HEALTHCARE FLEXIBILITY ACT. (NEW)

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View NCGA Bill Details2023-2024 Session
House Bill 681 (Public) Filed Tuesday, April 18, 2023
AN ACT TO ESTABLISH AN INTERSTATE COMPACT FOR THE LICENSURE OF THE PRACTICE OF MEDICINE, TO PROVIDE PRACTICE AUTHORITY FOR NURSE PRACTITIONERS, TO ENSURE FLEXIBILITY FOR ANESTHESIA SERVICE, TO REQUIRE NOTIFICATION FOR OUT-OF-NETWORK BILLING AT IN-NETWORK FACILITIES, AND TO LIMIT FACILITY FEES.
Intro. by K. Baker, Reeder, Lambeth, Potts.

Status: Re-ref Com On Finance (Senate action) (May 22 2024)

SOG comments (1):

Long title change

Committee substitute to the 1st edition changed the long title. Original long title was AN ACT TO ESTABLISH AN INTERSTATE COMPACT FOR THE LICENSURE OF THE PRACTICE OF MEDICINE AND A MILITARY RELOCATION LICENSURE PROCESS.

Bill History:

H 681

Bill Summaries:

  • Summary date: May 22 2024 - View Summary

    Senate committee substitute to the 1st edition makes the following changes.

    Designates the provisions pertaining to the new Interstate Medical Licensure Compact as Part I of the act. Changes the effective date from October 1, 2023, to when the act becomes law.

    Removes proposed new GS 90-12.02, which provided for a military relocation license to a physician or physician assistant not actively licensed by the State medical board to practice in the State so long as certain requirements are met. Also removes conforming changes to GS 90-13.1.

    Adds the following. 

    Part II

    Narrows the types of nursing and tasks that can be performed under GS 90-18(c)(14) (pertaining to practicing medicine without a license) to licensed advanced practice registered nurses engaged in the practice of advanced practice nursing without being considered practicing medicine or surgery. (Currently, exemption encompasses the practice of nursing by a registered nurse engaged in the practice of nursing and the performance of acts otherwise constituting medical practice by a registered nurse.) Specifies that the rules governing the advanced practice nursing will be develop the Board of Nursing (Board) with input from the Nurse Practitioner (NP) Advisory Committee (NPAC). (Currently, registered nurses engage in practice under rules jointly developed by the NC Medical Board and the Board of Nursing.)  

    Amends GS 90-18.2 (limits on NP’s) as follows. Defines advanced nursing practice, advanced practice registered nurse (APRN), collaborating provider (meaning a licensed physician or NP with at least 8,000 practice hours and in good standing with their respective licensing boards without any professional discipline in the preceding five years), and collaborative provider agreement. Amends who may use the title "nurse practitioner" to now be any nurse approved under GS 90-18(c)(14) to perform advanced nursing practice (was, to perform medical acts or tasks) or functions.

    Creates the NPAC. Provides for membership of NPAC.  Directs NPAC to assist the Board in proposing regulations for NPs under GS Chapter 90 and to comply with all open meeting requirements. Directs that any NP with 4,000 hours of practice as an NP who has not been disciplined by the Board in the preceding five years has independent authority to engage in advanced practice nursing. Requires an NP with less than 4,000 hours of practice as an NP to practice with a collaborating provider.

    Amends the conditions under which NP’s are authorized to write prescriptions as follows. Requires the NP to follow the rules adopted by the Board governing prescriptions (was, rules must be adopted by the Board and the Medical Board). Allows NPs holding an advanced NP license to write prescriptions (currently an NP with a current approval form from the Board and medical board).  Amends the written instructions prong so that it only applies to NP’s who are required to have a collaborating provider pursuant to a collaborating provider agreement (currently refers to supervising physician). Amends the controlled substances prong to specify that it only applies if the NP is required to have a collaborating provider (currently refers to supervising physician).

    Expands places where NPs are authorized to order medications, tests and treatment to include home health.  Amends the requirements governing the authorizations of the above as follows. Removes references to the Medical Board in provisions requiring NP’s to follow rules for diagnosing, treating, and facilitating patients’ management, including prescribing pharmacologic and nonpharmacologic interventions so that the Board is the only regulating entity. Makes conforming changes to remaining prongs so that the Board is the only regulating entity.  Amends the written instructions prong so it only applies to NP’s who are required to have a collaborating provider pursuant to a collaborating provider agreement (currently refers to supervising physician). Requires the NP to hold an APRN license. Removes the requirement that the hospital or other health facility’s written policy needs to be approved by the medical staff after consultation with the nursing administration.  

    Specifies that if an NP is required to have a collaborating provider then that provider is deemed to have ordered a prescription, order, or medical certification of the NP.  (Currently refers to supervising physicians.) Specifies that NP’s who are not authorized to have a collaborating provider are responsible for their own authorization and completion of a prescription, order or death certificate.

    Amends the schedule of fees in GS 90-171.27 (expenses payable from fees collected by the Board) to provide for an ANRP application fee not to exceed $100, an ANRP renewal fee not to exceed $100, and a reinstatement of a lapsed license to practice as an ANRP and renewal fee not to exceed $180. Removes references to nursing certificates in the schedule of fees.

    Effective January 1, 2025. Requires the Board to adopt rules to implement the provisions above by January 1, 2025.

    Part III

    Enacts new GS 90-18.9, providing as follows. Requires, consistent with the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) that an anesthesiologist providing medical direction to a certified registered nurse anesthetist performing anesthesia care must comply with all of the following in order to bill any third-party payor for medical direction services: (1) perform a pre-anesthetic examination and evaluation and document it in the medical record; (2) prescribe the anesthesia plan; (3) personally participate in and document the most demanding procedures in the anesthesia plan, if applicable; (4) ensure that any procedures in the anesthesia plan that the anesthesiologist does not perform are performed by a certified nurse anesthetist or anesthesiologist assistant, as appropriate; (5) monitor the course of anesthesia administration at frequent intervals and document that they were present during some portion of the monitoring; and (6) remain physically present and available for immediate diagnosis and treatment of emergencies. Enacts new GS 58-3-301 requiring an insurer offering a health benefit plan in this State to reimburse claims for medical direction of a nurse anesthetist at 50% of the rate of reimbursement the anesthesiologist would have received for services if the services had been performed without the nurse anesthetist. Also requires, consistent with TEFRA, that the insurer require that any anesthesiologist supervising a certified registered nurse anesthetist performing anesthesia care comply with the same requirements set out in new GS 90-18.8 and must also provide indicated post-anesthesia care. Defines the terms anesthesia care, anesthesiologist, certified registered nurse anesthetist, medical direction and TERFA as they are used in both statutes. Amends GS 135-48.51 to make new GS 58-3-301 applicable to the State Health Plan. Applies to services rendered or insurance contracts issued, renewed, or amended on or after October 1, 2024.

    Amends GS 58-93-120 to make new GS 58-3-3-1 applicable to prepaid health plans in the manner in which it applies to insurers.

    Requires the Department of Health and Human Services, Division of Health Benefits (DHB), to review the Medicaid State Plan and all applicable Medicaid clinical coverage policies to ensure that the Medicaid program is paying anesthesiologists for medical direction of nurse anesthetists at 50% of the reimbursement the anesthesiologist would receive if they performed the work alone. Also requires DHB to ensure that all requirements for reimbursement of anesthesiologist medical direction services comply with TEFRA. 

    Part IV

    Enacts new GS 58-3-295 to require all contracts or agreements for participation as an in-network health services facility between an insurer offering at least one health benefit plan in this state and a health services facility at which there are out-of-network providers who may be providing covered services to an insured person receiving care at the facility, to require that an in-network health services facility give at least 72 hours' advanced written notice to an insured with a scheduled appointment of any out-of-network provider who will be part of providing care. Sets out alternate requirements for timing of notice in situations in which there is not 72 hours between the appointment and when it is scheduled or when there is an emergency. Requires the notice to include: (1) all of the healthcare providers that will be rendering services who are not in-network and (2) the estimated cost to the insured of the services being rendered by those out-of-network providers. Defines a health care provider as any individual licensed, registered, or certified under GS Chapter 90, or under another state's laws, to provide health care services in the ordinary care of business or practice, as a profession, or in an approved education or training program in: (1) anesthesia or anesthesiology, (2) emergency services, (3) pathology, (4) radiology, or (5) rendering assistance to a physician performing any of these services.

    Applies to contracts entered into, amended, or renewed on or after October 1, 2024.

    Part V

    Enacts GS 131E-274, pertaining to facility fees, as follows. Sets forth eight defined terms. Lists the following limitations on facility fees: (1) that no health care provider can charge, bill, or collect a facility fee unless the services are provided on a hospital’s main campus, at a remote location of a hospital, or at a facility that includes an emergency department and (2) that regardless of where the services are provided, no health care provider can charge, bill, or collect a facility fee to outpatient evaluation and management services, or any other outpatient, diagnostic, or imaging services identified by the Department of Health and Human Services (DHHS). Requires the Department to annually identify services subject to the limitations on facility fees described above that may reliably be provided safely and effectively in non-hospital settings. Requires each hospital and hospital system to submit an annual report to the Department by July 1 of each year, which will be published on the Department’s website. Lists six things that the report must include, such as the name and full address of each facility owned or operated by the hospital or health system that provides services for which a facility is charged or billed.

    Specifies that any violation of the statute is considered an unfair and deceptive trade practice. Provides for an administrative penalty of not more than $1,000 per occurrence to any health care provider that violates the section. Effective January 1, 2025, and applies to facility fees charged on or after that date. 

    Requires the Department to adopt rules to implement this section by January 1, 2025. 

    Makes organizational changes. Makes conforming changes to the act’s titles.


  • Summary date: Apr 18 2023 - View Summary

    Enacts new Article 1M, Interstate Medical Licensure Compact, to GS Chapter 90. States the purpose and objectives of the Interstate Medical Licensure Compact (Compact) and sets forth 15 defined terms. Grants licensed physicians the opportunity to apply for issuance of an expedited license to practice in Compact states, subject to the requirements and restrictions provided in the Compact. Requires designation of a state of principal licensure where the physician has a full and unrestricted license to practice medicine which is the physician's principal residence, where the physician conducts at least 25% of their practice, and is the location of the physician's employer, or if no state applies, the state designated for federal income tax purposes; allows for re-designation of the principal state at any time.

    Details application procedures for a physician seeking licensure through the Compact, including (1) applying to the member board of the selected state of principal license, (2) the member board of the selected state of principal license conducting a criminal background check prior to the issuance of a letter of qualification either verifying or denying the physician's eligibility to the Interstate Medical Licensure Compact Commission (Commission), (3) completion of the registration process established by the Commission to receive a license in the member state selected as the principal license state, including payment of applicable fees, and (4) issuance of an expedited license by any member board authorizing the physician to practice medicine in the issuing state consistent with the medical practice act and application laws and regulations of the issuing member board and member state, subject to issuance or renewal fees. Provides for eligibility appeals to be made to the member state where the application is filed. Provides for the expedited license to be valid for a period consistent with the licensure period of the member state and in the same manner as required for other physicians holding a full and unrestricted license within the member state, and terminated for failure to maintain a license in the state of principal licensure for nondisciplinary reasons without redesignating a new state. Details expedited license renewal requirements and procedures. 

    Requires the Commission to establish a coordinated database and reporting system containing licensure, adverse action, and investigative information on all licensed individuals and applicants in members states. Provides for reporting and access by member states. Provides for joint investigations by member states and related authorities. Deems any disciplinary action taken by any member board against a physician licensed through the Compact to be unprofessional conduct subject to discipline by other boards in addition to violation of the medical practice act or regulations in the state. Provides for licensure status following disciplinary action to be automatically mirrored by member states who have issued licenses to the physician, with each member state maintaining individual reinstatement procedures following reinstatement of the principal state of licensure. Provides for a 90-day automatic suspension of licenses issued by member states when one member state revokes, surrenders, or suspends a license.

    Establishes the Interstate Medical Licensure Compact Commission (Commission) as a joint public agency created by member states. Provides for Commission membership, voting, meetings, powers and duties, executive committee, financing, recordkeeping, and member qualified immunity, defense, and indemnification. Among the 21 powers and duties charged of the Committee, includes prosecuting legal proceedings and actions, and the acquisition and disposal of property. Provides for Commission rulemaking procedures and effect, as well as member state rejection of a Commission rule.

    Details dispute resolution procedures between member states and Compact enforcement. Provides for member state default grounds and procedures, member withdrawal procedures and dissolution. Provides for the Compact to become effective upon enactment in the seventh member state. Details initial Commission powers, effect of Commission rules on joining states, and Compact amendment parameters. 

    Deems the provisions of the Compact severable and advises on its construction and effect on other laws. 

    Enacts GS 90-12.02 authorizing the issuance of military relocation licenses to a physician or physician assistant who is not actively licensed by the NC Board of Medicine (Board) to practice as a physician or physician assistant if six listed requirements are met including that they are a servicemember or the spouse of a service member in the US Armed Forces, resides in the State pursuant to military orders for military service, and holds a license in another jurisdiction that has licensing requirements substantially similar to or exceeds the licensure requirements of the State. Specifies that the military relocation license will remain active for the duration of military orders for military service in the State and upon completion of annual registration. Specifies that the license becomes inactive when the license holder relocates pursuant to military orders (1) to reside in another state or (2) expiring for military service in this State, or the servicemember separates from military service. Provides for notification to the Board upon events that render a license inactive. Allows for a military license to become a full license by completing an application for licensure under Article 1M. Allows the Board to waive the application fee if the application is submitted within one year of the issuance of the military relocation license. Permits the Board to impose additional requirements by rule.

    Makes conforming changes to the following statutes: GS 90-5.1 (authorizing the Board of Medical Examiners to appoint Commissioners to the Commission); GS 90-11 (authorizing background checks for Compact applicants); GS 90-13.1 (regarding licensing fees of the Board of Medical Examiners and the Commission for Compact applicants); GS 90-13.2 (regarding Compact licensing renewals); GS 90-14 (authorizing the Board of Medical Examiners to take disciplinary action for violations of the Compact); and GS 90-14.2 (regarding automatic disciplinary action upon Compact licensees).

    Effective October 1, 2023