35th Annual APRN Legislative Update: Updates to APRN practice authority in the United States : The Nurse Practitioner

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Feature: NP LEGISLATIVE UPDATES

35th Annual APRN Legislative Update

Updates to APRN practice authority in the United States

Haney, Beth DNP, FNP-C, FAANP, FAAN

Author Information
The Nurse Practitioner 48(1):p 20-47, January 2023. | DOI: 10.1097/01.NPR.0000903012.03553.a4
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Significant legislation has passed in 2022 that has expanded the reach of advanced practice registered nurses (APRNs). These successes include advances for not only NPs or certified NPs (CNPs), but all categories of APRNs, including certified nurse midwives (CNMs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs).

Decreasing or eliminating barriers to patient care is meaningfully improved by attaining Full Practice Authority (FPA) for APRNs in every state. FPA is defined by the American Nurses Association as “an APRN's ability to utilize knowledge, skills, and judgment to practice to the full extent of his or her education and training.”1 The American Association of Nurse Practitioners defines FPA for NPs as “the authorization of nurse practitioners (NPs) to evaluate patients, diagnose, order and interpret diagnostic tests and initiate and manage treatments — including prescribing medications — under the exclusive licensure authority of the state board of nursing.”2 To date, 27 states, two US territories, and Washington, D.C. have adopted modernized licensure laws for CNPs, and momentum is building (see Summary of practice authority for NPs in the US).3 In fact, research shows that states with FPA rank highest in the nation for healthcare access.4 Understanding the definition and patient care implications of FPA is important for moving the profession forward and liberating APRNs to work to the fullest extent of their education and experience.

The year 2022 was an exciting one for APRNs and their patients because some of the temporary state waivers permitted during the pandemic ultimately became permanent. Telehealth was also a growing avenue for healthcare, with many states adopting regulations streamlining and codifying healthcare delivery using audio and visual technology where appropriate.5

Widespread use of telehealth during the pandemic had a significant and positive impact on healthcare delivery. For appropriate types of visits, APRNs and their patients can enjoy a convenient, and oftentimes more cost-effective, experience. Patients can access their healthcare provider without having to find transportation to and from appointments, thereby potentially saving time and money and reducing environmental impact through decreased resource consumption. Telehealth is shown to improve healthcare access in rural areas and, although challenges exist, can be a means of providing cost-effective care in areas with limited healthcare providers.6

Several states have enacted cannabis legislation and 37 states, three territories, and Washington, D.C. allow medical use of marijuana.7 Effective July 2021, South Dakota APRNs who are licensed with authority to prescribe drugs may now certify patients for medical use of cannabis.8 In Minnesota, APRNs are authorized to enroll in the Medical Cannabis Registry to certify qualifying conditions for medical cannabis prescription.9

This 35th Annual Legislative Update covers practice changes as well as legislative and regulatory outcomes that most impacted APRNs and patient access across the country in 2022. Additionally, it highlights the ongoing expansion of telehealth and home health services provided by APRNs as well as reimbursement changes. State boards of nursing (BONs) and/or state nursing associations or their websites provided the total number of active clear licensed/certified APRNs in 2022 for this report (see Total number of active clear licensed/certified APRNs reported by BONs and/or state nursing associations in 2022).

Practice authority

Advancements in scope of practice

The passage of California Statutes Chapter No. 265, effective January 1, 2021, codified CNP scope of practice (SOP) expansion and “independent practice.” When the regulatory process is complete, the new statute will have eliminated physician-supervised practice by removing the “standardized procedure” requirement when the NP is nationally board certified and completes a 3-year or 4,600-hour transition to practice (TTP) period within defined settings categorized as training and experience requirements defined in BPC § 2837.103.10

However, in order for the NP to practice independently, outside of a defined healthcare setting, the NP must meet all of the requirements for independent practice. Proof of completion of a TTP by submitting to the board one or more attestations of a physician, a surgeon, an NP practicing pursuant to Section 2837.103 of the code, or an NP practicing pursuant to Section 2837.104 of the code is required. AB 890 created two different categories of NPs that are defined by the settings in which they practice and named for the section of the state code in which the law resides. Each category has different requirements the NP must complete before being allowed to practice without physician supervision.

The California Board of Registered Nursing is required to adopt regulations by January 1, 2023; however, the Board has indicated it will finish the regulations as close to that date as possible. When the regulations are finalized, approved, and deemed in accordance with the law, certain NPs will be able to practice without physician supervision. However, proposed language includes a number of stipulations that will need to be addressed.

Additionally, SB 1375 was signed into law by California Governor Gavin Newsom on September 27, 2022. SB 1375 aims to increase access to abortion care and reproductive health services in California. It clarifies existing laws so that trained and experienced NPs can provide abortion care without physician supervision.11

FU2-6
Figure:
Summary of practice authority for NPs in the US

Two more states have modernized SOP laws and enacted FPA for NPs through legislation in 2022: New York and Kansas.2New York NPs who have more than 3,600 hours of experience are no longer required to have collaborative relationships or sign and maintain form NP-CR. The New York State Budget was passed in 2022 and contained amendments to the Nurse Practitioner Modernization Act and updated FPA for experienced NPs.12

As of October 14, 2022, Kansas APRNs have achieved FPA. APRNs, as defined by K.S.A. 65-1113, “shall function in an expanded role to provide primary, secondary, and tertiary health care” within their advanced practice role.13 Kansas APRNs are authorized to make independent medical decisions about advanced practice nursing needs of families, patients, and clients and are “directly accountable and responsible to the consumer “.13

Utah has advanced NP practice authority by removing consultation and referral practice requirements and replacing them with a mentorship requirement for new NPs to prescribe Schedule II controlled substances (CSs). The mentorship requirement applies to NPs in independent solo practice with less than one year or 2,000 hours of experience as an APRN. The NP must fulfill certain other conditions, including documenting 1,000 hours of clinical experience, to be authorized to prescribe these substances, and the mentor must be a physician or APRN with at least 3 years of experience.14

The state of Alaska enacted HB 392 in October 2022, thereby providing that an APRN can issue or revoke a do not resuscitate order, sign death certificates, and administer life-sustaining procedures the same way physicians do under current Alaska law.15

Advancements in telehealth

The COVID-19 pandemic added significant gravity to the surging telehealth industry in the healthcare professions. The efficacy and efficiency of audio and video healthcare appointments were highlighted as more people decided to forgo in-person visits and utilize telehealth. Many healthcare providers at the forefront of the enormous growth in telehealth use had to learn quickly how to navigate the technical and legal ramifications of this rapidly growing form of healthcare delivery. Transportation issues, time away from home, and avoiding crowded medical facilities were just a few reasons telehealth became more popular.

However, there are some concerns regarding telehealth including privacy issues, patient access, and payment models. Simultaneously, questions about the number of primary care visits, patient satisfaction, and patient acceptance have been identified and studied as the number of telehealth visits continues to grow. Researchers found the number of primary care visits did not increase because telehealth was available and patient satisfaction was on par with in-person visits.16 Reimbursement issues have been addressed in some states, which require insurance companies to cover telehealth services and ensure payment parity between telehealth and in-person visits (see individual state details in this update). The patient's home is considered an approved location to receive services in these states.5

In Ohio, HB122 was signed into law and went into effect on March 23, 2022.17 It expressly authorizes APRNs to provide telehealth services and sets forth various standards of care that must be met when providing telehealth.

Maine passed S.P. 50 - L.D. 791 in June 2021, which allows healthcare providers to provide telehealth services as long as the licensee acts within the SOP of the licensee's license, in accordance with any requirements and restrictions imposed by this law, and in accordance with standards of practice.18

West Virginia passed a bill to allow licensed healthcare practitioners to practice interstate telehealth from within the state, provided that they are in good standing in all states of licensure and they pay a fee to become registered with the appropriate state medical board.19

Arizona passed HB 2454 that permanently allows healthcare providers licensed in another jurisdiction in good standing and not subject to past disciplinary action to practice telemedicine for Arizona patients. Licensees must register and act in compliance with Arizona laws including those regarding SOP and liability insurance, among others.20

Florida now allows out-of-state providers to practice telemedicine in the state, per state law. Florida requires that these providers register with the appropriate medical board, or the state's department of health if no board exists, per Florida Law § 2019-137.21

In New Hampshire, SB 390 was signed into law, thereby amending the state's definition of telemedicine to include new modalities, including audio-only phones. HB 1623 now also requires Medicaid and private payers to reimburse for telehealth services on the same basis that it reimburses for in-person care.22

Texas passed Senate Bill No. 40, which allows health professionals licensed by the Texas Department of Licensing and Regulation to provide telehealth services.23

In Vermont, H. 654 was signed into law, extending pandemic-era license waivers through June 30, 2023, including allowing healthcare practitioners licensed in other jurisdictions to practice telemedicine in Vermont as long as they are registered with the Office of Professional Regulation or Board of Medical Practice.24

Alaska enacted HB 265, through which a healthcare provider licensed in the state may provide telehealth care services within the provider's authorized SOP to a patient without first conducting an in-person visit.25 Also, S.B. 241 allows a licensed healthcare provider in good standing in another jurisdiction to provide services via telemedicine to Alaska patients, with the exception of prescribing CSs during a declared state of emergency.5

Reimbursement changes

There were a number of positive changes for NPs and other APRNs in 2022 but few related to reimbursement. In addition to reimbursement for telehealth services as described previously, Mississippi has enacted reimbursement regulations for NPs to receive up to 100% of the Medicaid reimbursement rate of physicians for comparable services and removed the 5% sequestration. CRNAs and CNMs are now reimbursed at up to 90% of the rate of physicians for comparable services. Mississippi NPs can order home health services.26

- Total number of active clear licensed/certified APRNs reported by BONs and/or state nursing associations in 2022
State Total APRNs NPs CNSs CNMs CRNAs
Alabama 8,481 6,477 60 25 1,919
Alaska ¥ 1479 1143 35 113 188
Arizona ¥ 12,325 10,829 148 300 1,048
Arkansas 6,209 5,135 148 33 893
California 41,174 33,632 3,248 1,401 2,893
Colorado ¥ 9,274 7,145 569 497 1,063
Connecticut ¥ 6,963 !
Delaware 3,059 2,509 132 54 364
Florida ¥ 39,753
Georgia 17,917 14,936 159 627 2,020
Hawaii ¥ 1,914
Idaho £ 3,479 2,919 39 71 450
Illinois £ 17,931 14,209 907 494 2,321
Indiana 9,486 ¥ ¥ 227 ¥
Iowa 7,486 6,502 67 153 764
Kansas ¥ 7,798 5,956 464 100 1,278
Kentucky 12,272 10,381 142 144 605
Louisiana 8,325 6,535 140 71 1,579
Maine 3,713 2,970 64 119 560
Maryland £ 9,385 7,912 116 309 904
Massachusetts ¥ 15,645 12,852 686 577 1,530
Michigan ¥ 11,635 8,600 235 200 2,600
Minnesota 11,081 7,997 454 408 2,222
Mississippi 7,620 6,581 ! 30 1,009
Missouri 14,291 11,688 294 177 2,132
Montana 2,978 2,587 38 93 260
Nebraska ¥ 3,901 3,012 84 61 744
Nevada ¥ 2,872 2,857 9 6 !
New Hampshire ¥ 2,656 2,103 19@ 123 411
New Jersey 12,500 ! (BOM)
New Mexico 2,604 2,044 53 161 346
New York 34,659~ 34,659 ! ! !
North Carolina 16,164 11,863 267 385 3,649
North Dakota 2,366 1,862 34 36 429
Ohio 25,695 20,682 1,028 486 3,499
Oklahoma 5,984 4,785 296 81 786
Oregon ¥ 6,122 5,595 153 403 655
Pennsylvania 16,307~ 16,307 264 ! 3,500! £
Rhode Island 2,494 2,138 130 ! 226
South Carolina 9,557 7,466 80 134 1,877
South Dakota 2,480 1,855 51 55 519
Tennessee 17,684 14,528 125 234 2,797
Texas 41,881 34,718 1,019 548 5,596
Utah 4,455 ¥ ¥ 201 429
Vermont ¥ 1,459 1,225 40@ 83 111
Virginia 15,239 12,099 403 442 2,295
Washington ¥ 10,847 9,052 86 552 1,157
West Virginia 4,798 3,817 29 78 874
Wisconsin ¥ 8,712+ + + 283 +
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
+Certified as Advanced Practice Nurse Prescribers (APNPs)
£Licensee/certification numbers obtained from state BON website or other online resource

Prescriptive authority

Effective January 1, 2023, an amendment to the Illinois Controlled Substances Act requires that prescribers offer patients prescriptions for naloxone hydrochloride or another similar FDA-approved drug, along with information on the drug's use and on overdose prevention, under certain specified conditions, including certain situations in which an opioid medication is prescribed. An Illinois prescriber who does not comply with specified requirements will be subject to disciplinary action under their licensing board.27

Effective October 14, 2022, Kansas APRNs may prescribe, procure, and administer any drug consistent with the licensee's specific role and population focus, including CSs, in accordance with the uniform controlled substances act as specified in K.S.A. 65-4101, and amendments thereto. However, APRNs may not prescribe, procure, or administer any drug that is intended to cause an abortion.13

Similarly, HB 2228 in Tennessee was signed into law and effective July 2022; it requires a healthcare prescriber, when prescribing an opioid to a patient, to offer a prescription for naloxone hydrochloride or another drug approved by the FDA for the complete or partial reversal of an opioid overdose event, to the patient under certain conditions.28

APRNs licensed in Alaska under AS 08.68 may prescribe, dispense, or administer through telehealth a prescription for a CS listed in AS 11.71.140 - 11.71.190 if the APRN complies with state and federal law governing the prescription, dispensing, or administering of a CS.25

South Dakota enacted a law in July 2021 to revise the definition of “practitioner” for purposes of the medical cannabis program to include APRNs. Pursuant to SDCL 34-20G, APRNs may now certify medical cannabis patients.29

West Virginia has eased rules on prescriptive authority by allowing qualified APRNs to have limited autonomous prescriptive authority following 3 years of a documented collaborative relationship with a physician and application and approval for prescriptive authority without a collaborative agreement by the Board. There are no other limitations on the prescribing authority of an APRN.30

South Carolina S.571/Act No. 22; Section 44-53-361, requires prescribers to offer a prescription for naloxone hydrochloride or another drug approved by the FDA for the complete or partial reversal of opioid depression to a patient under certain conditions.31

A change that affects NPs and CNSs in every state is that Section 3708 of the CARES Act amended section 1814(a) of the Social Security Act, allowing NPs and CNSs to certify patient eligibility under the Medicare home health benefit. NPs and CNSs can also oversee patients' plan of care. This is a permanent change and will continue after the end of the public health emergency.32,33

Conclusion

The intent of this overview is to provide an update on APRN practice throughout the country, with emphasis on NP practice. The dynamic nature of legislation in each state provides a look into current trends, and each state summary incorporates extensive references for all acts reported. The author would like to thank individual state BON representatives and APRN association representatives who contributed to this annual update through completion of a brief 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. In the following pages, each state's APRN practice authority as of the end of 2022 is summarized, and updates are highlighted as applicable.

    Alabama

    www.npalliancealabama.org

    www.abn.alabama.gov

    www.campaignforaction.org/state/alabama

    Practice authority

    The Alabama State BON has sole regulatory authority to establish qualifications and certification requirements of APRNs; conversely, the BON and BOME jointly regulate the collaborative practice of CRNPs and CNMs. All four categories of 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 are required as outlined in Alabama Board of Nursing Administrative Code Chapter 610-X-5-.09 and Chapter 610-X-5-.20 and include 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 (4,000 hours) of collaborative practice experience since initial certification or in the physician's practice specialty.

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

    CRNPs and CNMs are required to 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. Effective January 1, 2024, CRNPs and CNMs are required to complete CE prescribed by the BON regarding the rules and statutes governing collaborative practice in Alabama. There is no transition to practice requirement for APRNs in the state of Alabama.

    - Legislative update key
    1. ANP Advanced Nurse Practitioner

    2. APN Advanced Practice Nurse

    3. APNP Advanced Practice Nurse Prescriber

    4. APRN Advanced Practice Registered Nurse

    5. ARNP Advanced Registered Nurse Practitioner

    6. BC/BS Blue Cross/Blue Shield

    7. BOM Board of Medicine

    8. BOME Board of Medical Examiners

    9. BON Board of Nursing

    10. BOP Board of Pharmacy

    11. CE Continuing Education

    12. CHAMPUS Civilian Health and Medical Program of the Uniformed Service

    13. CNM Certified Nurse Midwife

    14. CNP Certified Nurse Practitioner

    1. CNS Clinical Nurse Specialist

    2. CPA Collaborative Practice Agreement

    3. CPNP Certified Pediatric Nurse Practitioner

    4. CRNA Certified Registered Nurse Anesthetist

    5. CRNP Certified Registered Nurse Practitioner

    6. CS Controlled substance

    7. DEA Drug Enforcement Administration

    8. DO Doctor of Osteopathic Medicine

    9. FNP Family Nurse Practitioner

    10. FPA Full Practice Authority

    11. GNP Geriatric Nurse Practitioner

    12. HMO Health Maintenance Organization

    13. MAT Medication-Assisted Treatment

    14. MCO Managed Care Organization

    1. NM Nurse Midwife

    2. NPA Nurse Practice Act

    3. NPI National Provider Identifier

    4. OTC Over-the-Counter

    5. PA Physician Assistant/Associate

    6. PCP Primary Care Provider

    7. PCNS Psychiatric Clinical Nurse Specialist

    8. PDMP Prescription Drug Monitoring Program

    9. PMHNP Psychiatric-Mental Health Nurse Practitioner

    10. PNP Pediatric Nurse Practitioner

    11. RNP Registered Nurse Practitioner

    12. R&R Rules and Regulations

    13. SOP Scope of Practice

    14. TTP Transition to Practice

    15. WHNP Women's Health Nurse Practitioner


    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 administer 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 (QACSC).

    CRNPs and CNMs are required by the BOME 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 QACSC 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, an important caveat is that 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/

    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 is considered a Full Practice state by the American Association of Nurse Practitioners. APRN SOP is defined under Alaska Administrative Code 12 AAC 44.430. 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 and there is no transition to practice requirement in the state. Authorized APRNs have independent prescriptive authority, including Schedule II-V CSs. APRNs are legally required to review the PDMP 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. APRNs licensed in Alaska under AS 08.68 may prescribe, dispense, or administer through telehealth a prescription for a CS listed in AS 11.71.140 - 11.71.190 if the APRN complies with state and federal law governing the prescription, dispensing, or administering of a CS. To renew prescriptive authority, APRNs must maintain national certification and complete the opioid CE requirement. Opioid prescribing limitations entail restrictions on the number of therapy days when prescribed by an APRN.

    Reimbursement

    All healthcare in Alaska is provided on a fee-for-service basis. FNPs, PNPs, PMHNPs, CNMs, and CRNAs are authorized by law to receive Medicaid reimbursement; NPs receive 85% of the physician payment. APRNs in Alaska can also provide telehealth and charge a fee for service that “must be reasonable and consistent with the ordinary fee typically charged for that service and may not exceed the fee typically charged for that service.” 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

    https://www.aznurse.org/

    https://www.aznurse.org/mpage/AzNPC_Home

    Practice authority

    The Arizona State Legislature grants APRNs authority but the BON alone regulates their practice. APRNs include CNPs (RNPs in statute), CNSs, CNMs, and CRNAs. 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. The American Association of Nurse Practitioners considers Arizona a Full Practice state.

    The last legislative session (2021) concluded with allowing NPs and CNSs to order home health care for patients enrolled in Medicaid (ARS 36-2939; Sec. 1 I) Effective April 13, 2022, the type of mental health professionals authorized to conduct psychiatric assessments of children and make recommendations regarding their care was expanded to include psychiatric and mental health NPs (ARS 8-272; B). In addition, 2022 legislation expanded the type of professionals who may provide services for the state sponsored first responder trauma care program to include mental health NPs and psychiatric CNSs (ARS 38-672; F; 2 [d]). Additional legislation provided a grant program to expand nurse education and training through augmenting faculty, including APRNs, and establishing clinical programs, such as a preceptor grant program that allows for stipends for preceptors (ARS Title 36, Chapter 16). Telehealth provisions have also been extended and expanded to include APRNs (ARS 20-841.09).

    Effective 2023, CNMs have been included as eligible providers for post-partum care (ARS 36-2901; 15).

    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 and 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 schedules II-V CSs, 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. RNPs who intend to hold or already hold a DEA registration number are required 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

    https://arna.nursingnetwork.com/

    www.campaignforaction.org/state/arkansas

    Practice authority

    The Arkansas BON regulates APRN practice and grants their authority to practice. The term “APRN” is defined and includes the CNP, CNM, CNS, and CRNA roles. CNPs are authorized to apply for “full independent practice authority” as defined in statute with credentialing from the Full Independent Practice Credentialing Committee (FIPCC). CNMs are authorized to apply for “full practice authority” as defined in statute.

    CRNAs practice in consultation with a physician. APRNs practice within scope and standards defined in Chapter 4, Section VI of the Arkansas State Board of Nursing Rules and the standards established by the national certifying body from which the APRN holds required certification for licensure. Arkansas is defined as a Reduced Practice state by the American Association of Nurse Practitioners.

    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. APRNs are now recognized as PCPs within the Arkansas Medicaid system. Hospital privileges for APRNs are determined on an individual facility basis according to the credentialing committee of each hospital.

    All APRNs are authorized to apply for a certificate of prescriptive authority.

    CNPs have full prescriptive authority including legend drugs, therapeutic devices, and schedule II-V CSs following 6,240 hours of practice under a CPA with a physician and approval by the FIPCC. CNMs have prescriptive authority including Schedule III - V CSs, but for Schedule II CS prescribing, a CPA is required. The CNS may apply for a prescribing certificate; however, a CPA with a physician and prescribing protocols are required for prescriptive authority. 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. Co-prescription of an opioid antagonist when an opioid or opioid/benzodiazepine is prescribed is required for all prescribers. Review of the PDMP prior to prescribing schedule II or III CSs and benzodiazepines is required of all prescribers for a first prescription 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 at 100% of the physician rate. 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

    CNPs, CNSs, CNMs, and CRNAs are among the roles that the California State Board of Registered Nursing (BRN) defines in statute as APRNs. The passage of California Statutes Chapter No. 265, effective 1/1/2021, codified NP SOP expansion and “independent practice.”

    When the regulatory process is complete, the new statute will have eliminated physician-supervised practice by removing the “standardized procedure” requirement when the NP is nationally board certified and completes a 3-year or 4,600-hour TTP period within defined settings categorized as training and experience requirements defined in BPC § 2837.103.

    The California BRN is required to adopt regulations by January, 1, 2023; however, the Board has indicated it will finish the regulations as close to that date as possible. When the regulations are finalized, approved, and deemed in accordance with the law, certain NPs will be able to practice without physician supervision. However, proposed language includes several stipulations that will need to be addressed.

    In order for the NP to practice independently, outside of a defined healthcare setting, the NP must meet all of the requirements for independent practice. Proof of completion of a TTP by submitting to the Board one or more attestations of a physician or surgeon, an an NP practicing pursuant to Section 2837.103 of the code, or an NP practicing pursuant to Section 2837.104 of the code is required. Additionally, SB 1375, signed into law September 27, 2022, provides that trained and experienced NPs can provide abortion care without physician supervision.

    CNMs may practice when providing care within the defined scope of services without physician supervision. 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 as the need increases for care access. 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 who have been certified by the BRN as independent practice providers are authorized to independently prescribe drugs and devices, including schedule II-V CSs, without physician supervision. CNMs are 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 schedule II-V CSs 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 CS and at least once every 3 months if the CS remains a part of the patient's treatment plan (with some exemptions). CNPs and CNMs may request, receive, and dispense pharmaceutical samples and dispense drugs, including CSs. CNSs and CRNAs do not have prescriptive authority in California.

    Reimbursement

    All nationally board-certified CNPs are reimbursed independently by the Medi-Cal system. Medi-Cal-covered services performed by CNPs, CNMs, and CRNAs are reimbursed at 85% 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

    https://dpo.colorado.gov/Nursing

    www.coloradonurses.org

    www.campaignforaction.org/state/colorado

    Practice authority

    The Colorado State BON grants advanced practice authority to RNs who meet the criteria set forth in the Colorado Nurse and Nurse Aide Practice Act (Practice Act) 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 FPA.

    The Practice Act and Rules do not address, and therefore do not prohibit, APRNs being designated as PCPs or being granted hospital privileges; however, APRNs are not currently recognized as PCPs in statutes and regulations under the jurisdiction of state agencies regulating healthcare. National 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 schedule II-V CSs. 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 the 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. Articulated Plans are no longer required.

    The Substance Use Disorders Prevention Act law requires 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. The 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. APRNs with prescriptive authority are authorized 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 a recognized provider type for Colorado's Medicaid program, which is known as Health First Colorado.

    The State of Colorado established a standardized health benefit plan, in which APRNs are recognized as “healthcare providers,” and receive reimbursement for service.

    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

    Practice authority

    The Connecticut Board of Examiners for Nursing regulates APRNs, defining APRNs in statute to include the CNP (NP in statute), CNS, and CRNA roles. APRN SOP, independent practice, and collaborative practice are defined in statute. CNM authority is regulated by the Department of Public Health, and SOP is recognized under a separate statute (Chapter 377, Midwifery). The passage of Public Act No. 19-98 in 2019 further acquired global signature authority, including workers' compensation, pharmacy collaborative drug management agreement, and psychiatric statute changes. APRNs are authorized to certify patients for medical marijuana use.

    A graduate degree in nursing or other related field and national board certification are required to practice. APRNs are statutorily recognized as PCPs and authorized to hold hospital privileges, including admission of patients. APRNs are authorized to issue orders for home healthcare services, hospice agency services, and home health aide agency services. APRNs are authorized to practice without a collaborative agreement following a TTP of no less than 3 years and no fewer than 2,000 hours of APRN practice in collaboration with a physician licensed in Connecticut. NP practice in Connecticut is considered FPA as defined by the American Association of Nurse Practitioners.

    APRNs are authorized to prescribe, dispense, and administer medications, including CSs, pursuant to a CPA. APRNs may independently prescribe, dispense, and administer medications including schedule II-V CSs following a TTP period of no less than 3 years and no fewer than 2,000 hours. APRNs and CNMs are legally authorized to request, receive, and dispense pharmaceutical samples.

    Opioid prescribing limitations for acute pain entail 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 use disorder or 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

    Practice authority

    The Delaware BON regulates the practice of APRNs, including the CNP, CNS, CNM, and CRNA roles. The BON has sole regulatory authority over APRNs and grants FPA upon issuance of an APRN license. APRN SOP is defined in statute, recognizing that APRNs are independent licensed practitioners; the law language includes FPA. 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. The American Association of Nurse Practitioners considers Delaware a Full Practice state.

    APRNs have authority to serve as PCPs by an insurer or healthcare services corporation. APRNs licensed by the BON may prescribe, order, procure, administer, store, dispense, and furnish OTC drugs, legend drugs, and schedule II-V CSs pursuant to applicable state and federal laws and within the APRN's role and population focus. Additionally, APRNs may order and prescribe nonpharmacologic interventions including: medical devices and durable medical equipment, nutrition, blood and blood products, and diagnostic and supportive services including home healthcare, hospice, and physical and occupational therapy. APRNs may receive, sign for, record, and distribute sample medications to patients in accordance with state law and US DEA laws, regulations, and guidelines. Section 1790, Chapter 17, Title 24 of the Delaware Code signed into law April 28, 2022 allows an APRN to prescribe medication for the termination of pregnancy including Mifeprex, Mifepristone, and Misoprostol.

    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. Family and pediatric NPs also receive Medicaid reimbursement at 100% of the physician payment.

    Florida

    www.floridasnursing.gov

    www.floridanurse.org

    www.campaignforaction.org/state/florida

    https://www.flanp.org/

    Practice authority

    The Florida BON regulates APRN practice, which is defined in statute and includes the CNP, CNS, CNM, and CRNA roles. APRNs practice within established protocols under the supervision of a physician. APRNs in primary care practice (family medicine, general pediatrics, and general internal medicine) may register for autonomous practice following 3,000 clinical practice hours in any state within the last 5 years immediately preceding the registration request. The term “primary care practice” has been defined by the BON in Florida Administrative Code 64B9-4.001. CNMs may engage in autonomous practice pursuant to Chapter 464.012. 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.

    APRNs practicing outside of primary care continue to practice pursuant to protocols established between an APRN and a doctor of medicine (MD), doctor of osteopathic medicine (DO), or dentist, which include the performance of medical acts of diagnosis, treatment, and operation. Within the framework of established protocols, APRNs may order diagnostic tests, physical therapy, and occupational therapy. Supervision is defined as the ability to communicate or establish contact by telephone; the supervising practitioner's on-site presence is not required. The American Association of Nurse Practitioners considers Florida a Restricted Practice state.

    APRNs are authorized to admit patients to a hospital and hold hospital privileges 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.

    APRNs without autonomous practice authority are authorized by supervisory protocol to prescribe, dispense, administer, or order any drug, including schedule II-V CSs as authorized in a BON-adopted CS formulary with certain exceptions. Additionally, psychiatric mental health board-certified APRNs may prescribe psychotropic CSs. APRNs are authorized to request, receive, or dispense pharmaceutical samples.

    Opioid prescribing restrictions limit opioid prescribing for acute pain to 3 days with exceptions in dispensing restrictions that allow for MAT. A 7-day supply is permitted if medically necessary based on professional judgment.

    Reimbursement

    APRNs receive Medicaid, Medicare, CHAMPUS, and third-party reimbursement. Medicaid reimburses APRNs at 100% of the physician rate only if the on-site physician countersigns within 24 hours. As of August 2, 2022, Medicaid reimburses APRNs at 80% of the physician rate if the physician is not on-site; services provided must be billed under the rendering APRN's Medicaid provider number (Florida Administrative Code Rule: 59G-4.002). 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

    https://www.sos.ga.gov/licensing-division-georgia-secretary-states-office

    https://uaprn.enpnetwork.com

    www.georgianurses.org

    https://campaignforaction.org/state/georgia

    Practice authority

    APRNs are defined in statute and include the 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: OCGA43-34-25 and OCGA 43-34-23. APRNs authorized to practice under OCGA 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 OCGA 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. Georgia is considered a Restricted Practice state by the American Association of Nurse Practitioners.

    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 schedule 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 to do so by law.

    Hawaii

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

    https://hapnhawaii.enpnetwork.com/

    www.campaignforaction.org/state/hawaii

    Practice authority

    The BON licenses and regulates APRNs in Hawaii. 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 National Council of State Boards of Nursing (NCSBN) Consensus Model Act. APRNs are authorized 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 PCPs 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. Hawaii is considered a Full Practice state by the American Association of Nurse Practitioners.

    The BON regulates APRN prescriptive authority, and APRNs have Practice Authority to prescribe medications, including Schedule 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 laws restrict initial concurrent prescriptions of opioids and benzodiazepines to 7 days.

    Reimbursement

    Current law provides direct reimbursement to APRNs and authorizes all insurers to legally recognize APRNs as PCPs. The reimbursement rate range is 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 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

    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 SOP is defined in statute and regulation (Idaho Code §54-1413 and IDAPA 24.34.01.280). 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. 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 FPA and independent prescribing and dispensing authority is granted to qualified APRNs upon licensure. Authorized APRNs may prescribe and dispense legend drugs and Schedule 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 except for CRNAs may apply for FPA as defined in 225 ILCS 65/65-43, eliminating the requirement for a collaborative agreement following a TTP period, with some exceptions for prescribing CSs. The TTP 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 the TTP is completed, the APRN may apply for FPA, which includes submitting an attestation of completion with the IDFPR. APRN SOP is defined in 225 ILCS 65/65-30 and all APRNs may practice only in accordance with their national certification. Prior to receiving an FPA license, APRNs must have a written collaborative agreement with a physician, podiatrist, or dentist, except for APRNs who provide services in a hospital, hospital affiliate, or ambulatory surgical treatment center ASTC, and have been granted clinical privileges by that facility. 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; however, new collaborative arrangements with podiatrists are prohibited after January 1, 2018, except for CRNAs.

    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 the 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 schedule II-V CSs. An Illinois Controlled Substances License is required to prescribe CSs, in addition to the US DEA registration. All prescribers are required to enroll in the Illinois Prescription Monitoring Program and check the program prior to initial prescription of Schedule II narcotics, such as opioids, and document the attempt in the patient's record.

    Prescribing benzodiazepines or 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 IDFPR. At least monthly, the APRN and physician must discuss the condition of any patients for whom a benzodiazepine or opioid is prescribed. APRNs without FPA have prescriptive authority, including prescribing schedule II-V CSs, which may be authorized by clinical privileges in a hospital, hospital affiliate, or ASTC, or may be delegated to an APRN by a physician or podiatrist as part of the written collaborative agreement during the TTP period. Delegation to prescribe CSs must be noted in the written collaborative agreement and the APRN must apply for a Mid-Level Practitioner Controlled Substance License. For APRNs prescribing CSs under a written collaborative agreement, the collaborating physician or podiatrist must have a valid, current Illinois CS license and federal registration. There are 80 hours of CE required for 2-year APRN licensure renewal and a minimum of 20 hours of pharmacotherapeutics must be completed, including 10 hours of opioid prescribing or substance use education. The American Association of Nurse Practitioners considers Illinois a Reduced Practice state.

    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, APRNs must also enroll as providers for each Medicaid MCO of which any of their patients are members. Statutory prohibition for third-party reimbursement to APRNs does not exist. APRNs receive direct or indirect reimbursement from some third-party payers.

    Indiana

    https://www.in.gov/pla/professions/nursing-home/

    www.indiananurses.org

    www.campaignforaction.org/state/indiana

    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” defined in IC 25-23-1-19.4 under a written CPA approved by the Board that includes how the APRN and licensed physician will cooperate, coordinate, and consult with each other on the provision of healthcare. Additionally, the CPA must include 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. APRNs with prescriptive authority are authorized to sign death certificates. The American Association of Nurse Practitioners considers NP practice in Indiana Reduced Practice.

    APRNs are authorized to practice in hospitals licensed under IC 16-21 but must have a CPA in place that describes the manner in which the APRN and licensed practitioner will cooperate, coordinate, and consult with each other. Additionally, APRNs can be granted privileges by the governing body of a hospital operated under IC 12-24-1 (state hospitals) that sets forth the manner in which an APRN and a licensed practitioner will cooperate, coordinate, and consult with each other. APRNs have authority to order home health services as defined in IC 16-27-1-5.

    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, authorize prescriptive authority for APRNs, including legend drugs and schedule II-V CSs. APRNs must obtain a BON-issued prescriber authority ID number, Indiana State Controlled Substances Registration, and US DEA registration. NPs are authorized to prescribe legend drugs to patients receiving care via telemedicine if they have established a provider-patient relationship and satisfy the standards of care and 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, sometimes referred to as “any authorized provider” backed by current law, that requires health insurance carriers to allow healthcare providers to become members of the carriers' networks of providers if certain conditions are met. 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://iowanpsociety.enpnetwork.com/

    https://campaignforaction.org/state/iowa

    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. ARNP practice is broadly defined in IAC 655-7.4. ARNPs practice autonomously within their specified role and population focus in accordance with national professional associations. Iowa is considered a Full Practice state by the American Association of Nurse Practitioners.

    ARNPs are statutorily recognized as PCPs; however, state law does not contain “any willing provider” language (sometimes referred to as “any authorized provider”) which would require health insurance carriers to allow healthcare providers to become members of the carriers' networks of providers if certain conditions are met. 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-related, and psychiatric mental health. Graduation from an Iowa BON-approved Advanced Practice Master of Science in Nursing program or completion of a formal Advanced Practice education program is required for licensure as an ARNP. Advanced Practice Doctoral preparation is also an acceptable method for licensure.

    Authorized ARNPs are granted full prescriptive authority within their specific role and population focus, including schedule 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).

    Effective June 22, 2022, the Iowa BON has adopted telehealth rules and regulations for ARNPs. An ARNP may, in accordance with all applicable laws and rules, provide healthcare services within their SOP to a patient through telehealth. An ARNP who provides services through telehealth to a patient physically located in Iowa must be licensed by the Board. A licensee who provides services through telehealth to a patient physically located in another state shall be subject to the laws and jurisdiction of the state where the patient is physically located (ARC 6317C).

    Reimbursement

    Iowa's Medicaid managed care and prepaid service programs reimburse ARNPs. Payment of necessary medical or surgical care and treatment is provided to an ARNP via third party reimbursement if the policy or contract would pay for the care and treatment when provided by a physician. MCOs are not 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

    https://ksbn.kansas.gov/npa/

    https://ksnurses.com

    www.campaignforaction.org/state/kansas

    Practice authority

    The Kansas BON grants authority to APRNs and regulates their practice. Recognized APRN roles include the CNP (NP in regulation), CNS, CNM (NM in regulation), and CRNA (registered nurse anesthetist [RNA] in statute). Effective October 14, 2022, APRNs, as defined by K.S.A. 65-1113 and amendments thereto, “shall function in an expanded role to provide primary, secondary, and tertiary health care in the APRN's role of advanced practice. Each APRN shall be authorized to make independent decisions about advanced practice nursing needs of families, patients, and clients and medical decisions. Each APRN shall be directly accountable and responsible to the consumer.” SOP is defined in statute and regulation with CNPs, CNSs, and CRNAs functioning without physician supervision in the delivery of healthcare services within their SOP. Kansas is considered a Full Practice state by the American Association of Nurse Practitioners.

    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 will be required beginning July 1, 2023.

    APRNs in Kansas are legally authorized to prescribe medications. In addition to DEA registration, APRNs must register with the BON to prescribe CSs. Prescription orders and labels must: (1) include the name, address, and telephone number of the practice location of the APRN; (2) be signed by the APRN with the letters A.P.R.N.; and (3) contain the DEA registration number issued to the APRN when a CS, as defined in K.S.A. 65-4101 and amendments thereto, is prescribed. APRNs are authorized to request, receive, and distribute pharmaceutical samples, if the drug is within their protocol.

    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

    https://kbn.ky.gov/

    www.kcnpnm.org

    www.campaignforaction.org/state/kentucky

    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. APRN SOP is defined in Kentucky statute 201 KAR 20:057, Section 3: “the advanced practice registered nurse shall seek consultation or referral in those situations outside the advanced practice registered nurse's scope of practice.” 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 schedule 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 and schedule III CSs without refill.

    Schedule IV and V CSs may be prescribed with refills not to exceed a 6-month supply. Gabapentin was rescheduled as a schedule V CS in Kentucky in 2017 and is 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 devote 1.5 of the 5 contact hours 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. Exceptions include documented justification for more than a 72-hour supply as part of a narcotic treatment program or for acute pain, chronic pain, pain associated with a valid cancer diagnosis, pain associated with end-of-life treatment, pain following a major surgery or treatment of significant trauma, or dispensing or administering directly to an ultimate user in an inpatient setting.

    APRNs are authorized to request, receive, and dispense nonscheduled legend pharmaceutical samples. APRNs may also dispense nonscheduled legend drugs from local, district, and independent health department settings subject to the direction of the appropriate governing board of the individual health department.

    APRNs are authorized to prescribe and supervise care and treatment by a home health agency (KRS 304.17-312).

    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, sometimes referred to as “any authorized provider,” which requires health insurance carriers to allow healthcare providers to become members of the carriers' networks of providers if certain conditions are met. APRNs are paid at 75% of the physician fee schedule for codes within the SOP according to 907 KAR 1:104 Section 2(b). 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 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

    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 CPA. 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. PMHNPs are now authorized to prepare and execute orders for the formal voluntary admission or noncontested admission of patients to licensed psychiatric hospitals. 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 drugs and schedule 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 CSs, and prescription of 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 if 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.

    CRNAs have 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.

    Reimbursement

    Qualified plans are prohibited from excluding direct reimbursement of healthcare services provided by an APRN. Medicaid recognizes NPs, CNSs, and CNMs as PCPs and recognizes those APRNs as the PCP or “medical home” under certain circumstances. APRNs are reimbursed at 80% of the physician rate per Medicaid, and 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.maine.gov/boardofnursing/

    www.mnpa.us/

    https://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. CNPs 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 or NP in the same practice category, or must be employed by a clinic or hospital that has a medical director who is a licensed physician. The American Association of Nurse Practitioners considers Maine a Full Practice state.

    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 emergency departments (EDs). CNPs are authorized to certify patients to receive therapeutic or palliative benefit from medical use of marijuana. 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 and diagnostic imaging tests in the perioperative and immediate postoperative periods.

    The hospital governing body has the authority, in accordance with state law, to grant medical staff privileges and membership to healthcare practitioners other than physicians. 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 receive and distribute drug samples as well as prescribe and dispense drugs or devices, including schedule II-V CSs, in accordance with rules adopted by the BON, following standard DEA regulation and with active DEA licenses. CNPs and CNMs are required to prescribe from FDA-approved drugs related to the nurse's specialty. CNPs and CNMs may prescribe schedule II-V CSs and drugs off-label, according to common and established standards of practice.

    CRNAs are authorized to order and prescribe medication during the perioperative and postoperative periods. CRNAs may prescribe schedule III, IIIN, IV and V CSs only: (1) for a supply of no more than 4 days with no refills; (2) for an individual who is an established client or patient of record; and (3) with a DEA issued number registered under a verified critical access or rural hospital address.

    Opioid prescribing is limited for all prescribers. Prescribers must successfully complete 3 hours of CE every 2 years on the prescription of opioid medication as a condition of prescribing them. Prescribers may not write a prescription for an opioid medication within a 30-day period to exceed a 30-day supply for chronic pain or within a 7-day period for a 7-day supply for acute pain, with some exceptions (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 a CNP as their PCP. However, MCOs are not required to credential any physician or CNP if their access standards have not been met.

    Reimbursement under indemnity plans is mandated for master's-prepared, certified psychiatric/mental health CNSs (MRS Title 24-A, Chapter 33) but 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.

    CRNAs can bill their services through insurance health plans and carriers may not prohibit CRNAs from participating in their provider network or billing the carrier directly because the provider is a CRNA. CRNAs must meet the same terms and conditions as other participants.

    Telehealth

    Public Law Ch. 291, passed in June 2021, allows healthcare providers to provide telehealth services as long as the licensee acts within the SOP of the licensee's license, in accordance with any requirements and restrictions imposed by this law, and in accordance with standards of practice. Additionally, an insurance carrier offering a health plan in Maine may not deny coverage on the basis that the healthcare service is provided through telehealth if the healthcare service would be covered if it were provided through in-person consultation as long as the provider is acting within the SOP of the provider's license and in accordance with rules adopted by the board, if any, that issued the provider's license related to standards of practice for the delivery of a healthcare service through telehealth.

    Maryland

    www.mbon.org

    www.npamonline.org

    www.maapconline.org

    www.campaignforaction.org/state/maryland

    Practice authority

    The Maryland BON regulates APRN practice, statutorily defining APRN in regulation (Code of Maryland Regulations [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, which considers NP practice in the state of Maryland Full Practice.

    A master's degree is the minimum required degree to enter practice in Maryland in addition to national board certification. NP applicants who have never been certified as an NP in Maryland or any other state are required to name an NP or physician licensed in Maryland as a mentor upon application to the BON. The mentor is available for advice, consultation, and collaboration as needed throughout an 18-month TTP period beginning on the date of application. CRNAs maintain an affirmation of collaboration with the BON that contains the name and license number of an anesthesiologist, physician, or dentist; however, there is no direct supervision requirement.

    NPs and CNMs who hold a state-controlled dangerous substances registration, are registered 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 schedule II-V CSs. In addition to federal DEA registration, CNPs and CNMs are required to obtain state controlled dangerous substances registration and must register with and use the Maryland PDMP. 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.

    New legislation passed in 2022 authorizes a nurse anesthetist licensed in Maryland to prescribe, order, and administer drugs, including controlled dangerous substances, subject to certain limitations, in connection with the delivery of anesthesia services.

    Additionally, CNPs and CNMs licensed in Maryland have been added to the list of providers with whom a dental hygienist must consult prior to providing certain dental treatments, and the state allows dental hygienists to provide services in expanded locations where a CNP or CNM works. Lastly, CNPs are authorized to prescribe and dispense auto-injectable epinephrine to certain certificate holders who operate youth camps. All became effective October 1, 2022.

    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 are 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. Maryland CNPs enrolled in Medicare as providers are authorized to order home health services and hospice under COMAR.

    PCPs are reimbursed for telemedicine services by Medicaid. The law allows due process for APRNs 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, Psychiatric Nurse Mental Health Clinical Specialist (PNMHCS), CNS, and CNM roles. APRNs enjoy FPA with a TTP for full prescriptive authority. The American Association of Nurse Practitioners considers Massachusetts a Full Practice state. SOP for all APRNs is consistent with the scope and standards of their APRN practice for which they are nationally certified, as defined within the BON rules and regulations. CNPs are authorized to issue written certifications of medical marijuana use within their SOP.

    Massachusetts recognizes CNMs and CNPs as PCPs. 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 PNMHCSs, including schedule II-IV CSs. Authorized APRNs must apply to the Massachusetts Department of Public Health for MA Controlled Substance Registration (MCSR) in addition to the DEA for DEA registration. CNPs, CRNAs, and PNMHCSs with less than 2 years supervised practice must establish written guidelines developed in collaboration with their supervising qualified healthcare professional, designated to provide supervision for prescriptive practice as is customarily accepted in the specialty area, as defined in 244 CMR 4.07. Written guidelines include a defined mechanism to monitor prescribing practices and must designate the qualified healthcare professional. Specifically, these qualified health professionals include physicians, CNPs, CRNAs, and PNMHCSs.

    Authorized APRNs may request, receive, and dispense pharmaceutical samples. For APRNs with supervised practice, the name of the supervising qualified healthcare professional must be included on the prescription in addition to the CNP, CRNA, or PNMHCS; however, the APRN is authorized to sign the prescription.

    Application for prescriptive authority and to renew authorization requires all prescribers to complete education relative to effective pain management, risks of opioid use including addiction, identification of patients at risk for substance use 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)).

    Reimbursement

    FNPs, PNPs, and adult NPs are reimbursed at 100% of the physician payment rate for Medic- aid unless the NP is employed by the hospital in a hospital-based practice. Massachusetts state law mandates reimbursement to NPs, PNMHCSs, CNMs, and CRNAs in accordance with Chapter 302 of the Acts and Resolves of 1994. These include indemnity plans, nonprofit hospital corporations, medical service corporations, and HMOs. Under Massachusetts state law, a CNP can be recognized and deliver care as a PCP, and carriers must allow patients to choose a CNP as their PCP.

    Michigan

    www.minurses.org

    https://www.michigan.gov/lara/bureau-list/bpl/health/hp-lic-health-prof/nursing

    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 those tasks which can be delegated by another licensee, 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, 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 schedule 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 complimentary starter dose drugs independently; however, delegation by a physician is required to order, receive, and dispense complimentary starter doses of schedules II-V CSs. The American Association of Nurse Practitioners considers Michigan a Restricted Practice state.

    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. APRNs are defined in statute (148.171 Subd. 3) and include the CNP, CNS, CNM, and CRNA roles. APRNs have FPA in Minnesota as defined by the American Association of Nurse Practitioners but with a TTP component for CNPs and CNSs. CNPs and CNSs are required to complete a “postgraduate practice” period of at least 2,080 hours utilizing 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). SOP is defined in statute and must be consistent with the APRN's education. APRNs are authorized to enroll in the Medical Cannabis Registry to certify qualifying conditions for medical cannabis. CRNAs and CNMs are not required to complete a postgraduate practice requirement.

    APRNs are not statutorily prohibited from holding hospital privileges including admitting privileges. Minnesota APRNs are licensed by the BON following completion of an accredited graduate-level APRN program and national certification by a recognized APRN certifying organization.

    APRNs may independently prescribe, receive, dispense, and administer drugs, including schedule 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 BON, 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

    Practice authority

    The Mississippi BON grants APRNs the authority to practice and regulates their practice. Mississippi defines APRNs as CNPs, CNMs, and CRNAs. SOP is defined and regulated by the BON, and CNPs, CRNAs, and CNMs practice in a collaborative relationship with a physician or, in the case of CRNAs, physician or dentist. The collaborating physician's 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 or dentist. Practicing in a site 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.

    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 schedule II-V CSs, based on the standards and guidelines of the CNP 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. Every certified APRN authorized to practice in Mississippi who prescribes any CSs (Schedules II, Ill, IV, or V) within Mississippi must be registered with the DEA. 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. The Mississippi legislature authorized CNPs to order home health and deleted the provision that required Medicaid to reduce the rate of reimbursement to “certain providers” for services by 5% of the allowed amount for that service.

    Missouri

    www.pr.mo.gov/nursing

    https://amnp.enpnetwork.com/

    www.campaignforaction.org/state/missouri

    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 must practice in collaboration with physicians in Missouri. SOP is defined in regulation and must be within the professional scope and standards of the APRN's role and population focus and consistent with the APRN's formal education, national certification, and regulations set forth by state and federal agencies for CS prescribing.

    APRNs practice in collaboration set forth in 20 CSR 2200-4.200 Collaborative Practice (CP) rule. Three focus areas in the CP rule include geographic areas to be covered, methods of treatment that may be covered by CP arrangements, and requirements for review of services provided pursuant to a CP arrangement. CRNAs practice under the direction of surgeons, anesthesiologists, dentists, or podiatrists and are not required to have CP arrangements. 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 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 schedule III-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. CNPs, CNSs, and CNMs must complete 1,000 hours of postgraduate clinical experience in the APRN role prior to application for CS authority. APRNs with a CP arrangement and CS prescriptive authority are authorized to prescribe hydrocodone-containing compounds from schedule II CSs and buprenorphine, with exceptions. A state Bureau of Narcotics and Dangerous Drugs number in addition to DEA registration is required. APRNs may receive and dispense sample medications within their prescriptive authority.

    Reimbursement

    APRNs are reimbursed by health insurers, HMOs, and non profit health plans for services if the services provided are within the SOP of the APRN. Medicaid reimbursement is made to APRNs enrolled as Missouri Medicaid fee-for-service providers and Medicaid-enrolled APRNs associated with federally qualified or rural healthcare facilities or both.

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

    https://boards.bsd.dli.mt.gov/nursing/

    www.mtnurses.org/

    www.campaignforaction.org/state/montana

    Practice authority

    The Montana BON grants APRNs authority to practice and regulates their practice. The APRN title is defined in regulation and includes CNP, CNS, CNM, and CRNA roles. APRN SOP is defined in Rules ARM 24.159.1405 and 24.159.1406, and 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. The American Association of Nurse Practitioners considers NP practice in Montana Full Practice.

    APRNs must have a graduate-level degree or postgraduate certificate from an accredited APRN program and hold national certification to practice. APRNs may only practice in the role and population focus in which the APRN is nationally certified. 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 schedule II-V CSs and are permitted to request, receive, and dispense drug samples. Renewal of prescriptive authority occurs every 2 years and includes an affirmation of a minimum of 12 contact hours of accredited education in pharmacology, pharmacotherapeutics, and/or clinical management of drug therapy. The prescriptive authority contact hours can be used to satisfy 12 of the required 24 contact hours to renew the general APRN license.

    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 TTP period supervised by an experienced physician or NP as defined, and the American Association of Nurse Practitioners considers Nebraska a Full Practice state. 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 integrated practice agreements (IPAs).

    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 schedule 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. BC/BS reimburses 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 direct providers 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 fewer than 2,000 hours) are required to complete a TTP 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. The American Association of Nurse Practitioners considers Nevada a Full Practice state.

    APRNs are not recognized as PCPs under Nevada state law. APRNs in Nevada are authorized to obtain membership on the medical staff of a hospital and 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 schedule II-V CSs, poisons, and dangerous drugs and devices when authorized by the BON and a certificate of registration is obtained from the BOP. 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. 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/new-hampshire-board-nursing

    https://www.nhnpa.org/

    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. All prescribers with DEA registration are required to register with the PDMP and complete the required contact hours of regulatory board–approved online CE or pass an online exam in the relevant area of pain management.

    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

    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. Alternatively, 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 schedule 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 the joint protocol must 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 (https://www.njconsumeraffairs.gov/prescribing-for-pain/Documents/Opioid-Law.pdf), 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. APNs can get credentialed by or obtain a provider number from these insurers, and after the APN is recognized as an Independently Licensed Practitioner/Provider (ILP), they can be directly reimbursed by Medicare and several other Medicaid HMOs.

    Aetna and Horizon BC/BS and some other Horizon MCOs will only credential and reimburse APNs who work under physician supervision and not as ILPs. The Horizon BC/BS website states: “A physician extender is a health care professional who is specially trained and certified to provide basic medical services under the supervision of a licensed physician.” Further, CRNAs are reimbursed at 50%. Both Horizon and Aetna have fairly consistently credentialed and directly reimbursed psychiatric APNs. 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, emulating Medicare.

    New Mexico

    www.nmna.org

    https://nmbon.sks.com/

    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. CNMs are regulated by the Department of Health and are recognized as PCPs in statute. The SOP of CNPs, CRNAs, and CNSs 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 master's-prepared and certified by a national certifying nursing organization.

    CNPs and CNSs have full, independent prescriptive authority, including schedule II-V CSs within the scope of the specialty practice and setting. A current state CS registration and DEA number is required unless the CNP or CNS has met registration waiver criteria from the New Mexico BOP. CNPs and CNSs maintain a formulary of dangerous drugs and CSs 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 schedule II-V CSs that have been prepared, packaged, or prepackaged by a pharmacist or pharmaceutical company. The American Association of Nurse Practitioners considers New Mexico a Full Practice state.

    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. CNPs who bill independently receive Medicaid reimbursement at 90% of the physician payment. All three of the managed-care groups contracted to provide Medicaid coverage have contracts with CNPs.

    New York

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

    www.nysna.org

    www.campaignforaction.org/state/new-york

    Practice authority

    The New York State Education Department licenses RNs and certifies CNPs (NP in statute) to practice. The term “APRN” is not defined in New York statutes or regulation. SOP 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 fewer than 3,600 hours of practice experience to practice pursuant to a written practice agreement with a collaborating physician. NPs who have more than 3,600 hours are no longer required to have collaborative relationships or sign and maintain form NP-CR, which was previously part of Education Law. The New York State Budget was passed and contained amendments to the Nurse Practitioner Modernization Act, updating FPA for experienced NPs. The American Association of Nurse Practitioners considers New York a Full Practice state.

    CRNAs are not recognized by the state of New York as advanced practice nurses and are regulated by the New York State Department of Health after obtaining an RN license.

    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 are authorized to prescribe or order medications, including schedule II-V CSs, and may dispense medications to their patients. CNMs are authorized to prescribe and administer drugs, immunizing agents, diagnostic tests and devices, and to order lab tests, limited to the practice of midwifery, and 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

    Practice authority

    A joint subcommittee of the North Carolina BON and the North Carolina Medical Board grants CNPs the authority to practice and regulates their practice. Both CRNAs and CNSs are solely regulated by the BON and 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 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 CNP. 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 North Carolina a Restricted Practice state.

    Monthly Quality Improvement Process meetings are required during the first 6 months of CNP practice with a new PSP, and every 6 months thereafter, and must be documented with CNP and PSP signatures. (This requirement was waived during the COVID-19 pandemic and the governor signed Session Law 2021-3 that extended the expiration until December 31, 2022.) 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 the APRN's population focus. CNPs and CNMs have full prescriptive authority, including schedule II-V CSs that are identified in their CPA. Dispensing medications is authorized under specific conditions and a dispensing license is required. CNPs are authorized to hand out, free of charge, starter doses or packets of prescription drug samples received from a prescription drug manufacturer in compliance with the Prescription Drug Marketing Act. CRNAs and CNSs do not have prescriptive authority in North Carolina.

    The 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. CNPs must consult with a supervising physician prior to prescribing certain schedule II and schedule III CSs labeled “targeted controlled substances” only when “the patient is being treated in a facility that primarily engages in the treatment of pain by prescribing narcotic medications.” CNPs must consult with the physician at least once every 90 days thereafter for continued prescribing to the same patient.

    Reimbursement

    CNPs/CNMs receive Medicaid reimbursement at 100% of the physician rate for primary care activities; however, 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 SOP. CRNA services and psychiatric/mental health CNS services are reimbursable by insurance.

    North Dakota

    www.ndbon.org

    www.ndnpa.org

    www.campaignforaction.org/state/north-dakota

    www.ndna.org

    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 with prescriptive authority may prescribe, administer, sign for, and dispense OTC drugs, legend drugs, and CSs, and procure pharmaceuticals, including sample legend drugs and schedule 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 85% 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. 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. The American Association of Nurse Practitioners defines Ohio NP practice as Reduced Practice.

    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 must hold national certification to enter practice. Effective March 23, 2022, HB122 expressly authorizes APRNs to provide telehealth services and sets forth various standards of care that must be met when providing telehealth.

    Prescriptive authority for CNPs, CNMs, and CNSs include schedule II-V CSs under Rule 4723-9-10 and in collaboration with a physician. CNPs, CNSs, and CNMs must register with the DEA and 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.

    For APRNs not practicing in a location or program recognized in law, APRN schedule II prescribing is limited to terminally ill patients, only after a physician has initiated the schedule II prescription, and only for a 72-hour period. 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 specialties. 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 APRN to be listed on managed care panels and insurance companies are statutorily mandated to reimburse CNMs. Workers' compensation continues to reimburse CNPs, CRNAs, and CNSs. Reimbursement is otherwise determined by the payer.

    Oklahoma

    https://nursing.ok.gov/

    https://npofoklahoma.com/

    https://campaignforaction.org/state/oklahoma

    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 an 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 SOPs 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 as a Restricted Practice state.

    CNPs are recognized as PCPs and hospital privileges are granted on an individual facility basis.

    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 schedule III, IV, and 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, as well as the availability of the APRN and physician to one another for communication. APRNs may only prescribe according to an exclusionary formulary approved by the board, must prescribe within their SOP, and may only prescribe schedule III, IV, and V CSs (30-day supply) if the Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD) and DEA registrations are obtained.

    Legislation signed by the Oklahoma governor (HB 3319) and effective July 1, 2022, provides that the BON may grant a temporary critical need license to APRNs licensed in other states during a state or national state of emergency to practice within their SOP. The APRNs may not have a restricted license or be under investigation by the issuing state. SB 1691, which was signed into law and became effective November 1, 2022, delineates when and what type of offenses relate to granting or denying occupational certification and licensing.

    Reimbursement

    Oklahoma's Medicaid plan includes CNPs as primary care managers. State law does not mandate reimbursement of CNPs; however, the Employees Group Insurance Division, formerly known as the Oklahoma State and Education Employees Insurance Company, recognizes CNPs as providers and lists them in the Health Choice directory. Negotiations continue with other third-party insurers. The Oklahoma BON does not regulate reimbursement.

    Oregon

    www.oregonrn.org

    www.oregon.gov/OSBN

    www.campaignforaction.org/state/oregon

    Practice authority

    The Oregon BON grants FPA to and regulates CNPs (NPs in regulation; CNMs are a category of NP), CNSs, and CRNAs. Nurses in all three categories of advanced practice must be credentialed with a license by the BON. “APRN” is not a protected title in the Oregon NPA. SOP is defined in regulation, Division 51, 53, and 55 of the NPA, and NPs are statutorily recognized as PCPs; permissive statutes allow for NP hospital privileges. 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. Since 2011, national board certification has been required to enter practice. Regulation of prescriptive authority is under the sole authority of the BON and is defined in Division 55 of the NPA. Oregon has legislated independent or plenary authority for NPs and CNSs to prescribe; NPs and CNSs are therefore able to obtain DEA numbers for schedule II-V CSs. NPs and CNSs with prescription-writing authority may receive and distribute prepackaged complimentary 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. Prescriptive privileges are optional for CNSs and CRNAs, and they 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.

    Pennsylvania

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

    www.pacnp.org

    https://www.pana.org

    www.campaignforaction.org/state/Pennsylvania

    Practice authority

    The Pennsylvania BON grants CRNPs, CNSs, and CRNAs authority to practice and regulates their practice. APRN is not defined in statute or regulation. A CRNP performs the expanded role in collaboration with a physician, which is defined as a process in which a CRNP works with one or more physicians to deliver healthcare services within the scope of the CRNP's expertise.

    The collaborative agreement is a signed, written agreement between the CRNP and a collaborating physician in which they agree to the details of their collaboration, including the elements in the definition of collaboration. The CRNP's SOP is defined in statute and regulation. CRNPs are recognized as PCPs by the Department of Human Services and many insurance companies, but some managed care companies do not recognize CRNPs as PCPs. The SOP of the CNS, defined in statute, prohibits the acts of medical diagnosis and prescribing. The term CRNA as well as defining CRNAs' SOP in statute among other provisions was recently approved. The CRNA performs their expanded role in cooperation with and under the overall direction of a physician, Doctor of Osteopathy, podiatrist, or dentist.

    The Pennsylvania Department of Health authorizes a hospital's governing body to grant and define the scope of clinical privileges to individuals with advice from medical staff. CRNPs must have a master's degree and pass a national certification exam to practice. CRNAs must have a master's degree, a doctoral degree, or a post-master's certificate and pass a national certification exam to practice. The BOM licenses and regulates CNMs. The American Association of Nurse Practitioners considers Pennsylvania a Reduced Practice state.

    The BON confers prescriptive authority, including schedule II-V CSs, to CRNPs with a collaborating physician. Regulations allow a CRNP to prescribe and dispense drugs if the CRNP has successfully completed a minimum of 45 hours of course work specific to advanced pharmacology and if the prescribing and dispensing is relevant to the CRNP's area of practice, documented in a collaborative agreement, not from a prohibited drug category, and conforms with regulations. The CRNP may write a prescription for a schedule II CS for up to a 30-day supply, and CRNPs may prescribe schedule III and IV CSs for up to a 90-day supply; schedule V is not restricted. CRNPs are authorized to request, receive, and dispense pharmaceutical sample medications. Prescription blanks must include the name, title, and Pennsylvania certification number of the CRNP.

    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 that 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 are regulated by the Rhode Island Department of Health. APRN SOP is defined within the NPA and 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. APRNs are considered licensed independent practitioners. The American Association of Nurse Practitioners considers Rhode Island a Full Practice state.

    The minimum degree to enter practice for all APRNs is completion of a graduate-or postgraduate-level APRN program and national board certification. With the passage of S614 in 2013, APRNs are granted independent prescriptive authority, including authority to prescribe, order, procure, administer, dispense, and furnish OTC drugs, legend drugs, 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 schedule II-V CSs. CRNAs, CNSs, 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. United Healthcare empanels 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/

    https://www.scnurses.org/page/APRN

    https://campaignforaction.org/state/south-carolina/

    Practice authority

    The South Carolina BON grants APRNs the authority to practice and regulates their practice. APRNs include NP, 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.

    For the performance of medical acts, including prescribing medications, NPs, 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. The collaborating physician must be licensed in South Carolina and practicing within its geographic boundaries. 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 six full-time equivalent (FTE) APRNs (a physician may request an exemption for collaborating with more APRN's through the Board of Medical Examiners). 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. The American Association of Nurse Practitioners considers South Carolina a Restricted Practice state.

    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, post-master's certificate, or a minimum of a master's degree in nursing and achieve national certification within 1 year of program completion to enter practice; however, psychiatric CNSs have up to 2 years to achieve this certification. Effective July 15, 2022, APRNs are allowed to supervise certified medical assistants (CMAs) per S.613/Act 171.

    NPs, CNSs, and CNMs are authorized to prescribe drugs and devices listed in the practice agreement including schedule 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 provided without a written practice agreement with 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 or for patients residing in long-term care facilities listed in the practice agreement may be prescribed, limited to a 30-day supply. In addition to required identification, written 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. Electronically prepared prescriptions require prescriber's name, address, and phone number and, where possible, the name of the physician. CRNAs are not required to obtain prescriptive authority to deliver anesthesia care (nor can they request prescriptive authority in SC; however, CRNAs must 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.

    Effective July 26, 2021, prescribers shall offer prescriptions for naloxone hydrochloride and provide overdose prevention education with opioids under certain circumstances per S.571/Act22 (in Section 44-53-361 [A]).

    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. Multiple payers recognize, enroll, and directly reimburse APRNs for services provided.

    South Dakota

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

    https://npasd.enpnetwork.com/

    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 FPA but must complete a TTP of 1,040 practice hours in a CPA 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, and 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, although certain exemptions are allowed.

    South Dakota's CNPs, CNMs, and CRNAs are authorized to prescribe legend drugs and schedule II, III, and IV CSs. CNPs, CNMs, and CRNAs have two CS registration options. They may seek independent state registration and DEA registration in schedule 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. Effective July 1, 2022, pursuant to SDCL 34-20G, South Dakota APRNs who are licensed with authority to prescribe drugs may now certify medical cannabis patients.

    CNPs, CNMs, and CRNAs may request and receive prepackaged drug samples, which the CNP, CNM, or CRNA are authorized to prescribe, and 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 CNP, 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. 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. APRNs are required to hold a master's degree or higher in a nursing specialty and national certification to enter practice.

    NPs with a BON-issued certificate of fitness to prescribe may prescribe legend drugs and schedule II-V CSs. An NP with a certificate of fitness to prescribe must file notice with the board, and include 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 at the beginning of a new episode of treatment and at other specific circumstances. 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 morphine milligram equivalent (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. Legislation enacted in 2020 authorizes nonphysician prescribers to prescribe and dispense buprenorphine products to treat opioid use disorder in recovery or MAT 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 APRNs into their networks. 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.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 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. Protocols are agreed on and signed by the APRN and delegating physician, reviewed and re-signed at least annually, and maintained in the practice setting of the APRN. The American Association of Nurse Practitioners considers Texas a Restricted Practice state.

    Hospitals may extend clinical privileges to APRNs but are not required to do so and must use a standard application form and afford due process rights in granting, modifying, or revoking those privileges. APRNs must 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 through 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, in accordance with regulatory standards and requirements. Schedule 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 schedule III-V CSs requires consultation with the delegating physician and documentation of the consult; and may not be authorized for a child under 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 is receiving hospice care. 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

    http://utahnp.enpnetwork.com

    https://dopl.utah.gov/nurse/index.html

    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 Utah a Reduced Practice state. 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 schedule II-V CSs.

    As of May 4, 2022, limitations on prescriptive authority regarding consultation and referral have been removed, except that APRNs (exclusive of CRNAs) who are engaged in independent solo practice and who have been licensed as an APRN for less than one year or have less than 2,000 hours of experience practicing as a licensed APRN must be board certified by a nationally recognized organization, have completed at least 30 hours of advanced pharmacology during graduate studies, have completed seven hours of CE pertaining to prescribing opioids, and have participated in a mentorship with a physician or APRN, with certain conditions, in order to prescribe or administer a Schedule II CS (UC 58-31b-803).

    Effective February 14, 2022, the Home Health rule amendment adds APRNs who are the PCP for a patient as “primary care providers” and enables them to order home health (Utah Admin. Code R432-700-4). This was originally part of the CARES home health COVID-19 pandemic response.

    CRNAs may order and administer drugs, including schedule 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://sos.vermont.gov/nursing/

    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 TTP 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 schedule 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-IV CSs and when starting a patient on non-opioid Schedules II-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 all four APRN roles, referred to as licensed NPs (LNPs) in Virginia statute. § 54.1-3000 of the Code of Virginia defines “APRN” as “a registered nurse who has completed an advanced graduate-level education program in a specialty category of nursing and has passed a national certifying examination for that specialty.”

    NP practice is based on a written or electronic practice agreement with a physician unless the NP has been issued the autonomous practice designation on their NP license. Physicians who enter into a practice agreement with an NP may only collaborate with up to six NPs with prescriptive authority except when a physician serves as a patient care team physician with up to 10 PMHNPs. 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.

    The autonomous practice designation is acquired by submission of attestation of full-time clinical experience from a patient care team physician. In the absence of the passage of legislation making the 2-year full-time TTP period permanent, Virginia's full-time TTP period reverted to 5 years on July 1, 2022. NPs possessing the autonomous practice designation must: 1) practice within the scope of their clinical and professional training and limits of their knowledge and experience and consistent with applicable standards of care; 2) consult and collaborate with other healthcare providers based on clinical conditions of the patient; and 3) establish a plan for referral of complex medical cases and emergencies to physicians or other appropriate healthcare providers. 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. NPs are included in the list of professions authorized to perform surgery and are authorized to certify medical necessity of durable medical equipment for Medicaid reimbursement.

    CNMs with less than 1,000 hours of clinical experience must practice in consultation with a licensed physician or a CNM with 2 or more years of clinical experience in accordance with a practice agreement.

    CRNAs practice under the supervision of a physician and possess prescriptive authority to prescribe to a patient requiring anesthesia, as part of the periprocedural care of such patient.

    On July 1, 2021, through a legislative change to §54.1-2957, CNSs moved from being registered by the BON to being jointly licensed by the BON and BOM to practice as APRNs. With this change in licensure status came the requirement to practice in consultation with a licensed physician in accordance with a practice agreement. CNSs may be granted prescriptive authority upon submission of evidence of qualification to prescribe.

    All APRNs who possess prescriptive authority may prescribe devices and schedule II-VI drugs and dispense drug samples under an exemption to the state Drug Control Act. The joint regulations of the BON and BOM include requirements for continued prescriptive authority 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.

    Reimbursement

    The Virginia BON does not regulate reimbursement and therefore cannot provide data regarding reimbursement.

    Washington

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

    https://auws.enpnetwork.com/

    www.wsna.org

    www.campaignforaction.org/state/washington

    Practice authority

    The Washington State Department of Health 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 , and includes performing procedures within the ARNP's SOP according to the commission approved certifying body as defined in WAC 246-840-302. 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. As of June 9, 2022, ARNPs have statutory authority to perform abortions.

    All ARNPs who receive prescriptive authority have the option to prescribe legend drugs and schedule 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 that the law did not have legal force in addressing reimbursement parity for ARNPs because it only applied to the agreement between the health plan and the patient. Consequently, many private insurance companies reimburse ARNPs at a lower rate than a physician for the same service. ARNPs are authorized to conduct the face-to-face encounter and order home health supplies and services per WAC § 182-551-2040 and 182-543-0500. Health plans are required to reimburse a provider for audio-video telehealth visits at the same rate as healthcare services provided in-person. In addition, audio-only telehealth calls are to be reimbursed under the same conditions applicable to audio-video telehealth visits. Conditions for audio-only calls will change in 2023.

    West Virginia

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

    www.campaignforaction.org/state/west-virginia

    https://wvnurses.nursingnetwork.com/

    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 of Nurse Practitioners considers West Virginia a Reduced Practice state.

    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 application and approval for prescriptive authority without a collaborative agreement by the Board. APRNs may not prescribe a Schedule I controlled substance but may prescribe up to a 3-day supply of a Schedule II narcotic. There are no other limitations on the prescribing authority of an advanced practice registered nurse,

    R&Rs 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 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.

    SB 334 codified telehealth definitions and practice requirements for APRNs (rule 19CSR16) it was signed into law and went into effect May 3, 2022.

    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, R&Rs have not been promulgated. NPs and CNMs are defined as PCPs and 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.

    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. The American Association of Nurse Practitioners considers Wisconsin a Reduced Practice state.

    There are no statutory requirements for hospitals to grant staff privileges to APRNs. 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 a 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 schedule II-V CSs appropriate to their area of competence. APNPs may dispense pharmaceutical samples to a patient at the treatment facility where they are 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. CHAMPUS reimburses NPs and home health RNs bill under their own provider number.

    Wyoming

    https://wsbn.wyo.gov

    www.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 Full Practice. APRNs are statutorily defined as PCPs and may be permitted to admit patients to a hospital and hold hospital privileges. 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. BON-approved APRNs may independently prescribe legend drugs 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.

    Keywords:

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

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