Report Title:

Health Care; Advanced Practice Registered Nurse; Primary Care Provider; Prescriptive Authority; Endorsement Licensure

Description:

Requires insurers, mutual and fraternal benefit societies, and health maintenance organizations to recognize advanced practice registered nurses as primary care providers.  Provides for licensure by endorsement.  Grants global signature authority and prescriptive rights.  Amends definition of advanced practice registered nurse.  Requires the Insurance Commissioner to perform a review of the effects of this Act in two years.  (HB1378 CD1)

HOUSE OF REPRESENTATIVES	H.B. NO.	1378
TWENTY-FIFTH LEGISLATURE, 2009		H.D. 2
STATE OF HAWAII		S.D. 2
		C.D. 1

A BILL FOR AN ACT

RELATING TO ADVANCED PRACTICE REGISTERED NURSES.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

     SECTION 1.  The legislature finds that there is a need for more access to health care professionals, particularly in rural areas.  Studies show that appropriately trained advanced practice registered nurses can provide high quality health care and achieve positive outcomes for patients.  Advanced practice registered nurses are capable of providing primary health care and play an important role in meeting the growing demand for primary health care, particularly in underserved areas.

     The legislature further finds that the disciplines of medicine and nursing and the roles of physicians and advanced practice registered nurses are complementary.  Ultimately, the interests of patients are well served when advanced practice registered nurses are included as an essential component of the primary health care team.

     The purpose of this Act is to recognize advanced practice registered nurses as participating primary health care providers for insurance coverage purposes, permit advanced practice registered nurses to sign documents relating to health care for their patients, clarify educational and other requirements for advanced practice registered nurses, and update the authority for advanced practice registered nurses to write prescriptions, including prescriptions for controlled substances, medical equipment, and therapeutic regimens, in accordance with their scope of practice.

     SECTION 2.  Chapter 431, article 10A, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

     "§431:10A-   Primary care provider; advanced practice registered nurse. (a)  Each policy of accident and health or sickness insurance delivered or issued for delivery in this state shall recognize advanced practice registered nurses, as defined under section 457-8.5(a), as participating providers, and shall include coverage for care provided by participating advanced practice registered nurses practicing within the scope of their licenses for purposes of health maintenance, diagnosis, or treatment, to the extent that the policy provides benefits for identical services rendered by another health care provider.

(b)  Notwithstanding any other law to the contrary, an insurer may recognize a participating advanced practice registered nurse as a primary care provider if the insured's policy requires the selection of a primary care provider.  The insurer shall include participating advanced practice registered nurses who practice as primary care providers on any publicly available list of participating primary care providers; provided that the insurer retains the right to determine the contracting criteria for a participating primary care provider.

(c)  For the purposes of this section, "participating advanced practice registered nurse" means an advanced practice registered nurse who has contracted with the insurer to provide health care services to its insureds."

     SECTION 3.  Chapter 432, article 1, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

     "§432:1-   Primary care provider; advanced practice registered nurse. (a)  Each policy of insurance delivered or issued for delivery in this state by a mutual benefit society shall recognize advanced practice registered nurses, as defined under section 457-8.5(a), as participating providers, and shall include coverage for care provided by participating advanced practice registered nurses practicing within the scope of their licenses for purposes of health maintenance, diagnosis, or treatment, to the extent that the policy provides benefits for identical services rendered by another health care provider.

(b)  Notwithstanding any other law to the contrary, an insurer may recognize a participating advanced practice registered nurse as a primary care provider if the insured's policy requires the selection of a primary care provider.  The insurer shall include participating advanced practice registered nurses who practice as primary care providers on any publicly available list of participating primary care providers; provided that the insurer retains the right to determine the contracting criteria for a participating primary care provider.

(c)  For the purposes of this section, "participating advanced practice registered nurse" means an advanced practice registered nurse who has contracted with the insurer to provide health care services to its insureds."

     SECTION 4.  Chapter 432, article 2, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

     "§432:2-   Primary care provider; advanced practice registered nurse. (a)  Each policy of insurance delivered or issued for delivery in this state by a fraternal benefit society shall recognize advanced practice registered nurses, as defined under section 457-8.5(a), as participating providers, and shall include coverage for care provided by participating advanced practice registered nurses practicing within the scope of their licenses for purposes of health maintenance, diagnosis, or treatment, to the extent that the policy provides benefits for identical services rendered by another health care provider.

(b)  Notwithstanding any other law to the contrary, an insurer may recognize a participating advanced practice registered nurse as a primary care provider if the insured's policy requires the selection of a primary care provider.  The insurer shall include participating advanced practice registered nurses who practice as primary care providers on any publicly available list of participating primary care providers; provided that the insurer retains the right to determine the contracting criteria for a participating primary care provider.

(c)  For the purposes of this section, "participating advanced practice registered nurse" means an advanced practice registered nurse who has contracted with the insurer to provide health care services to its insureds."

     SECTION 5.  Chapter 457, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

     "§457-   Global signature authority. (a)  Notwithstanding any other law to the contrary, advanced practice registered nurses shall be authorized to sign, certify, or endorse all documents relating to health care within their scope of practice provided for their patients, including workers' compensation verification documents, verification and evaluation forms of the department of human services and department of education, verification and authorization forms of the department of health, and physical examination forms; provided that nothing in this section shall be construed to expand the scope of practice of advanced practice registered nurses.

(b)  This section shall not apply to a certificate of disability that may be used to obtain parking privileges for disabled persons pursuant to part III of chapter 291."

     SECTION 6.  Section 329-1, Hawaii Revised Statutes, is amended as follows:

1.  By adding a new definition to be appropriately inserted and to read:

     ""Advanced practice registered nurse with prescriptive authority" means a person licensed under section 457-8.6 who is registered under this chapter to administer or prescribe a controlled substance."

     2.  By amending the definition of "practitioner" to read:

     ""Practitioner" means:

     (1)  A physician, dentist, veterinarian, scientific investigator, or other person licensed and registered under section 329-32 to distribute, dispense, or conduct research with respect to a controlled substance in the course of professional practice or research in this [State; and] state;

(2) An advanced practice registered nurse with prescriptive authority licensed and registered under section 329-32 to prescribe and administer controlled substances in the course of professional practice in this state; and

    [(2)] (3)  A pharmacy, hospital, or other institution licensed, registered, or otherwise permitted to distribute, dispense, conduct research with respect to or to administer a controlled substance in the course of professional practice or research in this [State.] state."

     SECTION 7.  Section 329-121, Hawaii Revised Statutes, is amended by amending the definition of "physician" to read as follows:

     ""Physician" means a person who is licensed under [chapters 453 and 460,] chapter 453 and is licensed with authority to prescribe drugs and is registered under section 329-32.  "Physician" does not include physician's assistant as described in section 453-5.3[.] or an advanced practice registered nurse with prescriptive authority as described in section 457-8.6."

     SECTION 8.  Section 423D-23, Hawaii Revised Statutes, is amended to read as follows:

     "§432D-23  Required provisions and benefits.  Notwithstanding any provision of law to the contrary, each policy, contract, plan, or agreement issued in the [State] state after January 1, 1995, by health maintenance organizations pursuant to this chapter, shall include benefits provided in sections 431:10-212, 431:10A-115, 431:10A-115.5, 431:10A-116, 431:10A-116.5, 431:10A-116.6, 431:10A-119, 431:10A-120, [and] 431:10A-121, and 431:10A-    , and chapter 431M."

     SECTION 9.  Section 457-8.5, Hawaii Revised Statutes, is amended to read as follows:

     "§457-8.5  Advanced practice registered nurse; qualifications; recognition; endorsement; fees; eligibility. 

     (a)  [The] Effective October 1, 2009, the board shall grant recognition as an advanced practice registered nurse[; provided the] to a nurse who has:

     (1)  A current, unencumbered license as a registered nurse in this [State;] state;

     (2)  An unencumbered license as a registered nurse in all other states in which the nurse has a current and active license;

     (3)  An unencumbered recognition as an advanced practice registered nurse or similar designation in all other states in which the nurse has a current and active recognition as an advanced practice registered nurse;

    [(4) A master's degree in nursing as specified in rules adopted by the board or a current certification for specialized and advanced nursing practice from a national certifying body recognized by the board; provided that certified nurse midwives shall maintain current certification from a national certifying body recognized by the board; and

(5)] (4) Completed an accredited graduate-level education program leading to a master's degree as a certified registered nurse anesthetist, a nurse midwife, a clinical nurse specialist, or a nurse practitioner;

(5) A current, unencumbered certification of having passed a national certification examination that measures role and population-focused competencies and is recognized by the board;

(6) Maintained continued competencies through recertification in role and population-focused competencies through a national certification program recognized by the board;

(7) Acquired advanced clinical knowledge and skills preparing the nurse to provide direct care to patients through a significant educational and practical concentration on the direct care of patients;

(8) Demonstrated a greater breadth of knowledge, a greater synthesis of data, greater complexity of skills and interventions, and greater role autonomy than demonstrated by a registered nurse;

(9) Been educationally prepared to assume responsibility and accountability for health promotion and maintenance and to assess, diagnose, and manage patient problems through the use and prescription of pharmacologic and non-pharmacologic interventions;

(10) Acquired clinical experience of sufficient depth and breadth to reflect the intended license; and

(11)  Paid the appropriate fees.

     (b)  [The board shall require certified nurse midwives to meet the requirements of subsection (a) in order to obtain recognition and maintain recognition as advanced practice registered nurses.]  Any person recognized as an advanced practice registered nurse prior to October 1, 2009, whose recognition was granted based on a master's degree in nursing or a current certification for specialized and advanced nursing practice from a national certifying body recognized by the board shall be eligible to renew that recognition; provided that all nurse licenses, recognitions, and prescriptive authorities or similar designations held by the person in any jurisdiction are unencumbered.

(c)  Any person applying for advanced practice registered nurse recognition by endorsement shall be granted recognition as an advanced practice registered nurse; provided that:

(1) The person applying is licensed as a registered nurse in this state; and

(2) All nurse licenses, recognitions, and prescriptive authorities or similar designations held by the person under the laws of this state, another state, or a United States territory are unencumbered, and the originating state's requirements were equal to or greater than the board's advanced practice registered nurse requirements which were in effect prior to October 1, 2009.

An advanced practice registered nurse shall be eligible to renew the recognition granted under this subsection; provided that all nurse licenses, recognitions, and prescriptive authorities or similar designations held by the person in this state, another state, or a United States territory are unencumbered.

     [(c)] (d)  Only a person who has a current, unencumbered recognition from the board to practice as an advanced practice registered nurse shall use the title "Advanced Practice Registered Nurse" and the abbreviation "A.P.R.N.".  No other person shall assume the title "nurse" or in any manner imply that the person is a nurse except as defined in section 457-2 or as provided in sections 457-7 and 457-8 or use the abbreviation "A.P.R.N." or any other words, letter, sign, or device to indicate that the person using the same is an advanced practice registered nurse.  Nothing in this section shall preclude a registered nurse who is not recognized by the board as an advanced practice registered nurse and who is currently certified by a national certifying body recognized by the board from using another title designated by certification."

     SECTION 10.  Section 457-8.6, Hawaii Revised Statutes, is amended to read as follows:

     "§457-8.6  Prescriptive authority for advanced practice registered nurses.  (a)  The board shall grant prescriptive authority to qualified advanced practice registered nurses and shall designate the requirements for advanced nursing practice related to prescriptive authority. [The Hawaii medical board shall submit an annual report of all amendments made to the formularies to the board.]  The board shall determine the exclusionary formulary for qualified advanced practice registered nurses who are granted prescriptive authority.

     (b)  The department of commerce and consumer affairs shall establish a joint formulary advisory committee composed of:

     (1)  Two persons licensed as advanced practice registered nurses and appointed by the board;

     (2)  Two persons licensed in medicine by the Hawaii medical board and appointed by the Hawaii medical board;

     (3)  Three persons licensed as pharmacists and appointed by the board of pharmacy;

     (4)  One representative of the University of Hawaii John A. Burns school of medicine appointed by the dean of the University of Hawaii John A. Burns school of medicine; and

     (5)  One representative from a school of nursing with an advanced practice registered nurse program.

The joint formulary advisory committee shall recommend the applicable formulary for persons recognized under this section.  The [Hawaii medical] board shall consider the recommendations of the joint formulary advisory committee in adopting the formulary.  The appropriate working relationship with licensed physicians shall be reflected in rules adopted by the board in accordance with chapter 91.

(c)  The board shall establish nursing requirements for education, experience, and national certification pursuant to rules adopted in accordance with chapter 91.

(d)  Advanced practice registered nurses shall be considered qualified if they have met the requirements of section 457-8.5(a), and have met the advanced pharmacology requirements for initial prescriptive authority pursuant to rules adopted by the board.  Only qualified advanced practice registered nurses authorized to diagnose, prescribe, and institute therapy or referrals of patients to health care agencies, health care providers, and community resources and, only as appropriate, to the practice specialty in which the advanced practice nurse is qualified, may:

(1) Prescribe, procure, administer, and dispense over the counter and legend drugs, and controlled substances pursuant to this chapter and to chapter 329; provided that an advanced practice registered nurse shall not request, receive, or sign for professional controlled substance samples;

(2) Prescribe, order, and dispense medical devices and equipment; and

(3) Plan and initiate a therapeutic regimen that includes nutritional, diagnostic, and supportive services including home health care, hospice, and physical and occupational therapy."

     SECTION 11.  The insurance commissioner shall perform a review in 2011, of the effects of this Act, and submit a report of the review's findings to the legislature not later than twenty days prior to the convening of the regular session of 2012.

     SECTION 12.  Statutory material to be repealed is bracketed and stricken.  New statutory material is underscored.

     SECTION 13.  This Act shall take effect upon its approval.