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									                                                       I Prescriptive Authority                             tions, and CNSs are not licensed or recognized
  Alabama
  http://www.abn.state.al.us
                                                       CRNPs and CNMs may “prescribe, administer,
                                                       and provide therapeutic tests and drugs” ex-
                                                                                                            separately from their RN license.

  I Legal Authority                                    cluding Schedules II-V controlled substances,        I Reimbursement
  The BON has sole authority to establish the qual-    within an approved formulary. A BON and BOME         All healthcare in Alaska is provided on a fee-for-
  ifications and certification requirements of         joint committee (composed of one CNM, CRNP,          service basis; managed care does not exist.
  APNs through R&Rs. APNs are defined as               RN, and three physicians) recommends R&R             FNPs, PNPs, and CNMs are authorized by law
  CRNPs, CNMs, CRNAs, and CNSs. CNSs and               governing the collaborative relationship be-         to receive Medicaid reimbursement; NPs re-
  CRNAs are not regulated by the joint commit-         tween physicians and CRNPs and CNMs and              ceive 80% of the physicians’ payment. A nondis-
  tee (BON and BOME), and are not eligible for         the prescription of legend (noncontrolled) drugs.    criminatory clause in the insurance law allows
  prescriptive authority. The BON and BOME reg-        The R&Rs limit the physician to three full-time      for third-party reimbursement to NPs, however,
  ulate the collaborative practice of physicians,      equivalent (FTE) CRNPs (120 hours weekly) with-      the BC/BS federal plan charges patients a $200
  CRNPs, and CNMs and require them to practice         out limit on the number of CRNPs. The physician      deductible to see NPs. This plan does not charge
  with BON- and BOME-approved protocols. The           is limited to four CNMs per three FTEs. Exemp-       a deductible to see a physician. Alaska legally
  collaborating physician and NP or CNM prac-          tions to this specification include public health    requires insurance companies to credential, em-
  ticing with the physician must sign the protocol.    employees and practices in place before the          panel, and/or recognize ANPs. Alaska does not
  “The term ‘collaboration’ does not require di-       R&Rs took effect. The joint committee consid-        have “any willing provider” language in current
  rect, on-site supervision of the activities of a     ers applications for ratio exemptions. The BON       law.
  CRNP or CNM by the collaborating physician.          and BOME shall approve the protocols and for-
  The term does require such professional over-        mulary of legend drugs that may be prescribed        I Prescriptive Authority
  sight and direction as may be required by the        by authorized CRNPs and CNMs. Authorization          Authorized NPs and CRNAs have independent
  R&R of the BOME and BON.” The CRNP or CNM            is tied to the collaborative agreement; if CRNPs     prescriptive authority, including Schedules II-
  and collaborating physician shall be present in      or CNMs change physicians, they must reapply.        V controlled substances, and may apply for
  any approved practice site a minimum of 10%          The CRNP or CNM is issued a four-digit Rx num-       DEA registration. They are legally authorized
  per month (if the CRNP’s or CNM’s collabora-         ber by the BON; the Rx pad must include the          to request, receive, and dispense pharmaceu-
  tion time is 30 or more hours per week) and a        physician name and address and the CRNP or           tical samples in Alaska. The Alaska Nurses As-
  minimum of 10% on a quarterly basis (if the col-     CNM name, RN license number, and Rx number.          sociation reports that problems have been
  laboration time is less than 30 hours per week).     The CRNP or CNM who is in collaborative prac-        documented with pharmacy warehouses re-
  Proposed rules in promulgation September 2006        tice and has Rx privileges may sign for and dis-     fusing to fill prescriptions written by ANPs.
  define “remote practice site,” where the col-        pense approved formulary drugs. The physician        Prescriptions are labeled with the APN’s name
  laborating physician must visit each remote site     must notify the BOME in writing within 5 days        only. Continuing education credits (30) are re-
  at least quarterly. The APN shall practice in ac-    of commencing or terminating a collaborative         quired for renewal of licensure (8 of which
  cordance with national standards and functions       agreement with a CRNP or CNM. CNSs and CR-           must be in Rx) every 2 years.
  identified by the appropriate specialty-certify-     NAs are not regulated by the joint committee
  ing agency and as congruent with Alabama law.        (BON and BOME) and are not eligible for pre-
  CRNP scope of practice is defined in statute and
  regulation. Alabama does not recognize APNs
                                                       scriptive authority.                                 Arizona
                                                                                                            http://www.azboardofnursing.org
  as “PCPs” and does not have “any willing                                                                  http://www.azbn.gov
  provider” language in statute. CRNPs are re-
  quired to have an MSN and national certifica-
                                                       Alaska
                                                       http://www.dced.state.ak.us/occ/pnur.htm
                                                                                                            % 2007 Legislative Activity
                                                                                                            SB 1100 passed in February 2007 and was signed
  tion on entry into practice, with a few excep-       I Legal Authority                                    into law by the governor in April. SB 1100 pro-
  tions: initial CRNP applicants are exempt from       ANPs are regulated by the Alaska BON. ANPs           vides statutory authority to Nurse Practitioners
  requirement for MSN on discretion of the BON         include NPs and CNMs and are defined as an           to provide a variety of services. These are ser-
  if graduation was prior to 1996 in a post-BSN NP     RN who, because of specialized education and         vices that were already in the SOP of a regis-
  program, or graduation prior to 1984 from a non-     experience, is certified to perform acts of med-     tered nurse practitioner; the bill updated the Ari-
  BSN program preparing NPs. CRNAs must have           ical diagnosis and prescription, as well as dis-     zona Revised Statues in the respective areas so
  a minimum of a master’s degree from an ac-           pense medical, therapeutic, or corrective mea-       that NP was added to the list of authorized
  credited nurse anesthesia graduate program           sures under regulations adopted by the BON.          providers.
  and be currently certified as a CRNA; CRNAs          Regulations require that an ANP must have a
  who graduated prior to December 31, 2003, are        plan for patient consultation and referral, but a    I Legal Authority
  exempt from the master’s degree requirement.         physician relationship is not required. SOP for      The Arizona BON grants APRNs authority and
  CNS approval requires MSN as a CNS and na-           ANPs is not directly defined in statute or regu-     regulates their practice. APRNs are defined as
  tional certification.                                lation; however, regulation refers to the national   RNPs, which include NPs (inclusive of CNSs) and
                                                       certifying body for definition of SOP in specialty   CNMs. According to the BON, a RNP will refer a
  I Reimbursement                                      areas. ANPs in Alaska are statutorily recognized     patient to a physician or other healthcare provider
  There are no legislative restrictions against APNs   as “PCPs.” Nothing in the law precludes admit-       if a situation or condition occurs in a patient that
  on managed care panels. The Alabama Medic-           ting privileges for ANPs; however, hospitals re-     is beyond the RNP’s knowledge and experience.
  aid Nurse Practitioner Program reimburses NPs;       quire a physician preceptor with the exception       No formal collaboration agreement is required.
  Alabama Medicaid does not reimburse for ser-         of the Federal Alaska Native Hospital. Entry into    RNP SOP is defined in regulation R4-19-507. RNPs
  vices provided in a hospital or emergency depart-    NP practice requires a master’s degree in nurs-      are not statutorily recognized as “PCPs”; how-
  ment. NPs are reimbursed through the KidsFirst       ing and national board certification. Continuing     ever, they are legally authorized to hold admit-
  Program. BC/BS will reimburse CRNPs and CNMs         education requirements for ANPs are 30 CEUs          ting and hospital privileges through R&Rs. RNPs
  in collaboration with a preferred physician          (8 of these must be Rx hours) every 2 years. CR-     must have a graduate degree in nursing and na-
  provider at 70% of the physician rate                NAs practice under separate rules and regula-        tional certification to enter into practice.

14 The Nurse Practitioner • Vol. 33, No. 1                                                                                                  www.tnpj.com
                                                                                                                Twentieth Annual Legislative Update



I Reimbursement                                      cate of prescriptive authority, including Sched-       state; however, “supervision” does not require
RNPs and other certified RNs may receive third-      ules III-V controlled substances, to qualified         the physical presence of a physician. NPs func-
party reimbursement, enabled by the Depart-          APNs in collaborative practice with a physician        tion under “standardized procedures” or proto-
ment of Insurance statutes. There is no Medic-       of comparable specialty/scope and using proto-         cols when performing medical functions, which
aid; the Arizona Health Care Cost Containment        cols for prescribing. Neither protocols nor col-       are collaboratively developed and approved by
System (AHCCCS) contracts with MCOs and              laborative practice agreements with a physician        the NP, physician, and administration in the or-
other provider networks on a capitated basis.        are required unless the APN has prescriptive au-       ganized healthcare facility in which they work.
AHCCCS NP reimbursement is 90% of the estab-         thority. Under R&R, an initial applicant for Rx au-    The SOP of a NP is defined within their stan-
lished physician rate.                               thority must (1) be an APN with completion of          dardized procedures, not in statute or regula-
                                                     pharmacology course work of 3 graduate credit          tion. NPs and CNMs are statutorily recognized
I Prescriptive Authority                             hours or 45 contact hours in a competency-tested       as “Primary Care Providers” in California’s Medi-
RNPs have full prescriptive and dispensing au-       pharmacology course; (2) have 300 hours of pre-        Cal system. APNs are not legally authorized to
thority, including controlled substances Sched-      cepted prescribing experience; and (3) include a       admit patients to the hospital; however, individ-
ules II-V, on application and fulfillment of BON-    collaborative practice agreement with a physi-         ual hospitals may grant hospital privileges to
established criteria. RNPs’ prescriptive and         cian. Endorsement applicants must provide Rx           APRNs. NPs entering practice after January 1,
dispensing authority is linked to the RNP’s SOP      evidence of at least 500 hours in the last year and    2008 must have a master’s degree to practice;
(according to the BON, prescribing to an adult       have a clear DEA history. APNs who have ful-           however, California does not require national
is outside of a PNP’s SOP). Prescribing without      filled requirements for prescriptive authority may     certification to practice.
documenting an examination is considered by          receive pharmaceutical samples and therapeu-
the BON to be a violation of the NPA. An RNP         tic devices appropriate to their area of practice,     I Reimbursement
with prescriptive and dispensing authority who       including Schedules III-V controlled substances.       All nationally board-certified nurse practitioners
wishes to prescribe a controlled substance must      APNs with prescriptive authority have implied          are reimbursed independently by the Medi-Cal
apply to the DEA for a registration number and       authority to give sample Rx drugs to patients.         system. Medi-Cal-covered services performed
file this number with the BON. Drugs, other than                                                            by NPs, CNMs, and CRNAs are reimbursed at
controlled substances, may be refilled up to 1                                                              100% of the physician reimbursement rate. Blue
year. CRNAs may prescribe drugs to be admin-
istered by a licensed certified or registered
                                                     California
                                                     http://www.rn.ca.gov/
                                                                                                            Cross of CA Medi-Cal Provider Directory lists NPs
                                                                                                            as PCPs under their area specialty. There is no
healthcare provider preoperatively, postopera-       http://www.canpweb.org                                 legal preclusion to third-party reimbursement of
tively, or as part of a procedure; CRNAs are not     % 2007 Legislative Activity                            services; however, policies vary from payer to
authorized to dispense.                              AB 139 (Bass): Governor Schwarzenegger signed          payer. Third-party payers are legally required,
                                                     AB 139, authorizing NPs and physician assistants       however, to reimburse BRN-listed psychiatric-
                                                     to perform physical examinations for the purposes      mental health nurses for qualifying services. Par-
Arkansas
http://www.arsbn.org
                                                     of obtaining a drivers license to operate a farm
                                                     labor vehicle, paratransit vehicle, or bus.
                                                                                                            ticipants in the state’s managed care programs
                                                                                                            for specified Medi-Cal beneficiaries may select
http://www.arna.org/                                      SB 102 (Migden): SB 102 passed and was            NPs and CNMs as their PCPs.
I Legal Authority                                    signed into law authorizing NPs, physician as-
The BON grants APNs authority to practice via        sistants and CNMs to consent a patient for blood       I Prescriptive Authority
second licensure, separate from RN licensure.        transfusion.                                           NPs and CNMs may furnish or “order” drugs or
APNs are licensed and defined as an ANP, CNM,             AB 1436 (Hernandez): NP scope of practice         devices, including contolled substance II-V
CNS, or CRNA. APNs practice independently with       bill seeks to define the scope of practice in Cali-    when the drugs or devices are furnished or or-
the exception of NPs who are not nationally certi-   fornia for NPs. Current law and regulation does        dered by an NP or CNM in accordance with a
fied. NPs who are not nationally certified qualify   not address NP scope separate from that of a reg-      standardized procedure. The act of “furnishing”
for licensure as an RNP; however, they must prac-    istered nurse. This is a 2-year bill. Other changes    is legally the same as the act of prescribing. Pre-
tice under physician direction/protocol. Hospital    included in this bill include the requirement of na-   scriptions are labeled with the NP’s or CNM’s
privileges for APNs are determined on a hospital-    tional certification as entry into practice.           name only. NPs and CNMs may request, receive,
to-hospital basis according to the credentialing          SB 236 (Runner): This is the republican cau-      and dispense pharmaceutical samples and may
committee of each hospital. In 2005, “Any Willing    cus healthcare reform bill which states the leg-       dispense drugs, including controlled substances
Provider” language was enacted. Graduate-level       islative intent to enact laws pertaining to health-    pursuant to a standardized procedure or proto-
APN education and national board certification is    care reform. Included in the language is the           col. NPs and CNMs must have authorization by
required for initial APN licensure.                  statement, “To allow NPs to establish and run          the BRN to furnish controlled substances and
                                                     primary health clinics.” This is a 2-year bill.        must register for a DEA number. To obtain a BRN-
I Reimbursement                                           The California Association for Nurse Practi-      issued furnishing number, NPs and CNMs must
The NPA mandates direct Medicaid reimburse-          tioners is in active negotiation and discussion        complete a 45-hour qualifying pharmacology
ment to APNs and RNPs. Medicaid reimburse-           with Governor Schwarzenegger, Assembly                 course and 520 hours of physician-supervised
ment is 80% of a physicians’ rate. APNs are not      Speaker Fabian Nunez, and Senate Pro tem Don           experience post certification.
recognized as PCPs for Medicaid. CNMs and            Perata on NP inclusion in the healthcare reform
some NPs are listed on managed care panels.          debate. The 2008 legislative session will be very
APNs are included in the any willing provider
law that was upheld in the 8th Circuit Court of
                                                     busy with healthcare reform in California.             Colorado
                                                                                                            http://www.dora.state.co.us/nursing
Appeals. A statutory provision exists for third-     I Legal Authority                                      http://www.nurses-co.org/
party reimbursement for CRNAs.                       The California BRN grants legal authority to prac-     I Legal Authority
                                                     tice, regulates, and issues separate certification     The Colorado BON grants APNs legal authority
I Prescriptive Authority                             to APRNs. APRNs are defined as NPs, CNMs,              to practice and also regulates their practice. Ti-
The NPA authorizes the BON to provide a certifi-     CRNAs, and CNSs. California is a supervisory           tle protection is provided to APNs, defined as

www.tnpj.com                                                                                                The Nurse Practitioner • January 2008 15
  Twentieth Annual Legislative Update



  NPs, CNSs, CNMs, and CRNAs. Use of APN ti-             respond with that of the APN. The APN shall pro-        I Prescriptive Authority
  tles requires BON registration. Colorado requires      vide the BON with the collaborating physician’s         APRNs working in a collaborative relationship
  APNs to have a collaborative agreement with a          name; that information will also be available to the    with a physician may prescribe, dispense, and
  physician for prescriptive privileges only. The        BOP, BOM, and (except for DEA numbers) the pub-         administer medications, including Schedule II–V
  collaborative agreement shall include duties and       lic. APN law states that nothing shall be construed     controlled substances that are expressly speci-
  responsibilities of each party, provision regard-      to limit the ability of the APN with prescriptive au-   fied in the written collaborative agreement. If the
  ing consultation and referral, and a mechanism         thority to make independent judgments, require          APRN prescribes non-controlled substances
  designed by the APN to ensure appropriate pre-         supervision by a physician, or require the use of       only, state-controlled substance registration or
  scriptive practice. CNMs shall have “a safe            formularies. APNs with prescriptive authority are       afederal DEA number is not required. If the APRN
  mechanism for consultation or collaboration            legally authorized to request, receive, and/or dis-     prescribes controlled substances in a hospital
  with a physician or, when appropriate, referral        pense pharmaceutical samples.                           setting only and the hospital has granted sub-
  to a physician.” APN SOP is founded on the rel-                                                                script authority under the hospital DEA number,
  evant educational program and core curriculum                                                                  a state-controlled substance registration num-
  as determined by accepted professional stan-
  dards. Although a function may be within an
                                                         Connecticut
                                                         http://www.dph.state.ct.us/
                                                                                                                 ber is required but a federal DEA number is not.
                                                                                                                 If the APRN prescribes controlled substances
  APN’s scope, the individual APN must have the          % 2007 Legislative Activity                             in any other setting, the state-controlled sub-
  requisite knowledge, judgment, and skill to safely     PA-06-195 passed, permitting a graduate APRN            stance registration and the federal DEA number
  and competently perform any undertaken func-           to work without a license for 120 days after grad-      are required. CRNAs can only administer drugs
  tion. APNs are not statutorily recognized as           uating in a hospital or other setting under the su-     during surgery when the physician, who is med-
  “PCPs;” however, they are not legally prohibited       pervision of a physician or other APRN. The             ically directing the prescriptive activity, is physi-
  from being PCPs. Currently, APNs may hold hos-         APRN may not prescribe or dispense drugs, and           cally present in the institution, clinic, or other
  pital privileges, but interpretation of a ruling       the hospital or other setting must verify that the      setting. APRNs are legally authorized to request,
  states that APNs may not admit patients to the         graduate has applied to take a national certifi-        receive, and dispense pharmaceutical samples.
  hospitals. After July 1, 2008, a graduate degree       cation exam and must end his work if notified
  in a nursing specialty will be the minimum de-         that the graduate has failed the exam.
  gree requirement to enter into practice. Current
  law states that an RN may be admitted onto the
                                                             PA-06-169 became effective October 2006
                                                         allowing APRNs to prescribe, dispense, and ad-
                                                                                                                 Delaware
                                                                                                                 http://professionallicensing.state.de.us/boards/
  APN Registry upon successful completion of a           minister medical therapeutics and corrective            nursing/
  nationally accredited education program for the        measures in collaboration in all settings.              http://www.delapn.org/links.php
  preparation as an APN or a passing score on a                                                                  % 2007 Legislative Activity
  certification exam of a nationally recognized ac-      I Legal Authority                                       APNs opposed HB 106, relating to certified pro-
  crediting agency. National board certification is      The Connecticut NPA defines APRNs as NPs,               fessional midwives (CPMs), creating licensure
  not required to enter into practice.                   CNSs, and CRNAs, and authorizes APRNs to                for CPMs. APNs, the medical society, the BON,
                                                         work in collaborative relationships with physi-         and others opposed the elimination of the col-
  I Reimbursement                                        cians. R&R specific to this law have not been           laborative agreement currently required by rules
  Medicaid reimbursement is available to PNPs,           written. Connecticut law defines collaboration          and regulations.
  FNPs, CNMs, and CRNAs in Colorado. Third-party         as a mutually agreed upon relationship between              Starting in July 2007, all new licensees for
  reimbursement is available to any RN; billed ser-      an APRN and a physician who is educated,                nursing now require criminal background
  vices qualify for reimbursement only if the type       trained, or has experience related to an APRN’s         checks.
  of service has a history of being reimbursable to      work. Current law exempts CRNAs because their
  other healthcare providers. No statutes require        service is under the direction of a licensed physi-     I Legal Authority
  insurance companies to credential, empanel,            cian. SOP for APRNs is defined in statute; how-         The Delaware BON regulates APNs and grants
  and/or reimburse APNs; however, some insur-            ever, CNM SOP is recognized under separate              APN authority to practice. APNs are defined as
  ance companies reimburse for NP services, es-          statute. The NPA specifically authorizes RNs to         NPs, CNSs, CNMs, and CRNAs. If the APN’s SOP
  pecially related to psychiatric APNs with pre-         operate under an order issued by an APRN.               does not include independent acts of diagnosis
  scriptive privileges. No statutes or rules prohibit    APRNs are statutorily recognized as “PCPs”, and         or prescribing, practice authority is governed
  or constrain APNs in managed care.                     are authorized to admit patients and hold hospi-        solely by the BON. If the APN wishes to provide
                                                         tal privileges. A master’s degree in nursing or         independent acts of diagnosis or prescribing, the
  I Prescriptive Authority                               other related field and national board certifica-       APN must apply to the JPC (composed of APNs,
  Colorado APNs enjoy full prescriptive authority in-    tion are required to enter into practice.               MDs, a pharmacist, and one public member). The
  cluding Schedules II-V controlled substances. For                                                              JPC is statutorily empowered, with BOMP ap-
  prescriptive authority eligibility, the prescribing    I Reimbursement                                         proval, to grant independent practice and/or pre-
  nurse must be listed on the APN registry and have      Medicaid regulations govern reimbursement to            scriptive authority to nurses who qualify. APNs
  a post-basic or graduate degree in a nursing spe-      APRNs under the remaining Medicaid fee-for-             must practice in a collaboratory relationship with
  cialty that includes at least 45 contact hours in      service programs. NPs, psychiatric CNSs, and            physicians while performing theses services. The
  health assessment, pharmacology, and patho-            CNMs are reimbursed for services under state            collaborative agreement is a written document
  physiology. The APN must have satisfactorily           insurance statutes, which affect only private in-       that outlines the process for consultation or re-
  completed education in the use of controlled           surers. Reimbursable services must be within            ferral complementary to the APN’s independent
  substances and prescription drugs, have post-          the individual’s SOP and must be services that          practice area. The collaborative agreement is
  graduate experience as an APN in a relevant clin-      are reimbursed if provided by any other health-         defined as “a true collegial agreement between
  ical setting of no less than 1,800 hours (in the im-   care provider. The law further states that insur-       two parties where mutual goal-setting access,
  mediately preceding 5-year period), and have a         ers cannot require supervision or signature by          authority, and responsibility for actions belong to
  written collaborative agreement with a physician       any other healthcare provider as a condition of         individual parties and there is a conviction to the
  whose medical education and active practice cor-       reimbursement.                                          belief that this collaborative agreement will con-

16 The Nurse Practitioner • Vol. 33, No. 1                                                                                                        www.tnpj.com
                                                                                                                 Twentieth Annual Legislative Update



tinue to enhance patient outcomes, and a writ-         approves and regulates APNs. APNs are defined         phone; on-site presence of the supervising prac-
ten document that outlines the process for con-        as APRNs or CNPs, CNMs, CRNAs, and CNSs.              titioner is not required. ARNPs are not statuto-
sultation and referral between an APN and physi-       Current law authorizes APNs to practice inde-         rily recognized as PCPs. ARNPs are authorized
cian licensed in Delaware, dentist, podiatrist, or     pendently without a physician collaborative           to admit patients to the hospital and hold hospi-
licensed health care delivery system.” If the          agreement or protocols. CNP SOP is defined in         tal privileges; however, this authority is depen-
agreement is with a licensed healthcare deliv-         statute, regulated by the BON, and without limi-      dent upon privileges granted by the institution.
ery system, the document must clarify that the         tations. APNs may apply for admitting privileges      ARNP applicants must have a master’s degree
system will supply appropriate medical back-up         to the hospital. Graduation from a post-basic NP      to qualify for initial certification and are required
for purposes of consultation and referral. Re-         program or national certification in a specialty      to hold national board certification to enter prac-
quirements for physician supervision, chart re-        area is required to enter into practice.              tice.
view, or on-site physician visits do not exist. APN
applicants must have a master’s degree or post-        I Reimbursement                                       I Reimbursement
basic certificate in a clinical nursing specialty,     APNs receive direct reimbursement for provid-         ARNPs receive Medicaid, Medicare, CHAM-
be nationally certified, submit a copy of their col-   ing drug abuse, alcohol abuse, and mental ill-        PUS, and third-party reimbursement; however,
laborative agreement, and show evidence of             ness care; healthcare plans or institutions are       Medicaid reimburses ARNPs at 100% of the
BON-specified relevant courses including ad-           prohibited from discriminating against APNs           physician rate only if the on-site physician coun-
vanced health assessment, diagnosis and man-           with clinical privileges. Legislative authority       tersigns the chart within 24 hours. Medicaid re-
agement of problems within the clinical specialty,     mandating APN reimbursement does not exist,           imburses ARNPs at 80% of the physician rate if
advanced pathophysiology and advanced phar-            however, private third-party payers reimburse         the physician is not on-site and does not coun-
macology. If the APN has graduated from an ap-         for NP services. APNs are statutorily recognized      tersign. Managed care companies are prohib-
proved program more than 2 years prior to appli-       as PCPs. NPs and CNMs receive Medicaid pay-           ited from discriminating against the reimburse-
cation, the APN must document the equivalent           ment as PCPs.                                         ment of ARNPs if based on licensure. Private
of at least 30 hours continuing education in phar-                                                           insurers must reimburse CNM services if the pol-
macology and other areas.                              I Prescriptive Authority                              icy includes pregnancy care.
                                                       The D.C. regulations provide for full prescrip-
I Reimbursement                                        tive authority including Schedules II-V con-          I Prescriptive Authority
Delaware has statutory provisions requiring            trolled substances. The law and R&R authorize         The BON/BOM joint committee allows pre-
health insurers, health service corporations, and      prescribing Schedules II-V controlled sub-            scriptive privileges for ARNPs; however, con-
HMOs to provide benefits for eligible services         stances and allow dispensing of all medica-           trolled substances are excluded. ARNPs pre-
when rendered by an APN acting within his or           tions, including sample medication. APNs are          scribe under a protocol, which broadly lists the
her SOP. APNs may be listed on provider panels;        authorized to request and receive pharmaceu-          medical SOP and generic categories from
some providers are recognizing APNs on man-            tical samples. The D.C. Pharmacy Board issues         which the ARNP can prescribe. ARNPs use
aged care provider panels. CNMs have legisla-          DEA number to providers with controlled sub-          their own prescription pad (containing name
tive authority under the Board of Health for third-    stance authority. Prescriptions are labeled with      and license number); the pharmacist is required
party reimbursement. FNPs and PNPs also                the APN name.                                         to put the prescribers name on the drug label.
receive Medicaid reimbursement at 100% of                                                                    ARNPs who dispense (distribute medication for
physician payment.                                                                                           reimbursement) must apply for dispensing priv-

I Prescriptive Authority
                                                       Florida
                                                       http://www.doh.state.fl.us/mqa/
                                                                                                             ileges. ARNPs are authorized to request, re-
                                                                                                             ceive, and/or dispense pharmaceutical sam-
JPC- and BOMP-approved APNs may prescribe,             % 2007 Legislative Activity                           ples.
administer, and dispense legend drugs, includ-         Although no legislative or regulatory action oc-
ing Schedules II-V controlled substances, par-         curred in 2007, plans are in motion to recognize
enteral medications, medical therapeutics, de-
vices, and diagnostics. Authorized APNs are
                                                       clinical nurse specialists as ARNPs.                  Georgia
                                                                                                             http://www.sos.state.ga.us/plb/rn/
assigned a provider identifier number; APNs            I Legal Authority                                     http://www.georgianurses.org/
must register with the State Controlled Sub-           The BON certifies and regulates ARNPs, who            % 2007 Legislative Activity
stance Agency and DEA, and use their number            are defined as NPs, CNMs, and CRNAs. ARNP             Senate Bill 222 was passed and signed into
for prescribing controlled substances. Autho-          SOP is defined in statute and includes the per-       law.This bill does not require CRNAs who grad-
rized APNs may request and issue professional          formance of medical acts of diagnosis, treat-         uated from an approved nurse anesthetist edu-
samples of legend drugs, including Schedule II-        ment, and operation pursuant to protocols es-         cational program prior to January 1, 1999 to hold
V controlled substances and properly labeled           tablished between the ARNP and physician, DO,         a master’s degree or other graduate degree.
over-the-counter drugs. The prescription order         or dentist. Within the framework of established
includes the APN’s name and prescriber identi-         protocols, ARNPs may order diagnostic tests           I Legal Authority
fication number and the prescriber’s DEA num-          and physical and occupational therapy. The de-        APRNs are authorized to practice and regulated
ber and signature when applicable.                     gree and method of supervision, determined by         by the BON. APRNs are defined as NPs, CNMs,
                                                       the ARNP and physician, DO, or dentist, is specif-    CRNAs, and CNSs in psychiatric/mental health.
                                                       ically identified in written protocols and shall be   APRN practice is collaboratory in nature. An
District of                                            appropriate for prudent healthcare providers un-      APRN is authorized to perform advanced nurs-

Columbia                                               der similar circumstances. ARNPs must file pro-
                                                       tocols with the BON yearly, and the physicians
                                                                                                             ing functions and certain medical acts that in-
                                                                                                             clude, but are not limited to, ordering drugs,
http://dchealth.dc.gov/prof_license/                   working with the ARNP must send the statement         treatments, and diagnostic studies through a
services/app_main_action.asp?strAppId=11               required in the medical practice act to the BOM.      “nurse protocol.” A “nurse protocol” is defined
I Legal Authority                                      BOM and BON rules define general supervision          as a written document signed by the NP and
The Washington, D.C. Department of Health BON          as the ability to communicate/contact by tele-        physician in whom the physician delegates au-

www.tnpj.com                                                                                                 The Nurse Practitioner • January 2008 17
  Twentieth Annual Legislative Update



  thority to the nurse to perform certain medical       ognized as PCPs. According to Hawaiian au-            to admit patients to hospitals and hold hospital
  acts and provides for immediate consultation          thorities, several insurance companies creden-        privileges in Idaho. Some facilities have granted
  with the delegating physician under OCGA 43-          tial APRNs for their provider panels. Some            APPNs privileges. State law requires a mini-
  34-26. APRNs may hold hospital privileges in lim-     APRNs are listed on managed care panels and           mum of an associate’s degree as entry into
  ited situations, according to the Georgia Nurses      are directly reimbursed for services. The reim-       practice; however, the NPA also requires na-
  Association. A master’s degree or higher in nurs-     bursement rate ranges from 85% to 100%. NPs           tional board certification to enter practice,
  ing or other related field and national board cer-    and CNSs are also reimbursed through CHAM-            which requires a master’s degree in nursing to
  tification is required for all APRNs at entry into    PUS. Medicaid expanded the types of APRNs             enter into most specialties.
  practice except for CRNAs educated prior to           they reimburse to include psychiatric CNSs and
  1999.                                                 additional specialties of NPs. Medicaid reim-         I Reimbursement
                                                        burses at 75% of physician payment. Hawaii            Listing APPNs on managed care provider pan-
  I Reimbursement                                       Health QUEST, a Medicaid waiver program, de-          els is neither specifically permitted nor prohib-
  There are no statutes mandating third-party re-       fines PNPs, FNPs, and CNMs as PCPs. However,          ited and is considered by third-party payers on
  imbursement for APRNs. FNPs, PNPs, OB/GYN             QUEST, unlike Medicaid, does not require the          an individual basis. BC/BS credentials NPs as
  NPs, CNMs, and CRNAs are eligible for Medic-          QUEST healthcare plans to include APRNs as            “preferred providers” within their program. NPs
  aid reimbursement from the Department of Com-         PCPs on their provider panels.                        receive their own Medicaid provider number and
  munity Health. Reimbursement rates vary: NPs                                                                may choose to file independently or with a group.
  and CRNAs are reimbursed at 90% of a physi-           I Prescriptive Authority                              Reimbursement rates are 85% of physician pay-
  cian’s payment and CNMs are reimbursed at 95%         The BON regulates APRN prescriptive authority         ment.
  of a physician’s payment. Some private insurers       and APRNs have legal authority to prescribe
  reimburse APNs but are not required by law to         Schedules II-V controlled substances provided         I Prescriptive Authority
  do so.                                                they have a supervisory relationship with a physi-    Prescriptive and dispensing authority is granted
                                                        cian. APRN prescriptive authority for nonsched-       to APPNs who have completed 30 contact hours
  I Prescriptive Authority                              uled medications is not supervised; however,          of pharmacology-specific formal instruction be-
  APRNs practice under protocol as defined by           APRNs must document with the BON that they            yond basic RN education. Authorized APPNs
  O.C.G.A 43-34-26. A process exists that permits       have a collegial working relationship with an MD      may prescribe and dispense legend and Sched-
  RNs (including APRNs) to administer, order, or        in the same institution and specialty area. APRNs     ules II-V controlled substances appropriate to
  dispense drugs under delegated medical au-            prescribe from an exclusionary formulary. To pre-     their defined SOP. Some dispensing restrictions
  thority, either as prescribed by a physician or as    scribe from the formulary, APRNs must have a          apply to Schedule II substances. Authorized
  authorized by protocol. BON regulations govern-       master’s degree in nursing or nursing science,        APPNs have their own DEA numbers and pre-
  ing protocols used by RNs require that the RN         30 hours of advanced pharmacology, 1,000 hours        scribe independently. APPNs are legally autho-
  document preparation and performance spe-             of clinical practice, and national certification.     rized to request, receive, and dispense pharma-
  cific to each medical act. “Medication orders”        APRNs with prescriptive authority are legally au-     ceutical samples and NP prescriptions are
  may be called into a pharmacy. APRNs are au-          thorized to request, receive, and dispense phar-      labeled with the NP’s name only.
  thorized to request and receive pharmaceutical        maceutical samples. NP prescribers’ prescrip-
  samples.                                              tions are labeled with both the NP and
                                                        physician’s name.                                     Illinois
                                                                                                              http://www.ildpr.com
  Hawaii
  http://www.hawaii.gov/dcca/areas/pvl/boards/          Idaho                                                 I Legal Authority
                                                                                                              The Illinois Department of Professional Regu-
  nursing                                               www2.state.id.us/ibn/ibnhome.htm                      lation’s APN Board grants authority and regu-
  I Legal Authority                                     I Legal Authority                                     lates the practice of APNs. APNs are defined
  The BON grants authority and regulates APRNs          The BON regulates and grants authority to prac-       as CNPs, CNSs, CNMs, and CRNAs. CNPs,
  in Hawaii. APRNs are defined in the NPA as an         tice for APPNs. APPNs are defined as NPs,             CNSs, and CNMs must have a written collabo-
  NP, CNS, CNM, or CRNA. Hawaii does not legally        CNMs, CNSs, and RNAs. APPN licensure re-              rative agreement with a physician that de-
  require a collaboratory or supervisory practice       quires RN licensure, completion of an approved        scribes the working relationship between the
  with a physician, with the exception of prescrib-     APPN program, and national certification. NPs,        APN and the physician and authorizes the cat-
  ing medications. A collegial working relationship     CNMs, and CNSs must practice in collabora-            egories of care, treatment, or procedures to be
  with a physician is required for prescribing pre-     tion with other health professionals. Revised         performed by the APN. Medical direction is ad-
  scription medications, and a supervisory rela-        NPA rules rely on the Decision Making Model           equate if the APN and physician jointly develop
  tionship with a physician is required for pre-        to determine an APPN’s scope of practice. The         the guidelines and periodically review them.
  scribing controlled substances. According to the      APPN can determine if a specific function can         The physician’s presence is not required at the
  BON, APRNs are considered independent                 be legally performed by determining if the act:       site where services are rendered; however,
  providers. The APRN’s SOP is defined in regula-       (1) is expressly forbidden in the NPA Rules and       telecommunication methods for consultation
  tion (administrative rules). Hawaiian law does        Regulations; (2) was taught in the APPN cur-          must be established, and the physician is ex-
  not specifically authorize APRNs to admit pa-         riculum and the APPN is clinically competent          pected to visit the site at least once a month.
  tients to the hospital or hold hospital privileges.   to perform it; (3) does not exceed employment         CNP scope of practice is not defined in statute;
  The minimum requirements to enter practice in         policies; (4) is consistent with national specialty   however, Section 1305.30 Written Collaboration
  Hawaii are a master’s in nursing and national         organization standards; and (5) is within the ac-     Agreements states, “The services to be pro-
  certification in the APRN’s clinical specialty.       cepted standard of care for the APPN’s geo-           vided by the advanced practice nurse shall be
                                                        graphic region and practice setting. APPNs are        services that the collaborating physician gen-
  I Reimbursement                                       not statutorily recognized as PCPs; however,          erally provides to his or her patients in the nor-
  Current law provides direct reimbursement to          Idaho does have “Any Wiling Provider” lan-            mal course of his or her clinical medical prac-
  all APRNs; however, APRNs are not legally rec-        guage in statute. APPNs are legally authorized        tice.” All new applicants must have a graduate

18 The Nurse Practitioner • Vol. 33, No. 1                                                                                                   www.tnpj.com
                                                                                                               Twentieth Annual Legislative Update



degree in their APN specialty or a graduate de-      early intervention and treatment for pregnant         Controlled Substances Registration before ob-
gree in nursing and a certificate from a gradu-      women who abuse alcohol or drugs or use to-           taining a federal DEA number. Prescriptions are
ate level program in one of the APN specialty        bacco. A designated seat is for an APN with a         labeled with the APN’s name only. APNs are not
areas. Additionally, APNs must hold national         collaborative agreement.                              permitted to prescribe Schedules III and IV con-
certification to enter into practice.                                                                      trolled substances for the purpose of weight re-
                                                     I Legal Authority                                     duction or to control obesity, and must follow
I Reimbursement                                      The Indiana State BON grants authority to and         specific guidelines before prescribing a stimu-
The Illinois Department of Public Aid provides       regulates APNs. The NPA defines APNs as NPs,          lant for attention deficit hyperactivity disorder.
direct reimbursement at 100% of physician rates      CNMs, or CNSs. The BON does not issue sepa-           CRNAs are not required to obtain Rx authority
to certified PNPs and FNPs who enroll indepen-       rate licenses to NPs or CNSs. CNMs must apply         to administer anesthesia.
dently as Medicaid providers. PNPs and FNPs          for “limited licensure” to practice. CRNAs are li-
may alternately choose to bill under a physician     censed and regulated by the BON under a sep-
and receive 100% reimbursement. Statutory pro-
hibition for third-party reimbursement to APNs
                                                     arate statute from the APNs. APNs without pre-
                                                     scriptive authority may function independently
                                                                                                           Iowa
                                                                                                           http://www.state.ia.us/nursing/
does not exist. APNs receive direct or indirect      in their advanced practice; however, a Written        % 2007 Legislative Activity
reimbursement from third-party payers in some        Collaborative Practice Agreement (WCPA) is            Legislation is pending to modify code language
cases.                                               necessary if the APN seeks prescriptive author-       which will authorize APNs to sign mental health
                                                     ity. APN SOP is defined in regulation. NPs are li-    and substance abuse evaluations, court reports,
I Prescriptive Authority                             censed following completion of a graduate pro-        and driver’s license restoration of privileges.
Delegated prescriptive authority is granted to       gram that is accredited according to BON
APNs by their written collaborative agreement        regulation or completion of a certificate NP pro-     I Legal Authority
for legend and Schedules III-V controlled sub-       gram and must hold national certification by a        The Iowa BON grants ARNPs authority to prac-
stances. APNs use prescription pads con-             national certifying body for NPs. If the NP holds     tice and regulates their practice through admin-
taining their name and their collaborating           a baccalaureate degree, national certification        istrative rules. ARNPs are defined as NPs, CR-
physicians’ name; only the APN’s signature is        is required to obtain prescriptive authority. NPs     NAs, CNMs, and CNSs. ARNPs are authorized to
required. APNs are not required to have their        with a graduate degree do not need to be na-          practice independently within their recognized
collaborating physician sign Illinois Department     tionally certified for prescriptive authority to be   nursing specialties, and collaborative practice
of Professional Regulation forms for prescrip-       granted.                                              agreements are not required by the BON. Scope
tive authority as long as they are not controlled                                                          of practice is broadly defined. ARNPs are statu-
substance prescriptions; in this case, APNs          I Reimbursement                                       torily recognized as PCPs; however, state law
need only note that the APN has prescriptive         Indiana is considered an “any willing provider”       does not contain “any willing provider” language.
authority in the collaborative agreement. In or-     state backed by current law. APNs may receive         ARNPs may hold hospital clinical privileges. Reg-
der for an APN to prescribe a controlled sub-        third-party reimbursement as determined by pay-       istration as an ARNP requires current licensure
stance, he or she has to first obtain an Illinois    ers. NPs receive Medicaid reimbursement at 85%        as a RN and certification by a national certifying
Controlled Substance License before applying         of a physician’s payment. Medicaid for children,      body. A master’s degree in nursing is only re-
for a DEA registration; the physician must sign      however, does not allow for NP reimbursement          quired for clinical nurse specialists.
a “Notice of Delegation of Rx Authority for Con-     under current managed care arrangements.
trolled Substances” form. The collaborating                                                                I Reimbursement
physician shall review medication orders peri-       I Prescriptive Authority                              Iowa’s Medicaid managed care and prepaid
odically. An APN may sign for and accept drug        The BON has legal authority to establish rules,       service programs reimburse ARNPs pursuant
samples if it is stipulated in the written collab-   and, with the approval of the BOM, to permit          to legislation passed in 2003. Payment of nec-
orative agreement.                                   prescriptive authority for APNs. The BON may          essary medical or surgical care and treatment
                                                     issue authorization to prescribe legend drugs         is provided to an ARNP in third-party reim-
                                                     and controlled substances if the qualified APN        bursement if the policy or contract would pay
Indiana
http://www.in.gov/pla/bandc/isbn/
                                                     submits proof of successful completion of a
                                                     graduate-level pharmacology course, consist-
                                                                                                           for the care and treatment when provided by a
                                                                                                           physician or DO. Managed care organizations
http://www.indiananurses.org                         ing of at least 2 accredited semester hours. Ad-      are not mandated to offer ARNP coverage un-
% 2007 Legislative & Regulatory                      ditionally, the APN must submit proof of collab-      less there is a contract or other agreement to
Activity                                             oration with a “licensed practitioner” (licensed      provide the service. Under 2003 legislation, all
Legislative successes include the passage of         physician, dentist, podiatrist, or osteopath) in      ARNPs are approved as providers of health-
the following:                                       the form of a WCPA. WCPAs must be approved            care services pursuant to managed care or pre-
PL 184: Permits advanced practice nurses to the      by the BON and include (1) the manner in which        paid service contracts under the medical as-
list of professionals who may certify an individ-    the APN and licensed physician will cooperate,        sistance program.
ual as being severely restricted in mobility for     coordinate, and consult with each other in the
purposes of issuance of a parking placard for a      provision of healthcare, and (2) the specifics of     I Prescriptive Authority
person with physical disabilities.                   the licensed physician’s reasonable and timely        Authorized ARNPs are granted full, independent
     PL 197: Provides that: (1) an OT may not pro-   review of the APN’s Rx practices, including the       Rx authority within their nursing specialty, in-
vide certain services unless the patient has been    provision for a minimum weekly review of 5%           cluding Schedule II-V controlled substance med-
referred by specified providers [includes APN],      random chart sampling. The BON issues a pre-          ications. ARNPs may prescribe, deliver, distrib-
and Removes: (1) the psychology board’s au-          scriptive authority identification number; the au-    ute, or dispense noncontrolled and controlled
thority to establish a list of restricted psychol-   thority limits APN prescribing to within the APN’s    drugs, devices, and medical gasses, including
ogy tests.                                           and collaborating physician’s SOP. APNs re-           pharmaceutical samples. ARNPs must register
     PL 193: Establishes the prenatal substance      questing authority to prescribe controlled sub-       with the DEA, and prescriptions written by
abuse commission to develop a plan to improve        stances must apply for and obtain Indiana State       ARNPs must be labeled with their name.

www.tnpj.com                                                                                               The Nurse Practitioner • January 2008 19
  Twentieth Annual Legislative Update



                                                                                                             supply with additional authority for psych/men-
  Kansas
  http://www.ksbn.org
                                                      Kentucky
                                                      http://kbn.ky.gov
                                                                                                             tal health clinicians. CS III medications for a 30-
                                                                                                             day supply have the following limitations: ARNPs
  % 2007 Legislative Activity                         http://www.kcnpnm.org                                  may prescribe a 14-day supply of benzodi-
  Minor changes in regulations related to ARNP        % 2007 Legislative Activity                            azepines and hydrocodone combination prod-
  education programs; several regulatory changes      Regulation 201 KAR 20:059 went into effect             ucts without refills. ARNPs are still able to pre-
  pending.                                            March 2007 which places additional limitations         scribe a 30-day supply of carisoprodol (Soma)
  I Legal Authority                                   on AP prescribing of controlled substances. Lim-       without refills. Other schedules IV and V may be
  The Kansas BON regulates the practice of            itations include a 14-day supply of lorazepam,         prescribed with refills not to exceed a 6-month
  ARNPs. The BON grants ARNP authority to             clonazepam, diazepam, alprazolam, and combi-           supply. CRNAs do not need CAPAs to deliver
  practice and defines them as NPs, nurse mid-        nation hydrocodone products in liquid and solid        anesthesia care. The ARNP alone signs his or
  wives (NMWs), NAs, and CNSs. ARNPs func-            forms without refills, and a 30-day supply of          her name to the prescription pad when prescrib-
  tion in collaboratory relationships with physi-     carisoprodol without refills.                          ing. ARNPs must complete 5 contact hours in Rx
  cians and other healthcare professionals in                                                                annually as part of their CE requirement. ARNPs
  the delivery of primary healthcare services.        I Legal Authority                                      are legally authorized to request and receive
  ARNPs make independent decisions about the          The Kentucky BON grants ARNPs authority to             drug samples (non-controlled legend medica-
  nursing needs of patients and interdependent        practice and regulates their practice. ARNPs are       tions only) and may dispense pharmaceutical
  decisions with physicians in carrying out           statutorily defined as NPs, CNSs, CNMs, and CR-        samples. Dispensing is applicable to ARNPs
  health regimens for patients; however, the          NAs. ARNPs practice in collaboration with a            working in health departments: ARNPs may dis-
  physical presence of a physician is not re-         physician in Kentucky for prescriptive purposes        pense with a written agreement with a local
  quired when care is given by the ARNP. SOP          only. ARNPs may practice autonomously within           pharmacist.
  is defined in statute and regulation; however,      their relative scopes of practice; however, they
  ARNPs are not recognized as “PCPs.” No spe-         must practice in accordance with the scope of
  cific language in statute authorizes or prohibits
  hospital privileges. Admitting and hospital priv-
                                                      practice (SOP) of the national certifying organi-
                                                      zation as adopted by the BON in regulation. NP
                                                                                                             Louisiana
                                                                                                             http://www.lsbn.state.la.us
  ileges are determined by individual institution     SOP is defined in Kentucky statute, KRS 314.011.       http://www.lanp.org/
  policy and procedure. New ARNP applicants           “ARNPs shall seek consultation or referral in sit-     I Legal Authority
  in all categories, except NMWs, require a mas-      uations outside their scope of practice.” ARNPs        APRNs are licensed by the BON and are defined
  ter’s degree or higher in nursing; however, na-     are recognized as “primary care providers” in          as NPs, CNMs, CRNAs or RNAs, and CNSs.
  tional board certification is not required to en-   regulation, and are legally authorized to admit        APRNs perform certain acts of medical diagno-
  ter practice in Kansas.                             patients to a hospital and hold hospital privileges;   sis in accordance with a “collaborative practice
                                                      however, hospital regulations permit medical           agreement,” a formal written statement ad-
  I Reimbursement                                     staff to set conditions. A master’s degree in nurs-    dressing the parameters of the collaborative
  Insurance companies are legally required to         ing and national board certification is required       practice which are mutually agreed upon by the
  reimburse all ARNPs for covered services in         to enter practice in Kentucky.                         APRN and physician(s) or dentist(s) including
  health plans. Medicaid has expanded payment                                                                consultation or referral availability, clinical prac-
  to include all covered services at 80% of physi-    I Reimbursement                                        tice guidelines, and patient coverage. APRNs’
  cian payments (except for practitioners per-        The state medical assistance program reim-             SOP is limited to their BON-recognized category
  forming early periodic screening diagnosis          burses ARNPs for services at 75% of physician          and area of specialization. The APRN SOP in-
  and treatment, who receive 100%). NAs re-           rates in all state regions except Jefferson County.    cludes “certain acts of medical diagnosis or
  ceive 85% of physician payments. Some insur-        In the Jefferson County region, there is capitated     medical prescriptions of a therapeutic or cor-
  ance companies are paying 85% of physician          managed care through a healthcare partnership,         rective nature, prescribing assessment studies,
  payments to ARNPs.                                  with reimbursement at physician rates. Kentucky        legend and certain controlled drugs, therapeu-
                                                      is an “any willing provider” state. In April 2003,     tic regimens, medical devices and appliances,
  I Prescriptive Authority                            the United States Supreme Court upheld the Ken-        receiving and distributing a therapeutic regimen
  ARNPs, with the exception of CRNAs, are             tucky law providing that a health insurer may not      of prepackaged drugs prepared and labeled by
  legally authorized to prescribe medications,        discriminate against any provider who is located       a pharmacist, and free samples supplied by a
  including Schedules II-V controlled sub-            within the geographic coverage area of the             drug manufacturer.” Louisiana State law in-
  stances pursuant to protocols jointly adopted       health benefit plan and who is willing to meet         cludes “Any Willing Provider” language pur-
  by the ARNP and “the responsible physician.”        the terms and conditions for participation estab-      suant to the passage of SB 135/Act 106, and
  Each written protocol must (1) specify the drug     lished by the health insurer (including Medicaid       APRNs are legally authorized to hold hospital
  class the ARNP is permitted to prescribe for        programs).                                             privileges. APRNs must be licensed as an RN,
  each classification of disease or injury; (2) be                                                           possess a master’s degree or higher, and be cer-
  maintained in a notebook or book of published       I Prescriptive Authority                               tified by a national certifying body recognized by
  protocols; and (3) contain the ARNP’s and           ARNPs may prescribe scheduled II-V controlled          the board or meet “commensurate require-
  physician’s annual signature. The prescrip-         substances and non-scheduled legend drugs              ments” if certification is not available.
  tion order must be signed by the ARNP and in-       pursuant to separate “Collaborative Agreement
  clude the name of the physician and ARNP.           for Prescriptive Authority for Non-Scheduled           I Reimbursement
  Prescription labels include both the ARNP and       Drugs (CAPA-NS),” and “Collaborative Agree-            The passage of SB 135/Act #106 in 2006 provides
  physician’s name. ARNPs are authorized to           ment for Prescriptive Authority for Controlled         that any qualified plan shall not exclude direct
  request, receive, and dispense pharmaceuti-         Substances (CAPA-CS). The CAPA-CS and NS               reimbursement of healthcare services provided
  cal samples, with the exception of controlled       defines ARNP scope of prescribing authority and        by an APRN as stated above. Medicaid Man-
  substances, if the drug is within their proto-      is signed by the ARNP and physician. ARNPs             aged Care is required to reimburse FNPs and
  col.                                                may prescribe CS II medications for a 72-hour          PNPs at a rate equal to that of physicians per-

20 The Nurse Practitioner • Vol. 33, No. 1                                                                                                    www.tnpj.com
                                                                                                               Twentieth Annual Legislative Update



forming the same service. Medicaid recognizes         rent law requires a master’s degree in nursing       are defined as NPs, Certified Registered Nurse
FNPs and PNPs as primary care case man-               (licensed after January 1, 2006) and national cer-   Anesthetists (CRNAs), CRNMs, and APRNs/Psy-
agers/providers and will give assignment of NPs       tification to enter into practice.                   chiatric Mental Health Nurses. APNs are legally
as the PCP or “Medical Home” under certain cir-                                                            required to have a written agreement with a col-
cumstances. APRN’s are reimbursed at 80% of           I Reimbursement                                      laborating physician, which must be approved
physician fees per Medicaid; all billing must be      The 1999 Act to Increase Access to Primary           by an equally represented physician and NP joint
under the APRN license, essentially eliminating       Health Care Services (HP617) requires reim-          committee. Once the agreement is approved,
“incident to” billing.                                bursement under an indemnity or managed care         NPs may perform the functions of the agreement
                                                      plan for patient visits to an NP or CNM when re-     independently. NP SOP is defined in regulation.
I Prescriptive Authority                              ferred from a PCP; requires insurers to assign       Current law recognizes APNs as “PCPs”. The
APRN’s have prescriptive authority in Louisiana,      separate provider identification numbers to          minimum degree required to enter practice in
including Schedules II-V controlled substances.       CNPs and CNMs; and allows managed care en-           the State of Maryland is an associate degree;
The BON has sole authority to develop, adapt,         rollees to designate CNPs as their PCP. However,     however, national board certification is required.
and revise R&R governing SOP, including Rx au-        managed care organizations are not required to
thority, the receipt and distribution of sample and   credential any physician or CNP if their “access     I Reimbursement
prepackaged drugs, and prescribing of legend          standards” have been met. Reimbursement un-          All nurses are entitled to private third-party and
and controlled drugs. An APRN who is granted          der indemnity plans is mandated for master’s-        Medicaid reimbursement for services if they are
limited Rx authority may request approval to pre-     prepared, certified psychiatric/mental health        practicing within their legal SOP. All Medicaid
scribe and distribute controlled substances as        CNSs; no other third-party reimbursement for         recipients have been assigned to a managed
authorized by the APRN’s collaborating physi-         APRNs is required by law. Some insurance car-        care organization; NPs (with the exception of
cian if the patient population served by the col-     riers, however, reimburse independent CNPs.          neonatal and acute care) and CRNMs have been
laborative practice has an identified need. Pre-      Medicaid reimburses in full, on a fee-for-service    designated as PCPs and may apply to be placed
scribing distributed controlled substances            basis, for services provided by certified family     on a provider panel. Medicaid reimburses at
(Schedules II-V) must be consistent with the          nurse practitioners, CPNPs and CNMs.                 100% of physician payment. Legislation allows
practice specialty of the collaborating physician                                                          due process for APNs listed on managed care
and the APRN’s licensed category and area of          I Prescriptive Authority                             panels; APNs are not to be arbitrarily denied.
specialization. APRN’s with authority to pre-         CNPs and CNMs may prescribe and dispense             Legislation passed in 2003 requires an HMO to
scribe or distribute controlled substances may        drugs or devices, including Schedule II-V con-       permit an enrollee to select a certified NP as the
not prescribe controlled substances to treat          trolled substances, in accordance with rules         enrollee’s PCP if (1) the NP provides services at
chronic or intractable pain or obesity, or them-      adopted by the BON; approved CNPs and CNMs           the same location as the NP’s collaborating MD
selves or family.                                     receive their own DEA numbers. BON rules re-         and (2) the collaborating MD provides the con-
                                                      quire CNPs and CNMs to have a pharmacology           tinuing medical management required. The law
                                                      course and prescribe from FDA-approved drugs         does not require that an HMO include NPs on
Maine
http://www.state.me.us/boardofnursing/
                                                      related to the nurse’s specialty. CNPs in inde-
                                                      pendent practice and CNMs may prescribe
                                                                                                           the HMO panel as PCPs. The state NP associa-
                                                                                                           tion signed an agreement letter with the state
http://www.mnpa.us                                    Schedule II-V controlled substances and drugs        medical society that neither will bring this issue
I Legal Authority                                     off-label, according to common and established       back to the legislature for 5 years.
The Maine BON authorizes and regulates APRN           standards of practice. Dependency on other pro-
practice. APRNs approved by the BON are de-           fessionals for APRN prescriptive authority does      I Prescriptive Authority
fined as CNPs, CNMs, CNSs, and CRNAs. A CNP           not exist, except in the case of CNPs working        NPs and CNMs have full prescriptive authority,
who qualifies as an APRN must practice for at         pursuant to medical delegation by a physician        including schedule II-V controlled substances.
least 24 months under the supervision of a li-        (an employment practice required by a number         The scope of prescriptive authority is defined by
censed physician or must be employed by a             of Maine hospitals). CNPs working pursuant to        the written agreement developed by the NP and
clinic or hospital that has a medical director who    medical delegation may now prescribe con-            collaborating physician. CNMs have statutory
is a licensed physician. The CNP must submit          trolled substance II medications after written re-   authority to prescribe based on a formulary mu-
written evidence to the BON upon completion           quest to the BoLM and their approval. APRNs          tually developed by the BON, BOM, and BOP.
of the required clinical experience.” After this      may receive and distribute drug samples in-          NPs and CNMs are authorized to obtain both fed-
24-month period, the CNP can practice inde-           cluded in the formulary for Rx writing.              eral and state DEA numbers. The Division of Drug
pendently. CNSs practice independently. CR-                                                                Control lists newly authorized NP and CNM pre-
NAs are responsible and accountable to a physi-                                                            scribers in their newsletter and sends a list of
cian or dentist. The APRN SOP, as defined in
regulation, includes standards of the national
                                                      Maryland
                                                      http://www.mbon.org
                                                                                                           authorized NP and CNM prescribers to pharma-
                                                                                                           cists. NPs and CNMs are legally allowed in most
certifying body and “consultation with or refer-      % 2007 Legislative Activity                          settings (those in which drug samples are state
ral to medical and other healthcare providers         SB 378 and HB 445 have been signed by the Gov-       authorized to be distributed) to dispense med-
when required by client healthcare needs”.            ernor requiring that the State Board of Nursing      ications. Prescription containers are labeled
CNPs and certified psychiatric CNSs may sign          consist of one member certified in an advanced       with the NP or CNM name.
documents for emergency involuntary commit-           practice nursing specialty.
ment through emergency departments. APRNs                  Regulations pertaining to CRNAs are pend-
are statutorily defined as “PCPs,” and may be
credentialed as Allied Staff for hospital privi-
                                                      ing. These require all CRNA graduates after Jan-
                                                      uary 2008 to hold a minimum of a master’s de-
                                                                                                           Massachusetts
                                                                                                           http://www.state.ma.us/reg/boards/rn/
leges. Admitting privileges are not granted in        gree.                                                http://www.mcnpweb.org
this authority. Workers’ compensation forms           I Legal Authority                                    % 2007 Legislative Activity
recognize CNPs and allow issuance of license          The Maryland Board of Nursing and Board of           S. 1226: A bill requiring health insurers to list NP’s
plates and cards for the physically disabled. Cur-    Medicine jointly regulate APN practice. APNs         as Primary Care Providers on their panel. This

www.tnpj.com                                                                                               The Nurse Practitioner • January 2008 21
  Twentieth Annual Legislative Update



  bill is sponsored by Massachusetts Coalition of          need to be submitted to the BON unless re-          reviewed annually. The DEA requires NPs and
  Nurse Practitioners MCNP.                                quested. Guidelines pertaining to prescriptive      CNMs to obtain DEA numbers for those pre-
        S. 1236, filed by a group of midwives and          practice shall include a defined mechanism to       scribing controlled substances. Schedule II con-
  nurse anesthetists seeking removal of the su-            monitor prescribing practices, including review     trolled substances may also be delegated if the
  pervisory language in the Nurse Practice Act.            with the supervising physician at least every 3     physician and NP or CNM are practicing within
                                                           months with the exception of initial prescription   a defined health facility (freestanding surgical
  I Legal Authority                                        of schedule II drugs, which requires review         outpatient facility, hospital, or hospice) and if, on
  The Massachusetts BON grants APNs authority              within 96 hours. Authorized APNs are allowed        discharge, the prescription does not exceed a
  to practice and regulates their practice. APNs           to request, receive, and dispense pharmaceuti-      7-day period. A supervising physician may dele-
  are defined as NPs, NAs, psychiatric clinical            cal samples. The prescription label and pad in-     gate in writing the ordering, receipt, and dis-
  nurse specialists (PCs) and CNMs. All APNs               clude the name of supervising physician and the     pensing of complimentary starter dose drugs
  practice in accordance with written guidelines           APN; however, the authorized APN signs the          other than controlled substances. Prescription
  developed in collaboration with the nurse and            prescription.                                       labels are labeled with the name of the physi-
  supervising physician. In all cases, the written                                                             cian.
  guidelines “designate a physician who shall pro-
  vide medical direction as is customarily ac-
  cepted in the specialty area.” If practicing in an
                                                           Michigan
                                                           http://www.michigan.gov/mdch/0,1607,7-132-          Minnesota
  institution, the nursing and medical administra-         27417_27529_27542—-,00.html                         http://www.nursingboard.state.mn.us
  tive staff must approve the guidelines. If there is      http://www.micnp.org/                               % 2007 Legislative Activity
  no nursing and medical administrative staff, the         I Legal Authority                                   SF 26: Amendment regarding examination for in-
  guidelines must be approved by the BON. Ad-              The BON authorizes advanced practice author-        dividuals operating X-ray equipment but pro-
  vanced practice R&Rs governing the ordering              ity as a specialty certification. Nurse special-    vides an exemption from the exam for certain
  of tests, therapeutics, and prescribing are pro-         ists are defined as CNMs, CRNAs, NPs. Nurse         healthcare practitioners, including CRNAs.
  mulgated by the BON in conjunction with the              specialists are not required to have physician          SF 26: Defines electronic transmission pre-
  BOM. All other areas of scope of practice are            collaboration or supervision, with the excep-       scription requirements and indicates that ”dis-
  exclusively under the BON. SOP is defined both           tion of prescriptive authority. Scope of practice   pense as written” must be specifically desig-
  in statute and regulation. Massachusetts does            is defined in statute, and under some HMOs and      nated, cannot be default
  not recognize APNs as PCPs and does not have             systems NPs are recognized as “PCPs.” Michi-
  “any willing provider” language in law. Creden-          gan does not have “any willing provider lan-        I Legal Authority
  tialing for hospital privileges varies according to      guage” in statute. Michigan statute does not        The Minnesota BON grants APRNs authority to
  hospital policies. Although Massachusetts does           specifically authorize nurse specialists to ad-     practice and regulates their practice. APRNs
  not have a minimum degree requirement for en-            mit patients or hold hospital privileges; how-      are defined as an RN certified by a national
  try into practice, national certification is required,   ever, according to the state nursing associa-       nursing certification organization acceptable
  which requires a minimum of a master’s degree            tion, this depends on the institution, but          by the BON to practice as a CNP, CNS, CNM, or
  to obtain.                                               hospitals generally grant these privileges.         CRNA. “The APRN must practice within a
                                                           Nurse specialists are required to have a mas-       healthcare system that provides for consulta-
  I Reimbursement                                          ter’s degree in nursing and national board cer-     tion, collaborative management, and referral
  FNPs, PNPs, and adult nurse practitioners are            tification to enter into practice.                  as indicated by the health status of the patient.”
  reimbursed at 100% of physician payment rate                                                                 Collaborative management is defined as a mu-
  for Medicaid unless the NP is employed by the            I Reimbursement                                     tually agreed on plan between an APRN and
  hospital in a hospital-based practice. Massa-            Medicaid directly reimburses all certified NPs      physician(s) that designates the scope of col-
  chusetts state law mandates reimbursement to             at 100% of the reimbursement rate. BC/BS di-        laboration necessary to manage the care of pa-
  NPs, PCs, CNMs, and NAs In accordance with               rectly reimburses all NPs, CNMs, and CRNAs,         tients in which the APRN and physician(s) have
  Chapter 302 of the Acts and Resolves of 1994.            however, the statute does not legally require in-   experience in providing care to patients with
  These include indemnity plans, nonprofit hos-            surance companies to credential, empanel, or        the same or similar medical problems. SOP for
  pital corporations, medical service corpora-             recognize nurse specialists                         CNPs is defined in statute, and CNPs are legally
  tions, and HMOs. BC/BS, Fallon and Neighbor-                                                                 recognized as PCPs. Minnesota state law does
  hood Health Plan credential NPs in private               I Prescriptive Authority                            not contain “any willing provider” language,
  practice settings to receive individual provider         Under the Michigan Public Health Code, a pre-       however. APRNs are legally authorized to ad-
  numbers. An HMO protection statute allows                scriber is defined as “a licensed health profes-    mit patients to a hospital and hold hospital priv-
  “other providers” to be listed on panels; how-           sional acting under the delegation and supervi-     ileges as defined within their SOP. Minnesota
  ever, the law does not specifically address              sion of and using, recording, or otherwise          does not identify a minimum degree require-
  APNs or require them to be listed as providers.          indicating the name of the delegating physician.”   ment for entry into practice; however, the state
                                                           NPs, CRNAs, and CNMs may prescribe noncon-          does require national board certification to en-
  I Prescriptive Authority                                 trolled substances as a delegated act of a physi-   ter practice.
  Massachusetts state law provides for prescrip-           cian. There is no requirement for a physician
  tive authority for NPs, CNMs, and PCs, includ-           countersignature. Under BOM administrative          I Reimbursement
  ing schedule II controlled substances. Autho-            rules, a physician may delegate prescriptive au-    APRNs may enroll with Medicaid as a provider
  rized APNs must apply to the Massachusetts               thority for schedule III-V controlled substances    and bill for services. FNPs, PNPs, GNPs, WH-
  Department of Public Health for state registra-          to NPs and CNMs if “the delegating physician        NPs, and ANPs are reimbursed by Medicaid at
  tion; then apply for a federal DEA number. Au-           establishes a written authorization,” containing    90% of the physician rate. CNPs, CNMs, CRNAs,
  thorized APNs have (1) prescribing guidelines            names and license numbers of the physician and      and CNSs in psychiatric health have legal au-
  mutually developed and agreed on by the nurse,           NP or CNM and the limitations or exceptions to      thority for private insurance reimbursement.
  and supervising physician; guidelines do not             the delegation. Written authorizations must be      Minnesota law prohibits HMOs and private in-

22 The Nurse Practitioner • Vol. 33, No. 1                                                                                                      www.tnpj.com
                                                                                                               Twentieth Annual Legislative Update



surers from requiring a physician’s co-signature      pervision of a physician, the insured shall be en-   tionally, APRNs are not legally authorized to ad-
when an APRN orders a laboratory test, X-ray,         titled to reimbursement whether the services are     mit patients or hold hospital privileges. NPs are
or diagnostic test.                                   performed by the physician or NP.                    required to hold a master’s degree in nursing
                                                                                                           and national certification to enter into practice
I Prescriptive Authority                              I Prescriptive Authority                             in Missouri.
APRNs who meet statutory requirements may             NPs have full prescriptive authority, including
prescribe, receive, dispense, and administer          Schedule II-V controlled substances, based on        I Reimbursement
drugs including controlled substances Sched-          the standards and guidelines of the NP’s national    Current law states “Any health insurer, nonprofit
ules II-V within the scope of their written agree-    certification organization and a BON-approved        health service plan, or HMO shall reimburse a
ment with a physician and within the practice         protocol that has been mutually agreed on by         claim for services provided by an APN, if such
specialty. CNPs, CRNAs, and CNSs must have a          the NP and qualified physician. The protocol         services are within the SOP of such a nurse.”
written agreement with a physician that defines       must outline diagnostic and therapeutic proce-       Medicaid reimbursement is made to APRNs en-
the delegated responsibilities related to pre-        dures and categories of pharmaceutical agents        rolled as Missouri Medicaid fee-for-service
scribing drugs and devices. CNMs have inde-           that may be ordered, administered, dispensed         providers and Medicaid-enrolled APRNs asso-
pendent Rx authority. The BON does not grant          and/or prescribed for patients with diagnoses        ciated with a federally qualified healthcare
prescriptive authority; however, they do have the     identified by the NP. NPs may receive and dis-       and/or rural healthcare facility. Medicaid reim-
authority to discipline the APRN if the prescrib-     tribute prepackaged medications or samples of        bursement is limited to services furnished by en-
ing practices are unsafe, unethical, or illegal. An   noncontrolled substances for which the NP has        rolled APRNs who are within the SOP allowed
authorized APRN who chooses to prescribe con-         Rx authority. Controlled substances (II-V) may       by federal and state laws and inpatient or out-
trolled substances must apply to the DEA and          be prescribed pursuant to additional BON rules       patient hospital services or clinic services fur-
verify compliance with Minnesota prescribing          and regulations: the NP must have a DEA num-         nished to the extent permitted by the facility. Re-
laws with the BON. APRNs have statutory au-           ber, completed a BON-approved educational            imbursement for services provided by APRNs is
thority to receive and dispense sample drugs          program, and submittal of a “controlled sub-         at the same rate and subject to the same limita-
within their authorized scope of practice.            stance prescriptive authority protocol” to the       tions as physicians.
                                                      BON. CNMs and CRNAs may order controlled
                                                      substances within a licensed healthcare facility     I Prescriptive Authority
Mississippi
http://www.msbn.state.ms.us
                                                      using BON-approved protocol or practice guide-
                                                      lines.
                                                                                                           Prescriptive authority for APRNs is limited to pre-
                                                                                                           scription drugs and devices without controlled
http://www.msnurses.org                                                                                    substances as delegated by a physician pur-
I Legal Authority                                                                                          suant to a written CP arrangement. Delivery of
The Mississippi BON grants APNs authority to
practice and regulates their practice. APNs are
                                                      Missouri
                                                      http://pr.mo.gov/nursing.asp
                                                                                                           such APRN healthcare services shall be within
                                                                                                           the APRN’s advanced clinical nursing specialty
defined as NPs, CRNAs, and CNMs and CNSs.             I Legal Authority                                    area and a mutual SOP with the physician, and
The R&Rs are jointly promulgated by the BON           The Missouri BON grants APRNs authority to           be consistent with the individual’s skill, training,
and BOM, and implemented by the BON. CNSs             practice and regulates their practice. APRNs         education, and competence. APRNs may re-
have title protection. NPs, CRNAs, and CNMs           are defined as NPs, CNSs, CNMs, and CRNAs.           ceive/dispense samples within their Rx author-
practice in a collaborative relationship with         APRNs practice in collaboration with physicians      ity. In certain instances, a state BNDD number
physicians in Mississippi. The collaborating          in Missouri. Collaborative practice includes         is required. Prescriptions written by a NP are la-
physicians’ practice must be compatible with          written agreements, written protocols, or writ-      beled with both the collaborating physician’s and
the NP’s practice. NPs must practice accord-          ten standing orders. Rules and Regulations de-       NP’s name.
ing to a BON-approved protocol agreed on by           fine the Collaborative Practice Rule (CP). Three
the NP and physician. NP applicants must sub-         focus areas in the CP rule include: (1) geographic
mit official evidence of graduation from a grad-
uate program with a concentration in the appli-
                                                      areas to be covered, (2) methods of treatment
                                                      that may be covered by CP arrangements, and
                                                                                                           Montana
                                                                                                           http://www.nurse.mt.gov
cant’s APN specialty. Practicing in a site not        (3) requirements for review of services provided     % 2007 Legislative Activity
approved by the BON, with a physician not ap-         pursuant to a CP arrangement. A written CP           HB 496 has been signed into law authorizing
proved by the BON, or according to a protocol         arrangement with a physician is not needed           ARNPs and PAs to complete medical examina-
not approved by the BON is in violation of the        when the APN is performing nursing acts con-         tions pertaining to traffic laws.
NPA R&Rs. SOP is defined in rules and regula-         sistent with the APRN’s skill, training, educa-      HB 497 has been signed into law and states that
tions. NPs are statutorily recognized as “PCPs”,      tion, and competence. A CP arrangement may           certification of a person as disabled for purposes
however, Mississippi law does not contain “any        be indicated to perform physician-delegated          of obtaining a permit to hunt from a vehicle may
willing provider” language. APNs are legally au-      medical acts within the mutual SOP of the physi-     be endorsed by an APRN or PA.
thorized to admit patients and hold hospital priv-    cian and APRN and consistent with the APRN’s
ileges. APNs are required to have a master’s de-      skill, training, education, and competence. CR-      I Legal Authority
gree in nursing and be nationally certified to        NAs practice under the direction of the surgeon      The Montana BON grants APRNs authority to
enter into practice.                                  or anesthesiologist. Individuals are recognized      practice and regulates their practice. APRNs
                                                      by their specific clinical nursing specialty area    are defined as NPs, CNSs, CNMs, and CRNAs.
I Reimbursement                                       as a CNS, NP, NM, or CRNA, which delineates          APRNs practice independently after completion
Medicaid reimbursement is available to APNs           their title and SOP as APRNs in rules and regu-      of specific curriculum requirements and a na-
at 90% of physician payment. Insurance law            lations. When practicing outside their recog-        tional certifying examination by a BON-recog-
specifies that whenever an insurance policy,          nized clinical nursing specialty, individuals must   nized national certifying body. According to the
medical service plan, or hospital service con-        practice and title as RNs only. Missouri law does    Montana BON, all APRNs involved in direct pa-
tract provides for reimbursement for any service      not recognize APRNs as “PCPs” and does not           tient care must have an approved quality assur-
within the SOP of a NP working under the su-          contain “any willing provider” language. Addi-       ance program in place. NP SOP is defined in

www.tnpj.com                                                                                               The Nurse Practitioner • January 2008 23
  Twentieth Annual Legislative Update



  Rule ARM 8.32.301, and NPs are statutorily rec-     tively and have joint responsibility for patient        an active certification/license in another state
  ognized as “PCPs.” Montana state law, how-          care, based on the SOP of each practitioner. The        or jurisdiction. If the applicant completed an APN
  ever, does not contain “any willing provider”       collaborative agreement is contained within the         program between July 1, 1992 and June 1, 2005,
  language. APNs are legally authorized to admit      integrated practice agreement (IPA). An IPA             the applicant must hold a current national certi-
  patients and hold hospital privileges; however,     specifies, “The collaborating physician shall be        fication as an advanced practitioner of nursing
  this varies according to the rules and bylaws of    responsible for supervision through ready avail-        OR hold a bachelor’s degree in nursing from an
  each hospital. APRNs must have a master’s de-       ability for consultation and direction of the ac-       accredited school AND must have worked 800
  gree in nursing and hold national certification     tivities of the NP.” If, after diligent effort, an NP   hours in APN practice during the 5 years imme-
  to enter into practice. All APRNs must achieve      is unable to obtain an IPA with a physician, the        diately preceding the application OR have com-
  mandatory continuing education hours for re-        APRN Board may waive the requirement for an             pleted a program designed to prepare an ad-
  newal every 2 years.                                IPA if the NP has demonstrated proper course            vanced practitioner of nursing in the preceding
                                                      work, holds a master’s degree or higher in nurs-        2 years. If the applicant completed an APN pro-
  I Reimbursement                                     ing, has completed 2,000 hours under the super-         gram after June 1, 2005, the applicant must hold
  Medicaid reimburses APRNs at 85% of physi-          vision of a physician, and will practice in a geo-      a master’s degree in nursing or related health
  cian payment. Montana law requires indemnity        graphic area where there is a shortage of               field. APNs in Nevada practice in collaboration
  plans to reimburse APRNs for all areas and ser-     healthcare services. NP SOP is defined in statute       with a physician. The APN must keep written
  vices for which a policy would reimburse a          and includes illness prevention, diagnosis, treat-      protocols at every job site, together with a col-
  physician; however, HMOs are not included in        ment, and management of common health prob-             laborative agreement signed by a BOME-ap-
  the indemnity insurers’ law, mandatory cover-       lems and chronic conditions. “PCP” status and           proved physician. APN SOP is defined in regu-
  age for APRNs does not apply to HMOs. APRNs         “any willing provider” language was not re-             lation and includes performance of “designated
  receive 85% of the physician payment from           ported in the survey. NPs without a master’s or         acts of medical diagnosis, prescribe therapeu-
  BC/BS. Medicare reimbursement consistent            doctoral degree, and/or at least 2,000 hours of         tic or corrective measures, and prescribe con-
  with 1990 federal guidelines is in effect. APRNs    physician-supervised practice must also have            trolled substances, poisons, dangerous drugs
  are included as providers for workers’ com-         jointly approved protocols. NPs licensed after          and devices.” APNs are not recognized as
  pensation.                                          1996 must have a master’s or doctoral degree to         “PCPs” under state law; however, APNs are
                                                      practice July 1, 2007, an NP in women’s health          legally authorized to admit patients to the hospi-
  I Prescriptive Authority                            and neonatal practice will also be required to          tal and hold hospital privileges.
  APRNs who desire Rx authority must apply for        have a masters or doctoral degree. Nebraska
  recognition by the BON through the recommen-        requires national board certification to enter          I Reimbursement
  dation of the Prescriptive Authority Committee,     practice.                                               APNs are recognized by insurance companies
  consisting of BON members. APRNs with Rx au-                                                                and receive third-party reimbursement. Reim-
  thority are authorized to prescribe all medica-     I Reimbursement                                         bursement from private insurance is at the same
  tions, including Schedules II-V controlled sub-     State legislation mandating third-party reim-           rate as the physician payment; however, Med-
  stances using their own DEA number, and are         bursement for NPs does not exist; consequently,         icaid reimbursement is available to all APNs at
  permitted to receive and dispense drug samples.     some NPs have been refused recognition as a             85% of physician reimbursement.
  Authority to prescribe is not dependent on any      provider. Medicaid reimburses NPs at 100% of
  other health professional. Prescribing APRNs        physician payment.                                      I Prescriptive Authority
  must have a quality-assurance program in place,                                                             BON-authorized APNs may prescribe controlled
  with a defined process of referral. The quality     I Prescriptive Authority                                substances, including controlled substance II-
  assurance method must be BON-approved be-           Nebraska NPs are authorized full prescriptive           V, poisons, and dangerous drugs and devices
  fore issuance of prescriptive authority and in-     authority including Schedules II-V medications,         pursuant to a protocol approved by a collabo-
  cludes 15 charts or 5% of all APRN charts re-       as defined in their statute. July 14, 2006 the limi-    rating physician: “A protocol must include that
  viewed quarterly by an APRN or physician in the     tation of prescribing Schedule II controlled sub-       an APN shall not engage in any diagnosis, treat-
  same specialty. Additional continuing education     stance for pain control only up to 72 hours, was        ment, or other conduct which the APN is not
  for prescriptive authority (additional to CE re-    removed. NPs may request, receive, and dis-             qualified to perform.” APNs may prescribe con-
  quirement for practice authority) is required for   pense pharmaceutical samples if the samples             trolled substances, poisons, and dangerous
  renewal every 2 years.                              are drugs within their prescribing authority. CR-       drugs and devices if authorized by the BON, and
                                                      NAs prescribe within their specialty practice;          if a certificate of registration is applied for and
                                                      authority is implied in the statute. Qualified CR-      obtained from the BOP. APNs register for their
  Nebraska
  http://www.hhs.state.ne.us/index.htm
                                                      NAs, NPs, and CNMs may receive DEA numbers.             own DEA numbers. APNs may pass a BON ex-
                                                                                                              amination for dispensing and, after passing the
  % 2007 Legislative Activity                                                                                 examination with BON approval, apply to the
  LB 256 passed the Nebraska State Legislature
  in 2005 and became effective July 1, 2007. This
                                                      Nevada
                                                      http://www.nursingboard.state.nv.us
                                                                                                              BOP for a dispensing certificate. Samples are
                                                                                                              not considered “dispensing”; APNs with pre-
  “umbrella” legislation defines APRN to include      I Legal Authority                                       scriptive authority may receive and distribute
  NPs, CRNAs, CNMs, and CNSs. It also provides        The Nevada BON grants APNs authority to prac-           samples without having dispensing authority.
  for the licensure of CNSs. A new APRN Board         tice and regulates their practice. To qualify for
  became effective on July 1, 2007.                   APN certification, an application must have com-

  I Legal Authority
                                                      pleted an education program to prepare an APN
                                                      (NP, CNS, CNW, nurse psychotherapist). If the
                                                                                                              New Hampshire
                                                                                                              http://www.state.nh.us/nursing
  The Nebraska APRN Board grants APRNs au-            applicant completed an APN program before               % 2007 Legislative Activity
  thority to practice and regulates their practice.   July 1, 1992, the applicant must have worked 800        HB 345, relative to certification of death certifi-
  APRNs are defined as NPs, CRNAs, CNMs, and          hours in APN practice during the 5 years imme-          cates. Effective immediately, NH-licensed
  CNSs. NPs and physicians practice collabora-        diately preceding the application and must have         ARNPs have statutory authority to certify a NH

24 The Nurse Practitioner • Vol. 33, No. 1                                                                                                   www.tnpj.com
                                                                                                                  Twentieth Annual Legislative Update



death record. As of January 1, 2008, all death         practice and regulates their practice. APNs are        ulates CRNAs and CNSs. CRNAs seeking initial
records must be certified electronically to the        defined as NPs and CNSs. APNs practice in col-         licensure must be at the master’s level or higher.
NH Department of Vital Statistics.                     laboration with physicians and are required to         CRNAs work in collaboration with a physician
     HB 673, allowing ARNPs to certify walking         have a Joint Protocol with the collaborating           and have Rx authority including Schedules II-V
disabilities. Effective August 17, 2007, NH-li-        physician for prescribing purposes only. SOP for       controlled substances. CNSs must be master’s
censed ARNPs will have statutory authority to          APNs is defined in statute. APNs are recognized        prepared and certified by a national certifying
certify for walking disability plates and placards     as “PCPs”; however, New Jersey does not have           nursing organization. CNSs “make independent
to the NH Department of Motor Vehicles.                “any willing provider” language in statute. APNs       decisions”; have “prescriptive authority,” in-
     NUR 302.04(a)(4): The NH BON undertook an         are legally authorized to admit patients and hold      cluding Schedules II-V controlled substances;
extensive revision of the rules in 2006/07. Among      hospital privileges; however, this is not defined      and can distribute prepackaged drugs. CNMs
the changes was a reduction in the number of           by statute or regulation. Privileges are deter-        are regulated by the Department of Health. CNPs
specialty categories (4) to which an ARNP may          mined through the credentialing/privileging            can serve as “acute, chronic, long-term, and
be licensed: Adult; Pediatric, CRNA and CNM.           process of individual healthcare institutions.         end-of-life health care providers.”
In addition, one fee will now cover one or more        APN applicants must be masters prepared in
categories.                                            nursing and national board certification is re-        I Reimbursement
                                                       quired to enter into practice in New Jersey.           Statutory authority for third-party reimbursement
I Legal Authority                                                                                             for NPs and CNSs has been in effect since 1987;
The New Hampshire BON grants ARNPs author-             I Reimbursement                                        however, reimbursement is not legally mandated
ity to practice and regulates their practice. Reg-     Private health plans, including Medicaid-man-          for CNP services, thus CNPs continue to meet
ulatory changes now recognize adult and PNPs,          aged care plans, are permitted to credential           resistance in being listed as PCPs with some
CRNAs, and CNMs. ARNPs do not require physi-           APNs as “PCPs,” but are not required to recog-         companies. FNPs and PNPs receive Medicaid
cian collaboration or supervision. ARNP SOP is         nize or reimburse them. Medicaid fee-for-ser-          reimbursement at 85% of physician payment. All
defined in statute. ARNPs are statutorily recog-       vice programs reimburse APNs at approximately          three of the managed care groups contracted
nized as “PCPs” in NH; however, state law does         85% of the physician rate, but the rate may vary       to provide Medicaid coverage have contracts
not include “any willing provider” language.           according to procedure and setting. BC/BS must         with NPs.
ARNPs may admit patients and hold hospital priv-       reimburse APNs directly if the reimbursed ser-
ileges; however, this is institutionally driven. The   vice can be performed within the APN’s SOP and         I Prescriptive Authority
minimum academic degree required to enter into         the APN is not an employee of a physician or an        CNPs have full, independent prescriptive au-
practice is a master’s degree in nursing and na-       institution. The state health benefits plan cover-     thority, including Schedules II-V controlled
tional certification by a BON-recognized certifi-      ing all public employees directly pays some            substances. BON prerequisites to prescribe
cation agency is required.                             APNs.                                                  controlled substances include experience with
                                                                                                              Rx writing, a state-controlled substance li-
I Reimbursement                                        I Prescriptive Authority                               cense, and a DEA number. Each CNP must
All major insurance companies, hospital service        APNs credentialed by the BON have full pre-            maintain a formulary. CNSs must have gradu-
corporations, medical service corporations, and        scriptive authority, including Schedules II-V con-     ate-level pharmacology, pathophysiology, a
nonprofit health service corporations must re-         trolled substances in accordance with a joint pro-     physical assessment course, and prescribe in
imburse ARNPs when the insurance policy pro-           tocol, which has been established by the APN           collaboration with a physician, CNP, or CNS
vides for any service that may be legally per-         and the collaborating physician. The joint proto-      with Rx authority during a 400-hour preceptor-
formed by the ARNP and such service is                 col is required for prescribing purposes only and      ship before they can prescribe independently.
rendered. ARNPs are recognized as PCPs by              is not a collaborative agreement for general prac-     CNMs have Rx authority; the Department of
several HMOs in the state. Medicaid reimburses         tice. APNs must apply for both a state controlled      Health has rule-making authority. CRNAs who
ARNPs at 100% of physician payment.                    dangerous substance number and a federal DEA           meet prescriptive authority requirements may
                                                       number. APNs are authorized to request, receive,       collaborate independently and prescribe and
I Prescriptive Authority                               and dispense pharmaceutical samples.                   administer therapeutic measures, including
BON-licensed ARNPs have plenary authority to                                                                  dangerous drugs and controlled substances
prescribe controlled and noncontrolled drugs                                                                  within emergency procedures, perioperative
from the official exclusionary formulary deter-
mined by the Joint Health Council, whose mem-
                                                       New Mexico
                                                       http://www.state.nm.us/nursing
                                                                                                              care, or perinatal care environments. CNPs and
                                                                                                              CNSs with prescriptive authority may distrib-
bership consists of three ARNPs appointed from         http://www.nmnpc.org                                   ute dangerous drugs and Schedules II-V con-
the BON, three physicians appointed by the             I Legal Authority                                      trolled substances that have been prepared,
BOM who work with ARNPs, and three                     The New Mexico BON grants APRNs authority              packaged, or prepackaged by a pharmacist or
PharmD’s appointed by the BOP. ARNPs are as-           to practice and regulates their practice. APRNs        pharmaceutical company. Prescription labels
signed a DEA number on request and after li-           are defined as CNP, CRNA, and a CNS. CNPs              are labeled with the CNP name, where appro-
censure as an ARNP. ARNPs are authorized to            practice independently without physician super-        priate.
request, receive, and dispense pharmaceutical          vision or collaboration requirements. CNP SOP
samples. Prescription labels are labeled with          is defined in statute 61.3.23.2 of Chapter 61, Arti-
the ARNP name.                                         cle 3 of the New Mexico Statutes. CNPs are
                                                       statutorily recognized as “PCPs”; however, New
                                                                                                              New York
                                                                                                              http://www.op.nysed.gov/nurse.htm
                                                       Mexico does not have “any willing provider” lan-       http://www.thenpa.org/
New Jersey
http://www.state.nj.us/lps/ca/medical.htm
                                                       guage contained within the statutes. CNPs are
                                                       legally authorized to hold admitting and hospital
                                                                                                              http://www.nysna.org
                                                                                                              % 2007 Legislative Activity
http://www.njsna.org                                   privileges. A master’s degree in nursing or higher     Many of The NPA’s sponsored and supported
I Legal Authority                                      and national board certification is required to        bills did advance but ultimately were negatively
The New Jersey BON grants APNs authority to            enter into practice as a CNP. The BON also reg-        impacted by the end-of-session breakdown of

www.tnpj.com                                                                                                  The Nurse Practitioner • January 2008 25
  Twentieth Annual Legislative Update



  the legislative process this year. Several bills      are authorized to diagnose, treat, and prescribe     regulated by the BON only. APRNs are defined
  passed either the Senate or Assembly but not          in accordance with collaborative practice. The       as NPs, CRNAs, CNSs, and CNMs. According
  both houses. The following is a list of The NPA       written agreement must include a provision for       to the North Carolina Nurses Association, NPs
  sponsored and supported bills and their status        dispute resolution between the NP and the            legally practice under a supervisory relation-
  at the end of the 2007 Regular Legislative Ses-       physician and provisions for a review by the         ship with a physician; however, this is referred
  sion:                                                 collaborating physician of a patient record sam-     to as a collaboratory practice. Collaborative
       S.599-A (Hannon)/A.7074-A (John): NP Au-         ple at least every 3 months. NPs are legally au-     practice must include a written collaborative
  thorization to Sign Death Certificates passed the     thorized to hold admitting privileges. A master’s    practice agreement (CPA) with a physician for
  Senate but remained in the Assembly Rules Com-        degree in nursing is required to enter into prac-    continuous availability and ongoing supervision,
  mittee.                                               tice; however, national board certification is not   consultation, collaboration, referral, and evalu-
       S.3094 (Volker)/A.5477 (Gottfried): NP Re-       required.                                            ation. After the first 6 months of NP practice, in
  imbursement Assurance Act, which would                                                                     which documented face-to-face meetings are
  have assured health plans do not deny reim-           I Reimbursement                                      required, NPs and physicians may meet by
  bursement for services provided by NPs act-           NPs of all specialties may register as Medic-        phone or electronically. The CPA also includes
  ing within their lawful scope of practice. This       aid providers and be reimbursed at 100% of the       the drugs, devices, medical treatments, tests,
  bill remained in the Insurance Committee in           physician rate. Nurses continue to be qualified      and procedures that may be prescribed, or-
  both houses.                                          providers and NPs are specifically mentioned         dered, and performed by the NP as well as a
       S.598 (Hannon)/A.8162 (Gottfried): NP Do Not     as qualified “primary care gatekeepers.” A law       plan for emergency services. The supervising
  Resuscitate Orders passed the Assembly, but           regulates the practice of HMOs: Provisions are       physician does not have to be on site. The NP
  remained in the Heath Committee in the Senate.        provider-neutral and apply equally to physician      shall be prepared to demonstrate to the BON or
       S.3093 (Volker)/A.6342 (Gottfried): NP Reim-     and nonphysician providers. Although there is        BOM the ability to perform medical acts as out-
  bursement Bill, Ensures that health plans that        no guarantee that APNs will have a role in man-      lined in the CPA. NP scope of practice is defined
  provide reimbursement to subscribers for cer-         aged care delivery, their rights are assured.        in both statute and regulation (21 NCAC
  tain physician services not exclude licensed and      The law also prohibits “gagging” healthcare          36.0800.0814). NPs are not recognized as “PCPs”
  certified nurse practitioners from their primary      providers, establishes due process for termi-        and North Carolina statutes do not contain “any
  care and specialty provider networks and must         nation of provider contracts, allows for access      willing provider” language. State law does not
  provide reasonable reimbursement to sub-              to specialty providers, includes continuity of       prohibit NPs from holding admitting and hospi-
  scribers who choose to receive such services          care provisions for ongoing care with providers      tal privileges; however, these are granted on a
  from a nurse practitioner. This bill passed the As-   outside of the plan, and requires the commis-        facility-by-facility basis. New NPs must have a
  sembly, but remained in the Heath Committee in        sioner of health to determine that there are suf-    master’s degree in nursing or in a field with pri-
  the Senate.                                           ficient providers to meet the covered patients’      mary focus on nursing and national board cer-
       S.1631-A (Maziarz)/A.5847-A(John) NP             needs. ‘Willing Provider’ legislation has been       tification is required to enter into practice. CR-
  Workers Compensation, was moved by the Sen-           proposed; the public health law would specify        NAs are regulated solely by the BON and do not
  ate Labor Committee to the Senate Rules Com-          “No HMO shall discriminate against any               have prescriptive authority. CNMs have their
  mittee, and remained in the Assembly Labor            provider who is located within the geographic        own separate statute and are regulated by a
  Committee.                                            coverage area of the health benefit plan and         midwifery joint committee. CNS recognition and
       S.5098 (Trunzo)/A.8430 (Morelle) NP Dis-         who is willing, capable, and can meet the terms      SOP is regulated by the BON, but does not in-
  tinctive License Plate, authorizes a distinctive      and conditions for participation.”                   clude prescriptive authority. CNSs with master’s
  license plate for members of the Nurse Practi-                                                             degrees in psychology/mental health may inde-
  tioner Association New York State. This bill was      I Prescriptive Authority                             pendently practice psychotherapy. All APRNs
  moved by the Senate Transportation Commit-            NPs have full prescriptive authority, including      are allowed to form corporations with physi-
  tee to the Senate Rules Committee, and re-            Schedule II-V controlled substances. NPs may         cians; however, CRNAs can only incorporate
  mained in the Assembly Transportation Com-            order drugs, devices, immunizing agents, tests,      with anesthesiologists.
  mittee.                                               and procedures in accordance with the prac-
       S.4647 (Hannon) /A.8392 (Gottfried): NP Im-      tice agreement and practice protocols without        I Reimbursement
  munization Bill authorizes nurse practitioners to     co-signature. NPs may receive and dispense           FNPs receive Medicaid reimbursement at 100%
  certify that an immunization may be detrimental       pharmaceutical samples if appropriately la-          of the physician rate for primary care activities.
  to a child’s health. This legislation remained in     beled and handed directly to the patient. Pre-       NPs who are enrolled in mental health programs
  the Senate Health Committee, and was ad-              scription labels are labeled with the NP’s name.     receive 85% of the physician rate. CHAMPUS
  vanced from the Assembly Health Committee to          Midwives are authorized to prescribe and ad-         also reimburses NPs. Statutory authority for
  the Assembly Calendar.                                minister drugs, immunizing agents, diagnostic        third-party reimbursement for NPs provides di-
                                                        tests, and devices, and order laboratory tests       rect reimbursement to NPs for services within
  I Legal Authority                                     limited to the practice of midwifery; they can       their scope that are reimbursable to a non-nurse
  The New York State Education Department               dispense pharmaceutical samples.                     provider. “No Discrimination in the Selection of
  grants NPs authority to practice and regulates                                                             Providers,” patients may choose services from
  their practice pursuant to Title VIII, Article 139                                                         a provider list that includes APRNs. The section,
  of NYS Education Law. APNs are defined as
  NPs. NPs are licensed as RNs by the BON and
                                                        North Carolina
                                                        http://www.ncbon.org
                                                                                                             “Provider Directory Information,” requires that
                                                                                                             every health benefit plan use a provider network
  certified by the State Education Department as        http://www.ncnurses.org/practice_npcouncil_          directory that includes all types of participating
  NPs. NPs are legally required to practice in col-     home.html                                            providers, including APRNs, upon participating
  laboration with physicians in accordance with         I Legal Authority                                    providers’ written request.
  a written practice agreement and written prac-        The North Carolina BON and the North Carolina
  tice protocols. NP SOP is defined in statute. NPs     BOM jointly grant NPs authority to practice and      I Prescriptive Authority
  are considered independent practitioners who          regulate their practice. CRNAs and CNSs are          NPs and CNMs have full prescriptive author-

26 The Nurse Practitioner • Vol. 33, No. 1                                                                                                  www.tnpj.com
                                                                                                                  Twentieth Annual Legislative Update



ity, including Schedules II-V controlled sub-        alternative arrangements for collaboration re-           I Prescriptive Authority
stances that are identified in their CPA. Dis-       garding prescriptive practices in the absence            Ohio state law grants full prescriptive authority
pensing may be done under specific conditions        of the physician. Communication between the              to qualified CNPs, CNMs, and CNSs on a vol-
and if a dispensing license has been obtained.       APRN and physician must occur at least once              untary basis, which includes Schedules II-V
NPs may refill legend drugs up to 1 year and         every 2 months. An affidavit from the physician          controlled substances under the following rules
may write controlled substance prescriptions         must be submitted, acknowledging the manner              and in collaboration with a physician. A sepa-
for 30 days; NPs may not refill any controlled       of review and approval of the planned prescrip-          rate approval process is required to apply for
substances. NPs with controlled substances           tive practices and that the APRN’s SOP is “ap-           prescriptive authority. APNs prescribe based
in their collaborative practice agreements must      propriately related” to the collaborating physi-         upon a formulary developed and approved by
obtain a DEA number (in addition to their pre-       cian’s specialty. The collaborative agreement            the Interdisciplinary Committee on Prescriptive
scribing number issued at the time of their ap-      requirement is solely for prescriptive authority.        Governance. The formulary lists (1) permitted
proval as NPs). Prescription labels include the      APRNs with prescriptive authority may apply for          drugs, (2) drugs excluded from use, (3) physi-
NP name only.                                        a DEA number.                                            cian-initiated drugs that can be renewed or ad-
                                                                                                              justed, and (4) drugs with special parameters.
                                                                                                              APNs are not permitted to prescribe newly re-
North Dakota
http://www.ndbon.org
                                                     Ohio
                                                     http://www.nursing.ohio.gov
                                                                                                              leased drugs until the Committee has reviewed
                                                                                                              them, and those who wish to prescribe drugs
I Legal Authority                                    http://www.ohnurses.org/                                 for off-label use must include parameters for
The North Dakota BON grants APRNs authority          % 2007 Legislative Activity                              off-label use in the standard care arrangement.
to practice and regulate their practice. APRNs       HB 253 (Rep. Oeslager): If passed, would en-             Schedule II controlled substances are limited
are defined as NPs, CNSs, NMs, and NAs, NPs          hance the APN’s authority to prescribe Sched-            to the care of terminally ill patients after physi-
practice in collaboration with a physician in        ule II controlled substances.                            cian-initiation and only for a 24-hour period.
North Dakota for prescriptive authority only. The        HB 67 (Rep. Patton): Passed and allows APNs          DEA registration is required. Pharmacists log
SOP for a NP is based upon the Decision-Mak-         to authorize an individual to obtain a handicap          the prescription by nurse prescriber, not by a
ing Model and as defined in specialty certifica-     designation on a motor vehicle.                          physician. The BOP and BON agree that the
tion. NPs are required to submit a SOP statement                                                              nurse with Rx authority may request, receive,
for review by the BON to apply for and renew         I Legal Authority                                        sign for, and distribute sample medications
their APRN license. APRN applicants for initial      The Ohio BON grants APNs authority to prac-              within their scope and within the formulary. Ac-
licensure must have a master’s degree with com-      tice and regulates their authority. APNs are de-         cording to the law, (1) no fee may be charged
pletion of an advanced practice track and na-        fined as CNPs, CRNAs, CNMs, and CNSs. Legal              for a sample, (2) only a 72-hour supply (or small-
tional board certification.                          authority to practice requires a collaborative           est commercially available size) may be dis-
                                                     practice arrangement between a physician and             pensed, and (3) samples of controlled sub-
I Reimbursement                                      a CNP, CNM, or CNS. These groups of nurses               stances may not be dispensed.
FNPs, PNPs, and CNMs, receive Medicaid re-           (except Psych/Mental Health CNSs) must de-
imbursement at 75% of the physician rate and         velop a standard care arrangement (practice
CNMs at 85% of physician rate. BCBSND reim-
burses CRNAs, CNMs, CNSs, and NPs based on
                                                     agreement) with the collaborating physician.
                                                     CRNAs are required to practice with a super-
                                                                                                              Oklahoma
                                                                                                              http://www.lsb.state.ok.us
the lesser of the 1) provider’s billed charges or,   vising physician. The SOP for CNPs is defined            http://www.ok.gov/nursing
2) 75% of the BC/BS physician payment system         in statute, ORC 4723.43. APNs are statutorily rec-       % 2007 Legislative Activity
in effect at the time the services are rendered.     ognized as providing “primary care services;”            OAC 485:10 was revised: In Subchapter 15, the
Any certified NP is eligible for a Medicaid          however, they are not currently authorized to            revisions in 485:10-15-5 clarified requirements
provider number. State law authorizes reim-          admit patients or hold hospital privileges. Cur-         for reinstatement and return to active of ad-
bursement for health services provided in the        rently, CNPs, CNSs, and CNMs do not have                 vanced practice recognition. In 485:10-15-6, the
scope of licensure by nurses with advanced li-       statutory authority to admit patients or hold hos-       specialty category for School Nurse Advanced
censure and mental health in their SOP. APRNs        pital privileges. Applicants for licensure must          Practice Registered Nurse was deleted since
are statutorily recognized as “PCPs.” Providers      have a master’s degree in nursing or a related           this certification examination is no longer of-
practicing more than 20 miles from the follow-       field that qualifies the individual to sit for the na-   fered. In Subchapter 16, requirements for re-
ing cities: Williston, Dickson, Minot, Bismark,      tional certifying exam. Certification from a na-         newal, reinstatement, and return to active sta-
Jamestown, Devils Lake, Grand Fords, Wah-            tional certifying body is also required to enter         tus for prescriptive authority were clarified.
peton, and Fargo shall be reimbursed the lesser      into practice.
of 1) provider’s billed charges or, 2) 85% of the                                                             I Legal Authority
BCBSND physician payment system(s) in effect         I Reimbursement                                          The Oklahoma BON grants APNs authority to
at the time services are rendered.                   Ohio’s Medicaid program recognizes CNPs cer-             practice and regulates their practice. APNs are
                                                     tified in family, adult, acute care, geriatric, neona-   defined as ARNPs, CNMs, CNSs, and CRNAs.
I Prescriptive Authority                             tal, pediatric, women’s health, and OB/GYN,              ARNPs function independently with the excep-
Authorized APRNs may prescribe legend drugs          CNMs, CRNAs, and CNSs certified in gerontol-             tion of prescriptive authority, which requires su-
and Schedule II-V controlled substances. For         ogy,medical/surgical, and oncology nursing spe-          pervision by a physician. APNs practice within
prescriptive authority, the APRN must submit a       cialties. Managed care organizations vary on             a SOP as defined by the NPA. The SOP for an
statement to the BON addressing methods and          empanelment. There are no legislative restric-           ARNP is defined in regulation and is further iden-
frequency of the collaboration for prescriptive      tions for an APN being listed on managed care            tified in specialty categories that delineate the
practices, which must occur as client needs dic-     panels; however, insurance companies are                 population served such as adult ARNP, family
tate but no less than once every 2 months; doc-      statutorily mandated to reimburse CNMs. Work-            ARNP, and so forth. ARNPs are listed as “primary
umentation methods of the collaboration              ers’ compensation continues to reimburse CNPs,           care managers” in the Oklahoma Medicaid sys-
process regarding prescriptive practices; and        CRNAs, and CNSs.                                         tem. Authorization to admit patients or hold hos-

www.tnpj.com                                                                                                  The Nurse Practitioner • January 2008 27
  Twentieth Annual Legislative Update



  pital privileges was not reported in this survey.        Final approval of regulations adopted in 2006
  CNSs must hold a master’s degree in nursing,
  and ARNPs and CNSs must be nationally board
                                                       was received by the DEA. This allows the Board
                                                       to begin issuing prescriptive and dispensing au-
                                                                                                           Pennsylvania
                                                                                                           http://www.dos.state.pa.us/nurse
  certified to enter into practice.                    thority to CNSs, including Schedule II-V medica-    http://www.pacnp.org
                                                       tions.                                              % 2007 Legislative Activity
  I Reimbursement                                                                                          On September 18, 2007, Act 48 of 2007, the
  Oklahoma’s Medicaid plan includes ARNPs as           I Legal Authority                                   amendment to the Professional Law, became
  “primary care managers.” State law does not          The Oregon BON grants APNs authority to prac-       effective. The law sets forth specific practices
  mandate reimbursement of ARNPs; however, the         tice and regulates their practice. APNs are de-     for CRNPs in PA and requires the CRNP to
  Oklahoma State and Education Employees In-           fined as NPs (which includes CNMs), CNSs, and       hold malpractice insurance. Also, on July 20,
  surance company does recognize ARNPs as              CRNAs. Nurses in all three categories of ad-        2007, Act 49 of 2007 was signed into law. This
  providers. Negotiation continues with other          vanced practice must be credentialed with a         act amends the Professional Nursing Law to
  third-party insurers.                                certificate by the BON. APNs in Oregon are in-      provide official recognition of the CNS.
                                                       dependent and are not required to have a col-
  I Prescriptive Authority                             laboratory or supervisory relationship with a       I Legal Authority
  The BON regulates optional prescriptive author-      physician. SOP is defined in regulation, Division   The Pennsylvania BON grants CRNPs authority
  ity for ARNPs, CNSs, and CNMs, which includes        50 of the Nurse Practice Act. Division 56 ad-       to practice and regulates their practice. A CRNP
  controlled substances Schedules III-V. Physi-        dresses prescriptive and dispensing authority       performs the expanded role in collaboration with
  cian supervision is required for the prescriptive    for both NPs and CNSs. NPs are statutorily rec-     a medical or osteopathic physician. Collabora-
  authority portion of advanced practice. Pre-         ognized as “PCPs” and permissive statutes al-       tion is defined as a process in which a CRNP
  scribing parameters include: (1) not be on the       low for NP hospital privileges. NPs may, how-       works with one or more physicians to deliver
  exclusionary formulary approved by the board,        ever, be refused privileges only on the same        healthcare services within the scope of the
  (2) must be within the ARNP, CNM, and CNS SOP,       basis as other providers. A master’s degree in      CRNP’s expertise. The CRNP’s SOP is defined in
  (3) include Schedules III-V controlled sub-          nursing or doctoral degree in nursing is required   statute and regulation. CRNPs are recognized
  stances (7-day supply) if state narcotics and DEA    for the CNS and the NP or CRNA educated af-         as PCPs by DPW and many insurance compa-
  registrations are obtained, and (4) include sign-    ter specific dates (see regulations for further     nies but there are some managed care compa-
  ing to receive drug samples. ARNPs, CNMs, and        information); however, national board certifi-      nies who do not recognize CRNPs as PCP. The
  CNSs must have 45 contact hours or 3 acade-          cation is not required to enter into practice in    Pennsylvania Department of Health Regulations
  mic hours of pharmacology in the 3 years imme-       Oregon.                                             authorizes a hospital’s governing body to grant
  diately preceding the initial application for Rx                                                         and define the scope of clinical privileges to in-
  authority and 15 contact hours or 1 academic         I Reimbursement                                     dividuals, with advice of the medical staff. After
  hour every 2 years for renewal. CRNAs have au-       NPs are entitled by law to reimbursement by         February 5, 2005, CRNPs must have a master’s
  thority to “order, select, obtain, and administer    third-party payers. APNs are designated as PCPs     degree and pass a national certification exami-
  legend drugs, Schedules II-V controlled sub-         on several HMO and managed care plans. Med-         nation; CRNPs without a master’s degree/certi-
  stances, devices, and medical gases, when en-        icaid reimburses NPs for services within their      fication are accepted if their CRNP was granted
  gaged in preanesthetic preparation and evalua-       SOP at the same rate as physicians. Numerous        prior to the law’s effective date. CNSs are not
  tion, anesthesia induction, maintenance and          administrative rules and statutes include NPs,      specifically defined or regulated beyond the RN
  emergence, and postanesthesia care.” Regula-         such as special education physical examina-         SOP. The BON does not track, monitor, or license
  tion is by the BON. The CRNA functions under         tions (Department of Education) and chronically     CRNAs. The BOM licenses and regulates CNMs.
  the supervision of a medical physician, DO, po-      ill and disabled motorist examinations (Depart-
  diatric physician, or dentist licensed in Oklahoma   ment of Motor Vehicles).                            I Reimbursement
  and under conditions in which timely on-site con-                                                        Third-party reimbursement is available for the
  sultation by such medical physician, DO, podi-       I Prescriptive Authority                            CRNP, CRNA, certified enterostomal therapy
  atric physician, or dentist is available. CRNAs      Regulation of Rx authority is under the sole au-    nurse, certified community health nurse, certi-
  must obtain state narcotics and DEA registra-        thority of the BON. The BON determines the for-     fied psych/mental health nurse, and certified
  tions to order Schedules II-V controlled sub-        mulary from which NPs and CNSs can pre-             CNS, provided the nurse is certified by a state or
  stances.                                             scribe, including Schedules II-V controlled         a national nursing organization recognized by the
                                                       substances. The NP/CNS formulary is based on        BON. Medicaid reimburses CRNPs and CNMs at
                                                       Drug Facts & Comparisons; new drugs are             100% of physician payment for certain services.
  Oregon
  http://www.oregon.gov/OSBN
                                                       added to the formulary at each BON meeting.
                                                       Criteria for inclusion: (1) Is the drug appropri-
                                                                                                           The State Department of Health allows HMOs to
                                                                                                           recognize CRNPs as primary care gatekeepers.
  http://npo.oregonrn.org/                             ate for NP/CNS SOP? (2) Would the NP/CNS use
  % 2007 Legislative Activity                          the drug? (3) Is the drug FDA-approved? Ore-        I Prescriptive Authority
  HB 2247 passed, expanding and clarifying the         gon has legislated independent or plenary au-       The BON confers prescriptive authority, includ-
  ability of NPs to see workers’ compensation pa-      thority for NPs to prescribe, so NPs are able to    ing Schedules II-V controlled substances, to
  tients and determine disability.                     obtain DEA numbers. NPs with prescription           CRNPs with a collaborating physician. Regula-
       SB 717 was defeated. This bill would have       writing authority may receive and distribute        tions allow a CRNP to prescribe and dispense
  created a SOP committee under the Board of           prepackaged complimentary drug samples.             drugs if the CRNP has successfully completed a
  Medical Examiners (later modified to provide for     NPs may apply to the BON for drug dispensing        minimum of 45 hours of course work specific to
  a nonregulatory institute) to evaluate scope of      authority if the NP’s patients have financial or    advanced pharmacology and if the prescribing
  practice changes and challenges by health pro-       geographic barriers to pharmacy services. NPs       and dispensing is relevant to the CRNP’s area of
  fessionals. The primary opposition to the bill was   do not have authority to prescribe under the        practice, documented in a collaborative agree-
  articulated by naturopaths, midwives, NPs, and       physician-assisted suicide law. Only physicians     ment, and not from a prohibited drug category.
  physical therapists.                                 can authorize medical marijuana use.                The CRNP may write a prescription for a Sched-

28 The Nurse Practitioner • Vol. 33, No. 1                                                                                                www.tnpj.com
                                                                                                                 Twentieth Annual Legislative Update



ule II controlled substance for up to a 72-hour        for persons eligible for Medicaid), allows CRNPs      Medical Office Assistant.
dose if the CRNP notifies the collaborating physi-     and CNMs to serve as PCPs. CRNAs receive                  South Carolina APRNs were not successful
cian within 24 hours. CRNPs may prescribe              third-party reimbursement for services under the      in getting revisions to the NPA out of committee.
Schedules III-V medications for up to a 30-day         supervision of anesthesiologists or dentists.
supply, however, the physician must authorize a                                                              I Legal Authority
refill. CRNPs are authorized to request, receive,      I Prescriptive Authority                              The South Carolina BON grants APRNs author-
and dispense pharmaceutical sample medica-             Rhode Island requires a collaborative practice        ity to practice and regulates their practice.
tions. Prescription blanks must include the name       agreement for prescriptive authority. CRNPs are       APRNs are defined as an NP, CNM, CNS, or
and certification number of the CRNP and iden-         authorized to apply for controlled substance reg-     CRNA. APRNs must have a collaboratory rela-
tify the collaborating physician. The collabora-       istration for privileges to prescribe legend and      tionship with a physician and may perform “del-
tive agreement is a signed, written agreement          Schedules II-V controlled substances. Prescrip-       egated medical acts” in addition to nursing acts
between the CRNP and a collaborating physi-            tive authority registration requires 30 hours of      as defined by the BON. “Delegated medical acts”
cian and must identify the parties to the agree-       pharmacy CE within 3 years prior to application,      may be performed by APRNs pursuant to an ap-
ment; area of practice; specify the categories of      Advisory Committee approval, and written col-         proved written protocol between the nurse and
drugs from which the CRNP may prescribe and            laborative guidelines with a physician. The CRNP      physician, and are defined as “additional acts
dispense; specify conditions for prescribing a         and collaborating physician or medical director       delegated by the physician that include formu-
Schedule II controlled substance; and specify          develop practice guidelines, which determine          lating a medical diagnosis and initiating, contin-
the circumstances and how often the collabo-           the drugs that will be prescribed from the for-       uing, and modifying therapies, including pre-
rating physician will personally see the patient,      mulary; the practice guidelines are kept at the       scribing drug therapy under approved written
be kept at the primary practice site, and be avail-    practice site and are updated annually. PCNSs         protocols.” NPs who manage delegated medical
able for inspection.                                   have authority to prescribe certain legend med-       aspects of care must have a supervising physi-
                                                       ications and controlled substances from Sched-        cian who can be accessed by electronic/tele-
                                                       ule II classified as stimulants and controlled sub-   phonic means, and operate within the “approved
Rhode Island
http://www.healthri.org/hsr/professions/n_pract.htm
                                                       stances from Schedule V that are described in
                                                       regulations. PCNSs prescribe in accordance
                                                                                                             written protocols.” APRNs are legally authorized
                                                                                                             to admit patients to a hospital and hold hospital
% 2007 Legislative Activity                            with annually updated practice guidelines, writ-      privileges; however, this is left up to the individ-
Global signature authority of CRNPs: Whenever          ten in collaboration with the medical director or     ual agency. APRNs must hold a master’s degree
any provision of the general or public law, or reg-    physician consultant of their individual estab-       in nursing and national board certification in an
ulation requires a signature, certification, stamp,    lishments. Draft guidelines “provide guidance to      advanced practice nursing specialty to enter into
verification, affidavit or endorsement by a physi-     licensed healthcare facilities relating to the        practice.
cian, it shall be deemed to include a signature,       proper storage, security, and dispensing of med-
certification, stamp, verification, affidavit or en-   ications.” The guidelines, referenced from state      I Reimbursement
dorsement by a CRNP; provided, however, that           statutes, state that licensed practitioners with      All NPs, regardless of specialty, may apply for a
nothing in this section shall be construed to ex-      authority to prescribe medications may procure        Medicaid provider number (now the NPI num-
pand the scope of practice of nurse practition-        and dispense (including drug samples) legend          ber), are paid 85% of the physician payment rate,
ers passed in the last legislative session             medications and Schedules II-IV controlled sub-       and are recognized as “PCPs.” The State Health
                                                       stances if the practitioner has obtained the re-      and Human Services finance commissioner re-
I Legal Authority                                      quired state and federal registrations.               quires that NPs have current, accurate, and de-
The Rhode Island BON grants APNs authority to                                                                tailed treatment plans. Approximately 22 payers
practice and regulates their practice. APNs are                                                              recognize, enroll, and directly reimburse APRNs
defined as CRNPs, CRNAs, and Psychiatric and
Mental Health Clinical Nurse Specialists (PC-
                                                       South Carolina
                                                       http://www.llr.state.sc.us/pol/nursing/
                                                                                                             for services provided. Dr. Stephanie Burgess, 1st
                                                                                                             APRN to sit on the advisory board for State Health
NSs). There are no requirements for physician          http://www.scnurses.org/A_P_SIG/                      and Human Services Board in SC- rest of Board
collaboration to practice as a CRNP, with the ex-      % 2007 Legislative Activity                           are MDs.
ception of prescriptive authority. SOP is defined      South Carolina had several issues brought to the
within the NPA. CRNPs are statutorily recog-           legislature including the passage of a bill autho-    I Prescriptive Authority
nized as “PCPs” in Rhode Island by the Medic-          rizing electronic prescribing, 90-day supply of       APRNs have prescriptive authority, including
aid managed care program. Nothing prohibits            controlled substance III-V. The BOM was de-           Schedule III-V controlled substances, and pre-
hospitals from granting admitting and hospital         feated in their efforts to amend the Medical Prac-    scribe according to practice agreement/proto-
privileges to providers; however, privileging is       tice Act to limit CRNAs with giving anesthesia in     col within the specialty area of the APRN. The
granted by the facilities based upon individual        outpatient office based surgery and in their ef-      BOP has opined that, “The supervising physi-
policies. The minimum degree to enter into prac-       forts to amend the Medical Practice Act that          cian is not the prescriber. The NP prescribes in-
tice is a master’s degree in nursing and national      would have limited the title “Dr” just to physi-      dependently of the supervising physician, has
board certification is required. CNMs have a sep-      cians. All providers who hold a doctorate can be      their own DEA registration, and must have a state
arate law and separate R&R that are not under          called “Dr.” as long as they present their addi-      and federal ID number.” The BON issues an ID
the BON. BON R&R define CNSs.                          tional credentials. A bill was defeated that would    number to the nurse authorized to prescribe.
                                                       authorize surgical technicians to obtain a license    State law requires prescriptions by NPs be
I Reimbursement                                        and recognition as first assistants. This bill was    signed by the NP, contain the NP’s BON-assigned
State law allows for direct reimbursement of psy-      opposed because it would allow unlicensed and         prescriptive authority number and place of prac-
chiatric CSs and CNMs. CRNPs and PCNSs prac-           unqualified technicians to perform Nursing and        tice, and the physician’s name and address
ticing in collaboration with or employed by a          APRN duties. Additionally, revisions to the Med-      preprinted on the prescription blank. APRNS with
physician, receive third-party reimbursement.          ical Act state a MD could not designate perfor-       prescriptive authority may request, receive, and
United Healthcare has begun to empanel NPs.            mance of licensed tasks through (like an APRN,        sign for professional samples, including Sched-
The RiteCare Program (managed care program             RN) to be done by an unlicensed person like a         ule III-V.

www.tnpj.com                                                                                                 The Nurse Practitioner • January 2008 29
  Twentieth Annual Legislative Update



                                                        ications is not restricted, with the exception of   I Prescriptive Authority
  South Dakota
  http://www.state.sd.us/doh/nursing
                                                        Schedule II controlled substances, which are
                                                        limited to a one-time, 30-day supply. Therefore,
                                                                                                            APNs that have a BON-issued certificate to pre-
                                                                                                            scribe may prescribe legend and schedule II-V
  I Legal Authority                                     the amount provided is at the professional dis-     controlled substances. A certificate to pre-
  The South Dakota BON and BOM jointly regu-            cretion of the CNP or CNM and the collaborat-       scribe requires master’s or doctorate in nurs-
  late the practice of CNPs and CNMs. APNs are          ing physician. CNPs or CNMs who accept con-         ing, preparation in specialized practitioner skills
  defined as CNPs, CNMs, CRNAs, and CNSs.               trolled substances, either trade packages or        at the master’s, postmaster’s, doctorate, or
  CNPs and CNMs practice in collaboration with          samples, must maintain a record of receipt and      postdoctoral level, three academic quarter
  a physician licensed in the state when perform-       disposition. CRNAs and CNSs do not have Rx au-      hours of pharmacology, or its equivalent, and
  ing overlapping functions between advanced            thority. CNSs may order and dispense durable        current certification in the appropriate nursing
  practice nursing and medicine. On-site physi-         medical equipment and therapeutic devices in        specialty area. APNs meeting these qualifica-
  cian collaboration is required one-half day per       collaboration with a physician.                     tions may sign prescriptions and/or issue med-
  week. CNSs are regulated by the BON and physi-                                                            ications, including controlled substance II-V
  cian supervision is not required; however, prior                                                          medications under protocols in any practice
  to ordering durable medical equipment or ther-
  apeutic devices, CNSs must collaborate with a
                                                        Tennessee
                                                        http://www.tnaonline.org
                                                                                                            site. The APN’s script pad must have the
                                                                                                            preprinted name and address of the supervis-
  physician. CRNAs are regulated by the BON and         http://www2.state.tn.us/health/Boards/Nursing/      ing physician and of the APN, however, the
  perform acts of anesthesia in collaboration with      I Legal Authority                                   name of the physician is no longer required on
  a physician licensed in the state as a member of      The Tennessee BON grants APNs authority to          the signature line. NPs may request, receive
  a physician-directed healthcare team. On-site         practice and regulates their practice. APNs         and issue pharmaceutical samples.
  supervision is not required. APNs are granted         are defined as NPs, CNMs, CRNAs, or CNSs.
  hospital privileges.                                  APNs meeting requirements for prescriptive

  I Reimbursement
                                                        authority are eligible for a certificate that is
                                                        designated “with certificate of fitness”. APNs
                                                                                                            Texas
                                                                                                            http://www.tbon.state.tx.us
  CNPs and CNMs receive Medicaid reimburse-             must hold a current RN license in Tennessee         http://www.cnaptexas.org
  ment at 90% of the physician payment rate. CR-        or a compact state if home state is a compact       http://www.texasnp.org
  NAs are reimbursed at the physician rate for ser-     state. APNs who prescribe must have proto-          % 2007 Legislative Activity
  vices provided under Medicaid. State insurance        cols that are jointly developed by the APN and      In the 2007 Texas Legislative Session, no bills
  law is silent regarding CNSs; however, CNSs may       the supervising physician. Medical Board rules      passed that expanded or restricted the author-
  be reimbursed under specific plans. Medicaid          that govern the supervising physician of the        ity of APNs. However, APNs actively protected
  reimbursement is allowed only if billed through       APN prescriber are jointly adopted by the           their interests. The pay category for NPs em-
  a physician’s practice. CNPs and CNMs receive         BOME and BON. Physicians who supervise              ployed by the state was increased by two grades.
  third-party reimbursement. State law mandates         APN prescriber practices are not required to        Eight bills were enacted that referred to “RNs,”
  that CRNAs, CNPs, and CNMs must be reim-              be on site, but must personally review and sign     “providers,” “practitioners” or “APNs” that
  bursed on the same basis as other medical             20% of the charts within 30 days. CRNAs and         would have referred to “physicians” if APNs had
  providers, assuming that the service is covered       CNMs are defined in the hospital licensure          not been strongly represented at the Texas Capi-
  under the policy; CRNAs, CNPs, and CNMs may           rules, which also provide that the medical staff    tol. An attempt to limit the ability of APNs to in-
  receive reimbursement when the service is cov-        may include CNMs; CNMs are not precluded            dependently perform sports physical exams for
  ered under the policy and they are acting within      from admitting a patient with the concurrence       student athletes was also defeated. The BON’s
  their SOP.                                            of a physician member of the staff. NPs have        Sunset Bill passed, reauthorizing the agency un-
                                                        admitting and clinical privileges in Medicare       til 2017, and changing the name of the Board of
  I Prescriptive Authority                              critical access hospitals; however, privileges      Nurse Examiners to the Texas Nursing Board.
  South Dakota’s CNPs and CNMs may prescribe            for NPs are not addressed in other hospital li-     The APRN Compact was also enacted. The re-
  legend drugs and controlled substances Sched-         censure rules and these privileges are incon-       tail clinics supported HB 1096 that would have
  ules II-IV as authorized by the collaborating         sistent across the state.                           reduced the amount of physician supervision re-
  physician agreement. CNPs and CNMs have two                                                               quired in alternate practice sites. The bill was
  controlled substance registration options: (1)        I Reimbursement                                     opposed by medical organizations and did not
  they may seek independent state registration          Tennessee private insurance laws mandate re-        pass the House.
  and independent DEA registration in all sched-        imbursement of APNs. A managed care antidis-
  ules as authorized by their collaborative agree-      crimination law prevents managed care organi-       I Legal Authority
  ment; or (2) they may act as an agent of an insti-    zation discrimination against APNs (specifically    The BON is authorized by the NPA to regulate
  tution, using the institution’s registration number   CNPs, CNSs, CNMs, and CRNAs) as a class of          APNs. Although RNs may practice based on a
  to prescribe, provide, or administer controlled       providers. However, not all organizations are, as   multi-state licensure privilege, APNs must ap-
  substances. Controlled substance authority is         of yet, credentialing and accepting APNs into       ply for authorization to practice as an NP, CNM,
  granted by separate application to the Depart-        their network. This is a major issue being ad-      CRNA, or CNS. The APN’s SOP is based on ad-
  ment of Health following collaborative agree-         dressed by TNA and private, APN practice own-       vanced practice education, experience, and
  ment approval by the BON and BOM. CNPs and            ers. BC/BS credentials APNs in most of their pro-   the accepted SOP of the particular specialty.
  CNMs may request and receive drug samples,            grams and provides 100% reimbursement to            Unless NPs receive a waiver, the BON will only
  provide drug samples, and provide a limited sup-      primary care NPs in the Tenn-Care program;          recognize NPs educated in nine specialties for
  ply of labeled medications. Medications and           BC/BS also reimburses CNMs and CRNAs. Other         entry into practice: 1) adult acute care; 2) pedi-
  sample drugs must be accompanied by written           managed care organizations participating in the     atric acute care; 3) adult; 4) family; 5) geriatric;
  administration instructions and documentation         TennCare program also credential APNs and as-       6) neonatal; 7) pediatric; 8) psychiatric-mental
  entered in the patient’s medical record. The pro-     sign an established patient panel upon individ-     health; and 9) women’s health. The APN acts
  vision of drug samples or a limited supply of med-    ual review of specialty.                            independently and/or in collaboration with the

30 The Nurse Practitioner • Vol. 33, No. 1                                                                                                  www.tnpj.com
                                                                                                                 Twentieth Annual Legislative Update



healthcare team. The authority to make a med-         cian consultation; and (4) physician consulta-         100% of the physician rate. CNMs are reim-
ical diagnosis and write Rx must be delegated         tion must be noted in the chart. APNs that pre-        bursed at 65% by Medicare, whereas other
by a MD or DO using written general delega-           scribe controlled substances must have a per-          APRNs receive reimbursement at 80% of the
tion protocols or collaborative agreement. The        mit from the Texas Department of Public Safety         physician rate.
rules refer to protocols as written authorization     and a DEA number. APNs with prescriptive au-
to provide medical aspects of care. Protocols         thority may request, receive, possess, and dis-        I Prescriptive Authority
should allow the APN to exercise professional         tribute samples of drugs they are authorized to        APRNs and CNMs have prescriptive authority
judgment and are not required to outline spe-         prescribe.                                             for all legend drugs and devices, including
cific steps the APN must take. Hospitals may                                                                 Schedules IV-V controlled substances, within
extend privileges to APNs but are not required                                                               their SOP. A consultation and referral plan is only
to do so. Hospitals electing to extend clinical
privileges to APNs must use a standard appli-
                                                      Utah
                                                      http://www.dopl.utah.gov/nurse.html
                                                                                                             needed if prescribing Schedules II or III con-
                                                                                                             trolled substances. APRN-CRNAs do not require
cation form, and afford due process rights in         % 2007 Legislative Activity                            a consultation or referral plan for their practice.
granting, modifying, or revoking those privi-         NPA was amended to include CRNAs subsumed              CRNAs may order and administer drugs, includ-
leges.                                                in the licensure category of APRNs; however,           ing Schedules II-V controlled substances, in a
                                                      CRNA scope of practice remained unchanged              hospital or ambulatory care setting; they may not
I Reimbursement                                       and authorizes a CRNA to select, order, and ad-        provide prescriptions to be filled outside the hos-
All APN categories are eligible for direct Med-       minister medications. The term “without pre-           pital. APRNs, CRNAs, and CNMs receive a DEA
icaid reimbursement at 92% of physician pay-          scriptive practice” means a CRNA may not write         number after passing a controlled substance ex-
ment rates. Under certain circumstances,              a prescription for a patient to be filled at a phar-   amination and obtaining a state-controlled sub-
physicians in the Texas Medicaid Program may          macy. The CRNA may write medication orders             stance license. APRNs and CNMs may sign for
bill for an APN’s services and receive 100%.          within a facility including pre- and post-op.          and dispense drug samples, and the NP name
Some programs such as Texas Health Steps re-               NPA was amended through H.B. 299, stating         is listed on the prescription label.
imburse all providers at the same rate. NPs can       that a person who is convicted of, pleads guilty
be PCPs in Texas Medicaid managed care                to, or has a plea in abeyance for a violent felony
plans. APNs are listed in the Texas Insurance
Code as practitioners that must be reimbursed
                                                      is barred from nurse licensure in Utah. Those
                                                      guilty of nonviolent felonies may not apply for li-
                                                                                                             Vermont
                                                                                                             http://www.vtprofessionals.org/nurses/
by indemnity health insurance plans. All HMOs         censure until 5 years prior discharge of sentence.     http://www.vtnpa.org/
and PPOs in Texas must list an APN on provider             Nurse Midwife Practice Act was amended,           I Legal Authority
panels if the APN’s collaborating physician is        changing the requirements for licensure. As of         The Vermont BON grants APRNs authority to
on the panel and the physician requests that          January 1, 2010, a graduate degree in nurse mid-       practice and regulates their practice. APRNs in-
the APN also be listed.                               wifery is required to be licensed as a CNM in          clude, but are not limited to, NPs in adult, pedi-
                                                      Utah.                                                  atrics, family and women’s health, CNMs, CR-
I Prescriptive Authority                                                                                     NAs and CNSs in psychiatric health. The BON
APNs must obtain a prescriptive authorization         I Legal Authority                                      endorses other CNSs under certain circum-
number from the BON. To receive the number,           The Utah BON in collaboration with the Division        stances. The APRN performs medical acts inde-
the nurse must have full authorization to prac-       of Occupational and Professional Licensing             pendently, within a collaborative practice with
tice as an APN in Texas and meet certain addi-        (DOPL) grants authority to practice via licensure      a physician, under practice guidelines that are
tional educational requirements. To use pre-          with an “APRN” or “APRN-CRNA without pre-              mutually agreed on between the APRN and col-
scriptive authority, APNs must practice in a          scriptive practice” license and regulates the          laborating physician. The practice guidelines
qualifying site and a physician must delegate         practice of APRNs and CRNAs. Licensed APRN             must be reviewed and signed annually and filed
prescriptive authority in that site using general     categories include NPs, CNSs, psychiatric/men-         at the workplace. APRN scope of practice is de-
delegation protocols. Sites qualifying for pre-       tal health nurses And CRNAs. CNMs are regu-            fined in statute and legally recognized as “PCPs,”
scriptive authority are (1) sites that serve med-     lated by a separate practice act and CNM board.        are endorsed by the BON to perform acts of med-
ically underserved populations, (2) physician         APRNs practice independently except for the            ical diagnosis and to prescribe medical, thera-
primary practice sites, (3) physician alternate       act of prescribing controlled substances Sched-        peutic, or corrective measures under the R&R.
practice sites; and (4) facility-based practices      ules II-III, where a consultation and referral plan    CNSs in psychiatric health do not need a collab-
in hospitals or long-term-care facilities. The del-   is required. The APRN SOP is defined by set stan-      orative physician if they do not have prescrip-
egating physician must spend some time at             dards from national professional specialty orga-       tive privileges. APRNs are authorized to admit
each site with the APN, but that time varies from     nizations, APRNs are not statutorily prohibited        patients to a hospital and hold hospital privileges,
once every 10 business days in a medically un-        from admitting patients and holding hospital priv-     according to agency protocols. APRNs are re-
derserved population site to the majority of the      ileges; however, this is decided upon by the in-       quired to have a master’s degree in nursing and
time in a physician’s primary practice site. The      dividual institution. All APRNs must be hold a         hold national board certification to enter into
Texas Medical Board has authority to waive            master’s degree prepared or higher and nation-         practice.
many of the supervisory and site requirements         ally certified to obtain licensure. During the 2004
for physicians who delegate prescriptive au-          legislative session, the Utah Legislature was the      I Reimbursement
thority. The BON is not part of this process.         first legislature to adopt the APRN compact.           BC/BS reimburses psychiatric NPs using a
Physicians may delegate prescriptive author-                                                                 provider number. All NPs receive Medicaid re-
ity for Schedules III-V controlled substances         I Reimbursement                                        imbursement at 100% of physician payment. The
with the following limitations: (1) APNs may only     The state insurance code has a nondiscrimina-          state Medicaid program provides enhanced re-
Rx a maximum 30-day supply; (2) the APN must          tion code; nothing prohibits reimbursement.            imbursement to physicians who care for patients
consult with the physician before authorizing a       CNMs, APRNs, and CRNAs, are reimbursed by              covered by both Medicare and Medicaid. The
refill; (3) APNs may not Rx controlled sub-           most insurance companies. Board-certified              medical case management fee rules do not in-
stances to a child under 2 years without physi-       PNPs and FNPs are reimbursed by Medicaid at            clude NPs as eligible PCPs. Although legislation

www.tnpj.com                                                                                                 The Nurse Practitioner • January 2008 31
                                                                                                                   Twentieth Annual Legislative Update



requiring or prohibiting third-party reimburse-         I Reimbursement
ment does not exist, insurance companies may
reimburse NPs depending on policies.
                                                        Effective August 1, 2007, the Virginia Department
                                                        of Medicaid Assistance Services is now enrolling
                                                                                                               Washington
                                                                                                               http://www.doh.wa.gov/nursing/
                                                        and reimbursing as separate Medicaid providers,        % 2007 Legislative Activity
I Prescriptive Authority                                the following specialties of NPs at 100% of the        HB 1666 was signed into law in May 2007, per-
APRNs have full prescriptive authority, includ-         physician rate: Pediatric, Adult, Family, Pediatric,   manently authorizing ARNPs to continue to sign
ing Schedule II-V controlled substances within          Women’s Health, Geriatric, Acute Care, Neona-          Labor and Industry (L and I) accident report forms
their practice guidelines. APRNs have the same          tal, and CNMs. Psychiatric NPs will be paid the        and certify time loss for injured workers. A bill
privileges dispensing and administering drugs           same rate for psychiatric diagnosis, evaluation        passed in 2004 first authorized ARNPs to per-
as physicians. NPs register for their own receive       and psychotherapy services as a psychiatric clin-      form these functions without a physician signa-
DEA numbers and are authorized to request, re-          ical nurse specialist, which is 67% of the rate cur-   ture, but was scheduled to sunset on June 30,
ceive and/or dispense pharmaceutical samples.           rently paid to Medicaid enrolled psychiatrists.        2007.
Prescriptions are labeled with the APRN’s name.         For other procedures, such as physical exami-
                                                        nations, psychiatric NPs will be reimbursed at         I Legal Authority
                                                        the same rate as other NPs. NPs can indepen-           The Nursing Care Quality Assurance Commis-
Virginia
http://www.dhp.state.va.us
                                                        dently bill insurers; however, payment is depen-
                                                        dent upon individual company policy. Virginia
                                                                                                               sion grants APNs authority to practice and reg-
                                                                                                               ulates their practice. APNs are designated as
http://www.vcnp.net/                                    does have an “any willing provider” law, but it        ARNPs. This includes NPs, CNMs, CRNAs, and
% 2007 Legislative & Regulatory                         applies only to mandated providers and, among          CNSs in psychiatric/mental health nursing.
Activity                                                APNs, only psychiatric CNSs and CNMs are man-          ARNP practice is independent and ARNPs as-
HB 2416 was introduced in the 2007 legislative          dated providers. CNMs and CNSs in psychiatric          sume primary responsibility for continuous and
session and sought to add NPs to the Virginia           health receive third-party reimbursement.              comprehensive management of a broad range
statute which provides immunity to physicians                                                                  of patient care, concerns, and problems. The
who fail to review or act on test results they re-      I Prescriptive Authority                               SOP for ARNPs is defined in statute and regu-
ceive, but neither requested or authorized.             Authorized LNPs may prescribe all legend drugs,        lation. ARNPs are statutorily defined as “PCPs”,
House Bill 2416, failed to report in the Civil Courts   including Schedules II-V controlled substances         and are legally authorized to admit patients to
of Justice subcommittee.                                as defined in the LNP’s Practice Agreement. A          a hospital and hold hospital privileges. How-
                                                        Practice Agreement, developed between the NP           ever, hospitals and medical staff have the right
I Legal Authority                                       and the supervising physician and submitted to         to make the decision on credentialing. A grad-
The Virginia BON and BOM have joint statutory           the Joint Boards of Nursing and Medicine, lists        uate degree and national certification is re-
authority to regulate licensed nurse practition-        the drug categories the NP will prescribe. NPs         quired to obtain licensure as an ARNP in Wash-
ers (LNPs). LNPs are defined as NPs, CNMs, and          may only prescribe legend drugs if “such pre-          ington.
CRNAs. CNSs are registered solely with the BON.         scription is authorized by the written agreement
The presidents of the BON and BOM each ap-              between the NP and physician.” The prescrip-           I Reimbursement
point three board members to the Committee of           tion must include the NP’s name and prescriptive       Medicaid reimbursement is available to ARNPs
the Joint Boards of Nursing and Medicine to ad-         authority number, and the patient must be in-          at 100% of physician payment. Washington in-
minister LNP regulations. LNPs must be nation-          formed in writing of the name and address of the       surance code bans discrimination against RNs,
ally certified to apply for state authorization.        supervising physician. Supervision means the           podiatrists, chiropractors, and certain mental
LNPs licensed in a category other than CNMs             physician documents being readily available for        health professionals. Rules governing payment
must practice under the medical direction and           medical consultation by the LNP or the patient,        to, and inclusion of, nurses prohibit artificial re-
supervision of a physician. CNMs practice in col-       with the physician maintaining ultimate respon-        ductions in the level of an indemnification ben-
laboration and consultation with a licensed             sibility for the agreed-upon course of treatment       efit based on a patient’s choice of nursing ser-
physician except for prescriptive authority,            and medications prescribed. Physicians who en-         vices rather than those of other health providers.
which still carries a statutory requirement for         ter into a Practice Agreement cannot supervise         A difference in payment between a physician
supervision. NP practice is based on education          and direct, at any one time, more than four NPs        and a nurse who provide the same services must
and a written protocol. An NP may practice              with prescriptive authority. Physicians who su-        result from the “disparity of fees actually
within the parameters of a written protocol with        pervise NPs must make periodic site visits, regu-      charged by medical doctors and RNs rather than
a supervising physician, as defined in regula-          larly practice in any location where the NP exer-      from an arbitrary formula based on assumptions
tion. According to the Virginia BON, NPs are not        cises prescriptive authority, and conduct monthly,     concerning the relative worth of physician-pro-
statutorily prevented from being “PCPs” and no          random review of patient charts on which the NP        vided services versus nurse-provided ser-
law or regulation prevents them from admitting          has entered a prescription for an approved drug        vices.” The law pertains to private insurers and
patients to the hospital and holding hospital priv-     or device. The joint regulations of the BON and        healthcare service contractors. The Women’s
ileges. Virginia state law does not include NPs         BOM include requirements for continued NP              Health Care Law allows women to directly ac-
in its “any willing provider” language. A master’s      competency including eight hours of continuing         cess a women’s healthcare practitioner of their
degree in nursing and national board certifica-         education in pharmacology or pharmacothera-            choice, without referral from another provider.
tion is required to enter into practice in Virginia.    peutics for each biennium. LNPs may receive and        The law applies to all insurance carriers regu-
In 2004, legislative changes were made to Vir-          dispense drug samples under an exemption to            lated by the insurance commissioner and in-
ginia Code that now include NPs whenever any            the state Drug Control Act, which states that the      cludes ARNP specialists in women’s health and
law or regulation requires a signature, certifica-      act “shall not interfere with any LNP with pre-        midwifery.
tion, stamp, verification, affidavit, or endorse-       scriptive authority receiving and dispensing to
ment by a physician. Among other things, NPs            his own patients manufacturer’s samples of con-        I Prescriptive Authority
are also authorized to certify medical necessity        trolled substances and devices that he is autho-       All ARNPs who qualify to receive prescriptive
of durable medical equipment that is to be reim-        rized to prescribe according to his practice set-      authority have independent authority to pre-
bursed by Medicaid.                                     ting and a written agreement with a physician.”        scribe legend and Schedule II-V controlled sub-

www.tnpj.com                                                                                                   The Nurse Practitioner • January 2008 33
  Twentieth Annual Legislative Update



  stances. The dispensing of Schedules II-IV con-       cluding Schedule III-V controlled substances.         I Prescriptive Authority
  trolled substances is limited to a maximum 72-        Rules and regulations specify that the ANP must       RNs may prescribe legend drugs and controlled
  hour supply of the prescribed drug. Indepen-          meet specified pharmacology education require-        substances as a delegated medical act under
  dent prescriptive authority entails an initial 30     ments and certify that they have a written collab-    the NPA. APRNs may receive “Advanced Prac-
  hours of pharmacotherapeutic education                orating relationship with a physician or osteopath.   tice Nurse Prescriber” (APNP) certification from
  within the area of practice obtained within the       The written collaborative relationship must in-       the BON for independent prescriptive authority.
  2-year period immediately prior to application.       clude guidelines or protocols describing the indi-    Eligible APRNs must be certified by a board-ap-
  For new graduates, if a pharmacokinetic prin-         vidual versus shared responsibility between the       proved APRN national certifying body, have
  ciples course occurred in a graduate program          ANP and physician, with periodic joint evaluation     completed 45 contact hours in clinical pharma-
  and the program of study occurred within the          of the practice and review and updating of the        cology/therapeutics within the 3 years preced-
  last 2 years, that qualifies for licensure. Renewal   written guidelines or protocols. No supervision       ing application, pass an APNP jurisprudence
  of Rx authority every 2 years requires 15 hours       requirement exists; ANPs are not required to be       examination, and hold a master’s degree in nurs-
  of pharmacotherapeutic education within the           employed by a collaborating physician. The ANP        ing or a related health field. DEA numbers are
  area of practice. ARNPs are legally authorized        works from an exclusionary formulary. Schedules       issued to APNPs. The APNP may prescribe
  to request, receive, and dispense pharmaceu-          I and II, anticoagulants, antineoplastics, radio-     Schedules II-V controlled substances and must
  tical samples. Prescriptions are labeled with         pharmaceuticals, and general anesthetics are          comply with restrictions regarding prescribing
  the ARNP’s name.                                      prohibited. A DEA number is issued directly to an     amphetamines and anabolic steroids. Sched-
                                                        ANP by the DEA. ANPs are authorized to sign for       ule II substances may only be prescribed as an
                                                        and provide drug samples.                             adjunct to opioid analgesic compounds for the
  West Virginia
  http://www.wvrnboard.com
                                                                                                              treatment of cancer-related pain, narcolepsy,
                                                                                                              hyperkinesis, drug-induced brain dysfunction,
  I Legal Authority
  The West Virginia BON grants authority to prac-
                                                        Wisconsin
                                                        http://www.drl.state.wi.us
                                                                                                              epilepsy, and depression refractory to other
                                                                                                              modalities, according to the BON. Drug samples
  tice and regulates the practice of ANP. R&R de-       I Legal Authority                                     may be dispensed if the APRN is certified to pre-
  fine advanced practice for RNs. ANP includes          The Wisconsin BON grants APRNs authority to           scribe; prepackaged doses may be dispensed
  NPs, CNSs, CNMs, and CRNAs. ANP SOP in-               practice and regulates their practice. APRNs          independently if the nearest pharmacy is more
  cludes the ability to assess, conceptualize, di-      are defined as NPs, CNSs, CNMs, and CRNAs.            than 30 miles away.
  agnose, analyze, plan, implement, and evalu-          NPs function under the NPA with a broad de-
  ate complex problems related to health. The           scription of nursing practice. SOP is defined in
  ANP SOP does not require collaboration with a
  physician unless the ANP is prescribing. The
                                                        statute and regulations which cover the per-
                                                        formance of a delegated medical acts by a RN:
                                                                                                              Wyoming
                                                                                                              http://nursing.state.wy.us/
  CNM is required to practice in a collaborative        (1) the RN must follow protocols or written or        I Legal Authority
  relationship with a physician. CRNAs adminis-         verbal orders; (2) as jointly determined by the       The Wyoming BON grants APRNs authority to
  ter anesthesia in the presence and under the          RN and physician, the ability to perform the del-     practice and regulates their practice. APRNs
  supervision of a physician or DDS. Hospital cre-      egation is based on the RN’s education, train-        are defined as NPs, CNMs, CRNAs, and CNSs.
  dentialing for ANPs is dependent upon individ-        ing, and experience; (3) the RN must consult          APRNs are not required to have a collabora-
  ual hospital policy. All ANPs must have a mas-        with the physician when the delegated medical         tory or supervisory relationship with a physi-
  ter’s degree in nursing and hold national board       act may harm the patient; and (4) the RN can          cian. The SOP of an APRN is defined in statute,
  certification to enter into practice.                 perform the delegated act under general su-           within the Nurse Practice Act, and includes
                                                        pervision-the physician does not have to be pre-      prescriptive authority and management of pa-
  I Reimbursement                                       sent in the facility. Hospital privilege laws are     tients. APRNs are statutorily defined as “PCPs”
  Family and pediatric NPs receive Medicaid re-         permissive, not prescriptive; therefore, some         and are legally authorized to admit patients to
  imbursement at 100% of the physician rate.            hospitals extend full admitting privileges to         a hospital and hold hospital privileges. A mas-
  State law requires insurance companies to re-         APRNs, others do not. A master’s degree in            ter’s degree in nursing and national board cer-
  imburse nurses for nursing services, if such ser-     nursing and national board certification are re-      tification is required to enter into practice as
  vices are commonly reimbursed for other               quired to enter into practice in Wisconsin.           an APRN in Wyoming.
  providers; however, rules and regulations have
  not been promulgated. NPs and CNMs are de-            I Reimbursement                                       I Reimbursement
  fined as “PCPs” (“a person who may be cho-            Medicaid reimbursement of 100% exists for             APRNs are authorized to receive Medicaid pay-
  sen or designated in lieu of a primary care physi-    specified reimbursable billing codes as sub-          ments at 100% of physician payment.
  cian who will be responsible for coordinating         mitted by all master’s degree prepared NPs or         All PCPs may receive third-party payment; how-
  the healthcare of the subscriber.”). The only re-     NPs certified by ANCC, NAPNAP, or NAACOG.             ever, policies differ among third-party payers.
  striction is that the NP or CNM must have a writ-     Reimbursement is up to the maximum allowed
  ten association with a physician listed by the        for physicians billing for the same service.          I Prescriptive Authority
  managed care panel; there is no requirement           Qualified NPs are paid directly regardless of         BON-approved APRNs may independently pre-
  for employment or supervision by the physician.       their employment site or arrangement. There           scribe legend and Schedules II-V controlled
  The Woman’s Access to Health Care Bill pro-           are Medicaid bonuses for NPs working in cer-          substances. APRNs are considered indepen-
  vided for direct access, at least annually, to a      tain areas or for certain pediatric visits. CHAM-     dent providers and register for their own DEA
  woman’s healthcare provider for a well-woman          PUS reimburses NPs; home health RNs bill un-          numbers. Additionally, APRNs who have pre-
  examination; providers include ANPs (CNMs,            der their own provider number. Third-party            scriptive authority are legally authorized to re-
  FNPs, WHNPs, Adult NPs, GNPs, or PNPs).               reimbursement has not been addressed leg-             quest, receive, and dispense pharmaceutical
                                                        islatively. Some managed care panels are open         samples. Prescriptions are labeled with the
  I Prescriptive Authority                              to NPs, but few allow NPs to be the PCP of            APRN name according to the Wyoming Board
  Qualified ANPs have prescriptive authority, in-       record.                                               of Nursing.

34 The Nurse Practitioner • Vol. 33, No. 1                                                                                                  www.tnpj.com

								
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