe and dispense legend and Schedules II–V CSs 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.
The Illinois Department of Financial and Professional Regulation (IDFPR) grants authority and regulates APRN practice. APRNs include CNP, CNS, CNM, and CRNA roles. APRNs have FPA as defined in 225 ILCS 65/65-43, eliminating the requirement for a collaborative agreement following a transition to practice period, with some exceptions for prescribing CSs (discussed below in Prescriptive Authority).
The transition to practice period includes completion of 250 hours of CE or training and at least 4,000 hours of clinical experience in collaboration with a physician following national certification in the APRN role. Once completed, the APRN and physician collaborator must file an attestation of completion with the department. APRN SOP is defined in 225ILCS 65/65-30. All APRNs may practice only in accordance with their national certification.
Prior to meeting FPA requirements, APRNs must have a written collaborative agreement with a physician, podiatrist, or dentist, except for APRNs who provide services in a hospital, hospital affiliate, or ASTC, and have been granted clinical privileges by that facility. If a collaborative agreement with a physician or podiatrist is terminated, the APRN is authorized to continue to practice for up to 90 days after the termination of the agreement, provided the APRN seeks any needed collaboration at a local hospital and refers patients who require services beyond the training and experience of the APRN to a physician or other healthcare provider.
Legislation effective as of January 1, 2018, prohibits new collaborative arrangements with podiatric physicians, except for CRNAs. APRNs who had an existing collaborative agreement with a podiatric physician prior to the enactment of P.A. 100-513 on January 1, 2018, may continue to practice in that collaborating relationship or enter a new written collaborative relationship with a podiatric physician.
The APRN must hold a graduate degree, 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. 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, 2023.
The Illinois Department of Healthcare and Family Services (HFS) administers the Illinois Medicaid program. APRNs 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 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 APRNs does not exist. APRNs receive direct or indirect reimbursement from some third-party payers.
APRNs with FPA are authorized to prescribe both legend drugs and Schedules II–V CSs and includes selection of, orders for, administration of, storage of, acceptance of samples of, and dispensing of OTC medications, legend drugs, and other preparations, including but not limited to botanical and herbal remedies. Application for a Mid-Level Practitioner Illinois Controlled Substances License is required to prescribe CSs, in addition to DEA registration. All prescribers are required to enroll in the Illinois Prescription Monitoring Program and required to check the Program prior to initial prescription of Schedule II narcotics, such as opioids, and document the attempt in the patient's record.
Prescribing benzodiazepines or Schedule II narcotic drugs is authorized only in a consultation relationship with a physician, which must be recorded using the Illinois Prescription Monitoring Program website by the physician and APRN with FPA and is not required to be filed with the Department of Financial and Professional Regulation. At least monthly, the APRN and physician must discuss the condition of any patients for whom a benzodiazepine or opioid is prescribed.
Prescriptive authority, including prescribing Schedules II, III, IV, and V CSs, may be authorized by clinical privileges in a hospital, hospital affiliate, or ASTC, or may be delegated to an APRN by a physician or podiatrist as a part of the written collaborative agreement during the transition to practice period. Delegation to prescribe CSs must be noted in the written collaborative agreement.
For APRNs prescribing CSs under a written collaborative agreement, the collaborating physician or podiatric physician must have a valid, current Illinois CS license and federal registration. In the case of prescribing Schedule II CSs, such delegation, whether by written collaborative agreement or by privileging by a hospital, hospital affiliate, or ASTC, must identify the specific Schedule II CSs by either brand name or generic name.
Of the 80 hours of CE required for 2-year APRN licensure renewal, a minimum of 20 hours of pharmacotherapeutics must be completed, including 10 hours of opioid prescribing or substance abuse education.
The Indiana State BON grants authority to and regulates APRNs, which include CNP (NP in regulation), CNM, CNS, and CRNA roles. The BON does not issue additional, separate licenses or certification to NPs or CNSs; however, CNMs apply for “limited licensure” to practice in that role. APRNs without prescriptive authority may function independently in their advanced practice as defined in regulation. APRNs seeking prescriptive authority must complete a graduate, postgraduate, or doctoral APRN program, hold national board certification in their APRN role, and submit proof of a written CPA with a licensed practitioner (licensed physician, dentist, podiatrist, or optometrist).
Written CPAs must be approved by the BON and include the way the APRN and licensed physician will cooperate, coordinate, and consult with each other on the provision of healthcare, and the specifics of the licensed physician's reasonable and timely review of the APRN's prescribing practices, including the provision for a minimum weekly review of 5% random chart sampling.
In hospitals, APRNs are authorized to practice in collaboration with a licensed practitioner as evidenced by a practice agreement; by privileges granted by the governing board of a hospital licensed under IC 16-21 (hospitals) with the advice of the medical staff that sets forth the manner in which the APN and licensed practitioner will cooperate, coordinate, and consult with each other; or by privileges granted by the governing body of a hospital operated under IC 12-24-1 (state hospitals) that set forth the manner in which the APN and licensed practitioner will cooperate, coordinate, and consult with each other.
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 the physician payment. Medicaid for children, however, does not allow for NP reimbursement under current managed-care arrangements. Recent legislation in 2016 directs Medicaid managed-care and fee-for-service plans to reimburse NPs and CNSs employed by community mental health centers for services as specified.
The BON has legal authority to establish prescriptive authority rules, and with the approval of the BOM, to authorize prescriptive authority for APRNs, including legend and CSs. APRNs must obtain a BON-issued prescriber authority ID number, Indiana State Controlled Substances Registration and federal DEA number. Recent legislation authorizes NPs to prescribe legend drugs to patients receiving care via telemedicine if they have established a provider–patient relationship, satisfy the standard of care, and document the prescription in the medical record.
CRNAs are not required to obtain prescriptive authority to administer anesthesia.
Opioid prescribing legislation passed in 2017 (IC 25-1-9.7), limited initial opioid prescriptions for acute pain in adults and children to 7 days. Exemptions to the number of days include cancer, palliative care, provider judgment, substance use disorder/MAT, and other exemptions adopted by medical licensing board rule.
The BON regulates the practice of APRNs, which are defined as ARNPs and include CNP, CNS, CNM, and CRNA roles. The ARNP must be certified by a national professional certification organization in at least one population focus, which includes family/individuals across the lifespan, adult/gerontology, neonatal, pediatrics, women's health/gender, and psychiatric mental health.
ARNPs practice autonomously within their specific role and population focus, and 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 active licensure as an RN and national board certification. The majority of ARNPs are educated at the master's or doctoral level.
Iowa's Medicaid managed-care and prepaid service programs reimburse ARNPs. Payment of necessary medical or surgical care and treatment is provided to an ARNP via third-party reimbursement if the policy or contract would pay for the care and treatment when provided by a physician 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 prescriptive authority within their specific role and population focus, including Schedules II–V CS medications. ARNPs may prescribe, deliver, distribute, or dispense noncontrolled and controlled drugs, devices, and medical gases, including pharmaceutical samples. ARNPs are required to complete a minimum of 2 contact hours of CE regarding the CDC guideline for prescribing opioids for chronic pain and must query the Prescription Monitoring Program database prior to prescribing or dispensing an opioid with some exceptions (IAC Chapter 7 Sections 655-7.6, 7.7).
The Kansas BON grants authority to APRNs and regulates the practice, issuing a separate license. Recognized APRN roles include the CNP (NP in regulation), CNS, CNM (NM in regulation), and CRNA (RNA in statute). CNPs, CNSs, and CRNAs function in collaborative relationships with physicians and other healthcare professionals in the delivery of primary healthcare services. The Independent Practice of Midwifery Act in 2016 authorized CNMs to practice without a collaborative agreement when such services were limited to those associated with a normal, uncomplicated pregnancy and delivery.
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 CNP, CNS, or CRNA 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 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 rate (except for practitioners performing early periodic screening diagnosis and treatment who receive 100%). Nurse anesthetists receive 85% of physician payments. Some insurance companies are paying 85% of physician payments to APRNs.
APRNs, except for CRNAs, are legally authorized to prescribe medications, including Schedules II–V CSs, pursuant to a collaborative practice agreement and written protocol. The protocol must contain 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.
CNMs may prescribe drugs and devices without a collaborative practice agreement when the service is associated with family planning services, including treatment or referral of a male partner for sexually transmitted infections, initial care of the newborn, and a normal, uncomplicated pregnancy and delivery. The prescription order must be signed by the APRN and include the name of the physician and APRN.
APRNs must register with the DEA and the BON if they prescribe CSs. Prescription labels include both the APRN's and physician's name. APRNs are authorized to request, receive, and distribute pharmaceutical samples, except for CSs, 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 (201 KAR 20:057, Section 3).” APRNs are recognized as practitioners in statute (KRS 314.195), included in the definition of “practitioner” for prescribing (KRS 217.015 , KRS 218A.010 ), and are legally authorized to admit patients to a hospital and hold hospital privileges; however, hospital regulations permit medical staff to set conditions (902 KAR 20:016 Section 3 [b][b]). A master's degree, doctorate, or postmaster's certificate as an APRN and national board certification are required to practice in Kentucky.
The state medical assistance program reimburses APRNs for services at 75% of the physician rate in all state regions. Kentucky is an “any willing provider” state. In April 2003, the US 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.
Legislation passed in 2018 requires APRNs to pass a jurisprudence exam for prescriptive authority in Kentucky, ensuring APRNs are familiar with the requirements of obtaining and maintaining prescriptive authority for nonscheduled legend drugs and CSs. APRNs have autonomous prescriptive authority for nonscheduled legend drugs following 4 years of prescribing experience under a Collaborative Agreement for Prescriptive Authority for Nonscheduled Drugs (CAPA-NS) with a physician licensed in Kentucky. CRNAs are not required to have a CAPA to deliver anesthesia care.
Prescribing of Schedules II–V CSs is authorized pursuant to a permanent Collaborative Agreement for Prescriptive Authority for Controlled Substances (CAPA-CS). The CAPA-CS and CAPA-NS define an APRN's scope of prescriptive authority and are signed by the APRN and the physician.
APRNs may prescribe scheduled medications with the following limitations: Schedule II CSs for a 72-hour supply; there are two exceptions: certified psychiatric/mental health APRNs may prescribe a 30-day supply of psychostimulants, and all APRNs may prescribe a 30-day supply of Schedule II controlled hydrocodone-combination products without refill.
Statute limits all prescribers to a 72-hour (3-day) supply of Schedule II CSs (including hydrocodone-combination products) when prescribing the Schedule II CS for acute pain, with exceptions including documentation for more than a 72-hour supply for acute pain justifying deviation from the 3-day supply; chronic pain; pain associated with a valid cancer diagnosis; pain associated with end-of-life treatment; part of a narcotic treatment program; pain following a major surgery or treatment of significant trauma; or dispensed or administered directed to an ultimate user in an inpatient setting.
Schedule III CSs may be prescribed for a 30-day supply without refills; Schedules IV and V CSs 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. Gabapentin was rescheduled as a Schedule V CS in Kentucky in 2017 and will be recorded and monitored in the Kentucky PDMP. APRNs must complete 5 pharmacology contact hours annually as part of their CE requirement (all APRNs with a CAPA-CS must include 1.5 of the 5 contact hours related to the use of the prescription monitoring system, pain management, or addiction disorders).
APRNs are legally authorized to request and receive, as well as dispense, nonscheduled legend pharmaceutical samples. APRNs may also dispense nonscheduled legend drugs from local, district, and independent health department settings subject to the direction of the appropriate governing board of the individual health department.
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 CPA, 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.
The APRN 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, excluding receipt of CSs samples.
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 BON, 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 rate 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 CSs. The BON has sole authority to develop, adapt, and revise R&Rs governing SOP, including prescriptive authority, the receipt and distribution of sample and prepackaged drugs, and prescribing legend and controlled drugs. An APRN who is granted limited prescriptive authority may request approval to prescribe and distribute CSs as agreed upon by the APRN's collaborating physician, and the patient population is served by the collaborative practice. All medical practitioners are limited to prescribe a 7-day supply of opioid medication when issuing a first-time prescription for outpatient use to an adult with an acute condition and any opioid prescription for a minor. Exceptions to the limitation are provided for in law.
Past amendment of regulations (Title 46, Part XL VII, §4513) provide for CRNA prescriptive authority without a CPA when prescribing or writing orders in a hospital or other licensed surgical facility for services related to anesthesia care. Rules continue to require a CPA for prescriptive authority of non-CRNAs. New provisions removed the requirement to submit the CPA to the Board.
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 except for services provided in critical access or rural hospitals following enactment of legislation in 2017 and are authorized to order appropriate lab tests and diagnostic imaging tests in the perioperative and immediate postoperative periods. 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. CNPs are authorized to certify patients to receive therapeutic or palliative benefit from medical use of marijuana.
The hospital governing body has the authority, in accordance to state law to grant medical staff privileges and membership to nonphysician practitioners. 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 practice.
The 1999 Act to Increase Access to Primary Health Care Services requires reimbursement under an indemnity or managed-care plan for patient visits to an NP or CNM when referred from a PCP, requires insurers to assign 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 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 Schedules II–V CSs, in accordance with rules adopted by the BON and require CNPs and CNMs to prescribe from FDA-approved drugs related to the nurse's specialty.
CNPs and CNMs may prescribe Schedules II–V CSs and drugs off-label, according to common and established standards of practice. CNPs and CNMs may receive and distribute drug samples included in the formulary for prescription writing.
CRNAs are authorized to order and prescribe medication during the perioperative and postoperative period. CRNAs may prescribe Schedules III, IIIN, IV, and V CSs only for a supply of not more than 4 days with no refills; and for an individual for whom the CRNA has at the time of the prescription, established a client or patient record.
Legislation passed in 2016 limits opioid prescribing for all prescribers. Limits to patient prescriptions include any individual or combination of opioid medication in an aggregate amount in excess of 100 morphine milligram equivalents (MME) per day; prescriptions for chronic pain may not exceed a 30-day supply for chronic pain and a 7-day supply for acute pain. Exceptions include cancer treatment, palliative care, hospice care, MAT, and other circumstances determined by the Department of Health and Human Services; direct administration/ordering of a benzodiazepine or opioid in the ED setting, inpatient hospital setting, long-term-care facility, or residential care facility. Prescribers must successfully complete 3 hours of CE every 2 years on the prescription of opioid medication as a condition of prescribing opioid medication (Public Law, Chapter 488).
The Maryland BON 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). NPs enjoy full practice authority with SOP defined in statute and regulations in accordance with the Standards of Practice of the American Association of Nurse Practitioners or any other national certifying body recognized by the BON.
NP applicants who have never been certified as an NP in Maryland or any other state are required to name a mentor (NP or physician licensed in Maryland) upon application to the BON who is available for advice, consultation, and collaboration as needed throughout an 18-month transition to practice period beginning the date of application. CRNAs maintain an affirmation of collaboration with the BON containing the name and license number of an anesthesiologist, physician, or dentist; however, there is no direct supervision requirement. A master's degree is the minimum required degree to enter practice in Maryland in addition to national board certification.
NPs and CNMs holding a state-controlled dangerous substances registration, registration with the Maryland Medical Cannabis Commission, and are in good standing with the state BON may issue written certification for medical marijuana use to qualifying patients.
All nurses are entitled to private third-party and Medicaid reimbursement for services if they are practicing within their legal SOP. All Medicaid recipients have been assigned to an MCO; CNPs (except for neonatal and acute care) and CNMs have been designated as PCPs and may apply for placement on a provider panel. Medicaid reimburses at 100% of physician payment.
Recent legislation requires Medicaid to reimburse PCPs for telemedicine services. The law allows due process for APNs listed on managed-care panels; APRNs are not to be arbitrarily denied. The law does not require that an HMO include CNPs on the HMO panel as PCPs. Several commercial insurers reimburse NPs directly; however, reimbursement is generally at a rate of 75% to 85% of a physician's fee schedule.
CNPs and CNMs have full prescriptive authority, including for Schedules II–V CSs. In addition to federal DEA registration, CNPs and CNMs are required to obtain a state DEA number. CNPs are legally authorized to prepare and dispense medications, including CSs in occupational health facilities, nonprofit clinics or health facilities, student health clinics within institutions of higher education, public health facilities, and nonprofit hospitals or nonprofit hospital outpatient facilities.
The Massachusetts BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CRNA, PCNS, CNS, and CNM roles. 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 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 nurse anesthetists 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–V CSs. Authorized APRNs must apply to the Massachusetts Department of Public Health for MA Controlled Substance Registration in addition to the DEA for DEA registration. CNPs, CRNAs, and PCNSs must establish written guidelines developed in collaboration with the nurse and supervising physician, which includes a defined mechanism to monitor prescribing practices and must designate a physician who will provide medical direction for prescriptive practice as is customarily accepted in the specialty area. When issuing a prescription for an opioid medication to an adult patient for outpatient use for the first time, the prescription is limited to a 7-day supply for all prescribers. Opiate prescriptions for a minor is limited to a 7-day supply at all times. Exceptions include chronic pain management, pain associated with cancer, or for palliative care.
Application for prescriptive authority and to renew authorization requires all prescribers to complete education relative to effective pain management, risks of abuse and addiction associated with opioid use, identification of patients at risk for substance abuse disorders, patient counseling, appropriate prescription quantities, and use of opioid antagonists, and opioid overdose prevention treatments are required for all prescribers prior to obtaining or renewing their professional licenses (M.G.L. c. 94C s.18(e)).
Initial prescription of Schedule II CSs requires review within 96 hours. Authorized APRNs can 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 Michigan BON grants legal authority to practice and regulates the practice of APRNs through certification issued to them as an RN. Newly defined in statute, APRNs include RNs who have been granted a specialty certification by the BON in the following roles: CNP, CNS, and CNM. CRNAs (NA in statute) are recognized by the BON and granted specialty certification but are not categorized as APRNs in statute. 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 interpreted NP practice as “supervised” due to their ability to “diagnose,” which is defined as the practice of medicine.
The certification recognizes the additional training and completion of a certification program that enables the RN to handle tasks of a more specialized nature that are delegated to him or her. APRN SOP is not defined within statute, and thus, is considered the RN SOP and what tasks can be delegated by another licensee, which is typically a physician.
Under some HMOs and systems, CNPs are recognized as PCPs. Michigan does not have “any willing provider” language in statute. Michigan statute does not specifically authorize APRNs to admit patients or hold hospital privileges; however, this depends on the institution, and hospitals generally grant these privileges. APRNs are required to have a graduate degree in nursing and national board certification to practice.
Medicaid directly reimburses all certified CNPs at 100% of the reimbursement rate. CRNAs and CNMs are also recognized by Medicaid and directly reimbursed. BC/BS directly reimburses all CNPs, CNMs, and CRNAs; however, the statute does not legally require insurance companies to credential, empanel, or recognize nurse specialists.
APRNs are authorized to prescribe nonscheduled prescription drugs; prescribing Schedules II–V CSs is authorized as a delegated act of a physician and must include the APRN and physician names and DEA numbers.
APRNs may order, receive, and dispense nonscheduled complementary starter dose drugs independently; however, delegation by a physician is required to order, receive, and dispense complementary starter doses of Schedules II–V CSs. Prescription labels include both the APRN and physician name.
The Minnesota BON grants APRNs the authority to practice through licensure and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. APRNs have full practice authority 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 APRNs 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 CSs, independently. 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 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 will 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 5:00 p.m.
CNPs and CNMs have full prescriptive authority, including Schedules II–V CSs, 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 prescriptive authority. Schedules II–V CSs 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 CS Rx authority protocol to the BON. CNMs and CRNAs may order CSs 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, and are not required to have a collaborative practice arrangement. 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 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, IV, and V CSs as delegated by a physician pursuant to a written CP arrangement. APRNs with a CP arrangement and CS prescriptive authority are authorized to prescribe hydrocodone-containing compounds from Schedule II CSs. Legislation passed in 2018 authorizes prescriptive authority for buprenorphine up to a 30-day supply without refill for patients receiving MAT for substance use disorders under the direction of the collaborating physician.
CNPs, CNSs, and CNMs must complete 1,000 hours of postgraduate clinical experience in the APRN role prior to application for CS authority. Hydrocodone-containing Schedule II and all Schedule III opioid prescriptions is 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 and dispense samples within their prescriptive authority. A state Bureau of Narcotics and Dangerous Drugs number, as well as a DEA number, is 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 have full practice authority following licensure. 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 24.159.1405 and 24.159.1406. APRNs are legally authorized to admit patients and hold hospital privileges; however, this varies according to the rules and bylaws of each hospital.
APRNs may sign, certify, stamp, verify, endorse, or sign affidavit documents when required by law or administrative rule. APRNs licensed after 2008 must have a graduate-level degree or postgraduate certificate from an accredited APRN program and hold national certification to practice. APRNs seeking licensure by endorsement from another state must hold national certification among other requirements. 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 prescriptive authority must apply for recognition by the BON. APRNs with prescriptive authority are independently authorized to prescribe all medications, including Schedules II–V CSs and are permitted to request, receive, and dispense drug samples. Renewal of prescriptive authority occurs every 2 years, including an affirmation of a minimum of 12 contact hours of accredited education in pharmacology, pharmacotherapeutics, and/or clinical management of drug therapy.
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 enjoy FPA following a 2,000-hour transition-to-practice period supervised by an experienced physician or NP, as defined. 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. 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 with a licensed physician or osteopathic physician. An IPA is not required for CRNA practice. CNS SOP 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 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. Medicaid reimburses NPs at 100% of the physician rate. Legislation passed in 2016 authorizes board-certified primary care NPs or those NPs who specialize in family practice, internal medicine, or pediatrics to be listed as a Direct Provider and be reimbursed for services under the Direct Primary Care Agreement Act.
Nebraska NPs are authorized full prescriptive authority, including Schedules II–V CSs as defined in Nebraska's statute. NPs may request, receive, and dispense pharmaceutical samples if the samples are drugs within their prescriptive 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 who 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 if the new graduate or those practicing for less than 2 years desire Schedule II CS prescribing authority.
APRN SOP is defined in the NPA and includes the nationally established scope and standards for the APRN role and global signature authority. APRNs are not recognized as PCPs under Nevada state law. Legislation passed in 2019 authorizes admission of an APRN to membership on the medical staff of a hospital. The new amendments further APRN authority to admit and care for patients in a hospital setting. APRN licensure after July 14, 2014, requires a master's or doctorate degree in nursing or related health field and national board certification.
APRNs are recognized by insurance companies and receive third-party reimbursement.
BON-authorized APRNs with FPA may prescribe Schedules II–V CSs, poisons, and dangerous drugs and devices when authorized by the BON and a certificate of registration is 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 CSs.
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; APRNs with prescriptive authority may receive and distribute samples without dispensing authority.
The New Hampshire BON grants APRNs authority to practice and regulates their practice. APRNs include 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 Hampshire; however, state law does not include “any willing provider” language. APRNs may admit patients and hold hospital privileges per individual institutional policy. The minimum academic degree required to enter 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.
The passage of legislation in 2016 requires all prescribers who possess DEA registration to register with the Prescription Drug Monitoring Program and shall complete and submit verification of 3 contact hours (of the 5 that are already required for renewal and reinstatement) of regulatory board-approved online CE or pass an online exam in the area of pain management, opioid prescribing, addiction disorder, or a combination, as a condition for initial licensure and license renewal or reinstatement. 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. CNMs are regulated by the New Jersey BOM. 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 master's-prepared in nursing, and national board certification is required to enter 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. After 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, NJ 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). If 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 CSs, 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 CSs, APNs must have both a state-controlled dangerous substance (CDS) number/federal DEA number and have modified the joint protocol to indicate whether prior consultation with the collaborating physician is necessary before initiating CDS prescriptions. In addition to basic pharmacology education requirements required for APN certification, all APNs must complete a one-time, 6-hour course in CS prescribing, including addiction prevention and management by an approved/accredited organization. APNs are authorized to request, receive, and dispense pharmaceutical samples.
The New Mexico BON grants APRNs the authority to practice and regulates the practice. APRNs include CNP, CNS, and CRNA roles. CNPs enjoy FPA and their SOP is defined in statute 22.214.171.124 of Chapter 61, Article 3 of the New Mexico Statutes. APRNs are statutorily recognized as PCPs when providing care within their SOP in several areas of New Mexico law; however, New Mexico does not have “any willing provider” language contained within the statutes. In 2019, legislation passed mandating hospital admitting and discharge privileges and membership on medical staff committees for CNPs, CNSs, and CNMs in parity with physician privileges. A master's degree in nursing or higher and national board certification are required to enter practice as a CNP.
CRNAs seeking initial licensure must hold a master's degree or higher and work in an interdependent relationship with a physician. CNSs must be master's prepared and certified by a national certifying nursing organization. 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 CSs. BON prerequisites to prescribe CSs include experience with prescription writing, a state-CS license, and DEA registration. CNPs prescribe in accordance with R&Rs, guidelines, and formularies promulgated by the Board. CNSs must have graduate-level pharmacology, pathophysiology, a physical assessment course, and prescribe in collaboration with a physician, CNP, or CNS with prescriptive authority during a 400-hour preceptorship before they can prescribe independently.
CNMs have prescriptive authority pursuant to the rule-making authority of the Department of Health. CRNAs who meet prescriptive authority requirements may collaborate independently, and prescribe and administer therapeutic measures, including dangerous drugs and CSs, within emergency procedures, perioperative care, or perinatal care environments. CNPs and CNSs with prescriptive authority may distribute dangerous drugs and Schedules II–V CSs that have been prepared, packaged, or prepackaged by a pharmacist or pharmaceutical company.
New York's NPA is codified in Education Law Article 139. The New York State Education Department certifies CNPs (NP in statute) to practice in defined areas, including family, gerontology, neonatology, obstetrics, oncology, pediatrics, perinatology, psychiatry, school health, women's health, holistic, and palliative care. The term APRN is not defined in New York statutes or regulation. NPs diagnose illnesses and physical conditions and perform therapeutic and corrective measures within the specialty area of practice in which the NP is certified.
New York's NPA requires all NPs with less than 3,600 hours of practice experience to practice pursuant to a written practice agreement with a collaborating physician. NPs with more than 3,600 hours of qualifying practice experience can opt to: practice in accordance to a written practice agreement with a collaborating physician, or practice and have collaborative relationships with one or more qualified physicians or a New York State Department of Health licensed hospital, nursing home, or clinic. Collaborative relationships are when an NP communicates, by phone, in person, in writing, or electronically with a qualified physician to exchange information to provide comprehensive care or to make referrals as necessary.
NPs are legally authorized to hold admitting privileges. A master's degree in nursing is required to enter 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.
In New York, most NPs have National Provider Identifiers (NPIs) issued by the US Center for Medicaid and Medicare Services. In New York, NPs can form and own private practices that provide NP services. NPs qualify as participating providers in New York's Medicaid program, Medicare program, and a variety of commercial managed-care and insurance plans.
NPs are eligible for full prescription privileges if they complete the coursework in prescription writing and record keeping required in New York State. NPs can prescribe or order medications, including Schedules II–V CSs, diagnostic tests, imaging studies, lab tests, and medical devices.
NPs can issue nonpatient-specific orders and protocols (standing orders) to be executed by registered professional nurses. NPs may dispense medications to their patients. Midwives are authorized to prescribe and administer drugs, immunizing agents, diagnostic tests, devices, and order lab tests limited to the practice of midwifery; they may dispense pharmaceutical samples packaged or prepackaged by a pharmacist or pharmaceutical company.
In North Carolina, APRN is defined in a regulation that includes CNP, CNS, CNM, and CRNA roles. A joint subcommittee of the North Carolina BON and the North Carolina Medical Board grants CNPs the authority to practice and regulate their practice. Both CRNAs and CNSs are regulated solely by the BON. CNMs are regulated by the Midwifery Joint Committee. Eligibility requirements for all APRN roles include a current unencumbered RN license, graduate education in one of the four recognized APRN roles, and initial and ongoing national certification in their population focus as an APRN.
CNPs legally practice under a supervisory relationship with a primary supervising physician (PSP). The parameters of the CNP's practice is operationalized through a CPA, which must describe the arrangement for CNP-PSP continuous availability to each other for the ongoing supervision, consultation, collaboration, referral, and evaluation of care provided by the NP. The CPA also includes the drugs, devices, medical treatments, tests, and procedures that may be prescribed, ordered, and performed by the CNP as well as a plan for emergency services.
During the first 6 months of CNP practice with a new PSP, monthly Quality Improvement Process meetings are required, then every 6 months after. These meetings must be documented with CNP and PSP signatures. State law does not prohibit CNPs from having admitting privileges and hospital privileges; however, these are granted on a facility-by-facility basis. APRNs are authorized to form professional corporations or professional limited liability companies for providing medical services.
CNPs/CNMs receive Medicaid reimbursement at 100% of the physician rate for primary care activities. CNPs who are enrolled as psychiatric/mental health providers receive 85% of the physician rate. Statutory authority for third-party reimbursement for CNPs provides direct reimbursement to CNPs for services within their scope. Psychiatric/mental health CNS services are reimbursable by insurance. CRNA services are reimbursable by insurance.
CNPs and CNMs have full prescriptive authority, including Schedules II–V CSs that are identified in their CPA. Dispensing may be done under specific conditions and if a dispensing license has been obtained. CNPs/CNMs may provide refills consistent with CS laws and regulations, which stipulate that prescriptions for Schedule II CSs cannot be refilled.
A new prescription must be issued. Adoption of the 2017 Strengthen Opioid Misuse Prevention (STOP) Act limits prescribers to a 5-day supply of any “targeted controlled substance” (G.S. 90-90 or  or G.S. 90-91[d]) upon initial consultation and treatment for acute pain, and a 5-day supply of any “targeted controlled substance” for postoperative acute pain relief for use following a surgical procedure, with some exceptions.
The STOP Act further requires the CNP to consult with a supervising physician prior to prescribing some certain Schedule II and Schedule III CSs labeled “targeted controlled substances” in a pain management clinic or where pain management services are advertised when use of the targeted CS is expected to exceed 30 days. CNPs must consult with the physician at least once every 90 days thereafter.
CNPs and CNMs with CSs in their collaborative practice agreements must obtain DEA registration (in addition to their approval number issued at the time of their approval as CNPs/CNMs), and the supervising physician(s) shall possess the same schedule(s) of CSs as the CNP's DEA registration. CNPs are authorized to hand out, free of 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. BC/BS 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 will be reimbursed the lesser of provider's billed charges or 85% of the BC/BS physician payment system(s) in effect at the time services are rendered.
Authorized APRNs may prescribe, administer, sign for, and dispense OTC, legend, and CSs and procure pharmaceuticals, including sample legend drugs and Schedules II–V CSs. For prescriptive authority, the APRN must apply to the BON and meet the requirements outlined in North Dakota Administrative Code 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. The BON issues APRN licenses with the designation of CNP, CRNA, CNM, or CNS. Legal authority to practice requires a CP arrangement (standard care arrangement in statute) between a physician or podiatrist and an APRN-CNP or APRN-CNS, and between a physician and an APRN-CNM in the form of a standard care arrangement (practice agreement). Psychiatric-mental health CNPs and CNSs may only enter a CP with a physician practicing in psychiatry, pediatrics, or family practice/primary care.
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 within the nurse's specialty, consistent with the nurse's education and certification.
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 hospital's medical staff. Applicants for APRN licensure must have a master's or doctoral degree in nursing or a related field that qualifies the individual to sit for the national certifying exam and hold national certification to enter practice.
Ohio's Medicaid program recognizes CNPs certified in family, adult, acute care, geriatric, neonatal, pediatric, and women's health/obstetrics. 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. The BON does not maintain information regarding reimbursement.
Ohio state law includes prescriptive authority within the APRN license issued to CNPs, CNMs, and CNSs including Schedules II–V CSs under rules and in collaboration with a physician. APRN-CNPs, APRN-CNMs, and APRN-CNSs register with the Ohio Automated Rx Reporting System and access the database information as required.
APRNs prescribe based upon an exclusionary formulary recommended by the Interdisciplinary Committee on Prescriptive Governance (CPG) and adopted by the BON. The exclusionary formulary states that a CNP, CNS, and CNM shall not prescribe any drug in violation of federal or Ohio law. By statute, the prescriptive authority of a CNP, CNS, or CNM shall not exceed the prescriptive authority of the collaborating physician or podiatrist. APRNs are permitted to prescribe newly released drugs if they are not of a type that is prohibited by the exclusionary formulary. The CPG will review newly released drugs to determine if they should be excluded under the formulary.
APRNs 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 CSs is limited to prescriptions issued from specific locations and programs recognized in Ohio nursing law and consistent with the APRN's standard care arrangement. Limitations are also placed on APRNs' prescribing of opioids for the treatment of acute pain.
APRNs who are not practicing in a location or program recognized in law are limited in their Schedule II CS prescribing to the care of terminally ill patients after a physician has initiated and only for a 72-hour period. DEA registration is required. APRNs with prescriptive authority may request, receive, sign for, and personally furnish sample medications. All samples of medications that are personally furnished by the APRN must be consistent with the APRN's scope and not excluded by state or federal law.
The Oklahoma BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNS, CNM, and CRNA roles. CNPs function independently except for prescriptive authority, which requires supervision by a physician. APRNs practice within a SOP as defined by the NPA. The SOP for a CNP is further identified in specialty population foci. Initial licensure as an APRN requires graduation from a graduate level accredited APRN program and national certification consistent with educational preparation.
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.
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. Negotiations continue with other third-party insurers.
The BON regulates optional prescriptive authority for CNPs, CNSs, and CNMs, which includes Schedules III, IV, and V CSs. Physician supervision is required for prescriptive authority, and applicants for prescriptive authority must submit a written statement from an Oklahoma licensed physician, which identifies a mechanism for appropriate referral, consultation and collaboration, and availability of communication between the APRN and physician to the BON. Prescribing parameters include the following: drugs must not be on the exclusionary formulary approved by the BON; must be within the CNP, CNM, and CNS SOP; include Schedules III, IV, and V CSs (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 CSs.
Legislation passed in 2019 requires CNPs, CNSs, and CNMs to complete 2 hours of CE in pain management or 2 hours of education in opioid use or addition, in addition to the 15 contact hours of pharmacotherapeutics for renewal of prescriptive authority.
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 or 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 practice. Only physicians can authorize medical marijuana use.
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 full payment parity from private insurers for NPs in independent practice and when billing through a clinic or practice. Numerous administrative rules and statutes include NPs, such as those for special education physical exams (Department of Education) and chronically ill and disabled motorist exams (Department of Motor Vehicles).
Regulation of prescriptive authority is under the sole authority of the BON and is defined in Division 56 of the NPA. 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 CSs. 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.
CRNAs are authorized to select, obtain, order, and administer preanesthetic medications, anesthetic agents, and medications necessary for implementing and managing pain management techniques during the postanesthesia period pursuant to ORS 851-052-0010. CRNAs may apply to the BON for limited prescriptive authority.
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 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 CRNP's SOP is defined in statute and regulation. CRNPs are recognized as PCPs by the Department of Human Services and many insurance companies, but some managed-care companies 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. CRNPs must have a master's degree and pass a national certification exam to practice. 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 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 CSs, 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, not from a prohibited drug category, and conforms with regulations. The CRNP may write a prescription for a Schedule II CS for up to a 30-day supply.
CRNPs may prescribe Schedules III and IV CSs 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 Rhode Island BON grants APRNs FPA and regulates their practice. APRNs include CNP, CNS, and CRNA roles. CNMs are licensed and regulated under separate R&Rs and 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 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. PCNSs practicing in collaboration with or employed by a physician receive third-party reimbursement; there is no collaborative or supervisory language in the statute as it pertains to CNPs. United Healthcare has begun to empanel NPs, and the Neighborhood Health Plan fully empanels CNPs as PCPs. 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 an anesthesiologist or dentist.
With the passage of S614 in 2013, APRNs are granted independent prescriptive authority, including authority to prescribe, order, procure, administer, dispense, and furnish OTC, legend, and CSs (General Laws in Chapter 5-34, Section 5-34-49) within their APRN role and population focus. CNPs may also be authorized to apply to prescribe Schedules II–V CSs. 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 are subject to the scope and standards of practice established by the board-approved credentialing organization representing their specialty area of practice. Additionally, APRNs may perform activities of advanced practice consisting of nonmedical acts such as population health management, quality improvement, or research projects within a healthcare system; and analysis of data and corresponding system recommendations, revisions, developments, or informatics.
For the performance of medical acts including prescribing medications, CNPs, CNSs, and CNMs practice pursuant to a written practice agreement developed with a licensed physician or medical staff who is readily available in person or by electronic means for consultation. Practice agreement requirements are defined in S.C. Code Ann. Section 40-33-34 (D)(2)(a)-(e). A licensed physician may enter into a practice agreement with a maximum of one physician to six full-time equivalent (FTE) APRNs. CNMs may also practice pursuant to written policies and procedures for practice developed with an OB/GYN physician. CRNAs practice pursuant to approved written guidelines developed with the supervising physician or dentist or by medical staff within the facility where practice privileges have been granted.
APRNs are authorized to admit patients to a hospital and hold hospital privileges at the discretion of the individual agency. APRNs must hold a doctorate, postmaster's certificate, or a minimum of a master's degree in nursing and achieve national certification within 2 years postgraduation to enter practice.
All NPs, regardless of specialty, may apply for an NPI number, are paid 85% of the physician 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 physicians.
NPs, CNSs, and CNMs are authorized to prescribe drugs and devices listed in the practice agreement including Schedules III, IV, and V CSs limited to medical problems within the specialty field of the NP, CNS, or CNM. The practice agreement may include Schedule II nonnarcotic substances; however, each prescription must not exceed a 30-day supply; schedule II narcotic substances may be prescribed not to exceed a 5-day supply and another prescription must not be written without written agreement of the physician with whom the NP, CNS, or CNM has entered into a practice agreement. Schedule II narcotic substances for patients in hospice or palliative care listed in the practice agreement may be prescribed, limited to a 30-day supply. In addition to required identification, prescriptions must be signed or electronically submitted by the NP, CNM, or CNS with the prescriber's BON-assigned identification number, all prescribing numbers required by law, and the name of the physician where possible. 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. APRNs with prescriptive authority may request, receive, and sign for professional samples included in the practice agreement.
The South Dakota BON regulates and licenses APRNs. The term APRN is defined in statute and includes CNP, CNS, CNM, and CRNA roles. CNMs and CNPs practice full scope without a collaborative agreement after verifying completion of a minimum of 1,040 hours of practice as a licensed CNM or CNP. Nurses who cannot verify licensed practice hours are required to submit a collaborative agreement with a South Dakota licensed physician, CNM, or CNP to meet the requirement; when the minimum hours are met, the collaborative agreement is retired.
CRNAs and CNSs are required to collaborate with a physician; no written agreement or on-site supervision is required. CRNAs and CNSs do not have prescriptive authority, and CNSs must collaborate before ordering durable medical equipment or therapeutic devices. All APRNs may be granted hospital privileges. APRN licensure requirements include holding an unencumbered South Dakota RN license or multistate privilege to practice, a graduate degree in nursing, and national certification within role and population foci; certain exemptions are allowed.
CNPs and CNMs receive Medicaid reimbursement at 90% of the physician 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 Schedules II, III, and IV CSs. CNPs and CNMs have two CS registration options. They may seek independent state registration and independent DEA registration in Schedules II, III, and IV, or they may act as an agent of an institution, using the institution's registration number to prescribe, provide, or administer CSs. CS authority is granted by separate application to the South Dakota Department of Health.
CNPs and CNMs may request and receive prepackaged drug samples, which the NP or nurse midwife are authorized to prescribe. A drug sample means a prepackaged unit of a prescription drug supplied by the manufacturer and provided at no charge to the patient. An NP or nurse midwife may provide prepackaged, labeled drug samples to the NP's or nurse midwife's patients for conditions being treated by the NP or nurse midwife. Each sample drug shall be accompanied by written administration instructions.
Prior to prescribing any CSs listed in SDCL Chapter 34-20B, an NP or nurse midwife who meets state and federal CS registration requirements will register with the state's PDMP and meet requirements in Chapter 34-20E, including standards for documentation of patient care. CRNAs and CNSs do not have prescriptive authority; however, CNSs may order and dispense durable medical equipment and therapeutic devices in collaboration with a physician.
The Tennessee BON grants APRNs authority to practice and regulates their practice. APRNs are defined in regulation and include CNP (NP in regulation), CNS, CNM, and CRNA roles. APRNs meeting requirements for prescriptive authority are eligible for a certificate that is designated “with certificate to prescribe.”
APRNs must hold a current RN license in Tennessee or a compact state if their home state is a compact state. APRNs who prescribe must have protocols that are jointly developed by the APRN and a collaborating physician. Medical Board rules that govern the collaborating physician of the APRN prescriber are jointly adopted by the BOM and BON.
Physicians who collaborate with APRN prescribers are not required to be onsite but must personally review and sign 20% of the charts within 30 days; physicians are authorized to review charts electronically when the APRN is working in a free or reduced-fee clinic. 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. APRNs are required to hold a master's degree or higher in a nursing specialty and national certification to enter practice in this state.
Tennessee's private insurance laws mandate reimbursement of APRNs. A managed-care antidiscrimination law prevents MCO discrimination against APRNs (specifically CNPs, CNSs, CNMs, and CRNAs) as a class of providers. However, not all organizations are credentialing and accepting APNs into their network (as of now). This is a major issue being addressed by the Tennessee Nurses Association and private APRN practice owners.
BC/BS credentials APRNs 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 APRNs and assign an established patient panel upon individual review of specialty.
NPs who have a BON-issued certificate of fitness to prescribe may prescribe legend and Schedules II–V CSs. An NP with a certificate of fitness to prescribe must file a notice with the board, containing the name of the nurse practitioner, the name of the licensed physician collaborating with the NP who has control and responsibility for prescriptive services rendered by the nurse practitioner, and a copy of the formulary describing the categories of legend drugs to be prescribed and/or issued by the NP. Legislation passed in 2018 (Public Chapter No. 1039) amends prescriber requirements, now requiring the provider to confer with the CS database prior to issuing a prescription for CSs as a new course of treatment, prior to the issuance of each new prescription for the CS for the first (90) days of a new episode of treatment, and shall check the CS database for that patient at least every 6 months when that prescribed CS remains part of the treatment [TCA, Section 53-10-310 (e) (1)].
Additionally, the 2018 legislation places limits and requirements on the number of opioids prescribed and dispensed, limiting opioid prescriptions to up to a 3-day supply with a total of 180 MME for those 3 days. This limitation to supply count is subject to several exceptions under certain circumstances outlined in Tennessee Code Annotated, Title 63, Chapter 1, Part 1. Prescribing under these exceptions requires the prescriber to check the CS monitoring database, personally conduct a physical exam of the patient, consider nonopioid alternatives, obtain informed consent, including counseling about neonatal abstinence syndrome and contraception for women of childbearing age, and document the ICD-10 code for the patient's primary disease as well as the term “medical necessity” on 30-day prescriptions. These 10-, 20-, and 30-day opioid prescriptions will only be filled by dispensers in an amount that is half of the full prescription at a time, requiring patients and pharmacists to consider whether the patient requires the full amount prescribed.
There are still further exceptions for patients, including those who are undergoing active or palliative cancer treatment; receiving hospice care; diagnosed with sickle cell disease; receiving opioid therapy in a hospital; currently treated by a pain management specialist or collaborating provider in pain management; and patients who have received a 90-day or more opioid prescription supply in the year prior to April 2018 or subsequently do under one of the exceptions, which include MAT or suffering severe burns or major physical trauma.
Both the collaborating physician's name and address must be printed on the prescription blank; however, the APRN 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 prescriptions must be delegated by an MD or DO using written protocols or other written authorization in addition to a prescriptive authority agreement detailing those drugs and devices that may be ordered or prescribed by the APRN. These two documents may be combined into a comprehensive document providing authority for both provision of medical aspects of care and prescribing or ordering.
Protocols are agreed on and signed by the APRN and delegating physician, reviewed and signed at least annually, and maintained in the practice setting of the APRN. Protocols 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. APRNs complete a graduate or postgraduate program accredited by a national accrediting body. CNSs must hold a minimum of a master's degree in nursing. All APRNs must hold national board certification in their role and population focus to practice.
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. APRNs may be PCPs in Medicaid and Children's Health Insurance Program managed-care networks regardless of whether their collaborating physician is in network. APRNs are listed in the Texas Insurance Code as practitioners who must be reimbursed by indemnity health insurance plans.
APRNs may be delegated prescriptive authority by a physician when a prescriptive authority agreement as defined in §222.5 of Title 22, Part 11, Chapter 222 including nonprescription drugs, dangerous drugs, and devices including durable medical equipment is in accordance with regulatory standards and requirements. Schedules III–V CSs may be delegated through the prescriptive authority agreement with the following limitations: prescriptions may not exceed a 90-day supply in the form of a new or refill; beyond the initial 90 days, the refill for Schedules III–V CSs requires consultation with the delegating physician and documentation of the consult; is not authorized for a child less than 2 years of age prior to consultation with the delegating physician and documentation of the consult.
Schedule II CS 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.
Recent legislative changes have delayed effective date for monitoring the Prescription Drug Monitoring Program. Effective March 1, 2020, APRNs must review the Prescription Monitoring Program prior to writing a prescription for an opiate, benzodiazepine, barbiturate, or carisoprodol (H&S Code §481.0764).
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 Utah 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 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 except for Schedule II CS 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 pursuant to institutional policy. All APRNs must hold a master's degree or higher and be 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 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, now including Schedules II–V CSs, within their SOP. A consultation and referral plan are required if the APRN is prescribing Schedule II CSs in an independent solo practice and 1) has been licensed as an APRN for less than 1 year or has less than 2,000 hours of experience practicing as an APRN or 2) owns or operates a pain clinic.
APRN-CRNAs do not require a consultation or referral plan for their practice. CRNAs may order and administer drugs, including Schedules II–V CSs, 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 CS exam and obtaining a state CS 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 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 an SOP defined in statute and regulations. The requirement for board-approved practice guidelines following the transition to practice requirement was removed in the 2018 legislative session; however, regulatory amendments have not been completed at the time of publication. According to agency protocols, APRNs are authorized to admit patients to a hospital and hold hospital privileges. APRNs are required to have a graduate degree in nursing and hold national board certification to enter 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. Legislation passed in 2017 authorizes reimbursement to APRNs providing telehealth services within and outside of a healthcare facility.
APRNs have full prescriptive authority, including Schedules II–V CSs, within the SOP. APRNs have the same privileges dispensing and administering drugs as physicians. Prescribers are required to query the Vermont Prescription Monitoring System when prescribing a new or renewal prescription for an opioid within Schedules II, III, and IV CSs and when starting a patient on nonopioid Schedules II, III, or IV CSs for nonpalliative long-term pain therapy for more than 90 days. NPs register for their own 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 include NP, CNM, and CRNA roles. CNSs are recognized as APRNs; however, CNSs are registered solely with the BON and do not have prescriptive authority. NPs practice in collaboration and consultation within a written or electronic practice agreement with a patient-care team physician as part of a patient-care team; however, legislation passed in 2018 authorizes an NP with the equivalent of 5 years of full-time clinical experience to practice without a written or electronic practice agreement following submission of an attestation of experience from a patient-care team physician to the boards.
NPs practicing without a written or electronic practice agreement must: practice within the scope of their clinical and professional training and limits of their knowledge and experience and consistent with applicable standards of care; consult and collaborate with other healthcare providers based on clinical conditions of the patient; and establish a plan for referral of complex medical cases and emergencies to physicians or other appropriate healthcare providers. LNPs identified CNMs practice in consultation with a licensed physician in accordance with a practice agreement, and LNPs identified as CRNAs practice 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 are required to enter practice in Virginia. NPs are also authorized to certify medical necessity of durable medical equipment for Medicaid reimbursement.
Board-certified NPs and CNMs are reimbursed by Medicaid at 100% of the physician rate. PMH 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, PMH NPs are reimbursed at the same rate as other NPs.
Legislation passed in 2019 prohibits accident and sickness insurance and health services plans from denying direct reimbursement for NP-provided healthcare services. 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 CSs, 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. NPs authorized to practice without a practice agreement may prescribe all legend drugs, including Schedules II–V CSs.
CNMs may prescribe Schedules II–V CSs. 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 prescriptive 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 CSs 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 and regulates APRN authority to practice; APRNs, titled Advanced Registered Nurse Practitioners in statute, include NP, CNS, 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 legally authorized to serve as PCPs, admit patients to a hospital, and hold hospital privileges. However, hospitals and medical staff have the right to make the decision whether to credential an ARNP. A graduate degree and national certification are required to obtain licensure as an ARNP in Washington.
Medicaid and Labor & Industries reimbursement is available to ARNPs at 100% of the physician rate. 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. King County Superior Court, however, ruled 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 have the option to prescribe legend drugs and Schedules II–V CSs. 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 for prescriptive authority is made within 2 years of graduation. Renewal of prescriptive 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.
The West Virginia BON grants authority to practice and regulates the practice of APRNs. APRNs include CNP, CNS, CNM, and CRNA roles. APRN SOP includes the autonomous ability to assess, conceptualize, diagnose, analyze, plan, implement, and evaluate complex problems related to health autonomously. 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 practice in 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 a PCP: 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, CNPs, CNMs, FNPs, WHNPs, adult NPs, GNPs, and PNPs.
Qualified APRNs have limited autonomous prescriptive authority, following 3 years of a duly documented collaborative relationship with a physician. APRNs work from an exclusionary formulary; Schedules I and II CSs, antineoplastics, radiopharmaceuticals, and general anesthetics are prohibited.
The law provides for the development of the Joint Advisory Council on Limited Prescriptive Authority, comprised of MDs, DOs, APRNs, a pharmacist, a consumer, and a representative from a school of public health or an institution of higher education who may advise the BON regarding collaborative agreements and evaluate applications for APRNs to prescribe without a collaborative agreement.
Prescriptive authority includes Schedules III, IV, and V CSs, with some restrictions. Drugs listed as Schedule III CSs are limited to a 30-day supply, and rules apply when prescribing for the treatment of a chronic condition (§30-7-15a [b]). Rules and regulations specify that APRNs must meet specified pharmacology education requirements. When required, 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.
Prior to the initial provision of a pain-relieving CS, the APRN must access the West Virginia Controlled Substances Monitoring Program repository and database to determine if the patient has obtained any CS 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. APRNs are authorized to sign for and provide drug samples.
The Wisconsin BON regulates the practice of APRNs (defined as APNs) 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). APNs 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 APN must have a master's or doctoral degree in nursing or a related field and national board certification to practice. Prescriptive authority requires additional certification by the BON as an Advanced Practice Nurse Prescriber (APNP). APNPs must additionally pass jurisprudence examination, submit evidence of completion of 45 contact hours in clinical pharmacology or therapeutics within 5 years preceding the application to enter into practice, and maintain malpractice insurance as specified in Wisconsin Administrative Rule §N 8.03.
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 CSs appropriate to the APNP's area of competence. Wisconsin Administrative Rule §N 8.06 describes limitations on prescriptive authority for Schedule II CSs, including amphetamines and sympathomimetic amine drugs or compounds designated as a schedule II CS with exceptions described in Wisconsin Administrative Rule §N 8.06 (3). Additional limitations include anabolic steroids for the purpose of enhancing athletic performance or nonmedical purpose. APNPs may dispense pharmaceutical samples to a patient at the treatment facility at which the patient is treated.
The Wyoming BON grants APRNs the authority to practice via licensure 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 NPA, 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 doctorate or master's degree in nursing in a specific APRN role and national board certification in that role are required to enter practice as an APRN in Wyoming.
APRNs are authorized to receive Medicaid payments at 85% of the physician rate. All PCPs may receive third-party payment; however, policies differ among third-party payers.
BON-approved APRNs may independently prescribe legend and Schedule II–V CSs. APRNs are considered independent providers and register for their own DEA numbers. APRNs who have prescriptive authority are legally authorized to request, receive, and dispense pharmaceutical samples.
Legislation passed in 2019 requires prescribers to query the Prescription Drug Tracking Program before first issuing a prescription for Schedule II–V CSs. Prescribers are required to repeat the search every 3 months after as long as the CS remains part of the patient's treatment. Exceptions include Schedule V nonopioid CSs. Additionally, prescribers must complete 3 hours of CE related to responsible prescribing of CSs and treatment of substance abuse disorders every 2 years.
Limitations to prescription of opioids or opioid combinations include a restriction to a 7-day supply in a 7-day period for acute pain in an opioid-naive patient. Exceptions include chronic pain, cancer treatment, palliative care, and other clinically appropriate exceptions defined by the board.