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Feature: NP LEGISLATIVE UPDATES

33rd Annual APRN Legislative Update

Unprecedented changes to APRN practice authority in unprecedented times

Phillips, Susanne J. DNP, APRN, FNP-BC, FAANP, FAAN

Author Information
doi: 10.1097/01.NPR.0000724504.39836.69
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The year 2020 saw unprecedented challenges for the US healthcare system due to the coronavirus disease 2019 (COVID-19) pandemic. In response to the urgent need for all healthcare providers to deliver healthcare services at the top of their license, education, and training, state governmental leadership focused heavily on removing practice barriers for many healthcare professions. This edition of the Annual APRN Legislative Update focuses on states' executive orders and emergency waivers enacted during the public health emergency that greatly reduced barriers to access to healthcare. State boards of nursing (BON) across the country, along with APRNs, swiftly answered the call during our nation's most critical time. Additionally, this report highlights major legislative accomplishments in California, Florida, and Kansas, where the governors enacted new laws that improved access to high-quality, safe, and effective healthcare by removing practice barriers for one or more APRN roles. Additional practice and reimbursement updates are found in the individual state updates on the following pages.

In September 2020, Governor Gavin Newsom signed into law Assembly Bill 890, Chapter 265 of the California Statutes of 2020 pertaining to nurse practitioner (NP) scope of practice, and Senate Bill 1237, Chapter 88 of the California Statutes of 2020 pertaining to certified nurse midwife (CNM) scope of practice. Effective January 1, 2021, NPs who practice in licensed healthcare settings as defined in statute, and meet education, transition to practice experience (3 years full-time equivalent [FTE] or 4,600 hours), and certification requirements, are authorized to practice independently under a newly defined scope of practice without standardized procedures and physician supervision. Additionally, effective January 1, 2023, NPs are authorized to practice independently under the newly defined scope of practice outside of specified settings or organizations (NP corporations) if they meet additional specified education and experience requirements as defined.

Additional provisions include, but are not limited to, the establishment of a Nurse Practitioner Advisory Committee who will make recommendations to the Board on all matters relating to NPs. This advisory committee will include four NPs, two physicians, and one public member. Regulations for implementation will occur in 2021.

Effective January 1, 2021, California's CNMs are authorized to attend cases of low-risk pregnancy and childbirth and to provide prenatal, intrapartum, and postpartum care, including family planning services, interconception care, and immediate care of the newborn without physician supervision in hospital and out-of-hospital settings. The new law authorizes a CNM to practice with a physician and surgeon under mutually agreed-upon signed policies and protocols that delineate parameters for collaboration, consultation, referral and transfer of care. Additional provisions clarify CNM prescriptive authority, authorized procedures, maternal and neonatal transfers, and birth certificates.

On March 11, 2020, Governor Ron DeSantis signed into law HB 607, now referred to as Chapter 2020-9 of the Laws of Florida pertaining to APRN autonomous practice. Effective July 1, 2020, APRNs engaged in primary care practice, including family medicine, general pediatrics, and general internal medicine, as defined by board rule, including CNMs may register for autonomous practice, removing the current requirement for an established protocol with a supervising physician or dentist. Requirements for autonomous practice include completion of 3,000 clinical practice hours as an APRN with an unencumbered license under the supervision of a physician within 5 years immediately preceding the registration request as well as completion of graduate-level coursework in differential diagnoses and pharmacology. Practice requirements set in statute will be regulated and interpreted by the BON, and, similar to California's legislation, a Council on APRN Autonomous Practice has been created.

Initially approved through Executive Order 20-26, Kansas APRNs and certified registered nurse anesthetists (CRNAs) are authorized to provide healthcare services within their scope of practice and in accordance with their education, training, and experience, without physician supervision or direction in designated healthcare facilities where the APRN or CRNA is employed or contracted to work to support the facility's response to the COVID-19 pandemic. This provision was codified on June 4, 2020, with enactment of House Bill 2016. These provisions are temporary and expire on January 26, 2021, unless further legislative action is taken.

State response to APRN practice authority

In response to the pandemic, most states' governors enacted emergency orders or waivers pertaining broadly or specifically to areas of APRN practice. These executive actions pertain to expanding capacity of the healthcare workforce, prescriptive authority, and telehealth delivery. Many of these emergency provisions extend through the end of the public health emergency; however, several of the provisions listed here have expired. Readers are encouraged to consult their respective BONs for the latest information on executive orders, emergency waivers, and emergency regulations pertaining to APRN practice authority.

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Figure:
Summary of practice authority for NPs

Seven states temporarily waived or suspended practice agreement requirements between APRNs and physicians for one or more APRN roles during the declared state of emergency. In an effort to swiftly improve access to critical healthcare services in a time of great need, APRNs were granted temporary authorization to practice to the fullest extent of their education and training without physician oversight—authority that had been previously granted in other states in absence of a national public health emergency.

On March 31, 2020, Secretary J. Michael Brown suspended statutes and regulations requiring collaborative agreements between Kentucky APRNs and physicians as a prerequisite for prescribing medication in an effort to ensure necessary health professionals were available to treat residents and to prevent the spread of COVID-19. The emergency order is in effect for the duration of the State of Emergency under Executive Order 2020-215 or until the order is rescinded by law. Similarly, on March 27, 2020, Governor Tony Evers signed Emergency Order 16, suspending required collaborative relationships between a Wisconsin advanced practice nurse prescriber and a physician or dentist. Emergency Order 16 remains in effect for the duration of the public health emergency.

Governor Jon Bel Edwards of Louisiana signed Emergency Proclamation Number 38 JBE 2020 on March 31, 2020, suspending collaborative practice agreement requirements for APRNs for the duration of the public health emergency. In New Jersey, Governor Philip D. Murphy signed Executive Order No. 112 on April 1, 2020, suspending statutory provisions for advanced practice nurses (APNs) requiring joint protocols with physicians, including collaborating physician's names on APN prescriptions or orders, review of records, and the requirement to obtain authorization to dispense narcotic drugs for maintenance treatment (MAT) or detoxification treatment, among other provisions. The order remains in effect for the duration of the declared State of Emergency.

Executive Order 202.10, signed by Governor Andrew Cuomo, temporarily authorizes New York's NPs to provide healthcare without a written practice agreement or collaborative relationship with a physician when the NP is acting within the scope of his or her education, training, and experience. This order was extended until December 3, 2020, at the time this report was published. Commissioner Monica Bharel, MD, of the Massachusetts Department of Public Health, ordered authorization of APRN independent practice in response to the State of Emergency and the spread of COVID-19, effective March 26, 2020. APRNs (except for CNMs) with at least 2 years of supervised practice experience are exempt from physician supervision and written prescriptive practice guideline requirements. The order remains in effect for the duration of the state of emergency. Similarly, Virginia NPs (except CRNAs) with at least 2 years or more of clinical experience are authorized under Executive Order #57 to practice in the role which they are certified, including prescriptive authority, without a practice agreement with a physician.

In several states, certain aspects of APRN statutes or regulations have been temporarily waived under executive order in an effort to enhance the workforce during the public health emergency. Alabama expanded physician FTE ratios for collaboration with CRNPs, CNMs, and physician assistants (PAs) from 1:4 to 1:9, and allowed a chief medical officer or designee to collaborate with an unlimited number of CRNPs, CNMs, and PAs within a licensed health facility. California and Oklahoma temporarily eliminated physician to APRN supervision ratios. Indiana authorized APRNs to provide services in multiple locations under a single collaboration agreement. Maine and Texas suspended supervision or collaborative practice agreements for APRNs practicing in designated disaster relief settings or assisting with COVID-19 response. West Virginia suspended requirements for supervision or presence of any other healthcare provider when anesthesia is administered by a CRNA. Missouri suspended chart review, mandatory physician presence, and geographic limitations of physician collaborators. Similarly, Tennessee removed chart review and collaborating physician in-person site visit requirements; however, these executive orders have expired.

Prescriptive authority changes

Emergency orders pertaining to use of chloroquine, hydroxychloroquine, and azithromycin

In the early days of the pandemic, there was a paucity of clinical treatment recommendations for COVID-19, and no recommendations for prevention or treatment of mild illness. In response to vigorous debate over potentially beneficial pharmacotherapy and, to preserve critical supply of these medications to treat FDA-approved conditions, state government leadership enacted emergency orders and prescribing recommendations for hydroxychloroquine, chloroquine, and azithromycin. By the fall of 2020, the COVID-19 Treatment Guidelines Panel of the National Institutes of Health published major revisions to the COVID-19 Treatment Guidelines, recommending against the use of chloroquine or hydroxychloroquine with or without azithromycin for the treatment of COVID-19.1,2 Readers are encouraged to review their state COVID-19 webpages for updates on the executive orders and recommendations pertaining to the use of these medications.

Several states, including Delaware, Idaho, Minnesota, and Nevada, limited the number of days of treatment with hydroxychloroquine, chloroquine, and/or azithromycin, in addition to requiring an FDA-approved diagnosis for their use on the prescription. New York further restricted prescriptions of hydroxychloroquine and chloroquine by restricting dispensing except when written as prescribed for an FDA-approved indication, for patients in inpatient or acute settings, for residents in a subacute part of a nursing facility, or as part of an IRB-approved study. New York's restriction expired on July 7, 2020.

- Total number of active clear licensed/certified APRNs reported by BONs and/or state nursing associations in 2020
State Total APRNs NPs CNSs CNMs CRNAs
Alabama 7445 5451 64 17 1913
Alaska 1479 1143 35 113 188
Arizona £ 11,545 10,080 161 294 1010
Arkansas ¥ 4,005 3,009 164 33 799
California 34,952 27,703 3,275 1,316 2,658
Colorado 9,274 7,145 569 497 1,063
Connecticut 5,769 !
Delaware 2,265 1,718 146 47 354
District of Columbia ¥ 1,162 1,375 44 96 147
Florida 37,529 30,699 219 866 5,745
Georgia £ 14,938 13,925 347 612 2,044
Hawaii ¥ 1,712
Idaho 2795 2101 49 80 565
Illinois 16,496 12,758 967 516 2,254
Indiana 7,518 6,593 274 126 525
Iowa 5,649 4,737 78 147 687
Kansas 7,025 5,269 470 90 1,196
Kentucky 9,869 8,099 153 132 1,485
Louisiana 7,164 5,361 159 64 1,580
Maine 2,889 2,194 70 104 521
Maryland £ 9,063 7,749 118 308 888
Massachusetts £ (Last BON Update 2018) 12,112 9,601 67 CNS, 663 PCNS 504 1,277
Michigan £ 11,635 8,600 235 200 2,600
Minnesota 9,798 6,760 480 376 2,182
Mississippi 6,408 5,431 ! 32 945
Missouri 12,250 9,726 324 156 2,044
Montana ¥ 1,665 1,367 38 68 1
Nebraska ¥ 2,284 1,622 86 46 530
Nevada ¥ 1,657
New Hampshire 2,656 2,103 19@ 123 411
New Jersey 10,707 ! (BOME)
New Mexico 3,836 2,978 97 223 538
New York ~ 29,801 ! ! !
North Carolina 13,810 9,635 256 350 3,569
North Dakota 1,774 1,301 38 24 411
Ohio 20,734 16,001 1,082 428 3,223
Oklahoma 4,494 3,418 287 64 725
Oregon £ 6,122 5,294 167 # 661
Pennsylvania 15,640~ 15,391 249 ! !
Rhode Island ¥ 309 207 6 83! 13
South Carolina ¥ 3,275 1,797 43 105 1,352
South Dakota 1,915 1,310 57 39 509
Tennessee £ 13,730
Texas £ 32,619^ 27,457 1,242 538 4,906
Utah ¥ 3,003 184 344
Vermont £ 1,032^ 1,088 37@ 84 108
Virginia £ 13,727 13,322 405 # #
Washington 9,807 8,079 78 527 1,123
West Virginia 3,913 2,966 33 69 845
Wisconsin £ 8,263+ + + + +
Wyoming 1,045 828 25 27 165
¥BON did not update this information and no information available on website; numbers reported last year
Combined with total number of APRNs/APNs/APNPs for that state
~“APRN” term is not defined in statute or regulation
!Not recognized as an APRN/ARNP/APN by the BON and not included in Total APRNs
@Psychiatric clinical nurse specialists recognized as APRNs only
#Licensed/certified as NPs by the BON OR BON & BOM and counted as NPs in total
+Certified as APNPs (Advanced Practice Nurse Prescribers)
£Licensee/certification numbers obtained from BON website or Member
^Unduplicated APRN total

The North Carolina BON went a step further, adopting 21 NCAC 36 .0817 COVID-19 Drug Preservation Rule, to prevent potential treatment shortages. This rule restricts the use of hydroxychloroquine, chloroquine, lopinavir-ritonavir, ribavirin, oseltamivir, darunavir, and azithromycin, requiring a written diagnosis from the prescriber consistent with evidence of its use. If prescribed for a patient diagnosed with COVID-19, the diagnosis must be indicated on the prescription and the medication limited to a 14-day supply without refills, unless a new prescription is issued. These medications may not be prescribed for the prevention of or in anticipation of the contraction of COVID-19. Exceptions to the rule include orders for administration to hospitalized patients. On October 7, 2020, 21 NCAC 36.0817 COVID-19 Drug Preservation Rule was modified, removing oseltamivir and azithromycin from the “Restricted Drugs List” by waiver, citing these medications were no longer subject to the issue of shortage. Ohio promulgated a similar emergency rule; however, as of July 30, 2020, Emergency Rule 4729-5-30.2 is no longer effective.

Healing Arts Boards in many states issued guidance and recommendations regarding prescribing of these medications. Missouri issued a Joint Statement from the Board of Registration for the Healing Arts & Board of Pharmacy recommending prescribers avoid prescribing hydroxychloroquine, chloroquine, and azithromycin for prophylactic use; avoid prescribing for family, friends, and coworkers; utilize a diagnosis code or diagnosis with the prescription; and limit treatment to a 14-day supply when needed. Similarly, the New Mexico Board of Pharmacy, Board of Nursing, and Medical Board issued a joint statement asking prescribers to prescribe appropriately, exercise good professional judgment, and adhere to evidence-based standards of practice in prescribing decisions.

On March 27, 2020, the South Carolina BON issued guidance to APRNs in concurrence with the Order of Joint Guidance of the Boards of Medical Examiners and Pharmacy, recommending against self-prescribing or prescribing hydroxychloroquine, chloroquine, and azithromycin to family members unless faced with a bona fide emergency involving actual diagnosis of a COVID-19 infection. Additionally, utilization of an FDA-approved diagnosis on prescriptions was recommended. Vermont issued similar guidance for all prescribers by the Department of Health. Prescribers are encouraged to prescribe antimalarial drugs chloroquine and hydroxychloroquine for individuals with diagnosed conditions and not for prevention.

The states of Oklahoma and Oregon had similar executive orders regarding prescribing antimalarial medications. They are repealed at the time of this writing.

Emergency orders pertaining to APRN prescriptive authority–Elimination of prescribing restrictions

A number or states have temporarily eliminated barriers for all prescribers to enhance access to timely treatment during the declared emergency. Hawaii's governor David Ige eased restrictions authorizing out-of-state physicians and nurses to prescribe and administer controlled substances without having to register in Hawaii as authorized in the United States Drug Enforcement Administration (DEA) COVID-19 Policy Concerning Separate Registration across State Lines dated March 25, 2020. Compliance with state law is otherwise required. Indiana's BON issued Executive Order Waiver 001 waiving requirements for APRNs to submit to their collaborating physician a random sampling of APRN chart documentation of medications prescribed within 7 days. The executive order waiver is in effect for the duration of the declared emergency.

The Mississippi BON issued a proclamation temporarily authorizing all APRNs with controlled substance prescriptive authority to utilize telehealth as a means of care delivery. Requirements for APRNs to personally examine patients prior to the issuance of a prescription or order the administration of medications, including controlled substances is lifted; however, APRNs are required to conduct an evaluation of the patient's condition and document the appropriate medical indication for the prescription. Similarly, New Hampshire suspended the prohibition of prescribing schedule II through IV controlled drugs by means of telemedicine during the declared state of emergency, prescriptions of schedule II through IV controlled drugs are authorized in accordance with Emergency Order #29 Exhibit H and Emergency Order #8.

West Virginia BON suspended the requirement for collaborative agreements with physicians for the prescribing of medications during the State of Emergency for APRNs approved to practice in West Virginia pursuant to Executive Order 17-20. Additionally, West Virginia APRNs may refill previously prescribed schedule II drugs and antineoplastics if the refill is required during the declared emergency. The prescribing physician's name must be included on the prescription.

Given the dynamic nature of executive orders and emergency waivers during the COVID-19 pandemic, it is important for readers to refer to their respective state BONs for the most up-to-date information. The intent of this overview is to provide a summary of APRN practice changes across the country. The author would like to thank individual state BON representatives and APRN association representatives who contributed to this annual update through completion of an annual survey. All efforts are made to ensure the information provided to readers is accurate and up-to-date through validation of adopted regulations and enacted legislation provided in the article. Additionally, the National Council of State Boards of Nursing (NCSBN) provides regular updates on information related to temporary/waived licensure, waived or suspended practice agreements, prescriptive authority waivers/guidance, and waivers affecting telehealth.3

REFERENCES

    Alabama

    www.npalliancealabama.org

    www.abn.alabama.gov

    www.campaignforaction.org/state/alabama

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Alabama State BON has sole regulatory authority to establish qualifications and certification requirements of APRNs; however, the BON and BOME jointly regulate the collaborative practice of CRNPs and CNMs. APRNs are defined as APNs in Alabama statute and include the CNP (CRNP in statute), CNS, CNM, and CRNA roles. CRNPs and CNMs practice within BON- and BOME-approved written collaborative practice agreement protocols; however, collaboration does not require direct, on-site supervision by the collaborating physician. Professional oversight and direction is required as outlined in Alabama Board of Nursing Administrative Code Chapter 610-X-5-.09 and Chapter 610-X-5-.20 and includes a requirement (minimum of 10% of CRNP/CNM's scheduled hours) for onsite physician attendance when the CRNP or CNM has fewer than 2 years of collaborative practice experience.

    Alabama meets the American Association of Nurse Practitioners' definition for Reduced Practice. APN scope of practice is defined in regulation and in accordance with national standards and functions identified by the appropriate specialty-certifying agency, congruent with Alabama law.

    CRNPs and CNMs 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 and Chapter 610-X-5-.14. There is no transition to practice requirement for APRNs in the state of Alabama.

    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, and, under limited circumstances, may prescribe Schedule II CSs, pursuant to BOME Administrative Code Chapter pursuant to the rules of Alabama BOME Chapter 540-X-18-.07. In addition to DEA registration, qualified CRNPs and CNMs must hold a Qualified Alabama Controlled Substances Registration Certificate.

    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. All CRNPs and CNMs are required to access the Alabama Controlled Substances Database.

    Reimbursement

    There are no legislative restrictions for APNs on managed-care panels. The Alabama 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.

    Alaska

    www.commerce.alaska.gov/web/cbpl/professionallicensing/boardofnursing.aspx

    https://anpa.enpnetwork.com

    www.campaignforaction.org/state/alaska

    https://www.aprnalliance.org/

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Alaska State BON regulates APRNs including statutory definitions of the 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.

    Alaska meets the American Association of Nurse Practitioner's Full Practice Authority definition. APRN SOP is defined under Alaska Administrative Code 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). Regulations require that an APRN have a plan for patient consultation and referral, but a physician relationship is not required.

    APRNs in Alaska are statutorily recognized as PCPs. Nothing in the law precludes admitting privileges for APRNs. Entry into APRN practice requires a graduate degree in nursing and national board certification is required. There is no transition to practice requirement in the state of Alaska.

    Authorized APRNs have independent prescriptive authority, including Schedules II–V CSs. APRNs are legally required to review the Prescription Drug Monitoring Program database prior to prescribing CSs and must complete 2 CE hours in pain management and opioid use and addiction each 2-year license renewal cycle. They are legally authorized to request, receive, and dispense pharmaceutical samples in Alaska. To renew prescriptive authority, APRNs must maintain national certification and complete the opioid CE requirement.

    Opioid prescribing limitations provide restrictions on the 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.

    Reimbursement

    All healthcare in Alaska is provided on a fee-for-service basis. FNPs, PNPs, PMHNPs, CNMs, and CRNAs are authorized by law to receive Medicaid reimbursement; NPs receive 85% of the physician payment.

    A nondiscriminatory clause in the insurance law allows for third-party reimbursement to NPs; Alaska legally requires insurance companies to credential, empanel, and/or recognize APRNs.

    Arizona

    www.azbn.gov

    http://arizonanp.enpnetwork.com www.campaignforaction.org/state/arizona

    Practice authority

    The Arizona State Legislature grants APRNs authority and the BON alone regulates their practice. APRNs include CNPs (RNPs in statute), CNSs, CNMs, and CRNA roles. According to Arizona Revised Statutes Title 32, Chapter 15 32-1601; 20 (vi), the following language was added to both the RNP and the CNM definitions:

    “...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 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.

    Prescribers must obtain a patient utilization report from the CSPMP's central database prior to prescribing an opioid analgesic or benzodiazepine CS in schedules II, III, or IV, with certain exceptions. 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.

    Reimbursement

    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.

    Arkansas

    www.arsbn.org

    www.arna.org www.campaignforaction.org/state/arkansas

    Practice authority

    The Arkansas BON grants APRNs authority to practice and regulates their practice. The term ‘APRN’ is defined and includes the CNP, CNM, CNS, and CRNA roles. APRNs practice independently, with the exception of RNPs (NPs who do not hold national certification). 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. A collaborative practice agreement with a physician and prescribing protocols are required for prescriptive authority.

    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 BON provides a certificate of prescriptive authority to qualified APRNs practicing in collaboration with an Arkansas-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. Prescriptive authority includes legend drugs, therapeutic devices, and Schedules III–V CSs. If expressly authorized by the collaborative practice agreement, Schedule II CSs may be prescribed under the following conditions: 1) hydrocodone-combination products are limited to 7 days for acute pain; 2) opioids when prescribed for a 5-day period or less; 3) 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. CRNAs are not required to have prescriptive authority to provide anesthesia care, including the administration of drugs or medication necessary for such care. APRNs who have fulfilled requirements for prescriptive authority may receive and dispense pharmaceutical samples and therapeutic devices appropriate to their area of practice.

    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 thereafter. PDMP review exceptions are described under Arkansas State Board of Nursing Rules Chapter 4, Section VIII (K).

    Reimbursement

    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.

    California

    www.rn.ca.gov

    www.canpweb.org

    www.campaignforaction.org/state/california

    Practice authority

    The California State Board of Registered Nursing (BRN) regulates APRNs, defining APRNs in statute including the CNP (NP in statute), CNS, CNM, and CRNA roles. The passage of Chapter No. 265, effective 1/1/2021, codified NP SOP and independent practice. The new statute eliminated physician-supervised practice by removing the “standardized procedure” requirement if the NP is nationally-board certified and completes a 3-year or 4,600-hour transition to practice period within defined settings. Effective 1/1/2023, NPs may practice within NP-owned practices following completion of the defined transition to practice period and additional experience as required by the BRN.

    The passage of Chapter No. 88, effective 1/1/2021, eliminated physician supervision of CNM practice when providing care within the defined scope of services. Scope of services includes attending cases of low-risk pregnancy and childbirth, routine prenatal, intrapartum, and postpartum care, including family-planning services, interconception care, and immediate care of the newborn, consistent with adopted standards.

    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, CNSs, and CNMs must hold a minimum of a master's degree in nursing or health-related field to practice; however, California does not require national certification to enter into practice. CNPs with independent practice must hold a master's degree in nursing or a doctorate in nursing and national certification; CRNAs are required to hold national certification to practice in the state of California.

    With the passage of legislation in 2020, CNPs in independent practice are authorized to prescribe drugs and devices, including schedule II – V CSs. CNMs are now authorized to furnish drugs and devices without a standardized procedure if the drugs and devices are within the scope of services of a CNM. CNMs may furnish or order drugs or devices, including schedules II – V CS outside of the scope of services defined in statute, when the drugs or devices are furnished in accordance with a standardized procedure. The act of “furnishing” is legally the same as prescribing.

    All prescribers are mandated to consult the Controlled Substance Utilization Review and Evaluation System (CURES) the first time a patient is prescribed, ordered, administered, or furnished a controlled substance (with some exemptions) and at least once every 4 months if the controlled substance remains a part of the patient's treatment plan (with some exemptions). CNPs and CNMs may request, receive, and dispense pharmaceutical samples and may dispense drugs, including controlled substances. CNSs and CRNAs do not have Rx authority in California.

    Reimbursement

    All nationally board-certified CNPs are reimbursed independently by the Medi-Cal system. Medi-Cal-covered services performed by CNPs, CNMs, and CRNAs are reimbursed at 100% of the physician reimbursement rate. Blue Cross of CA Medi-Cal Provider Directory lists CNPs as PCPs under their 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.

    Colorado

    www.dora.colorado.gov/professions/nursing

    www.coloradonurses.org

    www.campaignforaction.org/state/colorado

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Colorado State Board of Nursing (Board) grants advanced practice authority to Registered Nurses who meet the criteria set forth in the Colorado Nurse and Nurse Aide Practice Act (Practice Act) CRS 12-255-101 et seq and the Nursing Rules 3 CCR 716-1 (Rules) Rule 1.14 for inclusion on the Advanced Practice Registry (APR). The Board regulates the practice of APRNs, and affords title protection. APRNs include the CNP (NP in statute), CNS, CNM, and CRNA roles.

    APRNs listed on the registry prior to July 1, 2010, may retain their listing on the APR without certification as long as the APRN does not allow his or her advanced practice authority to lapse or expire. Professional liability insurance is required for all APRNs engaged in an independent practice.

    The scope of advanced practice nursing is an expanded scope of professional nursing practice within the APRN role and population focus, which may include, but is not limited to, performing acts of advanced assessment, diagnosing, treating, prescribing, ordering, selecting, administering, and dispensing diagnostic and therapeutic measures. The scope of advanced practice nursing does not include prescribing medication; however, the Board grants separate prescriptive authority. APRNs are considered independent practitioners. NP practice in Colorado meets the American Association of Nurse Practitioners' definition for Full Practice Authority.

    The Practice Act and Rules do not address, and therefore do not prohibit, APRNs being designated as Primary Care Providers (PCP) or being granted hospital privileges; however, APRNs are not currently recognized as PCPs in statutes and regulations under the jurisdiction of state agencies regulating healthcare. National certification in a role and, if applicable, population focus, is required of all APR applicants.

    The APRN may be granted prescriptive authority by the Board within the APRN's role and population focus, including prescribing schedules II–V controlled substances. APRNs applying for original prescriptive authority and prescriptive authority by endorsement must have 3 years of clinical work experience as an RN to be eligible to apply for provisional prescriptive authority (RXN-P) or full prescriptive authority (RXN) by endorsement. Effective July 1, 2020, the RXN-P must complete a 750-hour prescribing mentorship (decreased from previously required 1,000 hours) with a physician or an APRN with RXN and an active unrestricted DEA registration. APRNs who have active prescriptive authority in another state and more than 750 hours of safe prescribing experience in that state are not required to complete the mentorship period. Effective July 1, 2020, Articulated Plans are no longer required.

    In May 2019, the Substance Use Disorders Prevention Act became law, requiring the Board and other healthcare provider boards to adopt rules on substance use disorder training for prescribers. Training must consist of at least 2 credit hours per licensing cycle related to best practices of opioid prescribing, recognition of substance use disorders, referral for and treatment of substance use disorders, and use of the PDMP. This new law restricts APRNs and other prescribers from accepting direct or indirect benefits for prescribing specific medications. Nursing rules authorize APRNs with prescriptive authority to receive and distribute a therapeutic regimen of prepackaged and labeled drugs, including free samples.

    Reimbursement

    Medicaid reimburses APRN services; however, some managed-care Medicaid companies restrict independent APRNs from joining networks. Third-party reimbursement is available to APRNs, but third-party payers are not mandated to credential, empanel, or reimburse APRNs. Legislation passed in April 2019 authorized 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. CNMs are now a recognized provider type for Colorado's Medicaid program, which is known as Health First Colorado.

    Connecticut

    https://portal.ct.gov/DPH/Public-Health-Hearing-Office/Board-of-Examiners-for-Nursing/Board-of-Examiners-for-Nursing

    www.ctaprns.org

    www.campaignforaction.org/state/Connecticut

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Connecticut Board of Examiners for Nursing regulates APRNs, defining APRNs in statute including the CNP (NP in statute), CNS, and CRNA roles. APRN SOP, independent practice, and collaborative practice are defined in statute. 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).

    APRNs must practice in collaboration with a physician licensed in Connecticut for the first 3 years after obtaining a license in Connecticut. APRNs are authorized to practice without a collaborative agreement following no less than 3 years and no fewer than 2,000 hours of APRN practice. NP practice in Connecticut is considered Full Practice Authority as defined by the American Association of Nurse Practitioners.

    APRNs are authorized to prescribe, dispense, and administer medications, including controlled substances pursuant to a collaborative practice agreement. APRNs may independently prescribe, dispense, and administer medications including schedules II–V CSs following a transition to practice period of no less than 3 years and no less than 2,000-hours. APRNs and CNMs are legally authorized to request, receive, and dispense pharmaceutical samples.

    Opioid prescribing limitations for acute pain include that initial prescriptions for acute pain in adults are limited to 7 days and that any opioid prescribing for minors is limited to 5 days. Exceptions to the limitations include chronic pain, cancer pain, palliative care, provider judgment, and substance abuse disorder or medication-assisted treatment (MAT).

    Reimbursement

    Medicaid regulations govern reimbursement to APRNs under the remaining Medicaid fee-for-service programs. NPs, 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.

    Delaware

    https://dpr.delaware.gov/boards/nursing

    www.denurses.org

    www.campaignforaction.org/state/delaware

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Delaware BON regulates the practice of APRNs, including the CNP, CNS, CNM, and CRNA roles. The BON grants full practice and prescriptive authority upon issuance of an APRN license; however, full practice authority does not equate to the granting of independent practice as defined. The BON may grant APRNs independent practice following review and recommendation of the APRN applicant by the APRN Committee. The APRN seeking independent practice must practice under a collaborative agreement with a physician, podiatrist, or healthcare delivery system 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. 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. NP practice in the state of Delaware is considered Reduced Practice by the American Association of Nurse Practitioners.

    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 hold current certification by a national certifying body in the appropriate role and population focus area to be licensed in Delaware.

    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 who have been out of active clinical practice for > 2 years must comply with pharmacology and clinical practice CE requirements pursuant to 24 Del.C. §1918. APRNs may receive, sign for, record, and distribute sample medications to patients in accordance with state law and DEA laws, regulations, and guidelines.

    Reimbursement

    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 recognize APRNs 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.

    District of Columbia

    http://doh.dc.gov/service/board-nursing

    www.npadc.org

    www.campaignforaction.org/state/ district-of-columbia

    Practice authority

    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.

    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 medications. 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.

    Reimbursement

    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.

    Florida

    www.floridasnursing.gov

    www.floridanurse.orgwww.campaignforaction.org/state/florida

    Practice authority

    The Florida BON regulates APRN practice, which is defined in statute and includes the CNP, CNS, CNM, and CRNA roles. Legislation passed in 2020 authorizes APRNs in primary care practice (family medicine, general pediatrics, and general internal medicine) to register for autonomous practice following 3,000 clinical practice hours, within the last 5 years immediately preceding the registration request. Practice hours may include clinical instruction hours completed by the applicant in an APRN education program. The SOP for autonomous APRN practice is defined in Title XXXII, Chapter 464, Sections 464.0123, 464.012(3), and 464.012(4)(c) of the Florida Statutes, and includes prescriptive authority including CSs. The BON will promulgate rules in 2021 pertaining to this new law.

    APRNs practicing outside of primary care continue to practice pursuant to protocols established between an APRN and an MD, DO, or dentist, which include the performance of medical acts of diagnosis, treatment, and operation. 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 to 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 without autonomous practice authority are authorized by supervisory protocol to prescribe, dispense, administer, or order any drug, including schedules II–V CSs as authorized in a BON-adopted CS 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 restrictions 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.

    Reimbursement

    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 on-site and does not countersign. Managed care companies are prohibited from discriminating against the reimbursement of APRNs based on licensure. Private insurers must reimburse CNM services if the policy includes pregnancy care.

    Georgia

    www.sos.ga.gov/plb/nursing

    https://uaprn.enpnetwork.com

    www.georgianurses.org

    https://campaignforaction.org/state/georgia

    Practice authority

    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 1 of 2 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.

    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.

    Reimbursement

    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.

    Hawaii

    www.hawaii.gov/dcca/pvl/boards/nursing

    www.campaignforaction.org/state/hawaii

    Practice authority

    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.

    The BON regulates APRN prescriptive authority, and APRNs have Practice 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.

    Reimbursement

    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.

    Idaho

    https://ibn.idaho.gov/IBNPortal

    www.npidaho.org

    www.campaignforaction.org/state/idaho

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Idaho BON regulates the practice, licensure, and education of APRNs. APRN is defined in IDAPA 23.01.01 Rules of the Idaho Board of Nursing Section 271.02 and includes CNP, CNS, CNM, and CRNA roles. APRN scope and standards of practice is defined in statute and regulation (Idaho Code §54-1413 and IDAPA 24.34.01.280) and is consistent with the NCSBN Consensus Model. 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, and 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. The practice for NPs in the state of Idaho is considered Full Practice by the American Association of Nurse Practitioners. There is no transition period prior to full practice authority.

    Independent prescribing and dispensing authority is granted to qualified APRNs upon licensure. Authorized APRNs may prescribe and dispense legend and Schedules II–V CSs appropriate to their defined SOP. APRNs are legally authorized to request, receive, and dispense pharmaceutical samples.

    Reimbursement

    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 may apply for a Medicaid provider number and may choose to file independently or with a group. Reimbursement rates are 85% of the physician payment.

    Illinois

    www.idfpr.com/profs/nursing.asp

    www.isapn.org www.campaignforaction.org/state/illinois

    Practice authority

    The Illinois Department of Financial and Professional Regulation (IDFPR) regulates APRN practice, which includes the 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. 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. 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. CRNAs who completed their CRNA program prior to January 1, 1999 and have kept their certification current may be exempt; however, this exception will expire on June 30, 2023.

    APRNs with FPA are authorized to prescribe both legend drugs and Schedules II–V CSs and this 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.

    Reimbursement

    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.

    Indiana

    www.in.gov/pla/nursing.htm

    www.indiananurses.org

    www.campaignforaction.org/state/indiana

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Indiana State BON grants authority to and regulates APRNs, defined in IC 25-23-1-1, and includes CNP (NP in regulation), CNM, CNS, and CRNA roles. APRNs, except CRNAs, practice in collaboration with a licensed practitioner under a written collaborative practice agreement approved by the board and include how the APRN and licensed physician will cooperate, coordinate, and consult with each other on the provision of healthcare. Additionally, the CPA includes 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. SOP is defined in regulation 848 IAC Article 4. Legislation signed into law in 2020 authorizes APRNs with prescriptive authority to sign death certificates. The American Association of Nurse Practitioners considers NP practice in Indiana Reduced Practice.

    APRNs are authorized to practice in hospitals in collaboration with a licensed practitioner as evidenced by a collaborative practice agreement when the APRN is granted privileges by the governing board of a hospital licensed under IC 16-21 (hospitals) that sets forth the manner in which the APN and licensed practitioner will cooperate, coordinate, and consult with each other or by privileges granted by the governing body of a hospital operated under IC 12-24-1 (state hospitals) that set forth the manner in which the APRN and licensed practitioner will cooperate, coordinate, and consult with each other.

    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 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).

    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 schedules II – V CSs. APRNs must obtain a BON-issued prescriber authority ID number, Indiana State Controlled Substances Registration in addition to DEA registration. 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 standard of documentation.

    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.

    Reimbursement

    Indiana is considered an “any willing provider” state backed by current law. APRNs may receive third-party reimbursement as determined by payers. NPs receive Medicaid reimbursement at 85% of the physician payment and Medicaid managed-care and fee-for-service plans must reimburse both NPs and CNSs employed by community mental health centers for services as specified.

    Iowa

    www.nursing.iowa.gov

    https://campaignforaction.org/state/iowa/

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Iowa BON regulates the licensure, education, and practice of APRNs, which are defined as ARNPs in regulation and include CNP, CNS, CNM, and CRNA roles. ARNPs practice autonomously within their specified role and population focus in accordance with national professional associations, which is broadly defined in IAC 655 – 7.4. NP practice in the state of Iowa is considered Full Practice by the American Association of Nurse Practitioners.

    ARNPs are statutorily recognized as PCPs; however, state law does not contain “any willing provider” language. ARNPs may hold hospital clinical privileges. Licensure as an ARNP requires active licensure as an RN and national board certification 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. The majority of ARNPs are educated at the master's or doctoral level.

    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).

    Reimbursement

    Iowa's Medicaid managed care and prepaid service programs reimburse ARNPs. Payment of necessary medical or surgical care and treatment is provided to an ARNP via third-party reimbursement if the policy or contract would pay for the care and treatment when provided by a physician 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.

    Kansas

    www.ksbn.org

    www.kansasnps.com www.campaignforaction.org/state/kansas

    Practice authority

    The Kansas BON grants authority to APRNs and regulates the practice. Recognized APRN roles include the CNP (NP in regulation), CNS, CNM (NM in regulation), and CRNA (RNA in statute). SOP is defined in statute and regulation with CNPs, CNSs, and CRNAs functioning in collaborative relationships with physicians and other healthcare professionals in the delivery of primary healthcare services. CNMs are authorized to practice without a collaborative agreement when such services are limited to those associated with a normal, uncomplicated pregnancy and delivery.

    Any CNP, CNS, or CRNA who 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 is maintained at the APRN's principal place of practice. 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 provided by an APRN.

    APRNs are not recognized as PCPs in Kansas. 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).

    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 that may be prescribed by the APRN. These can be published protocols or practice guidelines that have been agreed upon by both the APRN and physician. In addition to DEA registration, APRNs must register with the BON to prescribe CSs. Prescription orders and labels must include the physician's name in addition to the name of the prescribing APRN. APRNs are authorized to request, receive, and distribute pharmaceutical samples, except for CSs, if the drug is within their protocol.

    CNMs may prescribe drugs and devices without a 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.

    Reimbursement

    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 pay 85% of physician payments to APRNs.

    Kentucky

    www.kbn.ky.gov

    www.kcnpnm.org

    www.campaignforaction.org/state/kentucky

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Kentucky BON grants APRNs authority to practice and regulates their practice. APRNs are defined in statute as CNPs, CNSs, CNMs, and CRNAs. APRNs practice autonomously within their relative SOPs; however, they must practice in accordance with the SOP of the national certifying organization as 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 [35], KRS 218A.010 [33]), 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 [8][b][2] [b]). A master's degree, doctorate, or postmaster's certificate as an APRN and national board certification are required to practice in Kentucky. The American Association of Nurse Practitioners considers NP practice in Kentucky Reduced Practice.

    APRNs must pass a jurisprudence exam for prescriptive authority, ensuring APRNs are familiar with the requirements of obtaining and maintaining prescriptive authority for nonscheduled legend drugs and CSs. APRNs have autonomous prescriptive authority for nonscheduled legend drugs following 4 years of prescribing experience under a Collaborative Agreement for Prescriptive Authority for Nonscheduled Drugs (CAPA-NS) with a physician licensed in Kentucky. CRNAs are not required to have a CAPA to deliver anesthesia care.

    Prescribing 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 must be signed by the APRN and the physician. APRNs may prescribe scheduled medications with the following limitations. 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.

    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).

    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.

    APRNs are 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.

    Reimbursement

    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.

    Louisiana

    www.lsbn.state.la.us

    www.lanp.org

    www.campaignforaction.org/state/louisiana

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Louisiana State BON regulates the practice, licensure, and education of APRNs. The APRN title is defined in regulation and includes CNP, CNM, CRNA, and CNS roles. The APRN authorized SOP is defined in regulation, must be consistent with the APRN's educational preparation, and authorizes medical diagnosis and management in collaboration with a physician or dentist under a collaborative practice agreement. The CPA is 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.

    Louisiana state law includes “any willing provider” language, and APRNs are 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. The American Association of Nurse Practitioners considers NP practice in Louisiana Reduced Practice.

    Prescriptive authority for APRNs includes legend and schedules II–V CSs, in which 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 including controlled substances, 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.

    Reimbursement

    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.

    Maine

    www.state.me.us/boardofnursing

    www.mnpa.us www.campaignforaction.org/state/maine

    Practice authority

    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.

    CNPs and CNMs may prescribe and dispense drugs or devices, including schedules II–V CSs, in accordance with rules adopted by the BON, and CNPs and CNMs are required 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 II, IIIN, IV, and V CSs only for a supply of no more than 4 days with no refills; and for an individual who is an established client or patient of record of the CRNA at the time of the prescription.

    Opioid prescribing is limited 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).

    Reimbursement

    The 1999 Act to Increase Access to Primary Health Care Services requires reimbursement under an indemnity or managed-care plan for patient visits to an NP or CNM when referred from a PCP, requires insurers to assign 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 not 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 for services provided by certified family NPs, CPNPs, and CNMs on a fee-for-service basis.

    Maryland

    www.mbon.org

    www.npamonline.org

    www.maapconline.org

    www.campaignforaction.org/state/maryland

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Maryland BON regulates APRN practice, statutorily defining APRN in regulation (COMAR 10.27.07.01). The APRN title includes the CNP (NP or CRNP in statute), CRNA, CNM, and CNS roles. Maryland also recognizes nurse psychotherapists as APRNs (APRN/PMH). NP SOP is 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. The American Association of Nurse Practitioners considers NP practice in the state of Maryland Full Practice.

    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 who hold 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. 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 state controlled dangerous substances registration. 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.

    Reimbursement

    All nurses are entitled to private third-party and Medicaid reimbursement for services if they are practicing within their legal SOP. All Medicaid recipients have been assigned to an MCO; CNPs (except for neonatal and acute care) and CNMs have been designated as PCPs and may apply for placement on a provider panel. Medicaid reimburses at 100% of physician payment.

    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.

    Massachusetts

    www.mass.gov/dph/boards/rn

    www.mcnpweb.org

    www.campaignforaction.org/state/massachusetts

    Practice authority

    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.

    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 include 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 are 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 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.

    Reimbursement

    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. All health insurers are required to recognize NPs as PCPs and include them in provider directories for consumer choice.

    Michigan

    www.minurses.org

    www.micnp.org

    www.campaignforaction.org/state/michigan

    Practice authority

    The Michigan BON grants APRN practice authority and regulates the practice. APRNs are defined in statute and include the CNP, CNS, and CNM roles. 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.

    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's name and DEA number. 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.

    Reimbursement

    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.

    Minnesota

    www.nursingboard.state.mn.us

    www.mnnp.org

    https://mnaprnc.enpnetwork.com/

    www.campaignforaction.org/state/minnesota

    Practice authority

    The Minnesota BON grants APRNs the authority to practice through licensure and regulates their practice. APRN is defined in statute (148.171 Subd. 3) and includes CNP, CNS, CNM, and CRNA roles. APRNs have full practice authority in Minnesota. SOP is defined in statute and must be consistent with the APRN's education. 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. The American Association of Nurse Practitioners considers NP practice in Minnesota Full Practice.

    CNPs and CNSs beginning practice after July 1, 2014 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 (Minnesota Statutes 2012, Section 148.211, Subd. 1c). CRNAs and CNMs are not required to complete a postgraduate practice requirement.

    APRNs are authorized to enroll in the Medical Cannabis Registry to certify qualifying conditions for medical cannabis. APRNs may independently prescribe, receive, dispense, and administer drugs, including schedules II–V CSs. CRNAs must hold a verbal agreement with a physician when providing nonsurgical pain therapies for acute pain, and a written prescribing agreement with a physician when providing nonsurgical pain therapies for chronic pain symptoms. APRNs must register their DEA number with the Board of Nursing, and they have statutory authority to request, receive, and dispense sample medications. All Minnesota APRNs who hold DEA registration must register and maintain an account with the Prescription Monitoring Program.

    Reimbursement

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

    Mississippi

    https://www.msbn.ms.gov

    https://www.msanp.org

    www.msnurses.org

    www.campaignforaction.org/state/Mississippi

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Mississippi BON grants APRNs the authority to practice and regulates their practice. APRNs include CNP, CNM, and CRNA roles. SOP is defined and regulated by the BON and CNPs, CRNAs, and CNMs practice in a collaborative relationship with physicians. 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. The American Association of Nurse Practitioners considers NP practice in Mississippi Reduced Practice.

    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.

    CNPs and CNMs have full prescriptive authority, including schedules II–V CSs, based on the standards and guidelines of the CNP's or CNM's national certification organization and a BON-approved CS Rx authority 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. CNMs and CRNAs may order CSs within a licensed healthcare facility using BON-approved protocol or practice guidelines.

    Reimbursement

    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 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.

    Missouri

    www.pr.mo.gov/nursing.asp

    www.missourinurses.org

    www.campaignforaction.org/state/missouri

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Missouri BON grants APRNs the authority to practice and regulates their practice. APRNs are defined in statute and regulation and include CNP, CNS, CNM, and CRNA roles. APRNs practice in collaboration with physicians in Missouri. SOP is defined in regulation and must be within the professional scope and standards of their APRN role and population focus and consistent with their formal education and national certification as well as regulations set forth by state and federal agencies for controlled substances prescribing.

    APRNs practice in collaboration set forth in 20 CSR 2200-4.200 Collaborative Practice 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 required 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. When practicing outside their recognized clinical nursing specialty, individuals must practice and title as RNs only. The American Association of Nurse Practitioners considers NP practice in Missouri Restricted Practice.

    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.

    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, and when it is within the APRN's specialty area and consistent with the individual's skill, training, education, and competence. 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. A state Bureau of Narcotics and Dangerous Drugs number in addition to DEA registration is required. Prescriptions written by an NP are labeled with both the collaborating physician's and NP's names. APRNs may receive and dispense sample medications within their prescriptive authority.

    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 are limited to a 120-hour supply with no refills.

    Reimbursement

    Current law states, “Any health insurer, nonprofit health service plan, or HMO shall reimburse a claim for services provided by an APRN, if such services are within the SOP of such a nurse.” Medicaid reimbursement is made to APRNs enrolled as Missouri Medicaid fee-for-service providers and Medicaid-enrolled APRNs associated with a federally qualified healthcare or rural healthcare facility or both.

    Medicaid reimbursement is limited to services furnished by enrolled APRNs who are within the SOP allowed by federal and state laws and inpatient or outpatient hospital/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.

    Montana

    www.bsd.dli.mt.gov/license/bsd_boards/nur_board/board_page.asp

    https://mtnurses.nursingnetwork.com

    www.campaignforaction.org/state/montana

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The Montana BON grants APRNs authority to practice and regulates their practice. APRN title is defined in regulation and includes CNP, CNS, CNM, and CRNA roles. APRN SOP is defined in Rule ARM 24.159.1405 and 24.159.1406, and the American Association of Nurse Practitioners considers NP practice in Montana Full Practice. According to the Montana BON, all APRNs are expected to engage in ongoing competence development per Rule ARM 24.159.1469. APRNs are legally authorized to admit patients and hold hospital privileges; however, this varies according to the rules and bylaws of each hospital.

    APRNs must have a 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.

    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.

    Reimbursement

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

    Nebraska

    http://dhhs.ne.gov/licensure/Pages/Nurse-Licensing.aspx

    www.nebraskanp.org

    www.campaignforaction.org/state/nebraska

    Practice authority

    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.

    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.

    Reimbursement

    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. Board-certified primary care NPs or NPs who specialize in family practice, internal medicine, or pediatrics are listed as a Direct Provider and are reimbursed for services under the Direct Primary Care Agreement Act.

    Nevada

    https://nevadanursingboard.org/

    www.nvnurses.org

    www.campaignforaction.org/state/nevada

    www.nonl.org

    Practice authority

    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 requires a master's or doctorate degree in nursing or related health field and national board certification. 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, may 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.

    Reimbursement

    APRNs are recognized by insurance companies and receive third-party reimbursement.

    New Hampshire

    https://www.oplc.nh.gov/nursing

    http://nhnpa.enpnetwork.com

    www.campaignforaction.org/state/new-hampshire

    Practice 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.

    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.

    Legislation passed in 2016 requires all prescribers who possess DEA registration to register with the Prescription Drug Monitoring Program and 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.

    Reimbursement

    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.

    New Jersey

    www.njconsumeraffairs.gov/nur/Pages/default.aspx

    www.njsna.org

    www.campaignforaction.org/state/new-jersey

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The New Jersey BON grants ARPNs authority to practice and regulates their practice. APRNs are defined in the NPA as APNs and include CNP, CNS, and CRNA roles. CNMs are regulated by the New Jersey BOM. APN SOP is defined in statute and requires joint protocols with a collaborating physician for prescribing drugs and devices only. The American Association of Nurse Practitioners considers NP practice in New Jersey Reduced Practice.

    APNs are recognized as PCPs and are authorized to admit patients and hold hospital privileges 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. APNs credentialed by the BON have full prescriptive authority, including schedules II– V CSs, in accordance with a joint protocol, established between an APN and a 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 and DEA registration, 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 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.

    Reimbursement

    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.

    New Mexico

    www.nmna.org

    www.nmnpc.org

    www.campaignforaction.org/state/new-mexico

    Practice authority

    The New Mexico BON grants APRNs the authority to practice and regulates the practice. APRNs include CNP, CNS, and CRNA roles. CNP, CRNA, and CNS SOP is defined in 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. CNPs, CNSs, and CNMs have hospital admitting and discharge privileges and membership on medical staff committees 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 masters prepared and certified by a national certifying nursing organization. CNMs are regulated by the Department of Health and are recognized as PCPs in statute.

    CNPs and CNSs have full, independent prescriptive authority, including schedules II–V CSs within the scope of the specialty practice and setting. A current state-controlled substance registration and DEA number is required unless the CNP or CNS has met registration waiver criteria from the New Mexico board of pharmacy. CNPs and CNSs maintain a formulary of dangerous drugs and controlled substances that may be prescribed and must be relevant to the prescriber's specialty and practice setting.

    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.

    Reimbursement

    Statutory authority for third-party reimbursement for CNPs 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 CNPs.

    New York

    www.nysed.gov

    www.nysna.org

    www.campaignforaction.org/state/new-york

    Practice authority

    The New York State Education Department licenses registered nurses and certifies CNPs (NP in statute) to practice. The term ‘APRN’ is not defined in New York statutes or regulation. Scope of practice is defined in statute, authorizing NPs to diagnose illnesses and physical conditions and perform therapeutic and corrective measures within the specialty area of practice in which the NP is certified, including ordering diagnostic tests. New York 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: 1) practice in accordance to a written practice agreement with a collaborating physician, or 2) 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 defined as communication 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. Certification as an NP requires completion of an educational program/master's degree in nursing registered by the Department of Education or current certification by a national certifying body approved by the Department. CNMs are not regulated or recognized by the BON but must complete a master's or higher degree program in midwifery or a related field that is accredited by the American College of Nurse Midwives Division of Accreditation.

    NPs authorized to prescribe or order medications, including schedules II–V CSs, may dispense medications to their patients. Certified nurse 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.

    Reimbursement

    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.

    North Carolina

    www.ncbon.com

    www.ncnurses.org

    www.campaignforaction.org/state/north-carolina

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    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 solely regulated by the BON. CNMs are regulated by the Midwifery Joint Committee. APRN is defined in regulation and includes CNP, CNS, CNM, and CRNA roles. NP SOP is defined in regulation (21 NCAC 36 .0802) for which educational preparation is established and for which competency has been maintained. Physician supervision (primary supervising physician – PSP) and collaboration is required for NP practice. The parameters of the CNP's practice are 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. The American Association for Nurse Practitioners considers NP practice in North Carolina Restricted Practice.

    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.

    Eligibility requirements for licensure in 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 and CNMs have full prescriptive authority, including schedules II–V CSs that are identified in their CPA. Dispensing is authorized under specific conditions and if a dispensing license has been obtained. 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.

    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[1] or [2] 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 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.

    Reimbursement

    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.

    North Dakota

    www.ndbon.org

    www.ndnpa.org

    www.campaignforaction.org/state/north-dakota

    www.ndna.org

    https://www.ncsbn.org/APRNState_COVID-19_Response.pdf

    Practice authority

    The North Dakota BON grants APRNs the authority to practice and regulates their practice. APRNs are defined in the NPA and include CNP, CNS, CNM, and CRNA roles. APRNs practice independently in North Dakota, and their SOP is defined in regulation, consistent with their nursing education and advanced practice certification. The American Association of Nurse Practitioners considers NP practice in the state of North Dakota Full Practice. APRNs are statutorily recognized as PCPs.

    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.

    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.

    Reimbursement

    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. All certified NPs are 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.

    Providers practicing more than 20 miles from Williston, Dickson, Minot, Bismarck, Jamestown, Devils Lake, Grand Forks, Wahpeton, and Fargo are reimbursed the lesser of the provider's billed charges or 85% of the BC/BS physician payment system(s) in effect at the time services are rendered.

    Ohio

    www.nursing.ohio.gov

    www.oaapn.org

    www.campaignforaction.org/state/ohio

    Practice authority

    The Ohio BON grants APRNs authority to practice and regulates their practice. The term ‘APRN’ is defined in statute and includes the CNP, CNS, CNM, and CRNA roles. SOP is defined in statute and requires a Standard Care Arrangement between a physician or podiatrist and a CNP, CNS, or CNM. Psychiatric mental health CNPs and CNSs may only enter a Standard Care Arrangement with a physician practicing in psychiatry, pediatrics, or family practice/primary care. The American Association of Nurse Practitioners defines Ohio NP practice as Reduced.

    Amended in 2020, the CRNA SOP is defined in statute, including evaluation, assessment, and prescriptive authority related to the administration of anesthesia when standards and procedures have been established within the healthcare facility.

    CNPs, CNSs, and CNMs 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.

    Prescriptive authority for CNPs, CNMs, and CNSs include schedules II–V CSs under rules and in collaboration with a physician. CNPs, CNSs, and CNMs must 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 in Administrative Rule. By statute, prescriptive authority of a CNP, CNS, or CNM shall not exceed the prescriptive authority of the collaborating physician or podiatrist. These APRNs are permitted to prescribe newly released drugs if they are not of a type that is prohibited by the exclusionary 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, subacute, and chronic pain.

    APRNs who are not practicing in a location or program recognized in law are limited in their schedule II CS prescribing. APRNs are limited to the care of terminally ill patients only after a physician has initiated the opioid prescription, 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.

    Reimbursement

    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.

    Oklahoma

    https://nursing.ok.gov/

    https://npofoklahoma.com/

    https://campaignforaction.org/state/oklahoma/

    Practice authority

    The Oklahoma BON grants APRNs the authority to practice and regulates their practice. APRN is defined in statute and includes CNP, CNS, CNM, and CRNA roles. APRNs practice within a SOP as defined by the NPA, authorizing CNPs, CNSs, and CNMs to function independently except for prescriptive authority, which requires supervision by a physician. The SOP for a CNP and CNS are further identified in specialty population foci. CRNAs function in collaboration defined as joint formulation, discussion, and agreement of the anesthesia plan with 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. The American Association of Nurse Practitioners defines Oklahoma NP practice as Restricted.

    CNPs are recognized as PCPs and hospital privileges are not expressly prohibited. Initial licensure as an APRN requires graduation from a graduate-level accredited APRN program and national certification consistent with educational preparation.

    The BON regulates optional prescriptive authority for CNPs, CNSs, and CNMs, which includes Schedules III, IV, V CSs. Prescriptive authority requires physician supervision, and APRNs with prescriptive authority must submit a written statement from an Oklahoma-licensed physician to the BON. The written statement must identify the mechanism for appropriate referral, consultation, and collaboration, and the availability of communication between the APRN and physician. APRNs may only prescribe according to an exclusionary formulary approved by the board, must be within the APRN's scope of practice, and may only include schedules III, IV, and V CSs (30-day supply) if the Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) and DEA registrations are obtained. The written statement may 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.

    CNPs, CNSs, and CNMs must complete 2 hours of CE in pain management or 2 hours of education in opioid use or addiction, in addition to the 15 contact hours of pharmacotherapeutics for renewal of prescriptive authority.

    Reimbursement

    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.

    Oregon

    www.oregonrn.org

    www.oregon.gov/OSBN www.campaignforaction.org/state/oregon

    Practice 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; 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.

    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.

    Reimbursement

    By law, NPs are entitled 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).

    Pennsylvania

    www.dos.pa.gov/ProfessionalLicensing/BoardsCommissions/Nursing/Pages/default.aspx

    www.pacnp.org

    www.campaignforaction.org/state/Pennsylvania

    Practice authority

    The Pennsylvania BON grants CRNPs and CNSs authority to practice and regulates their practice. The term ‘APRN’ is not defined in statute or regulation. CRNP SOP is defined in the NPA, authorizing CRNPs to perform acts of medical diagnosis in collaboration with a physician when practicing within a clinical specialty as certified by the Board. A 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 American Association of Nurse Practitioners considers the practice of Pennsylvania's NPs Reduced.

    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.

    The BON confers prescriptive authority including schedules II – V CSs to CRNPs with a collaborating physician following completion of educational requirements. Prescribing and dispensing medications must conform to regulations and must be relevant to the CRNP's area of practice and documented in a collaborative agreement. CRNPs are not authorized to prescribe from a prohibited drug category.

    Prescriptions for a schedule II CS are limited to a 30-day supply, where schedules III and IV are authorized for up to a 90-day supply; Schedule V is not restricted. CRNPs are authorized to request, receive, and dispense pharmaceutical sample medications.

    Reimbursement

    Third-party reimbursement is available for the CRNP, CRNA, certified enterostomal therapy nurse, certified community health nurse, certified psychiatric/mental health nurse, and certified CNS, provided the nurse is certified by a state or 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.

    Rhode Island

    www.health.ri.gov/for/nurses

    http://npari.enpnetwork.com www.campaignforaction.org/state/ rhode-island

    Practice authority

    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).

    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).

    Reimbursement

    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.

    South Carolina

    https://llr.sc.gov/nurse/www.scnurses.org

    www.campaignforaction.org/state/ south-carolina

    Practice authority

    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.

    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.

    Reimbursement

    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 the State Health and Human Services Board in South Carolina, while the rest of the Board consists of physicians.

    South Dakota

    http://doh.sd.gov/Boards/Nursing

    www.npasd.org

    https://campaignforaction.org/term-location/south-dakota

    Practice authority

    The South Dakota BON regulates and licenses APRNs. The term ‘APRN’ is defined in statute and includes CNP, CNS, CNM, and CRNA roles. SOP is defined in statute and CNMs and CNPs have full practice authority. CNMs and CNPs must complete a transition to practice of 1,040 practice hours in a collaborative practice agreement with a South Dakota licensed physician, 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. The American Association of Nurse Practitioners considers South Dakota NP practice Full Practice.

    CRNA practice does not require a collaborative agreement or on-site supervision. CNS practice requires physician collaboration before ordering durable medical equipment or therapeutic devices. A written agreement or on-site supervision is not required.

    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.

    South Dakota's CNPs, CNMs, and CRNAs are authorized to prescribe legend drugs and schedules II, III, and IV CSs. CNPs, CNMs, and CRNAs have two CS registration options. They may seek independent state registration and 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, CNMs, and CRNAs may request and receive prepackaged drug samples, which the NP, CNM, or CRNA are authorized to prescribe and may provide drug samples to patients they are treating. Each sample drug shall be accompanied by written administration instructions.

    Prior to prescribing any CSs listed in SDCL Chapter 34-20B, the NP, CNM, or CRNA who meets state and federal CS registration requirements must register with the state's PDMP and meet requirements in Chapter 34-20E, including standards for documentation of patient care. CNSs do not have prescriptive authority; however, CNSs may order and dispense durable medical equipment and therapeutic devices in collaboration with a physician.

    Reimbursement

    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 and they are acting within their SOP.

    Tennessee

    www.tnaonline.org

    www.tn.gov/health

    www.campaignforaction.org/state/tennessee

    Practice authority

    The Tennessee BON grants APRNs authority to practice and regulates their practice. APRNs are defined in statute 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 who prescribe practice pursuant to protocols jointly developed by the APRN and a collaborating physician. Medical Board rules governing the collaborating physician of the APRN prescriber are jointly adopted by the BOM and BON. Physician collaboration with APRN prescribers 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. On-site supervision is not required. The American Association of Nurse Practitioners considers NP practice in the state of Tennessee Restricted.

    CRNAs and CNMs are defined in 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.

    NPs with 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 notice with the board, and include the name of the NP, the name of the licensed physician collaborating with the NP who has control and responsibility for prescriptive services rendered by the NP, and a copy of the formulary describing the categories of legend drugs to be prescribed and/or issued by the NP. 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.

    Prescribers are required to confer with the CS database prior to issuing a prescription for CSs of a new episode of treatment, prior to the issuance of each new prescription for the CS for the first ninety (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, statutory limitations and requirements on the number of opioids prescribed and dispensed are in place, 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.

    Legislation enacted in 2020 authorizes nonphysician prescribers to prescribe and dispense buprenorphine products to treat opioid use disorder in recovery or medication-assisted treatment under certain conditions with physician supervision and oversight (Public Chapter No. 761).

    Reimbursement

    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 this writing). 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.

    Texas

    www.bon.texas.gov

    www.cnaptexas.org

    www.texasnp.org

    www.campaignforaction.org/state/texas

    Practice authority

    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.

    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 prescription; 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.

    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.

    Reimbursement

    All APRN categories are eligible for direct Medicaid reimbursement at 92% of physician payment. Under certain circumstances, physicians in the Texas Medicaid Program may bill for an APRN's services and receive 100%. Some programs, such as Texas Health Steps, reimburse all providers at the same rate. 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.

    Utah

    www.dopl.utah.gov/index.html

    http://utahnp.enpnetwork.com

    www.campaignforaction.org/state/utah

    Practice authority

    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-302. Licensed APRN roles include CNP, CNS, psychiatric/mental health nurse, CNM, and CRNA. CNMs are regulated by a separate practice act and CNM board. The APRN SOP is defined by set standards from national, professional, and specialty organizations and APRNs practice independently without physician supervision or collaboration except for schedule II CS authority as described below. The American Association of Nurse Practitioners considers the practice of NPs in Utah Reduced.

    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 hold national board certification to be licensed in Utah.

    APRNs, including CNMs, have prescriptive authority for all legend drugs and devices within their defined SOP, including schedules II–V CSs. A consultation and referral plan are required if the APRN prescribes 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.

    Reimbursement

    The state insurance code has a nondiscrimination code; nothing prohibits reimbursement. APRNs are reimbursed by most insurance companies. Medicaid empanels and reimburses 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.

    Vermont

    https://www.sec.state.vt.us/professional-regulation/list-of-professions/nursing.aspx

    www.vtnpa.org

    www.campaignforaction.org/state/vermont

    Practice authority

    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. 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. The American Association of Nurse Practitioners considers Vermont a Full Practice state.

    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.

    Reimbursement

    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.

    Virginia

    www.dhp.virginia.gov

    www.vcnp.net

    www.campaignforaction.org/state/virginia

    Practice authority

    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 as 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.

    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.”

    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.

    Washington

    www.doh.wa.gov/LicensesPermitsandCertificates/NursingCommission.aspx

    www.auws.org

    www.wsna.org

    www.campaignforaction.org/state/washington

    Practice authority

    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 SOP is defined in statute and regulation and is considered independent, assuming primary responsibility for continuous and comprehensive management of a broad range of patient care, concerns, and problems. The American Association of Nurse Practitioners considers NP practice in the state of Washington to be Full Practice.

    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.

    All ARNPs who receive prescriptive authority have the option to prescribe legend drugs and schedules II–V CSs. ARNPs are legally authorized to request, receive, and dispense pharmaceutical samples.

    Reimbursement

    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.

    Effective January 1, 2021, a new law requires health plans to reimburse a provider for telehealth visits at the same rate as healthcare services provided in-person.

    West Virginia

    https://wvrnboard.wv.gov/Pages/default.aspx

    www.campaignforaction.org/state/west-virginia

    Practice authority

    The West Virginia BON grants authority to practice and regulates the practice of APRNs. The term ‘APRN’ is defined in statute and regulation and includes the 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. The American Association for Nurse Practitioners considers NP practice in the state of West Virginia Reduced.

    APRNs are defined in regulation as Primary Health Care Professionals. 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.

    Qualified APRNs have limited autonomous prescriptive authority following 3 years of a duly documented collaborative relationship with a physician and approval by the Joint Advisory Council on Limited Prescriptive Authority. The Joint Advisory Council on Limited Prescriptive Authority is 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. APRNs work from an exclusionary formulary; Schedules I and II CSs, antineoplastics, radiopharmaceuticals, and general anesthetics are prohibited (exception granted during the 2020 COVID-19 Pandemic). APRNs are authorized to sign for and provide drug samples.

    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.

    Reimbursement

    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 provides 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.

    Wisconsin

    www.wisconsinnurses.org

    www.dsps.wi.gov/Licenses-Permits/Credentialing/Health-Professions

    www.campaignforaction.org/state/wisconsin

    Practice authority

    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.

    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.

    Reimbursement

    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.

    Wyoming

    wsbn.wyo.gov

    wcapn.org

    www.campaignforaction.org/state/wyoming

    Practice authority

    The Wyoming BON grants APRNs the authority to practice via licensure and regulates their practice. APRN is defined in statute and includes the CNP, CNS, CNM, and CRNA roles. APRN SOP is defined in statute and includes prescriptive authority and management of patients commensurate with national organizations and accrediting agencies. The American Association of Nurse Practitioners considers NP practice in Wyoming to be Full Practice.

    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.

    BON-approved APRNs may independently prescribe legend and schedule II-V CSs. APRNs with prescriptive authority are legally authorized to request, receive, and dispense pharmaceutical samples.

    Reimbursement

    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.

    Legislative update key

    ANP Advanced Nurse Practitioner

    APN Advanced Practice Nurse

    APNP Advanced Practice Nurse Prescriber

    APRN Advanced Practice Registered Nurse

    ARNP Advanced Registered Nurse Practitioner

    ASTC Ambulatory Surgical Treatment Center

    BC/BS Blue Cross/Blue Shield

    BOM Board of Medicine

    BOME Board of Medical Examiners

    BON Board of Nursing

    BOP Board of Pharmacy

    BRN Board of Registered Nursing

    CHAMPUS Civilian Health and Medical Program of the Uniformed Service

    CNM Certified Nurse Midwife

    CNP Certified Nurse Practitioner

    CNS Clinical Nurse Specialist

    CPA Collaborative Practice Agreement

    CPNP Certified Pediatric Nurse Practitioner

    CRNA Certified Registered Nurse Anesthetist

    CRNP Certified Registered Nurse Practitioner

    CS Controlled substance

    DEA Drug Enforcement Administration

    DO Doctor of Osteopathic Medicine

    FNP Family Nurse Practitioner

    FPA Full Practice Authority

    GNP Geriatric Nurse Practitioner

    HMO Health Maintenance Organization

    MCO Managed Care Organization

    NCSBN National Council of State Boards of Nursing

    NM Nurse Midwife

    NPA Nurse Practice Act

    NPI National Provider Identifier

    PA Physician Assistant

    PCP Primary Care Provider

    PCNS Psychiatric Clinical Nurse Specialist

    PDMP Prescription Drug Monitoring Program

    PMHNP Psychiatric-Mental Health Nurse Practitioner

    PNP Pediatric Nurse Practitioner

    RNP Registered Nurse Practitioner

    R&R Rules and Regulations

    SOP Scope of Practice

    WHNP Women's Health Nurse Practitioner

    Keywords:

    advanced practice registered nurse; legislative update; practice authority; prescriptive authority regulation; statutes; updates

    Wolters Kluwer Health, Inc. All rights reserved.