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 advanced practice nursing will be developed by 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 NPs) 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 NPs 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 NPs 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 NPs 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 NPs 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 NPs 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 58-3-301 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.

House committee substitute to the 2nd edition makes the following changes.

Part I

Makes a technical correction to the statutory citation of GS 135-3(8).  

Part V

Removes Part V of the act, which made changes to GS 135-18.8, GS 218-38.3, GS 135-75, GS 120-4.32, and GS 127A-40 concerning the sunset on the eligibility of newly domiciled employees or retiree associations to receive periodic deductions from retirement benefits.