Legislative Update Key

TABLE

TABLE. No caption available.

Alabama

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

Legal Authority

The BON is the sole state authority to establish the qualifications and certification requirements through R&R for APNs (CRNPs, CNMs, CRNAs, and CNSs). Initial CRNP applicants are exempt from requirement for MSN on discretion of the BON, if graduation was prior to 1996 in BON certified NP program, or graduation prior to 1984 from non-BSN program preparing NPs. Effective Jan. 1, 2004, the BON will approve the practice of CRNAs, if they have earned at least a master's degree from an accredited nurse anesthesia graduate program and are currently certified as a CRNA; CRNAs who graduated prior to Dec. 31, 2003, are exempt from the master's degree requirement. The CRNA shall practice in accordance with standards of the American Association of Nurse Anesthetists. The BON may approve CNSs if they have attained a master's degree or higher and are nationally certified. The SOP for the CNS is the same as for the CRNP. The BON and BOME regulate (through R&R) the collaborative practice of physicians and CRNPs, CNSs, and CNMs and require them to practice with BON- and BOME-approved protocols. The protocol must include a formulary of drugs, treatments, tests, and procedures; a predetermined plan for emergency services; a referral process; a mechanism for quality analysis; and a written plan for review of medical records. The protocol must be signed by the collaborating physician and the NP, CNS, or CNM practicing with the physician. "The term collaboration does not require direct, on-site supervision of the activities of a CRNP, CNS, or CNM by the collaborating physician. The term does require such professional oversight and direction as may be required by the R&R and BOME." The collaborating physician shall be present in a practice site a minimum of 10% per month (if the CRNP's collaboration time is thirty or more hours per week) and a minimum of 10% on a quarterly basis (if the CRNP's collaboration time is less than 30 hours per week).

Reimbursement

The state BC/BS is the administrator of the State Employees Insurance Benefits plan (SEIB). The state nursing association is working with the SEIB to improve and expand NP reimbursement. There are no legislative restrictions against APNs on managed care panels. The Alabama Medicaid Nurse Practitioner Program reimburses NPs; Alabama Medicaid does not reimburse for services provided in a hospital or emergency department. NPs are reimbursed through the KidsFirst Program.

Prescriptive Authority

CRNPs, CNSs, and CNMs may "prescribe, administer, and provide therapeutic tests...and drugs" within an approved formulary. A BON and BOME joint committee (composed of one CNM, CRNP, and RN and three physicians) recommends R&R governing the collaborative relationship between physicians and CRNPs, CNSs, and CNMs and the prescription of legend (noncontrolled) drugs. The R&R specify a 2:1 ratio (CRNP:MD) and a 3:1 ratio (CNM:MD) or a combination of CRNP, CNS and CNM:MD). Exemptions to this specification include public health employees and practices in place before R&R took effect. The joint committee considers applications for ratio exemptions. The BON and BOME shall approve the protocols and formulary of legend drugs that may be prescribed by authorized CRNPs, CNSs, and CNMs. Authorization is tied to the collaborative agreement; if CRNPs or CNMs change physicians, they must reapply. The CRNP, CNS, or CNM is issued a number by the BON; the Rx pad must include the physician name and address, and the CRNP or CNM name and his or her Rx number. RN license numbers are required for Medicaid. The CRNP, CNS, or CNM who is in collaborative practice and has Rx privileges may sign for and dispense approved formulary drugs.

Alaska

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

Legal Authority

NPs have statutory authority to practice as ANPs, which include NPs and CNMs. CRNAs have their own R&R. CNSs are not licensed separately from their RN license. An ANP is defined as an RN who, because of specialized education and experience, is certified to perform acts of medical diagnosis and prescription and dispensing of medical, therapeutic, or corrective measures under regulations adopted by the BON. ANPs must have a plan for patient consultation and referral, but a physician relationship is required. The federal Alaska Native Hospital allows ANPs to admit independently; the other hospitals require a physician preceptor. Nothing in the law precludes admitting privileges for ANPs. Continuing-education requirements for ANPs are 30 CEUs (8 of these must be pharmacology hours) every 2 years.

Reimbursement

All health care is provided on a fee-forservice basis; managed care does not exist in Alaska. A nondiscriminatory clause in the insurance law allows for third-party reimbursement to NPs. However, the BC/BS (federal plan) charges patients a $200 deductible to see NPs and no deductible to see physicians. 1992 R&R allow CNMs, PNPs, and FNPs to receive Medicaid reimbursement; NPs receive 80% of the physicians' payment.

Prescriptive Authority

Authorized NPs have independent Rx authority, including Schedules II-V controlled substances. A 1992 law permits CRNAs to prescribe. ANPs receive their own DEA registration. The law allows ANPs to dispense drugs under regulations adopted by the BON.

Arizona

http://www.azboardofnursing.org

Legal Authority

RNP is defined in the NPA statute; corresponding R&R outline the SOP. RNPs include NPs and CNMs. RNPs have a statutory defined SOP that includes (1) assessing clients, synthesizing and analyzing data, and understanding and applying principles of health care at an advanced level; (2) managing the physical and psychosocial health status of clients; (3) analyzing multiple sources of data, identifying alternative possibilities as to the nature of a health care problem and selecting, implementing, and evaluating appropriate treatment; (4) making independent decisions in solving complex client care problems; (5) Diagnosing, performing diagnostic and therapeutic procedures, prescribing, administering, and dispensing therapeutic measures, including legend drugs, medical devices, and controlled substances within the SOP of RNP practice on meeting the requirements established by the BON, and (6) referring clients to other health care providers when appropriate. CNSs must have a master's degree in nursing; they are not allowed to prescribe legend drugs or controlled substances.

Reimbursement

RNPs and other certified registered nurses receive third-party reimbursement, enabled by the Department of Insurance statutes. There is no Medicaid; the Arizona Health Care Cost Containment System (AHCCCS) contracts with PCPs on a capitated basis. Some NPs have directly contracted with AHCCCS as PCPs. As of 1999, AHCCCS NP reimbursement is 90% of the established physician rate.

Prescriptive Authority

RNPs have full Rx and dispensing authority on application and fulfillment of BON-established criteria. RNPs Rx and dispensing authority is linked to the RNP's SOP (e.g. it is considered by the BON to be outside the SOP for a PNP to Rx for an adult). Rx without documenting an examination is considered by the BON to be a violation of the NPA. The pharmacy statute enables RNPs to prescribe, with corresponding R&R in the NPA. No annual CEU documentation is required for renewal of Rx and dispensing authority. RNPs receive their own DEA numbers and may prescribe Schedules II-V controlled substances. An RNP with Rx and dispensing authority who wishes to Rx a CS shall apply to the DEA for a registration number and file this number with the BON. Drugs, other than controlled substances, may be refilled up to 1 year. CRNAs may prescribe drugs to be administered by a licensed certified or registered health care provider preoperatively, postoperatively, or as part of a procedure; CRNAs are not authorized to dispense.

Arkansas

http://www.accessarkansas.org/nurse/

Legal Authority

The NPA provides second licensure by the BON for APNs who are nationally certified in one of four categories: CNM, CNS, CRNA, or NP. R&R provide for SOP as defined by the national certifying body. A consulting physician is only required for CNMs; CNMs must have an agreement with a consulting physician if providing intrapartum care. NPs not nationally certified qualify for licensure as an RNP and practice under physician direction/protocol. Since November 2000, new RNP licenses are no longer issued. Graduate-level APN education is required for initial APN licensure after January 2003. The CRNA SOP is defined as the administration of anesthetics under the supervision of, but not necessarily in the presence of, a physician or DDS; CRNAs may order RNs to administer drugs pre- and postoperatively for any procedure that has been/will be provided. If the hospital/institution authorizes the CRNA to act as its agent under its DEA number, the physician need not sign the orders. Hospital privileges for APNs are determined on a hospital-to-hospital basis, according to the medical board of each hospital.

Reimbursement

The NPA mandates direct Medicaid reimbursement to APNs and RNPs. Medicaid reimbursement is 80% of physicians' rate. APNs cannot be PCPs for Medicaid. BC/BS reimburses ANPs who have a collaborative practice agreement. Services are filed under the collaborative physician's name and are paid at the physician's rate. Reimbursement is limited to H&M 99203 and 99213 and below. CNMs, and some NPs, are listed on managed care panels. A statutory provision exists for third-party reimbursement for CRNAs.

Prescriptive Authority

The NPA authorizes the BON to provide a certificate of Rx authority to qualified APNs in collaborative practice with a physician of comparable specialty/scope and using protocols for prescribing. Neither protocols nor a collaborative practice agreement with a physician is required unless the APN has Rx authority. Under R&R, an initial applicant for Rx authority must (1) be an APN with completion of pharmacology coursework of three graduate credit hours or 45 contact hours in a competency tested pharmacology course; (2) have 300 hours of precepted prescribing experience; (3) have 1,000 hours of post-APN education program experience; and (4) include a collaborative practice agreement with a physician. Endorsement applicants must provide Rx evidence of at least 1,000 hours in the last year and have a clear DEA history. This Rx authority includes Schedules III-V controlled substances after a DEA number is obtained. APNs who have fulfilled requirements for Rx authority may receive legend drug samples and therapeutic devices appropriate to their area of practice, including Schedules III-V controlled substances. A 2001 attorney general decision opined that APNs with Rx authority have implied authority to give sample Rx drugs to patients.

California

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

Legal Authority

The California Board of Registered Nursing (BRN) issues separate certification to NPs, CNMs, CRNAs, and CNSs. Advanced practice titles are protected. NPs function under "standardized procedures" or protocols when performing medical functions. The standardized procedures shall (1) be in writing and signed by the authorized organized health care system personnel, (2) specify which standardized procedure functions may be performed, (3) specify state requirements that are to be followed, (4) specify experience, training, and/or education requirements for performance of a procedure, (5) establish a method of evaluation, (6) specify the scope of supervision for the persons authorized to perform the procedure functions, (7) specify the circumstances that require immediate communication with the patient's physician, and (8) specify record keeping and periodic review requirements. The standardized procedures are agency-specific and must meet certain requirements, including collaborative development by nursing, medicine, and the administration within the agency. The level of "supervision" required is specific to the practice setting as specified in the standardized procedure. Supervision does not require the physical presence of a physician. CNMs under supervision of a physician with a current obstetrics practice attend normal childbirth and provide prenatal, interpartum, and postpartum care. "Supervision" does not require the physical presence of the physician. Under new legislation (effective Jan. 2004) the supervising physician and surgeon at a clinic may delegate the supervision of medical assistants to NPs or CNMs.

Reimbursement

Medi-Cal must reimburse FNPs and PNPs for Medicaid-covered services. BC of CA Medi-Cal Provider Directory lists NPs as PCPs under their area specialty. CNMs and CRNAs may receive direct Medi-Cal reimbursement. All NPs and CNMs may be reimbursed indirectly (payment made to physician, hospital, or clinic). Third-party payers may directly reimburse NPs, CNMs, and CRNAs. Third-party payers are required to reimburse BRN-listed psychiatric-mental health nurses for qualifying services. Participants in the state's managed care programs for specified Medi-Cal beneficiaries may select NPs and CNMs as their PCPs. NPs, CNMs, and CRNAs may be professionally exempt from mandatory overtime in the labor code, providing the definition for professional is met.

Prescriptive Authority

NPs and CNMs may furnish or "order" drugs or devices when (1) the drugs or devices are furnished or ordered by an NP or CNM in accordance with standardized procedures, and (2) when incidental to the provision of family planning services, routine health care, prenatal care, or to essentially healthy persons. Furnishing does not require the physical presence of the physician. Physician supervision includes collaboration on the development and approval of the standardized procedure and physician availability by telephone. Pharmacists must include both the NP's or CNM's and physician's name on the drug label. NPs and CNMs may sign for, request, and receive pharmaceutical samples and may dispense drugs, including controlled substances pursuant to a standardized procedure or protocol. A physician or surgeon shall not supervise more than four NPs or CNMs one time. Previously, drugs and devices furnished or ordered by the NP may include Schedules III-IV controlled substances. New legislation (effective Jan. 2004) expands NP Rx to include Schedule II adding additional requirements: The NP furnishing or ordering Schedule II by approved standardized procedure shall address the diagnosis of illness, injury, or condition for which the Schedule II is Rx. When Schedule II or III is Rx by an NP, the CS shall be furnished or ordered in accordance with a patient-specific protocol approved by the treating or supervising physician. The new law requires NPs to complete a CE course that includes Schedule II CS based upon BON standards. NPs authorized by the BRN to furnish or order controlled substances are authorized to register for a DEA number. CNMs may furnish or order noncontrolled and Schedules III-V controlled substances within a patient-specific, physician-approved standardized procedure or protocol in practice settings (including licensed birth centers). CNMs may furnish Schedule II controlled substances only in a licensed acute care hospital. CNMs must register with the DEA. To obtain a BRN-issued furnishing number, the CNM/NP must complete a qualifying pharmacology course and 520 hours of physician-supervised experience within 6-12 months.

Colorado

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

Legal Authority

Definitions in the NPA are broad; SOP is based on the individual nurse's knowledge, judgment, and skill. Title protection is provided for APNs (NPs, CNSs, CNMs, and CRNAs); use of these titles requires BON registration. Educational requirements include a master's degree in a clinical specialty area and/or BON-approved certification for CNSs; completion of an accredited program and certification for CNMs and CRNAs; and completion of an accredited NP program and/or certification for NPs. (An appropriate graduate degree will be required after June 30, 2008 for all four types of APNs.) APN SOP is founded on the relevant educational program and core curriculum as determined by accepted professional standards. Although a function may be within an APN's SOP, the individual APN must have the requisite knowledge, judgment, and skill to safely and competently perform any undertaken function. As of 2001, a CNM shall have "a safe mechanism for consultation or collaboration with a physician or, when appropriate, referral to a physician."

Reimbursement

Third-party reimbursement is available to any RN; billed services qualify for reimbursement only if the type of service has a history of being reimbursable to other health care providers (a fiscally neutral bill). No statutes or rules prohibit or constrain APNs in managed care. Medicaid reimbursement is available to PNPs, FNPs, CNMs, and CRNAs.

Prescriptive Authority

Rx authority legislation includes prescription drugs. Schedules II-V CS are approved after receiving a DEA number. For Rx authority eligibility, the prescribing nurse must be listed on the APN registry and have a post-basic or graduate degree in a nursing specialty that includes at least 45 contact hours in health assessment, pharmacology, and pathophysiology. The APN must have satisfactorily completed education in the use of controlled substances and prescription drugs; have postgraduate experience as an APN in a relevant clinical setting of not less than 1,800 hours (in the immediately preceding 5-year period); and have a written collaborative agreement with a physician whose medical education and active practice correspond with that of the APN. The Rx collaborative agreement shall include the duties and responsibilities of each party, provisions regarding consultation and referral, a mechanism designated by the APN to ensure appropriate Rx practice, and other provisions established by the board. The APN shall provide the BON with the collaborating physician's name; that information will also be available to the BOP, BOM, and (except for DEA numbers) the general public. The APN Rx section of law states that nothing shall be construed to limit the ability of the APN with Rx authority to make independent judgments, require supervision by a physician, or require the use of formularies. APNs with Rx authority may dispense or distribute drug samples pertaining to their area of specialty practice.

Connecticut

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

Legal Authority

The NPA was amended in 1999 to allow APRNs (NPs, CNSs, and CRNAs) to work in collaborative relationships with physicians. R&R specific to this law have not been written. The collaborative agreement with respect to Rx authority must be in writing. The bill defines collaboration as a mutually agreed on relationship between an APRN and a physician who is educated, trained, or has experience related to an APRN's work. The collaboration between the physician and the APRN must include (1) reasonable and appropriate consultation and referral, (2) patient coverage in the absence of the APRN, (3) a method for reviewing patient outcomes, and (4) a method of disclosing the collaborative relationship to the patient. The bill exempts CRNAs, as their service is under the direction of a licensed physician. The 1999 NPA may be further revised to clarify: (1) Must an APRN also be a current licensed RN in the state? At this time, the APRN needs only "to be eligible for a license." (2) Can RNs continue to operate under an order issued by an APRN? This question is complicated by 2002 legislation that allows pharmacists to manage inpatient drug therapy with physician collaboration. CNM SOP is recognized under a separate 1984 statute.

Reimbursement

CNPs, psychiatric CNSs, and CNMs are reimbursed for services under state insurance statutes. The statutes affect only private insurers. Nurse providers must have a fee-for-service practice, either private or collaborative. Reimbursable services must be within the individual's SOP and must be services that are reimbursed if provided by any other health care provider. The law further states that insurers cannot require supervision or signature by any other health care provider as a condition of reimbursement. Medicaid regulations govern reimbursement to APRNs under the remaining Medicaid fee-for-service programs.

Prescriptive Authority

APRNs working in the collaborative relationship may prescribe, dispense, and administer medications, including Schedules II-V controlled substances that are expressly specified in the written collaborative agreement. The prescriptive form must include the name, address, and phone number of the APRN or CNM and can include the collaborative physician's name. If the APRN prescribes noncontrolled substances only, state-controlled substance registration or a federal DEA number is not required. If the APRN prescribes controlled substances in a hospital setting only and the hospital has granted subscript authority under the hospital DEA number, a state-controlled substance registration number is required but a federal DEA number is not. If the APRN prescribes controlled substances in any other setting, the state-controlled substance regulation and the federal DEA number are required. CRNAs can only administer drugs during surgery when the physician, who is medically directing the Rx activity, is physically present in the institution, clinic, or other setting.

Delaware

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

Legal Authority

APNs include NPs, CNSs, CNMs, and CRNAs. If the APN's SOP does not include independent acts of diagnosis or prescribing, practice authority is governed solely by the BON. Otherwise, the APN applies to the JPC (composed of APNs, MDs, a pharmacist, and one public member). The JPC is statutorily empowered, with Board of Medical Practice (BOMP) approval, to grant independent practice and/or Rx authority to nurses who qualify. APN applicants must have completed a post-basic APN program that meets BON standards, be nationally certified, submit a copy of their collaborative agreement, and show evidence of BON-specified relevant pharmacology CEUs within the past 2 years. The collaborative agreement is a written document that outlines the process (for consultation, referral and/or hospitalization complementary to the APN's independent practice area). The collaborative agreement is defined as "a true collegial agreement between two parties where mutual goal-setting access, authority, and responsibility for actions belong to individual parties and there is a conviction to the belief that this collaborative agreement will continue to enhance patient outcomes, and a written document that outlines the process for consultation and referral between an APN and physician, dentist, podiatrist, or licensed health care delivery system." If the agreement is with a licensed health care delivery system, the document must clarify that the system will supply appropriate medical back-up for purposes of consultation and referral. Requirements for physician supervision, chart review, or on-site physician visits do not exist.

Reimbursement

Health insurers, health service corporations, or HMOs shall not deny benefits for eligible services when rendered by an APN acting within his or her SOP. APNs may be listed on provider panels; some providers are recognizing APNs on managed care provider panels. CNMs have legislative authority under the Board of Health for third-party reimbursement. FNPs and PNPs also receive Medicaid reimbursement at 100% of physician payment.

Prescriptive Authority

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

District of Columbia

http://dchealth.dc.gov/prof_license/services/boards_main_action.asp?strAppId=11

Legal Authority

APNs include NPs, CNMs, CRNAs, and CNSs. APN practice is defined in the 1985 Health Occupations Revision Act (HORA). 1995 amendments granted APNs authority to practice without a physician collaborative agreement and dropped requirements for APNs to function under protocols and SOP limitations for various specialties. The APN SOP is regulated by the BON. APNs may apply for hospital privileges. New APRN rules promulgated by the BON in December 2003, implemented the 1995 law.

Reimbursement

The 1995 HORA amendment authorized direct reimbursement of APNs for providing drug abuse, alcohol abuse, and mental illness care; health care plans or institutions are prohibited from discriminating against APNs with clinical privileges. Legislative authority that mandates APN reimbursement does not exist. Private, third-party payers reimburse for NP services. APNs are statutorily recognized as primary care providers. NPs and CNMs receive Medicaid payment as PCPs.

Prescriptive Authority

The D.C. statute and regulations provide for full APN Rx authority. The collaborative agreement requirement has been abolished. The law and R&R authorize prescribing Schedules II-V controlled substances. The statute allows dispensing. The D.C. Pharmacy Board began issuing DEA numbers in 1995.

Florida

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

Legal Authority

ARNPs are certified by the BON and include NPs, CNMs, and CRNAs. Initial ARNP certification requires 500 supervised clinical hours in the educational program. An ARNP shall only perform medical acts of diagnosis, treatment, and operation pursuant to a protocol between the ARNP and a physician, DO, or DDS. The degree and method of supervision, determined by the ARNP and physician, DO, or DDS, shall be specifically identified in written protocols and shall be appropriate for prudent health care providers under similar circumstances. The BOM and BON rules define general supervision as the ability to communicate/contact by telephone; on-site presence of the supervising practitioner is not required. ARNPs in private practice must find a physician willing to sponsor the ARNP's protocols. ARNPs must file protocols with the BON yearly, and the physicians working with the ARNP must send the statement required in the medical practice act to the BOM. ARNP applicants must have a master's degree to qualify for initial certification. ARNPs, within the framework of established protocols, may order diagnostic tests and physical and occupational therapy. In compliance with the Mandatory Practitioner Profiling statute, all health care providers are required to submit information on criminal history, financial responsibility, liability actions, and fingerprinting. ARNPs must show proof of malpractice insurance or provide a reason for exemption.

Reimbursement

ARNPs receive Medicaid, Medicare, CHAMPUS, and third-party reimbursement. Medicaid reimburses ARNPs at 80% of physician payment; Medicaid only pays 100% if an on-site physician countersigns the chart within 24 hours. Managed care companies are prohibited from discriminating against the reimbursement of ARNPs if based on licensure. Private insurers must reimburse NM services if the policy includes pregnancy care.

Prescriptive Authority

The BON/BOM joint committee allows Rx privileges for ARNPs; however, controlled substances are excluded. ARNPs prescribe under their protocol, which broadly lists the medical SOP and generic categories from which the ARNP can prescribe. ARNPs use their own Rx pad (containing name and license number); the pharmacist is required to put the prescriber's name on the drug label. As of July 1, 2003, a new legible Rx law requires that written prescriptions be legibly printed or typed and be signed by the prescribing practitioner on the day issued. ARNPs who dispense (distribute medication for reimbursement) must apply for dispensing privileges. Giving free samples is allowed and not considered dispensing.

Georgia

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

Legal Authority

APRNs authorized to practice by the BON include NPs, CNMs, CRNAs, and CNSs in psychiatric mental health. CNSs in psychiatric/mental health must have a master's degree or higher to be authorized by the BON to practice. Psychiatric NPs must have dual authorization as NPs and CNSs in psychiatric/mental health. A master's degree or higher in nursing within the respective specialty and national certification is required for all APRNs. 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 by protocol. A physician may delegate to an APRN, in accordance with a "nurse protocol," the authority to order controlled substances from a BOME formulary and the authority to order drugs, medical treatments, and diagnostic studies. The R&R for this statute, however, have not been written and no formulary has been developed. Nurse protocol is defined as a written document signed by the NP and physician by which the physician delegates authority to the nurse to perform certain medical acts and provides for immediate consultation with the delegating physician. Public hospitals may (but are not required to) grant privileges to nonphysicians if they are qualified for staff privileges pursuant to the hospital's governing body bylaws.

Reimbursement

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

Prescriptive Authority

A process exists that permits RNs (including APRNs) to administer, order, or dispense drugs under delegated medical authority, either as prescribed by a physician or as authorized by protocol. BON regulations governing protocols used by RNs require that the RN document preparation and performance specific to each medical act. Ordering is not construed to be prescribing nor the issuance of a written prescription. "Medication orders" may be called into a pharmacy. There are continuing legislative efforts to amend the current limitation and allow for such orders to be transmitted in writing.

Hawaii

http://www.state.hi.us/dcca/pvl/areas_nurse.html

Legal Authority

APRNs are defined in the NPA as either having a "master's degree in nursing as specified in rules adopted by the BON or a current certification for specialized and advanced nursing practice from a national certifying body recognized by the BON." Each APRN's (NP, CNS, CNM, and CRNA) SOP is defined in administrative rules.

Reimbursement

Legislation provides direct reimbursement to all APRNs. Several insurance companies are in the process of credentialing APRNs for their provider panels. Some APRNs are listed on managed-care panels and are directly reimbursed for services. The reimbursement rate ranges from 85% to 100%. NPs and CNSs are also reimbursed through CHAMPUS. Medicaid expanded the types of APRNs they reimburse to include Psychiatric CNSs and additional specialties of NPs (only PNPs and FNPs were reimbursed before). Medicaid reimburses at 75% of physician payment. Hawaii Health QUEST, a Medicaid waiver program, defines PNPs, FNPs, and CNMs as PCPs. However, QUEST, unlike Medicaid, does not require the QUEST health care plans to include APNs as PCPs on their provider panels.

Prescriptive Authority

Under a 2002 law, Rx authority for APRNs is regulated by the BON. During the 2003 legislative session, a sweeping Administration Bill reversed the 2002 bill. The Governor's office has reported that in their opinion the reversal of the 2002 bill (related to the BON jurisdiction) occurred in error and will be rectified. In the meantime, the BON is still regulating APNs' Rx authority. The BOME submits an annual report of permissible formulations to the BON. The Department of Commerce and Consumer Affairs establishes a joint formulary advisory committee (composed of two APRNs, two MDs, three pharmacists, and one medical school and one nursing school appointee). The joint formulary advisory committee makes formulary recommendations to the BOME. The advisory formulary committee has forwarded recommendations to allow APNs to Rx CS under physician supervision. The BOME is currently considering these recommendations. APRN Rx authority is not supervised; however, APRNs must document with the Department of Commerce and Consumer Affairs that they have a collegial working relationship with an MD working in the same "institution" and specialty area. APRNs prescribe from an exclusionary formulary that excludes controlled substances. To prescribe from the formulary, APRNs must have a master's degree in nursing or nursing science, 30 hours of advanced pharmacology, 1,000 hours of clinical practice, and national certification. Master's and nonmaster's-prepared APRNs can prescribe controlled substances under protocols when the physician agrees. APRNs with prescriptive authority may receive pharmaceutical samples.

Idaho

http://www2.state.id.us/ibn/ibnhome.htm

Legal Authority

In 1998, the NPA established licensure for NPs as a category of advanced practice professional nurses (APPN), which also includes CNMs, CNSs, and RNAs. APPN licensure requires RN licensure, completion of an approved APPN program, and national certification. The BON solely regulates practice. NPs, CNMs, and CNSs must practice with physician supervision, consultation, collaboration, and referral. Supervision is defined as "designation of a course of action or provision of guidance and direction." Revised NPA rules (effective 2003) rely on the Decision Making Model (DMM) to determine an RN and APPN's SOP (instead of BON described SOP lists). The APPN can determine if a specific function can be legally performed by determining if the act: (1) is expressly forbidden in the NPA R&R; (2) was taught in the APPN curriculum and if the APPN is clinically competent to perform it; (3) does not exceed employment policies; (4) is consistent with national specialty organization standards; and (5) is within the accepted standard of care for the APPN's geographic region and practice setting. RNAs practice in collaboration with physicians. Hospital privileges for APNs are not specifically permitted or prohibited by the NPA. Some facilities have granted APNs privileges.

Reimbursement

Listing APNs on managed care provider panels is neither specifically permitted nor prohibited and is under discussion by third-party payers. In 2000, BC/BS agreed to place NPs on their preferred provider list. NPs receive their own Medicaid provider number and may choose to file independently or with a group. Reimbursement rates are 85% of physician payment.

Prescriptive Authority

Rx and dispensing authority is granted to APPNs who have completed 30 contact hours of pharmacology-specific formal instruction beyond basic RN education. Authorized APPNs may prescribe and dispense legend and schedules II-V controlled substances appropriate to their defined SOP. Some dispensing restrictions apply to schedule II substances. Authorized APPNs have their own DEA numbers and prescribe independently.

Illinois

http://www.ildpr.com

Legal Authority

CNPs, CNSs, CNMs, and CRNAs are title protected and statutorily recognized as APNs. APNs may not use the title "Dr." in a clinical setting. All new applicants must have a graduate degree in their APN specialty. Practice is regulated by the Department of Professional Regulation's APN Board (composed of four APNs, three physicians who must be in a collaborative practice with an APN, and two public members). CNPs, CNSs, and CNMs must have a written collaborative agreement with a physician that describes the working relationship between the APN and the physician and authorizes the categories of care, treatment, or procedures to be performed by the APN. Medical direction is adequate if the APN and physician jointly develop the guidelines and periodically review them. The agreement need not describe the exact steps for a specific condition, disease, or symptom but must specify which authorized procedures require a physician's presence. The physician's presence is not required at the site where services are rendered; however, telecommunication methods for consultation must be established, and the physician is expected to visit the site at least once a month. The APN shall provide services that the collaborating physician generally provides. Ratios are not specified; however, the Medical Practice Act prohibits a physician from entering into an "excessive number" of written collaborative agreements with licensed APNs, resulting in an inability to adequately collaborate and provide medical direction. CRNAs provide anesthesia services by order of, or by having an anesthesia plan with, or by having a practice agreement with a physician, dentist, or podiatrist. Legislation of 2002 amends the School Code and Transportation Code to allow APNs to sign physical examination forms and requires the Department of Human Services to include the Illinois Society for Advanced Practice Nursing in developing and distributing a health education brochure.

Reimbursement

The Illinois Department of Public Aid has provided direct reimbursement at 70% of physician rates to certified PNPs and FNPs who enroll independently as Medicaid providers. PNPs and FNPs may alternately choose to bill under a physician and receive 100% reimbursement. Statutory prohibition for third-party reimbursement to APNs does not exist. APNs receive direct or indirect reimbursement from third-party payers in some cases.

Prescriptive Authority

Delegated Rx authority is granted to APNs by their written collaborative agreement for legend and Schedules III-V controlled substances. APNs use Rx pads containing their names and their collaborating physicians' names; only the APN's signature is required. APNs do not need their collaborating physicians to sign IDPR (Illinois Department of Professional Regulation) forms for prescriptive authority as long as they are not Rx CS; in this case APNs need only note that the APN has Rx authority in the collaborative agreement. In order for an APN to Rx CS she/he has to first obtain a CSL (Illinois Controlled Substance License) before applying for a DEA #; the physician must sign a "Notice of Delegation of Rx Authority for Controlled Substances" form. Medication orders shall be reviewed periodically by the collaborating physician. An APN may sign for and accept drug samples if it is stipulated in the written collaborative agreement.

Indiana

http://www.in.gov/hpb/boards/isbn/appinst.html

Legal Authority

The NPA defines APN as an NP, CNM, or CNS. The BON does not issue separate licenses to NPs or CNSs. CNMs must apply for "limited licensure" to practice. APNs without Rx authority may function in their advanced practice with the RN license. The BON has R&R defining APNs. A written collaborative practice agreement (WCPA) is not necessary unless the APN seeks Rx authority. A 2003 law (Act 1437) specifies that between 1%-10% of APNs (with Rx authority) practice agreements shall be audited. NPs can independently sign for federal trucking physical examinations; they cannot independently sign for school physical examinations. The NPA defines CRNAs as separate from APNs.

Reimbursement

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

Prescriptive Authority

The BON has legal authority to establish rules, with the approval of the BOM, to permit Rx authority for APNs. Medical board approval (of the BON R&R for APN prescribing) became effective in 1994. The BON may issue authorization to prescribe legend drugs and controlled substances if the qualified APN submits proof of successful completion of a graduate-level pharmacology course, consisting of at least 2 accredited semester hours and submits proof of collaboration with a "licensed practitioner" (licensed physician, dentist, podiatrist, physician, or osteopath) in the form of a WCPA. WCPAs must be approved by the BON and include (1) the manner in which the APN and licensed physician will cooperate, coordinate, and consult with each other in the provision of health care, and (2) the specifics of the licensed physician's reasonable and timely review of the APN's Rx practices, including the provision for a minimum weekly review of 5% random chart sampling. The BON issues an Rx authority identification number; the authority limits APN prescribing to within the APN's and collaborating physician's SOP. APNs requesting authority to prescribe controlled substances must apply for and obtain Indiana State Controlled Substances Registration prior to obtaining a federal DEA number. APNs cannot prescribe Schedules III and IV controlled substances for the purpose of weight reduction or to control obesity. APNs must follow specific guidelines before prescribing a stimulant for attention deficit hyperactivity disorder. A 2003 BON Rule concerning Rx authority for APNs waives a pharmacology requirement for certain APNs transferring into the state (as long as they meet CE requirements) and requires renewal applicants to submit proof of 30 hours or more of CE during the past 2 years along with a current signed and dated collaborative practice agreement. CRNAs are not required to obtain Rx authority to administer anesthesia.

Iowa

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

Legal Authority

Advanced practice administrative rules are in the administrative code. ARNPs (NPs, CRNAs, CNMs, and CNSs) are registered by the BON in addition to their RN license. ARNPs may practice independently. Collaborative practice agreements are not required. In addition to independent functions, an ARNP may perform selected medically delegated functions when a collaborative practice agreement exists. The Hospital Fairness Bill allowed ARNPs to obtain hospital clinical privileges. A 2002 Senate bill removed barriers to CNP care provided in birth centers; CNMs now follow the practice act for care provision in any site.

Reimbursement

Payment of necessary medical or surgical care and treatment is provided to an ARNP if the policy or contract would pay for the care and treatment when provided by a physician or DO. Managed care organizations are not mandated to offer ARNP coverage unless there is a contract or other agreement to provide the service. Under 2003 legislation, ARNPs are approved as providers of health care services pursuant to managed care or prepaid service contracts under the medical assistance program.

Prescriptive Authority

Authorized ARNPs are granted independent Rx authority. ARNPs may prescribe, deliver, distribute, or dispense uncontrolled and controlled drugs, devices, and medical gasses. Registration with the federal DEA and the Iowa BOP extends this authority to controlled substances. ARNPs write prescriptions using their own Rx pads.

Kansas

http://www.ksbn.org

Legal Authority

BON-recognized ARNP status (for NPs, CNMs, CRNAs, and CNSs) is required for RNs practicing with an expanded SOP. There is additional statutory recognition for CRNAs. New ARNP applicants require a master's degree or higher in nursing. ARNPs function in collegial relationships with physicians and other health care professionals in the delivery of primary health care services. ARNPs make independent decisions about the nursing needs of patients and interdependent decisions with physicians in carrying out health regimens for patients. ARNPs are directly accountable and responsible to the consumer. The physical presence of the physician is not required when care is given by the ARNP. Effective 2002, ARNPs are authorized to sign handicap parking applications.

Reimbursement

A 1990 statutory requirement reimburses all ARNPs for covered services in health plans. Medicaid has expanded payment to include all covered services at 80% of physician payments (except for practitioners performing early periodic screening diagnosis and treatment, who receive 100%). CRNAs receive 85% of physician payments. Some insurance companies are paying 85% of physician payments to ARNPs.

Prescriptive Authority

A pharmacy law permits ARNPs, except CRNAs, to prescribe pursuant to protocols jointly adopted by the ARNP and "the responsible physician." Each written protocol must (1) specify the drug class the ARNP is permitted to prescribe for each classification of disease or injury, (2) be maintained in a notebook or book of published protocols, and (3) contain the ARNP's and physician's annual signature. The prescription order must be signed by the ARNP and include the name of the physician and ARNP. ARNPs are eligible to apply for DEA numbers and permitted to receive drug samples, if the drug is within their protocol.

Kentucky

http://kbn.ky.gov

Legal Authority

State law licenses ARNPs, including NPs, CNSs, CNMs, and CRNAs. ARNPs must maintain RN licensure and be registered as ARNPs. ARNPs must practice in accordance with the scope and SOP of the national certifying organization as adopted by the BON. ARNPs shall seek consultation or referral in situations outside their SOP. ARNPs may sign high school athletic physical examination forms.

Reimbursement

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

Prescriptive Authority

ARNPs may prescribe nonscheduled legend drugs pursuant to a collaborative practice agreement (CPA) that defines ARNP scope of prescribing authority and is signed by the ARNP and physician. CRNAs do not need CPAs to deliver anesthesia care. The BON has defined "collaboration" and "CPA," and specific information that must be contained in the CPA (e.g., ARNP and collaborating physician's name, practice address, and area of practice). The ARNP alone signs his/her name to the Rx pad when prescribing. ARNPs must complete 5 contact hours in pharmacology (every 2 years for relicensure) as part of their CE requirement. ARNPs may receive drug samples (noncontrolled legend medications only) and may dispense drug samples to patients at no charge. Dispensing is applicable to ARNPs working in health departments: ARNPs may dispense with a written agreement with a local pharmacist.

Louisiana

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

Legal Authority

APRNs are licensed by the BON and include NPs, CNMs, CRNAs, RNAs, and CNSs. APRNs must be certified by a national certifying body recognized by the board or meet "commensurate requirements" if certification is not available. APRNs must also be licensed as an RN and possess a master's degree or higher. APRNs' SOP is limited to their BON-recognized category and area of specialization. The APRN SOP includes "certain acts of medical diagnosis or medical prescriptions of a therapeutic or corrective nature, prescribing assessment studies, legend and certain controlled drugs, therapeutic regimens, medical devices and appliances, receiving and distributing a therapeutic regimen of prepackaged drugs prepared and labeled by a pharmacist and free samples supplied by a drug manufacturer." In 2003, Act 1094 passed, which removed the phrase "under the direction of a licensed physician or dentist." APRNs perform certain acts of medical diagnosis in accordance with a 'collaborative practice agreement' (a formal written statement addressing the parameters of the collaborative practice which are mutually agreed upon by the APRN and one or more physicians or dentists including consultation or referral availability, clinical practice guidelines, and patient coverage). The BON determined that CPT codes 32000, 31515, and 32020 can be within the APRN's SOP and that CPT codes 33210, 31515, and 93503 are not within the APRN's SOP.

Reimbursement

General mandatory reimbursement for APRNs does not exist. Medicaid managed care is required to reimburse APRNs at a rate equal to that of physicians performing the same service.

Prescriptive Authority

Limited Rx and dispensing authority is permitted for approved NPs, CNSs, and CNMs in collaborative practice with physicians. Act 1094 removed the regulation of Rx authority for APRNs from a Joint Administrative Committee (which included the BON and BOME). The BON now has sole authority to develop, adapt and revise R&R governing SOP including Rx authority, the receipt and distribution of sample and prepackaged drugs, and Rx of legend and certain controlled drugs. The BON hopes to promulgate new R&R by Spring 2004. Under the previous rules: The applicant for Rx authority must provide evidence of a collaborative practice agreement with a licensed physician or physician group and include a plan of accountability to include clinical practice guidelines, availability of collaborating physician, and patient care coverage plans with documented review of the guidelines with the on-call physician. The Rx R&R limit one physician with no more than two APRNs and require, with some site exceptions, that the physician visit the APRN practice site at least weekly. An APRN who is granted limited Rx authority may request approval to prescribe and distribute controlled substances as authorized by the APRN's collaborating physician if the patient population served by the collaborative practice has an identified need. Rx on distributed controlled substances (Schedules III-V) must be consistent with the practice specialty of the collaborating physician and the APRN's licensed category and area of specialization. The BON approved certain Schedule II drugs to treat ADHD. An APRN granted authority to prescribe or distribute controlled substances may not prescribe controlled substances to treat chronic or intractable pain or obesity or oneself or family.

Maine

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

Legal Authority

APRN regulation is under the BON. APRNs include CNMs, CNPs, CNSs, and CRNAs approved by the BON. The APRN SOP includes national standards of the national certifying body and "consultation with or referral to medical and other health care providers when required by client health care needs. A CNP who qualifies as an APRN must practice for at least 24 months under the supervision of a licensed physician or must be employed by a clinic or hospital that has a medical director who is a licensed physician. The CNP must submit written evidence to the BON upon completion of the required clinical experience." After this 24-month period, the CNP can practice independently. CNSs practice independently. CRNAs are responsible and accountable to a physician or dentist. CNPs and certified psychiatric CNSs may sign documents for emergency involuntary commitment through emergency departments. There is no statutory requirement promoting or inhibiting the inclusion of APRNs on hospital medical staffs. Workers' compensation forms recognize CNPs and allow issuance of license plates and cards for the physically disabled.

Reimbursement

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

Prescriptive Authority

A CNP or CNM who qualifies as an APRN may prescribe and dispense drugs or devices in accordance with rules adopted by the BON; approved CNPs and CNMs receive their own DEA numbers. BON rules require CNPs and CNMs to have a pharmacology course and prescribe from FDA-approved drugs related to the nurse's specialty. CNPs and CNMs may prescribe Schedule II controlled substances and drugs off-label, according to common and established standards of practice. Dependency on other professionals for APRN prescriptive authority does not exist. APRNs may receive and distribute drug samples included in the formulary for Rx writing.

Maryland

http://www.mbon.org

Legal Authority

APNs include NPs, CRNAs, CRNMs, and APRNs/PMHNs (PMH; psychiatric mental health). NPs are certified to practice through the BON; requirements include passing a national certification examination and submitting a written agreement with a collaborating physician (the agreement is approved by an equally represented physician and NP joint committee). Once the agreement is approved, NPs may perform the functions of the agreement independently. CRNMs are certified to practice through the BON; requirements include passing a national certification examination and submitting a written agreement with a backup physician. CRNAs are certified to practice through the BON; requirements include passing a national certification examination and submitting a collaborative agreement with an anesthesiologist, physician, or dentist. APRNs/PMHNs are certified to practice through the BON; requirements include a master's degree or higher and national certification as a CS in psychiatric/mental health nursing. APRNs/PMHNs practice independently, make mental health diagnoses, and provide psychotherapy.

Reimbursement

All nurses are entitled to private third-party and Medicaid reimbursement for services if they are practicing within their legal SOP. All Medicaid recipients have been assigned to a managed care organization; CRNPs (with the exception of neonatal and acute care) and CRNMs have been designated as PCPs and may apply to be placed on a provider panel. Medicaid reimburses at 100% of physician payment. Legislation allows due process for APNs listed on managed care panels; APNs are not to be arbitrarily denied. In 2003, Senate Bill 687 took effect. The bill requires an HMO to permit an enrollee to select a certified NP as the enrollee's PCP if (1) the NP provides services at the same location as the NP's collaborating MD and (2) the collaborating MD provides the continuing medical management required. The bill does not require that an HMO include NPs on the HMO panel as PCPs. The state NP association signed an agreement letter with the state medical society that neither will bring this issue back to the legislature for 5 years.

Prescriptive Authority

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

Massachusetts

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

Legal Authority

RNs who apply for BON authorization in advanced nursing practice (NPs, NAs, psychiatric CNSs, and CNMs) must have satisfactory completion of a formal education program that has been approved by a national professional nurses accrediting body that the BON recognizes and which has as its objective the preparation of nurses to perform as an NP, CNS, NM, or NA. Advanced practice R&R governing the ordering of tests, therapeutics, and prescribing are promulgated by the BON in conjunction with the BOM. All other areas of SOP are exclusively under the BON. All APNs shall practice in accordance with written guidelines developed in collaboration with the nurse and physician. In all cases, the written guidelines shall "designate a physician who shall provide medical direction as is customarily accepted in the specialty area." If practicing in an institution, the nursing and medical administrative staff must approve the guidelines. If there is no nursing and medical administrative staff, the guidelines must be approved by the BON. Credentialing for hospital privileges varies according to hospital policies.

Reimbursement

Psychiatric CNSs, midwives, CRNAs, and NPs are reimbursed according to state law. This law only includes indemnity plans, not HMOs and other managed care arrangements. BC/BS credentials NPs in private practice settings to receive individual NP provider numbers. An HMO protection bill allows "other providers" to be listed on panels; however, the law does not specifically address APNs or require them to be listed as providers. FNPs, PNPs, and ANPs are reimbursed at 100% of physician payment for Medicaid unless the NP is employed by the hospital in a hospital-based practice.

Prescriptive Authority

NPs, CNMs, and psychiatric CNSs have Rx authority for Schedules II-VI controlled substances. Authorized APNs must apply to the state Department of Public Health for a state DEA number; they then apply for a federal DEA number. Authorized APNs have (1) prescribing guidelines mutually developed and agreed on by the nurse, employer, and supervising physician; guidelines need not be submitted to the BON unless requested (the guidelines pertaining to Rx practice shall include a defined mechanism to monitor prescribing practices, including review with a supervising physician every 3 months); and (2) proof of 24 hours of pharmacology content. The Rx pad has the name of supervising physician; the authorized APN signs the Rx.

Michigan

http://www.michigan.gov/cis

Legal Authority

The Michigan BON grants "specialty certification" to CNMs, CRNAs, and NPs. CNSs may qualify for certification as NPs. Nurses with specialty certification are not required to have physician collaboration or supervision, except for Rx authority.

Reimbursement

Medicaid directly reimburses all certified NPs at 100% of the reimbursement rate. BC/BS directly reimburses all NPs, CNMs, and CRNAs.

Prescriptive Authority

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

Minnesota

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

Legal Authority

APRN is defined as an RN certified by a national nurse certification organization acceptable by the BON to practice as a CNP, CNS, CNM, or CRNA. The BON maintains a registry of all certified APRNs. Collaborative management is defined as a mutually agreed on plan between an APRN and physician(s) that designates the scope of collaboration necessary to manage the care of patients in which the APRN and physician(s) have experience in providing care to patients with the same or similar medical problems. CNPs, CNSs, and CRNAs must practice within the context of collaborative management. CNMs must practice within a system that provides for consultation, collaborative management, and referral. In 2003, APNs gained authority to sign for Department of Transportation handicap permits and the authority to sign for certain mental health commitment holds.

Reimbursement

NPs, CNMs, CRNAs, and CNSs in psychiatric health have legislative authority for private insurance reimbursement. APRNs can 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. It is unlawful for an HMO or private insurer to require a physician cosignature when an APN orders a laboratory test, X-ray, or diagnostic test.

Prescriptive Authority

APRNs who meet statutory requirements may prescribe, receive, dispense, and administer drugs (including controlled substances and the authority to receive and dispense sample drugs) within their authorized SOP. The BON does not grant Rx authority but disciplines the APRN if the prescribing practices are unsafe, unethical, or illegal. CNPs, CRNAs, and CNSs must have a written agreement with a physician that defines the delegated responsibilities related to prescribing of drugs and devices. CNMs have independent Rx authority. An authorized APRN who wants to prescribe controlled substances must apply to the DEA and verify compliance with Minnesota prescribing laws with the BON.

Mississippi

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

Legal Authority

NPs, CRNAs, and CNMs are certified by the BON. The R&R are jointly promulgated by the BON and BOM and implemented by the BON. To become certified, the RN must successfully complete an appropriate NP program, be nationally certified as an NP, and submit practice documentation of a collaborative, consultative relationship with a physician whose practice is compatible with the NP. NPs must practice according to a BON-approved protocol agreed on by the NP and physician. CRNAs may also collaborate/consult with licensed dentists. NP applicants must submit official evidence of graduation from a graduate program with a concentration in the applicant's APN specialty. Practicing in a site not approved by the BON, with a physician not approved by the BON, or according to a protocol not approved by the BON is in violation of the NPA R&R. BON R&R provide title protection for CNSs. NPs can sign for disability verification, disability license plates, testing of minors for sexually transmitted infections without parental consent, and proof of immunization for Medicaid. NPs can perform the assessment and attest to the health of a child for adoption. Prior to 1995, the BOM ruled that if an NP treats patients in a "freestanding clinic" (more than 15 miles from the supervising physician), the physician must obtain BOM approval to collaborate with the NP. Legislation of 1995 provides that any action taken to prohibit NPs from practicing to the full extent of their SOP is prohibited, that "any R&R that impact the practice of NPs shall hereafter be jointly promulgated by the BON and BOM."

Reimbursement

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

Prescriptive Authority

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

Missouri

http://www.ecodev.state.mo.us/pr/nursing

Legal Authority

Statutory definition of APN in the NPA includes NPs, CNSs, NMs, and RNAs. Pursuant to the BON's application process, a "Document of Recognition" may be granted by the BON if the APN rule requirements are met. Individuals are recognized by their specific clinical nursing specialty area as a CNS, NP, NM, or RNA, which delineates their title and SOP as APNs. When practicing outside their recognized clinical nursing specialty, individuals must practice and title as RNs only. Continuing recognition as APNs is accomplished through ongoing compliance with APN rule requirements. Additional legislation permits collaborative practice arrangements between RNs recognized as APNs and physicians using written agreements, written protocols, or written standing orders. Joint BON and Board of Healing Arts rulemaking activity, with BOP input, culminated in a Collaborative Practice (CP) rule. Three focus areas in the CP rule are (1) geographic areas to be covered, (2) methods of treatment that may be covered by CP arrangements, and (3) requirements for review of services provided pursuant to a CP arrangement. A written CP arrangement with a physician is not needed when the APN is performing nursing acts consistent with the APNs skill, training, education, and competence. A CP arrangement may be indicated to perform physician-delegated medical acts within the mutual SOP of the physician and APN and consistent with the APN's skill, training, education, and competence. In the 2003 legislative session, an Anesthesiologist Assistant bill was passed that exempts CRNAs from the collaborative practice requirements and allows CRNAs to practice under the direction of the surgeon or anesthesiologist.

Reimbursement

Legislation states "Any health insurer, nonprofit health service plan, or health maintenance organization shall reimburse a claim for services provided by an APN, if such services are within the scope of practice of such nurse." Medicaid reimbursement is made to APNs enrolled as Missouri Medicaid fee-for-service providers and Medicaid-enrolled APNs associated with a federally qualified health care and/or rural health care facility. Medicaid reimbursement is limited to services furnished by enrolled APNs who are within the SOP allowed by federal and state laws and regulations, and for inpatient or outpatient hospital services or clinic services, are furnished to the extent permitted by the facility. Reimbursement for services provided by APNs is at the same rate and subject to the same limitations as physicians.

Prescriptive Authority

BON-recognized APNs may be delegated administering, dispensing, prescribing, or other medical methods of treatment authorities by a physician pursuant to a written CP arrangement. Delivery of such APN health care services shall be within the APN's advanced clinical nursing specialty area and a mutual SOP with the physician and be consistent with the individual's skill, training, education, and competence. APNs may receive/dispense samples within their Rx authority. Delegated Rx authority does not include controlled substances; therefore, a DEA number is not available. In certain instances, a state BNDD number is required.

Montana

http://www.discoveringmontana.com/dli/bsd/license/hc_licensing_boards.htm

Legal Authority

APRNs, including NPs, CNSs, CNMs, and CRNAs, are recognized and allowed by the BON to practice independently after completion of specific curriculum requirements and a national certifying examination by a BON-recognized national certifying body. APRN new graduate applicants must have a master's degree and national certification. Hospital privileges vary according to the rules and bylaws of each hospital. APRNs may sign death certificates. A 2003 legislative act provided for attending APRNs to be recognized as health care providers with the authority to follow 'a living will' protocol and a 'do not resuscitate' protocol; prior to this act only physicians had this authority.

Reimbursement

BON-approved APRNs have third-party reimbursement for all areas and services for which a policy would reimburse a physician. As HMOs are not included in the indemnity insurers law, mandatory coverage for APRNs does not apply to HMOs. APRNs receive 85% of the physician payment from BC/BS. Medicaid has reimbursed at 85% of physician payment since 1986. Medicare reimbursement consistent with 1990 federal guidelines is in effect. APRNs are included as providers for workers' compensation.

Prescriptive Authority

APRNs who desire Rx authority apply to the Prescriptive Authority Committee. In 2001, BON and BOME R&R removed the BOME and BOP members of this committee; the committee now contains only BON members. CNSs (except psychiatric specialty) are not eligible for Rx authority. APRNs with Rx authority can prescribe all medications, including Schedules II-V controlled substances, using their own DEA number. Authority to prescribe is not dependent on any other health professional. Prescribing APRNs must have a quality-assurance program in place, with a defined process of referral. The quality assurance method must be BON-approved prior to issuance of Rx authority. The quality assurance method must include 15 charts or 5% of all APN charts, reviewed quarterly. Review includes review by either an APRN or physician of the same specialty. New APRN applicants must complete 15 hours of CE pharmacology (in addition to their master's degree program) before application. CE is required for renewal every 2 years. APRNs can receive and dispense drug samples.

Nebraska

http://www.hhs.state.ne.us/index.htm

Legal Authority

APNs are licensed as APRNs by the APRN Board, or certified as CRNAs or CNMs by the BON and BOM. The Board of APRNs consists of five APRNs, five MDs, three consumers, and one pharmacist. The CNS is not a legally expanded role, but there is title protection in the statute. APRN scope is statute defined and includes illness prevention and diagnosis and treatment and management of common health problems and chronic conditions. APRNs must maintain liability insurance ($200,000 per incident and $600,000 aggregate per year) and maintain an integrated practice agreement (IPA) with a collaborating physician. APRNs and physicians shall practice collaboratively and have joint responsibility for patient care, based on the SOP of each practitioner. The IPA specifies that "the collaborating physician shall be responsible for supervision through ready availability for consultation and direction of the activities of the APRN." If, after diligent effort, an APRN is unable to obtain an IPA with a physician, the APRN Board may waive the requirement for an IPA if the APRN has demonstrated proper course work, has a master's degree or higher in nursing, has completed 2,000 hours under the supervision of a physician, and will practice in a geographic area where there is a shortage of health care services. APRNs without a master's or doctoral degree, and/or at least 2,000 hours of physician-supervised practice must also have jointly approved protocols. APRNs licensed after 1996 must have a master's or doctoral degree to practice, except for women's health and neonatal. CRNAs must practice with consultation, collaboration, and the consent of a physician. CNMs must have a practice agreement jointly approved by the BON and BOM that delineates delegated medical duties; CNMs function under protocols.

Reimbursement

State legislation mandating third-party reimbursement for APNs does not exist; consequently, some APNs have been refused recognition as a provider. Medicaid reimburses ARNPs at 100% of physician payment.

Prescriptive Authority

Rx authority for APRNs is in the ARNP statute, defining the APRN SOP as "prescribing therapeutic measures and medications" and "dispensing incident to practice only sample medications." Schedule II is limited to 72 hours and pain control only. CRNAs prescribe within their specialty practice; authority is implied in the statute. Qualified CRNAs and APRNs receive DEA numbers. CNMs may not obtain DEA numbers, as their authority to prescribe is dependent, based on the practice agreement.

Nevada

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

Legal Authority

APN is a protected title recognized by the BON (title includes NPs, CNMs, and nurse psychotherapists with a master's degree). The BON may grant a certificate of recognition as an APN to appropriately qualified RNs; the BON-recognized APN may "perform designated acts of medical diagnosis, prescribe therapeutic or corrective measures, and prescribe controlled substances, poisons, dangerous drugs and devices." An applicant for an APN certificate of recognition must have completed a BON-approved program and present evidence to the BON of continuous AP practice of 400 hours per year in 3 of the 5 years prior to the application or present evidence that the applicant will complete 1,000 hours of practice (without Rx writing) under the supervision of a physician or certified APN. Applicants completing an APN program after 2005 must be master's prepared. Applicants must present a signed letter of agreement with a collaborating physician (licensed in Nevada) to the BON. The APN must keep written protocols at every job site, together with a collaborative agreement signed by a physician. The BOME has changed a regulation, "supervision of APNs," to "collaboration of APNs" (BOME input); The BOME regulation, applicable to physicians, includes a provision that makes the physician apply for approval status and limits the number of APNs with whom any one physician can collaborate. The BON audits 5% of APN practices each year. The BON R&R certify CNSs who meet educational requirement as APNs. CRNAs and CNSs function independently but may not prescribe. CRNAs are not considered APNs and do not have a collaborative practice agreement. CRNAs must have a BSN; after 2005, they must have a master's degree.

Reimbursement

APNs and CRNAs receive third-party reimbursement. Hospital privileges are available to qualified APNs. Reimbursement from private insurance is at the same rate as the physician payment. Medicaid reimbursement is available to all APNs at 85% of physician payment.

Prescriptive Authority

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

New Hampshire

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

Legal Authority

NPs, NMs, NAs, and psychiatric mental health CSs are licensed by the BON as ARNPs. ARNP applicants must provide (1) an official transcript of an approved educational program (including more than 225 hours of theoretical nursing content, more than 480 hours of clinical nursing practice with a precepted experience, and a formal pharmacology course or documentation from the program director that pharmacologic interventions have been integrated into the curriculum); (2) national certification in the requested category; and (3) 30 contact hours of CE in a specialty area within 2 years prior to application. ARNPs do not require physician collaboration or supervision. ARNPs and other licensed nurses may delegate patient care tasks (within their SOP) to licensed and unlicensed personnel, such as EMTs, PAs, medical assistants, and technicians. Psychiatric mental health NPs employed by the Department of Corrections are indemnified and defended under the same conditions as psychiatrists. Occupational therapists can accept referrals from ARNPs.

Reimbursement

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

Prescriptive Authority

BON-licensed ARNPs have plenary authority to prescribe controlled and noncontrolled drugs from the official exclusionary formulary determined by the Joint Health Council whose membership consists of three ARNPs appointed from the BON, three physicians appointed by the BOM who work with ARNPs, and three pharmacists appointed by the BOP. ARNPs are assigned a DEA number on request and after licensure as an ARNP. ARNPs also have dispensing authority.

New Jersey

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

Legal Authority

NPs and CNSs must be BON-certified as advanced practice nurses. APNs sign their credentialing title as RN, APN,C. NP and CNS applicants must be master's prepared in the appropriate specialty and have completed a graduate-level credit course in pharmacology. Each certification applicant must pass the highest level practice examination in their specialization approved by the Board. The following categories of NPs or CNSs may be certified: adult health, family, pediatric, school, gerontologic, women's health; OB/GYN, neonatal; psychiatric/mental health, community health, perinatal; maternal/child, oncology, critical care, emergency burns/trauma, medical/surgical, and rehabilitation. Other categories may be approved by the Board through the rule making process. A master's degree is required for family planning NPs. CNMs are regulated by the BME and have a separate authority to prescribe under the BME. CRNAs do not have legislative recognition. CRNAs have petitioned the BON for rule making to be recognized as APNs; the BON is in the process of drafting the regulations. Statutory requirements for hospital privileges do not exist; however, most hospitals have a bylaw provision credentialing APNs. The Department of Health and Senior Services (DHSS) has adopted changes to hospital regulations to allow APNs to perform the admitting history and physical examination, order consultations by other providers, and discharge patients from the emergency department without requiring physician cosignatures or assessments, unless the condition is emergent. DHSS has also reformed long-term-care regulations to include APNs: "APNs are permitted to assume many responsibilities that were previously required to be performed only by physicians." The School Health Law (except regarding drug and alcohol abuse) and the long-term-care institution regulations regarding Advanced Directives have added "APN" throughout the regulations where only "physician" had been. New 2003 regulations through DHS allow APNs to sign certifying an inability to work in the Work First N.J.-Welfare to Work program and to initiate DNR orders in residents for Developmentally Disabled or Mentally Ill funded by Medicaid. A new 2003 law allows patients to self-refer in all cases to a physical therapist (except when seeking care under worker's compensation for auto-accident related injuries); previously patients had to be referred by a physician.

Reimbursement

Private health plans, including Medicaid-managed care plans, are permitted to use APNs as PCPs but are not required to recognize or reimburse an APN. In the past year, an increasing number of HMOs/insurers began credentialing/empaneling and directly reimbursing APNs. Medicaid fee-for-service reimburses APNs at approximately 85% of the physician rate, but the rate may vary according to procedure and setting. BC/BS must reimburse APNs directly if the reimbursed service can be performed within the APN's SOP and the APN is not an employee of a physician or an institution. The state health benefits plan covering all public employees directly pays some APNs.

Prescriptive Authority

Authorized APNs may prescribe and order noncontrolled substances. APNs may prescribe for Schedules II-V controlled substances, in both inpatient and outpatient settings, but only in the following circumstances: to continue, adjust, or reissue an order or prescription for a controlled dangerous substance originally prescribed by the collaborating physician, provided there is prior consultation with the collaborating physician or a physician designated by the collaborating physician; or for a patient in an end-of-life situation or as part of a treatment plan for a patient with terminal illness (when life expectancy is predicted as 12 months or less). APNs must apply for a state-controlled dangerous substances number and a DEA number to prescribe controlled substances. APNs prescribe and order medications using jointly developed protocols. The Division of Consumer Affairs (DCA), which oversees the BON and the BME, has established regulations that establish standards for the joint protocol between nurses and collaborating physicians. "Collaboration" is the ongoing process by which an APN and a physician engage in practice, consistent with agreed upon parameters of their respective practices. "Joint protocol" is an agreement or contract between an APN and a collaborating physician that conforms to the standards established by the DCA. The joint protocol shall be (1) signed by the APN and the physician; (2) maintained on the premises of every office in which the APN practices; (3) updated and reviewed at least annually to reflect changes in the practice, skills of the APN, and reference materials containing practice guidelines or accepted standards of practice. The content of a joint protocol shall address (1) the nature of the practice, the patient population, and settings; (2) the record keeping methodology used in the practice; (3) a list of categories of medications appropriate to the practice; (4) specific requirements with respect to the record of medications prescribed or dispensed, dosages, frequency, duration, instructions for use, and authorizations for refills; (5) any medical conditions or findings within the nature of the practice that require direct consultation prior to the prescribing or ordering of medications or devices; (6) identification of the means of communication between the APN and the collaborating physician can be in direct communication; and (7) identification of reference materials containing practice guidelines or accepted standards of practice. APNs can receive and dispense drug samples. Cosignatures are not required for APN documentation, order, or prescription for controlled and noncontrolled medications. S1711, a bill introduced in 2003, seeks authority for APNs to initiate CS Rx without restriction (not just in end-of-life situations).

New Mexico

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

Legal Authority

The NPA defines CNP as a PCP who can practice independently without physician supervision or collaboration requirements. BON-approved CNPs receive a CNP designation on their RN license; there is no certification designation of the specialty. The CNP must have completed a graduate program for the education and preparation of NPs. The BON also regulates CRNAs and CNSs. CRNAs seeking initial licensure must be at the master's level or higher. CRNAs work in collaboration with a physician and have Rx authority including Schedules II-V CS. CNSs must be master's prepared and certified by a national certifying nursing organization. CNSs "make independent decisions"; have "prescriptive authority," including Schedules II-V controlled substances; and can distribute prepackaged drugs. CNMs are regulated by the Department of Health. CNPs can serve as "acute, chronic, long-term, and end-of-life health care providers."

Reimbursement

Statutory authority for third-party reimbursement for NPs and CNSs has been in effect since 1987, but CNPs continue to meet resistance in being listed as PCPs. FNPs and PNPs receive Medicaid reimbursement at 90% of physician payment. All three of the managed care groups contracted to provide Medicaid coverage have contracts with NPs.

Prescriptive Authority

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

New York

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

Legal Authority

NPs are licensed as RNs and certified by the State Education Department as NPs. NPs are considered independent practitioners and are authorized to diagnose, treat, and prescribe in collaboration with a physician in accordance with a written practice agreement and written practice protocols. The written agreement must include a provision for dispute resolution between the NP and the physician and provisions for a review by the collaborating physician of a patient records sample at least every 3 months. Cosignatures are not required. NPs may: (1) prescribe home health aid and personal care services, legally function; (2) function as school district medical inspectors; (3) certify that cosmetology and nail applicants are free from disease; and (4) sign for physical examinations for bus drivers. A 2003 law amended the education law stating that respiratory therapy services may be Rx by an NP. Midwives are separately licensed to manage normal pregnancies, childbirth and postpartum care, newborn evaluations, and primary preventive reproductive care and prescribe in collaboration (with practice agreements and protocols) with a physician. Although certified midwives may continue to use the title "nurse midwife," individuals do not have to be licensed as a nurse to be licensed as a "midwife."

Reimbursement

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

Prescriptive Authority

The law authorized and the state attorney general endorsed Rx of drugs (Schedules II-V), devices, and immunizing agents without restriction. The DEA has granted individual numbers to NPs since the attorney general interpretation. NPs may order drugs, devices, immunizing agents, tests, and procedures in accordance with the practice agreement and practice protocols without cosignature. NPs can receive and dispense pharmaceutical samples if appropriately labeled and handed directly to the patient. Midwives are authorized to prescribe and administer drugs, immunizing agents, diagnostic tests, and devices, and order laboratory tests limited to the practice of midwifery; they can dispense pharmaceutical samples.

North Carolina

http://www.ncbon.org

Legal Authority

NPs apply to a joint subcommittee of the BON and North Carolina Medical Board to obtain practice approval. New NPs must have a master's degree. NPs may own their practice as long as they contract with a physician. NPs must have a collaborative written practice agreement with a physician for continuous availability and ongoing supervision, consultation, collaboration, referral, and evaluation and a documented face-to-face consultation every 6 months. NP SOP can include those medical acts for which NPs can document training and that are included in the site protocols approved by the NP and physician. The supervising physician does not have to be on site. The NP shall be prepared to demonstrate to the BON or BOM the ability to perform medical acts as outlined in the site-specific written protocols. CRNAs are regulated solely by the BON and do not have Rx authority. CNMs have their own separate statute and are regulated by a midwifery joint committee. CNS recognition and SOP is regulated by the BON, but does not include Rx authority. CNSs with master's degrees in psychology/mental health may independently practice psychotherapy. All APRNs are allowed to form corporations with physicians; however, CRNAs can only incorporate with anesthesiologists.

Reimbursement

NPs receive Medicaid reimbursement at 100% of the physician rate. CHAMPUS also reimburses NPs. Statutory authority for third-party reimbursement for NPs provides direct reimbursement to NPs for services within their scope that are reimbursable to a nonnurse provider. 2001 legislation covers access to medical advice and care by providing continuity of care, referrals to specialists, selection of specialists as PCPs, direct access to health care providers, and many other liability and risk management provisions that are beneficial to the consumer. In the section "No Discrimination in the Selection of Providers," patients may choose services from a provider list that includes APRNs. The section "Provider Directory Information" requires that every health benefit plan use a provider network directory that includes all types of participating providers, including APRNs, upon participating providers' written request.

Prescriptive Authority

NPs and CNMs may prescribe any drugs and devices, including controlled substances, that are identified in their site-specific written protocols. NPs are also authorized to compound, dispense, and procure drugs. NPs may refill legend drugs up to 1 year and may write controlled substance prescriptions for 30 days; NPs may not refill any controlled substances. The protocols must be signed by the NP and all supervising physicians for that practice site and be maintained on site. A DEA number must be obtained. NPs with controlled substances in their protocols must obtain a DEA number (in addition to their prescribing number issued at the time of their approval as NPs).

North Dakota

http://www.ndbon.org

Legal Authority

APRNs (NPs, CNSs, nurse clinicians, NMs, and NAs) are regulated by the BON after demonstrated advanced education and certification. APRN applicants for initial licensure must have a master's degree with a nursing focus. APRNs must maintain national certification and submit a SOP statement for review by the BON to renew their APRN license. The BON must be notified of an SOP change or change or addition to practice location.

Reimbursement

A third-party reimbursement law gives benefits for health services provided in the scope of licensure by nurses with advanced licensure and mental health in their SOP. FNPs, CNMs, and PNPs receive Medicaid reimbursement at 75% and CNMs at 85% of physician payment. BC/BS reimburses CRNAs, CNMs, CNSs, and NPs at 75% of allowable charges.

Prescriptive Authority

Authorized APRNs may prescribe controlled and noncontrolled drugs. Rx practice is defined in the NPA as assessing the need for drugs, immunizing agents, or devices and writing a Rx to be filled by a licensed pharmacist. For Rx authority, the APRN must submit a statement to the BON addressing methods and frequency of the collaboration for Rx practices, which must occur as client needs dictate but no less than once every 2 months;[middle dot]documentation methods of the collaboration process regarding Rx practices; and alternative arrangements for collaboration regarding Rx practices in the absence of the physician. Communication between the APRN and physician must occur at least once every 2 months. An affidavit from the physician must be submitted, acknowledging the manner of review and approval of the planned Rx practices and that the APRN's SOP is "appropriately related" to the collaborating physician's specialty. The collaborative agreement requirement is solely for Rx authority. APRNs with Rx authority may apply for a DEA number.

Ohio

http://www.state.oh.us/nur/

Legal Authority

Legislation of 1996 recognizes four groups of nurses in advanced practice roles (CNP, CRNA, CNM, and CNS) and provides for collaborative arrangements between backup physicians and these four groups of nurses. CNPs, CNMs, and CNSs (except psych/mental health CNSs) must develop a standard care arrangement (practice agreement) with the collaborating physician. CRNAs practice with a supervising physician. All new applicants for licensure must have a master's degree in nursing or a related field. Certification from a national certifying body is required. CNSs and NPs were included in 1998 legislation concerning do-not-resuscitate orders. As of 2003, the term 'APN' refers to advanced practice nurses within Ohio's advanced practice pilot programs. CNPs, CNSs, CNMs, and CRNAs who are not part of the pilot program are accurately referred to as 'nurses in advanced practice roles' (NAPR) or 'certificate of authority holders.' Legislation regarding 'APNs' is slated to expire in January 2004; new 2004 legislation will likely be introduced defining 'APN' as a CNP, CNS, CRNA, or CNM who holds a certificate of authority.

Reimbursement

As of June 2002, the state Medicaid administration recognizes FNPs, ANPs, ACCNPs, GNPs, NNPs, PNPs, WHNPs, OB/GYN NPs, CNMs, CRNAs, and certified clinical nurse specialists (CCNS) in gerontologic, medical/surgical, and oncology specialty areas. New Medicaid providers must have master's degrees after January 1, 2003. Managed care organizations vary on empanelment. There are no legislative restrictions for 'NAPR' being listed on managed care panels. Workers' compensation continues to reimburse CRNAs, CNPs, and CNSs.

Prescriptive Authority

Legislation grants Rx authority to qualified CNPs, CNMs, and CNSs. A master's degree is required for an Rx license. Rx authority is voluntary and is a separate approval process from the certificate to practice. Applicants must have current RN and 'NAPR' licensure, a standard care arrangement with their collaborating physician, and an acceptable course in pharmacology completed within the past 3 years. 'NAPR' prescribe under their own authority as soon as the certificate is received. The first certificate is an "externship" certificate to prescribe (CTP-E). During the 1,500-hour externship, the 'NAPR' prescribes under the supervision of a collaborating physician. The externship must have 500 hours direct supervision, meaning the physician must be available on site; the remaining hours consist of indirect supervision (the physician must provide timely reviews of prescriptions and prescribing practices). APNs who prescribe in another state and are moving to Ohio may receive credit for up to 1,000 hours of indirect supervision for prior prescribing within the past 3 years. Upon externship completion, the 'NAPR' applies for the CTP. At this stage, the 'NAPR' prescribes within the collaborative arrangement, unsupervised. Compliance with further quality assurance measures is also required. By law, the interdisciplinary Committee on Prescriptive Governance develops and revises the formulary. The committee is comprised of four nurses in advanced practice roles, four physicians, and two pharmacists. Schedules II-V controlled substances are included on the formulary. Schedule II drugs are limited to the care of terminally ill patients after physician-initiation and only for a 24-hour period. The formulary lists (1) prescribable drugs, (2) drugs excluded from use, (3) physician-initiated drugs that can be renewed or adjusted, and (4) drugs with special parameters. 'NAPR' cannot prescribe newly released drugs until the committee has reviewed them, and those who wish to prescribe drugs for off-label use must include parameters for off-label use in the standard care arrangement. The DEA issues numbers to CTP-E and CTP holders. Pharmacists log the prescription by nurse prescriber, not by physician. The BOP and BON agree that the nurse with Rx authority may request, receive, sign for, and distribute sample medications within their scope and within the formulary. According to the law, (1) no fee may be charged for a sample, (2) only a 72-hour supply (or smallest commercially available size) may be dispensed, and (3) samples of controlled substances may not be dispensed.

Oklahoma

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

Legal Authority

APNs (ARNPs, CNMs, CNSs, CRNAs) are defined in the NPA and regulated by the BON. APNs must complete a formal program of study approved by the BON and be nationally certified by an appropriate certifying body. The ARNP practices within the SOP as defined by the NPA. The SOP applies to identified specialty categories which further delineate the population served: adult, school nurse, family, geriatric, neonatal, pediatric, women's health care, and acute care. In 2003, two specialties were added: Adult Psychiatric and Mental Health and Family Psychiatric and Mental Health.

Reimbursement

Legislation addressing third-party reimbursement for NPs does not exist. After Rx authority legislation passed, the state Medicaid managed care HMO added NPs as primary care managers in rural areas only. A major insurance company in the state (Oklahoma State and Education Employees Insurance) added NPs as providers in 1997. Negotiation continues with other third-party insurers.

Prescriptive Authority

The BON regulates optional Rx authority for ARNPs, CNSs, and CNMs. Physician supervision is only required for the Rx authority portion of advanced practice. Prescribing parameters include that the Rx (1) not be on the exclusionary formulary approved by the Board, (2) must be within the ARNP, CNM, and CNS SOP, (3) include Schedules III-V controlled substances (7-day supply) if state narcotics and DEA registrations are obtained, and (4) include signing to receive drug samples. ARNPs, CNMs, and CNSs must have 45 contact hours or 3 academic hours of pharmacology in the 3 years immediately preceding the initial application for Rx authority and 15 contact hours or 1 academic hour every 2 years for renewal. CRNAs have authority to "order, select, obtain, and administer legend drugs, Schedules II-V controlled substances, devices, and medical gasses, when engaged in preanesthetic preparation and evaluation, anesthesia induction, maintenance and emergence, and postanesthesia care." Regulation is by the BON. The CRNA functions under the supervision of a physician, DO, or dentist licensed in Oklahoma, and under conditions in which timely on-site consultation by such physician, DO, or dentist is available. CRNAs must have a minimum of 15 CEUs for initial application for Rx authority, 8 CEUs for biennial renewal in advanced pharmacology related to administration of anesthesia within the 2 years immediately preceding the date of initial application and renewal, and evidence of professional liability insurance. CRNAs must obtain state narcotics and DEA registrations to order Schedules II-V controlled substances.

Oregon

http://www.osbn.state.or.us

Legal Authority

Authority for NP, CNS, and CRNA practice is granted through the NPA and regulated by the BON. The BON adopted administrative rules for CNS practice in 2001. Nurses in all three categories of advanced practice must be credentialed with a certificate by the BON. A master's degree is required for all categories of advanced practice. Permissive statutes allow for NP hospital privileges; NPs may be refused privileges only on the same basis as other providers. As of 2002, NPs can sign death certificates and admit patients for home health services not covered by Medicare. New (2003) legislation (to be enacted in 2004) will permit NPs to participate in worker's compensation claims.

Reimbursement

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

Prescriptive Authority

Regulation of Rx authority is under the sole authority of the BON. The BON determines the formulary from which NPs can prescribe Schedules II-V controlled substances. The NP formulary is based on Drug Facts & Comparisons; new drugs are added to the formulary at each BON meeting. Criteria for inclusion include (1) Is the drug appropriate for NP SOP? (2) Would the NP use the drug? and (3) Is the drug FDA approved? Oregon has legislated independent or plenary authority for NPs to prescribe, so NPs are able to obtain DEA numbers. NPs with prescription writing authority may receive and distribute prepackaged complimentary drug samples. A new law (2003) allows CNPs to apply to BON for emergency drug dispensing authority if the CNP's patients have financial or geographic barriers to pharmacy services. NPs do not have authority to prescribe under the physician-assisted suicide law. Only physicians can authorize medical marijuana use.

Pennsylvania

http://www.dos.state.pa.us/bpoa/nurbd/mainpage.htm

Legal Authority

CRNP regulation is under the sole authority of the BON. A CRNP performs the expanded role in collaboration with a physician (not a DO). Collaboration is defined as a process in which a CRNP works with one or more physicians to deliver health care services within the scope of the CRNP's expertise. The physician(s) may or may not be on site and collaboration is incorporated in the following ways (1) immediate availability through voice or direct communication, (2) a predetermined plan for emergency services, and (3) a regularly scheduled basis for consultation, chart review, and "establishing and updating standing orders, drug and other medical protocols," and "periodic updating in medical diagnosis and therapeutics." CRNPs must have a master's degree and pass a national qualifying examination; CRNPs without a master's degree/certification are accepted if their CRNP was granted prior to the law's effective date. CNSs are not specifically defined or regulated beyond the RN SOP. The BON does not track, monitor, or license CRNAs. The BOM licenses and regulates CNMs. The Pennsylvania Department of Health Regulations authorizes a hospital's governing body to grant and define the scope of clinical privileges to individuals, with advice of the medical staff. New (2003) legislation adds CRNPs to the list of prescribers in the state's elderly prescription program.

Reimbursement

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

Prescriptive Authority

The BON confers Rx privileges to CRNPs. Regulations allow a CRNP to prescribe and dispense drugs if the CRNP has successfully completed not less than 45 hours of course work specific to advanced pharmacology and if the prescribing and dispensing is relevant to the CRNP's area of practice, documented in a collaborative agreement, and not from a prohibited drug category. The CRNP may write a prescription for a Schedule II controlled substance for up to a 72-hour dose if the CRNP notifies the collaborating physician within 24 hours. The Rx pad must include the name and certification number of the CRNP and identify the collaborating physician. The collaborative agreement is a signed, written agreement between the CRNP and a collaborating physician and must identify the parties to the agreement (CRNP, collaborating physician, substitute physician); area of practice; specify the amount of professional liability insurance carried by the CRNP; specify the categories of drugs from which the CRNP may prescribe and dispense; specify conditions for prescribing a Schedule II controlled substance; contain attestation that the physician has knowledge and experience with the drugs that the CRNP will prescribe; and specify the circumstances and how often the collaborating physician will personally see the patient, be kept at the primary practice site, and be available for inspection. A physician may have a collaborative agreement with no more than four CRNPs (with a prescribing and dispensing agreement) at any one time; a limit does not exist regarding CRNPs who do not prescribe and dispense. A 2003 Department of Health policy interpretation authorizes CRNPs to provide services (including Rx in inpatient setting regulated by the Department) as long as the CRNP is under the supervision of a member of the medical staff.

Rhode Island

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

Legal Authority

APN practice is covered under the NPA. Effective January 1, 2004, Psychiatric and Mental Health Nurse Clinical Specialists (PCNSs) are licensed as APNs. APNs now include Certified Registered NPs (CRNP), CRNAs, and PCNSs. A joint-practice Advisory Committee (three physicians, three CRNPs, and one consumer) meets regularly to assess CRNP practice to improve patient care and to review applications and complaints. The committee reports to the BON. There are no requirements for physician collaboration (except for Rx authority). CNMs have a separate law and separate R&R that are not under the BON. BON R&R define CNSs.

Reimbursement

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

Prescriptive Authority

CRNPs can apply for Controlled Substance registration for privileges to Rx legend and Schedules II-V CS. Rx registration requires 30 hours of pharmacy CE within 3 years prior to application, Advisory Committee approval, and written collaborative guidelines with a physician. A six-member Formulary Committee recommends what the drug formulary contains. The CRNP and collaborating physician or medical director write their own practice guidelines (determining which drugs will be prescribed from the formulary); the practice guidelines are kept at the practice site and updated annually. The CRNP uses a Rx pad that has the site identified on the pad. Pharmacies have a list of all CRNPs with Rx privileges. Effective Jan. 1, 2004, PCNs may Rx certain legend medications, CS from Schedule II classified as stimulants, and CS from Schedule V that are described in regulations. PCNSs may Rx in accordance with annually updated guidelines, written in collaboration with the medical director or physician consultant of their individual establishments. To qualify for Rx privileges, the PCNS must show evidence of 30 hours of education in pharmacology of psychotropic drugs within three years of application; to maintain Rx privileges, the PCNS must obtain 30 hours CE in pharmacology of psychotropic drugs every six years. Draft guidelines "provide guidance to licensed health care facilities relating to the proper storage, security, and dispensing of medications." The guidelines, referenced from state statutes, state that licensed practitioners with authority to prescribe medications may procure and dispense (including drug samples) legend medications and Schedules II-IV controlled substances if the practitioner has obtained the required state and federal registrations.

South Carolina

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

Legal Authority

The NPA contains BON R&R for NPs, CNMs, and CNSs functioning in the extended role, and CRNAs. An NP, CNM, and CNS functioning in an extended role shall perform delegated medical acts pursuant to an approved written protocol between the nurse and physician. "Delegated medical acts" are additional acts delegated by the physician that include formulating a medical diagnosis and initiating, continuing, and modifying therapies, including prescribing drug therapy under approved written protocols. NPs who manage delegated medical aspects of care must have a supervising physician and operate within the "approved written protocols." Approved written protocols are specific statements developed collaboratively by the physician and the nurse that establish physician delegation for the medical aspects of care, including prescribing medications. The protocols must be reviewed and signed annually. When application is made for more than three NPs to practice in the extended role under one physician or when the NP is performing delegated medical acts in a practice site greater than 45 miles from the physician, the BON and BOM will determine if adequate supervision exists. For official recognition as an NP, CNM, or CNS functioning in the extended role, or CRNA, new applicants to the BON must provide evidence of certification and a master's degree in nursing. The BON conducts a random survey of the protocols, practitioner, and practice site. Proposed changes (Jan. 2004) to the NPA would BON license APRNs and authorize them to Rx (including Schedules III-V CS) within their specialty field and as authorized by the physician and listed in their approved written protocols.

Reimbursement

All NPs can apply for a Medicaid provider number; NPs are paid 80% of the physician payment rate. The state health and human services finance commissioner requires that NPs have current, accurate, and detailed treatment plans.

Prescriptive Authority

NPs, CNMs, and CNSs functioning in the extended role can prescribe. Prescriptions by NPs are limited to "drugs and devices utilized to treat common, well-defined medical problems within the specialty field of the NP as authorized by the physician and listed in the approved written protocols." NPs cannot prescribe Schedules II-IV controlled substances. NPs may prescribe Schedule V drugs. The BOP has opined that "The supervising physician is not the prescriber and the NP is not working under the physician's supervision. The NP prescribes independently of the supervising physician." NPs can obtain DEA numbers from the Department of Health and Environmental Control. The BON issues an identification number to the nurse authorized to prescribe. Prescriptions are signed by the NP with the BON-assigned Rx authority number; the physician's name and address must be preprinted on the form. As of 2001, the NP or CNS with Rx authority may request, receive, and sign for professional samples (except Schedules II-IV controlled substances) and may distribute to patients per approved written protocols.

South Dakota

http://www.state.sd.us/dcr/nursing

Legal Authority

CNPs and CNMs are regulated by a joint BON and BOM board. CNPs and CNMs must submit a collaborative agreement with a physician licensed in the state prior to performing the overlapping scope of advanced practice nursing and medical functions. On-site physician collaboration is required one-half day per week. CNSs are regulated by the BON. Physician supervision is not required. Prior to ordering durable medical equipment or therapeutic devices, CNSs must collaborate with a physician. CRNAs are regulated by the BON. CRNAs perform acts of anesthesia in collaboration with a physician licensed in the state as a member of a physician-directed health care team. On-site supervision is not required. APNs are granted hospital privileges.

Reimbursement

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

Prescriptive Authority

CNPs and CNMs may prescribe legend drugs and Schedules II-IV controlled substances as authorized by the collaborating physician agreement. CNPs and CNMs have two controlled substance registration options: (1) they may seek independent state registration and independent DEA registration in all schedules as authorized by their collaborative agreement; or (2) they may act as an agent of an institution, using the institution's registration number to prescribe, provide, or administer controlled substances. Controlled substance authority is granted by separate application to the Department of Health following collaborative agreement approval by the BON and BOM. CNPs and CNMs may request and receive drug samples, provide drug samples, and provide a limited supply of labeled medications. Medications and sample drugs must be accompanied by written administration instructions and documentation entered in the patient's medical record. The provision of drug samples or a limited supply of medications is not restricted, with the exception of Schedule II controlled substances, which are limited to a one-time, 48-hour supply. Therefore, the amount provided is at the professional discretion of the CNP or CNM and the collaborating physician. CNPs or CNMs who accept controlled substances, either trade packages or samples, must maintain a record of receipt and disposition. CRNAs and CNSs do not have Rx authority. CNSs may order and dispense durable medical equipment and therapeutic devices in collaboration with a physician.

Tennessee

http://www.tnaonline.org

Legal Authority

APNs practice under a broad NPA and a BON administrative rule that authorizes the expanded role. APNs have title protection as NPs, CRNAs, CNMs, and CNSs; new legislation (2003) mandates that APNs must apply to the BON for a certificate to practice as an APN. APNs who prescribe must have protocols that are jointly developed by the APN and the supervising physician. Medical board rules that govern the supervising physician of the APN Rx writer are jointly adopted by the BOME and BON. Physicians who supervise APN Rx practices are not required to be on site, but must personally review and sign 20% of the charts within 30 days. The BON has sole authority to establish the qualifications, competencies, training, education, and experience required to prescribe. APNs who hold a "certificate of fitness" to prescribe are recognized in the law as NPs. CRNAs and CNPs are defined in the hospital licensure rules, which 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.

Reimbursement

Tennessee private insurance laws mandate reimbursement of APNs. A managed care antidiscrimination law prevents managed care organization discrimination against APNs (specifically CNPs, CNSs, CNMs, and CRNAs) as a class of providers. BC/BS provides 100% reimbursement to primary care NPs in the Tenn-Care program; BC/BS also reimburses CNMs and CRNAs.

Prescriptive Authority

APNs who have a BON-issued certificate of fitness to prescribe (which requires a master's or doctorate in nursing; preparation in specialized practitioner skills at the master's, postmaster's, doctorate, or postdoctoral level; three academic quarter hours of pharmacology, or its equivalent; and current certification in the appropriate nursing specialty area) may write and sign prescriptions and/or issue legend drugs under protocols in any practice site. This authority includes prescribing Schedules II-V controlled substances. The APN's script pad must have the preprinted name and address of the supervising physician and of the APN. New legislation (2003) removes the requirement that the APN must include the name of the physician on the signature line, thus the Rx is deemed to be that of the APN. NPs may receive and issue drug samples.

Texas

http://www.bne.state.tx.us and http://www.cnaptexas.org

Legal Authority

Nurses in advanced practice (NPs, CNMs, CRNAs, and CNSs) must be recognized by the BNE as APNs. The NPA provides the BNE authority to regulate advanced practice nursing, including setting educational requirements, and CE requirements for Rx authority. The APN's SOP is based on advanced practice educational preparation, continued experience, and the accepted SOP of the particular specialty. The APN acts independently and/or in collaboration with the health team. The authority to make a medical diagnosis and write Rx must be delegated by an MD or DO, using written general delegation protocols or practice guidelines. The BNE rules refer to protocols as written authorization to initiate medical aspects of care. Protocols should allow the APN to exercise professional judgment and are not required to outline specific steps the APN must take. Hospitals may extend privileges to APNs but are not required to do so. Hospitals electing to extend clinical privileges to APNs must afford due process rights in granting, modifying, or revoking those privileges. APNs may perform and sign for physical examinations required for school bus drivers and cosmetologists. In 2003, H.B. 1095 passed allowing APNs to Rx CS, Schedules III-V. H.B. 1095 requires hospitals, HMOs and PPOs to use a standardized application form when credentialing APNs.

Reimbursement

All APN categories are eligible for direct Medicaid reimbursement at 85% of physician payment rates. Medicaid rules permit APN services provided under jointly developed protocols to be billed as a physician service at 100% of the physician rate. NPs can be PCPs in the primary care management model for Texas Medicaid managed care. Most NP categories must have a Medicare provider number before they will be granted a Medicaid number. HMOs and PPOs are required to list an APN on provider panels if the APN's collaborating physician is on the panel and the physician requests that the APN also be listed. Insurance companies, HMOs, and PPOs are prohibited from discriminating against APNs.

Prescriptive Authority

The 2003 legislation allows physicians to delegate Rx authority for CS Schedules III-V including the following: (1) APNs may only Rx a maximum 30 day supply; (2) the APN must consult with the physician before authorizing a refill; (3) APNs may not Rx CS to a child under 2 years without physician consultation; and (4) physician consultation must be noted in the chart. APNs must obtain an RX authority authorization number from the BNE. To receive the number, the nurse must be authorized to practice as an APN in Texas and meet certain additional educational requirements. To use Rx authority, APNs must practice in a qualifying site; a physician must delegate Rx authority in that site using general delegation protocols. The physician must submit a form to the Texas State BME indicating to whom he/she is delegating authority and in what site. Sites qualifying for Rx authority are (1) sites that serve medically underserved populations, (2) physician alternate practice sites, (3) physician primary care practice sites; and (4) facility-based practices in hospitals or long-term-care facilities. The delegating physician must spend some time at each site with the APN, but that time varies from once every 10 business days in a medically underserved population site to the majority of the time in a physician's primary practice site. The BME has authority to waive many of the supervisory requirements based on the recommendation of an advisory committee consisting of five APNs, five physicians, and five Pas. APNs with Rx authority may request, receive, possess, and distribute samples of drugs they are authorized to prescribe.

Utah

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

Legal Authority

APRNs include NPs, psychiatric/mental health specialists, and other CNSs. Licensing of APRNs, and CRNAs occurs through the BON under the Division of Occupational and Professional Licensing (DOPL). CRNAs are not recognized in state law as APRNs; CRNAs hold separate licensure and are regulated under the same NPA but under a different classification. CNMs are regulated by a separate practice act and CNM board. All APRNs must be master's degree prepared. APRNs licensed after July 1, 1992, must be nationally certified to obtain licensure. The APRN SOP is defined by set standards from each national professional specialty organization. Physician collaboration is required only for APRNs prescribing Schedules II-III controlled substances. A DOPL-sponsored, 2001 legislative initiative eliminated mandatory peer review for renewal.

Reimbursement

The state insurance code has a nondiscrimination code; nothing prohibits reimbursement. CNMs, APRNs, and CRNAs, are reimbursed by most insurance companies. The state health department Medicaid advisory board implemented certified PNP and FNP reimbursement at 100%. CNMs are reimbursed at 65% by Medicare, whereas other APRNs receive reimbursement at 80%.

Prescriptive Authority

APRNs and CNMs can prescribe within their SOP. A consultation and referral plan is only needed if prescribing Schedules II or III controlled substances. CRNAs do not require a consultation or referral plan for their practice. CRNAs may order and administer drugs, including Schedules II-V controlled substances in a hospital or ambulatory care setting; they may not provide prescriptions to be filled outside the hospital. APRNs, CRNAs, and CNMs receive a DEA number after passing a controlled substance examination and obtaining a state-controlled substance license. APRNs and CNMs may sign for and dispense drug samples.

Vermont

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

Legal Authority

APRNs are endorsed by the BON to perform acts of medical diagnosis and to prescribe medical, therapeutic, or corrective measures under the R&R. The APRN performs medical acts independently, within a collaborative practice with a physician, under practice guidelines that are mutually agreed on between the APRN and collaborating physician. Practice guidelines (1) describe the clinical site, focus of care, and category of clients;(2) index a copy of standards for clinical practice, including method of data collection, assessment, plan of care, and criteria for consultation and referral, including emergency referral or delineation of clinical privileges; (3) include the name of at least one physician practicing the same specialty area who will be used routinely for collaboration, consultation, and referral; and (4) include method of quality assurance. The practice guidelines must be reviewed and signed annually, and filed at the workplace. APRN R&R include (but are not limited to) ANPs, PNPs, FNPs, WHNPs, CNMs, CRNAs, and CNSs in psychiatric health. The BON endorses other CNSs if they are nationally certified and if their formal educational program, approved by the BON, includes (1) a hands-on supervised clinical preceptorship;[middle dot](2) advanced physical assessment and differential diagnosis;[middle dot](3) advanced pharmacology "geared toward the nurse prescriber" with a clinical management component. CNSs in psychiatric health do not need a collaborative physician if they do not have Rx privileges.

Reimbursement

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

Prescriptive Authority

Prescriptions, including Schedules II-V controlled substances, may be written and signed by the APRN for medications covered in the practice guidelines. A list of BON-endorsed APRNs is made available to the BOP. NPs receive DEA numbers. APRNs have the same privileges dispensing and administering drugs as physicians.

Virginia

http://www.dhp.state.va.us

Legal Authority

The BON and BOM have statutory authority to regulate licensed nurse practitioners (LNPs): NPs, CNMs, and CRNAs. CSs are registered solely with the BON. The presidents of the BON and BOM each appoint three board members to the Committee of the Joint Boards of Nursing and Medicine to administer LNP regulations. LNPs must be nationally certified to apply for state authorization and must practice under the medical direction and supervision of a physician. NP practice is based on education and written protocols; the NP may practice only within the SOP agreement with a supervising physician. "Supervision means that the physician documents being readily available for medical consultation by the LNP or the patient, with the physician maintaining ultimate responsibility for the agreed upon course of treatment and medications prescribed." Physical therapists may treat on referral of an LNP. After Jan. 1, 2004, license renewing LNPs are required to complete at least 40 hours CE in the area of their specialty practice. LNPs with prescriptive authority must complete an additional 8 hours of CE in pharmacology or pharmacotherapeutics.

Reimbursement

NPs can independently bill insurers, but are not always paid because they are not mandated providers. As of 1997, CNMs and CNSs in psychiatric health receive third-party reimbursement. FNPs, PNPs, and CNMs receive Medicaid reimbursement at 100% of physician payment.

Prescriptive Authority

Authorized LNPs (as designated by the BON and BOM) may prescribe all Schedule VI legend drugs. A Practice Agreement with the physician is submitted to the joint boards; this agreement lists the drug categories the NP will prescribe. NPs may only prescribe legend drugs if "such prescription is authorized by the written agreement between the NP and physician." The Rx can contain only the NP's name, but the patient must be informed in writing of the name and address of the supervising physician. Each physician may have a Practice Agreement with four NPs in both for-profit and nonprofit sites. As of January 1, 2002, NPs acting under a Practice Agreement with a supervising licensed physician are authorized to prescribe Schedules IV-VI drugs; authorized NPs may prescribe Schedules III-VI controlled substances after July 2003. The supervising physician develops a written agreement with each NP, listing the controlled substances the NP is authorized to prescribe. Periodic site visits are required by physicians who supervise NPs. The joint regulations of the BON and BOM include requirements for continued NP competency (for example, CE testing). The regulations also address ethics, standards of care, patient safety, the use of new pharmaceuticals, and communication with patients. The Joint Commission on Health Care (with full cooperation of nursing, NP, and physician boards and societies) must study the impact of the new Rx regulations on legal, reimbursement, and safety issues and present a findings report to the 2004 general assembly. LNPs may receive and dispense drug samples under an exemption to the state Drug Control Act, which states that the act "shall not interfere with any LNP with prescriptive authority receiving and dispensing to his own patients manufacturer's samples of controlled substances and devices that he is authorized to prescribe according to his practice setting and a written agreement with a physician."

Washington

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

Legal Authority

Advanced practice is authorized by the Nursing Care Quality Assurance Commission (NCQAC) for ARNPs (family, pediatric, adult, geriatric, school, neonatal, WHNPs; acute care NPs; CNMs; CRNAs; and CNSs in psychiatric/mental health nursing or psychiatric NPs). ARNP practice incorporates the use of independent judgment, as well as collaborative interaction with other health care professionals when indicated in the assessment and management of wellness and conditions appropriate to the ARNP's specialty. The NCQAC (formerly, the BON) approved a regulation that would ensure that only highly competent and appropriately educated APNs are permitted to obtain ARNP licensure. CNSs are not listed as ARNPs by the Washington Administrative Code criteria and do not have ARNP status. To avoid adopting new rules for each new ARNP specialty, the commission is considering primarily protecting the titles ARNP, CRNA, and CNM. New 2003 law clarifies that ARNPs may make determinations about whether an individual meets the statutory criteria to qualify for special parking privileges. ARNPs can also sign patient death certificates and complete written reports for probate court guardianship proceedings.

Reimbursement

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

Prescriptive Authority

ARNPs have independent practice with Rx authority for Schedule V and legend drugs. ARNPs (except CRNAs) have Rx authority for Schedules II-IV controlled substances if there is collaboration, a JPA, and DEA request. A JPA is a Joint Practice Arrangement between the ARNP and a physician and only applies to prescribing Schedule II-IV CS. The dispensing of Schedules II-IV controlled substances is limited to a maximum 72-hour supply of the prescribed drug. Independent Rx authority entails an initial 30 hours of pharmacotherapeutic education within the specialty area. Renewal of Rx authority every two years requires 15 hours of pharmacotherapeutic education within the specialty area.

West Virginia

http://www.wvrnboard.com

Legal Authority

R&R define advanced practice for RNs. Licensed RNs may announce advanced practice if they have BON-recognized national certification. All ANPs must have an MSN. No special license is issued; the RN license includes the title granted by the approved national certifying body. ANPs include NPs, CNSs, CNMs, and CRNAs. ANP SOP includes the ability to assess, conceptualize, diagnose, analyze, plan, implement, and evaluate complex problems related to health. The ANP SOP does not require collaboration with a physician unless the ANP is prescribing. The CNM is required to practice in a collaborative relationship with a physician. CRNAs administer anesthesia in the presence and under the supervision of a physician or DDS.

Reimbursement

A state law requires insurance companies to reimburse nurses for nursing services, if such services are commonly reimbursed for other providers; R&R have not been promulgated. NPs and CNMs are defined as "primary care providers" (i.e., "a person who may be chosen or designated in lieu of a primary care physician...who will be responsible for coordinating the health care 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. FNPs and PNPs receive Medicaid reimbursement at the same level as physicians; reimbursement for adult, geriatric, mental health, and women's health NPs will likely be added in 2004. The Woman's Access to Health Care Bill provided for direct access, at least annually, to a woman's health care provider for a well woman examination; providers include ANPs (CNMs, FNPs, WHNPs, ANPs, GNPs, or PNPs).

Prescriptive Authority

Qualified ANPs have Rx authority, including controlled substances. The R&R specify that the ANP must meet specified pharmacology education requirements and certify that they have a written collaborating relationship with a physician or osteopath (i.e., written guidelines or protocols describing the individual versus shared responsibility between the ANP and physician, with periodic joint evaluation of the practice). No supervision requirement exists; ANPs are not required to be employed by a collaborating physician. The ANP works from an exclusionary formulary (Schedules I and II, anticoagulants, antineoplastics, radiopharmaceuticals, and general anesthetics are prohibited). A DEA number is issued directly to an ANP by the DEA. ANPs are authorized to sign for and provide drug samples.

Wisconsin

http://www.drl.state.wi.us

Legal Authority

APRN is the protected title for NPs, CNSs, CNMs, and CRNAs. NPs function under an NPA with a broad description of nursing practice. The following BON R&R cover the performance of a delegated medical act by an RN: (1) the RN must follow protocols or written or verbal orders; (2) as jointly determined by the RN and physician, the ability to perform the delegation is based on the RN's education, training, and experience; (3) the RN must consult with the physician when the delegated medical act may harm the patient; and (4) the RN can perform the delegated act under general supervision-the physician does not have to be present in the facility. For APNs who wish to have independent Rx authority (II-V), the BON grants an advanced practice nurse prescriber (APNP) designation after all criteria are met. A BON rule states, "to promote case management, the APNP may order laboratory testing, radiographs, or electrocardiograms appropriate to his or her area of competence as established by his or her education, training, or experience." APNPs shall work in a collaborative relationship with a physician, defined by law as the "process which involves two or more health care professionals working together, in each other's presence when necessary, each contributing one's respective area of expertise to provide more comprehensive care than one alone can offer." The APNP and the physician must document this relationship. Hospital privilege laws are permissive, not prescriptive; therefore, some hospitals extend full admitting privileges to APRNs, others do not.

Reimbursement

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

Prescriptive Authority

RNs may prescribe (including controlled substances) as a delegated medical act under the NPA. APRNs may receive APNP certification from the BON for independent Rx authority. Eligible APRNs must be certified by a board-approved APRN national certifying body, have completed 45 contact hours in clinical pharmacology/therapeutics within the 3 years preceding application, pass an APNP jurisprudence examination, and hold a master's degree in nursing or a related health field. After initial Rx authority certification, the APNP must submit evidence to the board of an average of 8 CE contact hours per year in clinical pharmacology/therapeutics relevant to the APNP area of practice. DEA numbers are issued to APNPs. The APNP may prescribe Schedules II-V controlled substances and must comply with restrictions regarding prescribing amphetamines and anabolic steroids. Drug samples may be dispensed if the APRN is certified to prescribe; prepackaged doses may be dispensed independently if the nearest pharmacy is more than 30 miles away.

Wyoming

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

Legal Authority

The NPA authorizes the BON to recognize APNs after demonstrated advanced education or national certification. APNs include NPs, CNMs, CRNAs, and CNSs. The NPA defines APN as an RN who performs advanced nursing acts and who may perform medical acts, including Rx or providing prepackaged drugs, except Schedule I drugs. BON R&R specify that the APN must have a collaborative plan which describes the APN's SOP, methods of quality assurance, and consultation and referral patterns and strategies for collaboration. According to a 1994 letter of advice from the attorney general, collaboration as it applies to the advanced practitioner of nursing (including the CRNA), does not mean a supervised/dependent form of practice. APNs are specified as providers on worker's compensation lists and may order physical therapy without a physician cosignature (physical therapy statute).

Reimbursement

All PCPs should receive third-party reimbursement. Medicaid payments to APNs are at 100% of physician payment.

Prescriptive Authority

BON-approved APNs may independently prescribe legend and Schedules II-V controlled substances. APNs must show (1) proof of 30 hours of pharmacotherapeutic education within the last 5 years; (2) a statement declaring personal or professional liability coverage; (3) a copy of their plan of practice and collaboration, which specifies the APN's medical referral plan for critical or complicated medical situations requiring a DDS or physician; (4) evidence of at least 400 hours of practice as an APN, including practice during educational program before Rx application. The BON provides a list of approved APNs to the BOP. The attorney general ruled that APNs are independent practitioners and may apply for independent DEA numbers.