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

Reorganizes the existing provisions into Part I of the act and changes the effective date from October 1, 2025, to January 1, 2026.

Adds the following new content and makes conforming changes to the act’s titles.

Part II.

Establishes an internationally-trained physician employee license in GS 90-12.03, as follows. Requires the Medical Board to receive satisfactory verification of 11 listed requirements before issuing such a license, including (1) that the applicant has been offered employment as a physician in full-time capacity at a licensed hospital in the State or in a medical practice located in a rural county with a population of less than 500 people per square mile in North Carolina where a physician licensed in NC is physically practicing on-site at the rural practice; (2) that the applicant demonstrates competency to practice medicine, as described; and that the applicant is legally authorized to work in the US. Prevents holders of such licenses from practicing medicine or surgery outside of their place of employment and makes violations a Class 3 misdemeanor with a fine of up to $500 for each offense. Allows the Medical Board to revoke licensee’s license upon notice to the licensee. Specifies that an internationally-trained physician employee license becomes inactive when the person ceases to be employed as described above or when they obtain any other license to practice medicine issued by the Medical Board. Allows a physician with an internationally-trained physician employee license in good standing with four-years of practice to apply for a full medical license. Directs the Medical Board to grant the application if the applicant has no disciplinary actions by any state, federal or foreign regulatory agency, no pending investigations by any state, federal or foreign regulatory agency, no misdemeanor convictions in the two years preceding their application for a full license, no felony convictions, no pending misdemeanor or felony charges, and no adverse actions affecting their privileges or ability to practice. Requires the Medical Board to collect information necessary to evaluate the implementation and success of pathway to licensure including the specified 11 topics. Requires an annual report on this information to the specified NCGA committee.

Requires the Medical Board to adopt rules necessary to issue an internationally-trained physician employee license. Allows the Medical Board to establish a time limit for the term of an internationally-trained physician employee and to implement the Compact, discussed above. 

States the NCGA’s intent that the provisions of Part II be severable.

Effective January 1, 2026.

Part III.

Amends the supervision provisions under the Psychology Practice Act (GS 90-270.139) as follows. Enacts GS 90-270.139(e1), which exempts certain licensed psychological associates from supervision if they have met the following requirements: (1) 4,000 hours of post-licensure experience in the delivery of psychological services under the supervision of one or more qualified licensed psychologists or qualified licensed psychological associates within a time period of at least 24 consecutive months and less than 60 consecutive months; (2) documents that performance ratings for those 4,000 hours have been average or above average; and (3) they submit an application for independent practice with proof of the required hours. Requires the NC Psychology Board (Board) to approve a licensed psychological associate to engage in independent practice if the licensed psychological associate meets those requirements. Makes conforming changes to GS 90-270-139(e) and deletes all of the specified activities for when a licensed psychological associate needs supervision set forth in GS 90-270-139(e)(3). Instead, provides that a licensed psychological associate needs supervision when they engage in psychology; also deletes the Board’s rulemaking authority related to this provision and for defining further activities that require supervision.

Expands the requirements for licensure as a psychological associate in the practice of neuropsychology (defined) or forensic pathology (defined) under GS 90-270.145 by requiring those applicants to demonstrate to the Board specialized education and training to practice in those areas including graduate level course work, continuing education, supervised training experience, or any other factors the Board deems appropriate.

Amends GS 90-270.153 (pertaining to certification as a health services provider under the Psychology Practice Act) to allow for licensed psychological associates with certification as a health services provider psychological associate to provide health services without supervision on meeting the requirements in GS 90-270.139 as described above. Provides that a licensed psychological associate licensed before June 30, 2013, who can demonstrate that they have been provided health services psychology under supervision for 4,000 hours without at least 24 consecutive months and less than 60 consecutive months, meets certification requirements.

Amends GS 90-270.140, to provide that as the term of a psychologist member expires on the Psychology Board, or as a vacancy of a psychologist member occurs for any other reason, instructs the Board, the North Carolina Psychological Association, or its successor, and the North Carolina Association of Professional Psychologists, or its successor, to form a nominating committee and, having sought nominees from licensees for each vacancy, to submit to the Governor a list of the names of three eligible persons.

Effective, October 1, 2025.

Part IV.

Enacts new Article 18J, Physician Assistant Licensure Compact (PA Compact), to GS Chapter 90. States the purpose of the PA Compact and sets forth 22 defined terms, including adverse action (any administrative, civil, equitable, or criminal action permitted by a state's laws which is imposed by a Licensing Board or other authority against a PA License or license application or compact privilege such as license denial, censure, revocation, suspension, probation, monitoring of the licensee, or restriction on the licensee's practice), qualifying license (an unrestricted license issued by a participating state to provide medical services as a PA), remote state (a participating state where a licensee who’s not licensed is seeking to exercise compact privileges), and significant investigative information (investigative information that a licensing board, after an inquiry or investigation that includes notification and an opportunity for the PA to respond if required by state law, has reason to believe is not groundless and, if proven true, would indicate more than a minor infraction). 

Lists eight requirements for a State to participate in the PA Compact, including that it licenses PAs who have, amongst other things, passed a nationally recognized exam; conducts certain background checks; and grants PA compact privileges to qualifying licensees from participating states. Specifies that participating states may charge a fee for granting PA Compact privileges. Adds new GS 90-270.203, listing 12 requirements a licensee must meet to be granted compact privileges, including graduation from certain PA programs, certifications, holding a qualifying license, and no felony or misdemeanor convictions along with other background qualifiers. Specifies that compact privileges are valid until the expiration or revocation of the licensee’s qualifying license. Directs that if the participating state in the PA Compact where the licensee is licensed takes adverse action (defined), then the licensee’s compact privileges in any remote state in which they have privileges are lost until the license is no longer limited or restricted and two years have elapsed from the date that the license became no longer limited or restricted and the licensees again meets the 12 requirements for compact privileges in GS 90 270.203(a). Requires that, for each remote state where a PA seeks authority to prescribe controlled substances, the PA must satisfy all requirements imposed by the state in granting or renewing such authority. 

Adds new GS 90-270.204, requiring that the licensee identify the participating state where they are applying along with (1) the address of their primary residence, (2) requirement to immediately report any changes of primary residence, and (3) the licensee consents to service of process at their primary residence. 

Adds new GS 90-270.205, pertaining to adverse actions. Designates the participating state where the PA is licensed with exclusive power to impose adverse action against the PA’s qualifying license issued by that state. Lists four things that remote states have the authority to do, including taking adverse action against a PA’s compact privilege or other action necessary to protect the health and safety of its citizens. Requires the licensee's participating state to give priority and effect to reported conducted received from any other participating state as if the conduct occurred in the participating state itself. Requires the participating state to apply its own laws to determine appropriate action. Allows participating states to recover costs of investigation and disposition of cases from licensees subject to an adverse action. Allows for adverse actions by participating states based on factual findings of a remote state. Provides for joint investigations by participating and remote states. Specifies that if an adverse action is taken against the qualifying license, then the PA’s compact privileges in all remote states are deactivated until two years have elapsed after all restrictions have been removed from the license. Provides for a disciplinary order and notice by the participating state to the administrator of the data system established under GS 90-270.207.

Adds new GS 90-276.206, establishing a PA Licensure Compact Commission (Commission), a joint government agency and national administrative body. Provides for Commission membership; voting; meetings; powers and duties; an executive committee; financing; recordkeeping; and member-qualified immunity, defense, and indemnification. Among the 23 powers and duties charged of the Committee, includes establishing a code of ethics, prosecuting legal proceedings and actions so long as the standing of any state licensing board to sue or be sued under applicable law is not affected, and the acquisition and disposal of property. Provides for Commission rulemaking procedures and effect, including a participating state challenge of a Commission rule if it conflicts with the state’s law pertaining to medical services that a PA may perform in the state and rejection of a rule by a majority of participating state legislatures. 

Adds new GS 90-270.207, requiring the Commission to establish a coordinated database and reporting system containing licensure, adverse action, and the reporting of the existence of significant investigative information on all licensed PAs and applicants denied a license in participating states. Designates information provided to a participating state from the database is an authenticated business record entitled to a hearsay exception in any relevant judicial, quasi-judicial, or administrative proceeding in a participating state when certified by the Commission or an agent thereof. 

New GS 90-270.208 sets out the Commission’s rulemaking powers and the impact of those Rules. Sets out the process for adopting rules, including when a Participating State rejects a rule.

Adds new GS 90-270.209, detailing oversight of the PA Compact by the executive and judicial branches in each participating state, dispute resolution procedures between member states, and PA Compact enforcement by the Commission. Provides for member state default grounds and procedures, member termination procedures, and dissolution. Provides for venue and available remedies in legal action against the Commission. Specifies that only a participating state can enforce the PA Compact against the Commission. Adds new GS 90-270.210, that provides for the Compact to become effective upon enactment in the seventh member state and withdrawal procedures by member states. Requires the Commission to review all participating state charters once the PA Compact becomes effective to ensure they are all in compliance with the model compact. Allows for a participating state to default if its compact is materially in conflict with the model compact. 

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

Makes conforming changes to GS 90-9.3 (requirements for licensure as a physician assistant).

Amends GS 90-13.2 to require privilege holders to register annually with the North Carolina Medical Board in accordance with new Article 18J. Requires physician assistants to pay an annual registration fee of $140; adds an additional $25 for failure to register.

Imposes an initial PA licensure or privilege fee of $230 under GS 90-13.1 (license fees).

Expands the definitions of license and licensee in GS 90-1.1 to include a physician assistant compact privilege and physician assistant compact privileges issued to a holder of a qualifying license in a qualifying state, respectively.

Amends GS 90-5.1by expanding the Board’s powers to include implementing the Physician Assistant Licensure Compact, including issuing compact privileges, and appointing a delegate to serve on the Commission, as described.

Makes conforming change to GS 90-11 (criminal background checks) to account for privilege holder applicants.

Expands the Board’s disciplinary authority under GS 90-14 to include violations of the PA Licensure Compact, consistent with the provisions of the compact for compact privilege holders.

Effective nine months after the part becomes law.

Part V.

Amends GS 90-85.3A to allow a pharmacist to (1) administer drugs and (2) order and perform a CLIA-waived test and initiate treatment bast on the result of the CLIA-waived test for influenza according to statewide protocols. Prohibits a pharmacist from treating a health condition under this statute with any controlled substance classified in Schedules I through IV. Defines CLIA-waived test in GS 90-85.3 as a lab test approved by the FDA and waived under the federal Clinical Laboratory Improvement Amendments of 1988. Effective October 1, 2025.

Enacts GS 58-3-241, requiring health benefit plans to cover healthcare services provided by pharmacists if (1) the service or procedure was performed within the pharmacist’s licensed scope of practice and (2) the health benefit plan would have covered the service if it had been performed by another healthcare provider. Defines healthcare provider, healthcare services, and pharmacist. Specifies that the participation of a pharmacy in a drug benefit provider network of a health benefit plan does not satisfy any requirement that insurers offering health benefit plans include pharmacists in medical benefit provider networks. Requires an insurer to accept a claim under this statute regardless of whether it is submitted by a pharmacist or a pharmacy submitting the claim on behalf of a pharmacist the pharmacy employs or contracts with. Applies all requirements relating to coverage of prescription drugs and pharmacy services under GS Chapter 58 governing health benefit plans to pharmacy benefits managers as well as insurers. Amends GS 58-3-230 (uniform provider credentialing) to require insurers that delegate credentialing agreements or requirements for pharmacists licensed under Article 4A of GS Chapter 90 of the General Statutes or the relevant laws of another state to a contracted healthcare facility shall accept the credentialing for all pharmacists employed by, or contracted with, those healthcare facilities. Enacts new GS 58-65A-55 making all requirements related to coverage of prescription drugs and pharmacy services that apply to health benefits plans applicable to a pharmacy benefits manager in the same way. Effective October 1, 2025, and applies to insurance contracts entered into, renewed, or amended on or after that date.

Requires the State Health Director to issue a standing order authorizing a pharmacist to order and perform a CLIA-waived test and initiate treatment for influenza according to the GS 90-58.3A, as amended. Makes the order effective until the earlier of the date of the effective date of the permanent rules described below or January 1, 2027.

Requires the Medical Board and Board of Pharmacy, in conjunction with the State Health Director, to adopt rules implementing Section 5.1 (which amended GS 90-85.3 and GS 90-85.3A) and sets out five minimum requirements for those rules, including, an approved course of treatment pharmacists my implement for influenza, and patient parameters necessitating referral to a primary, urgent, or emergency care provider.

Part VI.

Amends GS 90-1.1 (setting forth definitions related to the practice of medicine) to add a new definition for team-based setting or team-based practice, to include any of the following:

(1) a medical practice where: (i) the majority of the practice is owned collectively by one or more licensed physicians; (ii) an owner who is a physician licensed to practice medicine in North Carolina has consistent and meaningful participation in the design and implementation of health services to patients, as defined by rules adopted by the North Carolina Medical Board (Medical Board); and (iii) the physicians and team-based physician assistants (team-based PAs) who provide services at the medical practice work in the same clinical practice area.

(2) hospitals, clinics, nursing homes, and other health care facilities with active credentialing and quality programs where physicians have consistent and meaningful participation in the design and implementation of health services to patients, as defined by rules adopted by the Board.

Excludes a medical practice that specializes in pain management from the definition of team-based practice or team-based setting. 

Enacts new GS 90-9.3A, which provides as follows. Sets out the following a physician assistant (PA) must meet to practice as a team-based PA if the PA practices in a team-based setting or team-based practice: (1) more than 4,000 hours of clinical practice experience as a licensed PA and more than 1,000 hours of clinical practice experience within the specific medical specialty of practice with a physician in that specialty and (2) submission of proof satisfactory to the Medical Board of practice in a team-based setting and the requisite clinical hours. Authorizes the Medical Board to adopt rules setting other requirements for practice or additional information required. Requires team-based PAs to collaborate and consult with or refer to the appropriate members of the health care team as required by the patient's condition and as indicated by the education, experience, and competencies of the physician assistant and the standard of care. The degree of collaboration must be determined by the practice, which may include decisions by the employer, group, hospital service, and the credentialing and privileging systems of a licensed facility. Authorizes the Medical Board to adopt rules to establish requirements for the determination and enforcement of collaboration, consultation, and referral. States that team-based PAs are responsible for the care they provide. Requires a team-based PA practicing in a perioperative setting to be supervised by a physician.

Amends PA general licensure requirements (GS 90-9.3) and limited volunteer licensure requirements (GS 90-12.4) to exempt team-based PAs from having to submit supervising physician information. 

Makes technical change to GS 90-12.4B.

Amends GS 90-18.1 (limitations on PAs) as follows:

• Requires all PAs to clearly designate their credentials as a PA in all clinical settings.
• Exempts team-based PAs from the supervising physician requirement to write prescriptions for drugs. 
• Changes the designated PA supervisor from licensed pharmacist to licensed physician for a PA to be able to compound and dispense drugs. Requires PA to also follow all applicable state and federal laws and rules governing compounding and dispensing (was, only the rules and regulations of the North Carolina Board of Pharmacy). Requires the PA to register with the Board of Pharmacy.
• Only requires a supervising physician to provide a PA written instructions about medications, tests, or treatments in order for the PA to be able to order those medications, tests, or treatments if the PA is subject to a supervisory arrangement. Exempts team-based PAs who may prescribe, order, administer, and procure drugs and medical devices without physician authorization from provision holding supervising physician responsible for authorizing a PA prescription or order. Allows for those practicing in a team-based setting to plan and initiate a therapeutic regimen that includes ordering and prescribing non-pharmacological interventions, including durable medical equipment, nutrition, blood, blood products, and diagnostic support services, including home health care, hospice, and physical and occupational therapy.
• Allows for PAs to authenticate any document (was, just death certificates) so long as it may have been authenticated by a physician. Deletes language deeming completion of a death certificate by a PA as authorized by a supervising physician and holding the physician responsible for that authorization. 
• Bars PAs from performing final interpretations of diagnostic imaging studies (computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography (PET), mammography, and ultrasound services). Requires physician to provide final interpretation of diagnostic imaging studies. Allows for PA to conduct a final interpretation of plain film radiographs only when supervised by a physician.
• Makes conforming changes to refer to new "team-based practice." 

Amends definition of qualified technician in the Woman’s Right to Know Act (GS 90-21.81) to include PAs with certification in obstetrical ultrasonography.  

Amends definition of attending providers in GS 58-3-169 (requiring insurance coverage for minimum hospital stays after birth) to include PAs.

Amends GS 110-91 (governing licensure requirements for child care facilities) to allow PAs to be able to complete a child health assessment before a child is admitted or within 30 days of admission to a child care facility.  

Requires the Board to adopt permanent rules to implement the above provisions. Makes the provision effective when the Board adopts the permanent rules or June 30, 2026, whichever is first.

Repeals GS 90-8.2(a) (requiring the NC Medical Board [Board] to appoint and maintain a subcommittee to work jointly with a subcommittee of the Board of Nursing [NB] to develop rules to govern the performance of medical acts by registered nurses). Makes conforming changes to GS 90-18 (practice without a license), GS 90-18.2 (limitations on nurse practitioners), GS 90-171.23(b) (powers and duties of the NB), GS 90-18.8 (limits on nurse-midwives), GS 90-178.3 (regulation of midwifery), GS 90-178.4 (administration of article pertaining to certified nurse midwives), GS 90-178.5 (qualifications for approval as a certified nurse midwife), GS 90-178.6 (denial, revocation, or suspension of approval-midwifery licensure), and GS 90-178.7 (enforcement).

Amends GS 90-171.23 authorizing the NB to grant prescribing, ordering, dispensing, and furnishing authority to nurse practitioners. Gives the NB sole authority to adopt rules and enforce regulations governing the practice of nurse practitioners, nurse midwives, and the practice and conduct of nurse midwifery (including the authority to adopt rules to implement and enforce the provisions of Article 10A, governing the practice of midwifery, of GS Chapter 90).

Repeals GS 90-171.37(b) (requiring the NB’s discipline of a registered nurse to not interfere with the Board’s authority to enforce rules and regulations governing the performance of medical acts by a registered nurse).

Modifies the NB’s reporting requirements under GS 90-178.4 so that it no longer must annually report all receipts of every kind and nature, as well as the compensation paid the members of the joint subcommittee and the necessary expenses incurred by them in the performance of their duties to the State Treasurer. Removes provisions providing compensation to members of the NB who are not officers or employees of the State and for reimbursement of travel and subsistence expenses of State employee members at the statutory rate.  

Removes the nurse practitioner member of the Board in GS 90-2 and increases the number of physician assistants on the Board from one member to two. Makes conforming changes. Makes conforming changes to GS 90-3 (review panel recommendations for certain Board members).

Directs the NB to adopt permanent rules to implement the above provisions. Makes the provisions effective when the NB adopts the permanent rules or June 30, 2026, whichever is first.

Part VII.

Amends GS 90-18(c), listing actions that do not constitute practicing medicine or surgery under Article 1, Practice of Medicine. Replaces subdivision (3a) to now exclude the provision of health care services by a licensed pharmacist under a collaborative practice agreement with at least one physician performed pursuant to rules developed by a joint subcommittee of the Medical Board and Board of Pharmacy and approved by both Boards (currently, excludes the provision of drug therapy management by a licensed pharmacist engaged in the practice of pharmacy pursuant to an agreement that is physician, pharmacist, patient, and disease specified when performed pursuant to rules approved by the Boards). Defines health care services as medical tasks, acts, or functions authorized through written agreement by a physician and delegated to a pharmacist for the purpose of providing drug therapy, disease, or population health management for patients. 

Amends GS 90-18.4, which sets limitations on clinical pharmacist practitioners, to eliminate references to drug therapy management. Provides that physicians can authorize clinical pharmacist practitioners to provide health care services so long as the Boards have adopted rules governing the approval of individual practitioners, the practitioner has current approval from both Boards, and the Medical Board has assigned an identification number to the practitioner that is shown on written prescriptions. Eliminates limitations relating to practitioners' prescription substitutions and authority to order medication and tests. Deems orders written by a clinical pharmacist practitioner for medications, tests, or other devices to have been authorized by the supervising physician, with the supervising physician responsible for authorizing the order, and authorizes registered nurses, licensed practical nurses, and pharmacists to perform the order in the same manner as if the order were received from a licensed physician. Authorizes institutional and group practices to implement site-specific, multi-provider collaborative practice agreements for the care of their patients. Requires the institution or group practice to develop an oversight policy and requires evaluation of the practitioners engaged in the agreement by an appointed supervising physician. Lists six requirements that apply to clinical pharmacist practitioners and supervising physicians engaging in collaborative practice, including (1) requiring a clinical pharmacist practitioner to have a site-specific supervising physician, (2) requiring the supervising physician to conduct periodic review and evaluation of the health care services provided by the clinical pharmacist practitioner, (3) allowing a physician to supervise any number of clinical pharmacist technicians as the supervising physician deems can be safely and effectively supervised, (4) requiring delegated health care services to be included in the written agreement between the supervising physician and the clinical pharmacist practitioner, (5) allowing a supervising physician to include a statement of authorization in the written agreement to allow the clinical pharmacist practitioner to conduct drug substitutions as specified, and (6) allowing supervising physicians to add other advanced practice providers they supervise to the collaborative practice agreement. Allows for the health care settling location of health care services provided by the clinical pharmacist practitioner to be fully or partially embedded for a site-specific practice. Requires the supervising physician to determine the setting location and include the location in the site-specific collaborative practice agreement. 

Amends the definition of clinical pharmacist practitioner in GS 90-85.3 to include authorization to perform medical acts, tasks, and functions for drug therapy, disease, or population health management agreements with physicians pursuant to GS 90-18.4, as amended.

Enacts new GS 58-50-296, which requires insurers offering a health benefit plan that delegates credentialing agreements or requirements for licensed pharmacists to a contracted healthcare facility to accept the credentialing for all pharmacists employed by, or contracted with, those healthcare facilities.

Enacts new GS 58-3-241 to require health benefit plans offered by insurers to cover healthcare services provided by a pharmacist if (1) the service or procedure was performed within the pharmacist's licensed scope of practice, (2) the plan would have provided reimbursement if performed by another health care provider, and (3) the pharmacist provided the service or procedure pursuant to any requirements of the insurer related to the service or procedure. Specifies that the participation of a pharmacy in a drug benefit provider network of a health benefit plan does not satisfy any requirement that insurers offering health benefit plans include pharmacists in medical benefit provider networks. Defines healthcare services as any of the following health or medical procedures or services rendered by a healthcare provider: (1) testing, diagnosis, or treatment of a health condition, illness, injury, or disease, including testing, diagnosis, or treatment rendered by a pharmacist acting within the pharmacist's scope of practice; (2) dispensing of drugs, medical devices, medical appliances, or medical goods for the treatment of a health condition, illness, injury, or disease; and (3) administration of a vaccine or medication.

Amends GS 58-56-25 to make all requirements relating to the coverage or prescription drugs and pharmacy services under GS Chapter 58 that are applicable to health benefits applicable to a pharmacy benefits manager in the same way they apply to an insurer.

Applies to contracts entered into, renewed, or amended on or after October 1, 2025.

Directs the Boards to adopt temporary implementing rules. 

Effective October 1, 2025, unless otherwise provided.

Part VIII.

Establishes standards for surgical smoke evacuation in hospitals (new GS 131E-78.4) and ambulatory surgical facilities (new GS 131E-147.2). Requires licensed hospitals and ambulatory surgical facilities to adopt and implement policies that require the use of smoke evacuation/filtering systems during any surgical procedure likely to generate surgical smoke. Defines smoke evacuation/filtering system and surgical smoke. Authorizes the Department of Health and Human Services to take adverse action for violations. Effective January 1, 2026.

Part IX.

Directs the Commission for Mental Health, Developmental Disabilities, and Substance Abuse Services (Commission) to adopt a staff definitions rule under 10A NCAC 27G .0104 followed by a permanent rule under GS Chapter 150B to implement new qualifications for Associate Professionals, Qualified Professionals, and Qualified Substance Abuse Prevention Professionals.

Provides that the new qualifications, in addition to the current qualifications in rule, for an Associate Professional are that they may be a community college graduate with an associate degree in a human services field with less than two years of experience. The qualifications for a Qualified Professional are that they may be a community college graduate with an associate degree in a human services field and two years of full-time or pre- or post-associate degree accumulated supervised mental health, developmental disabilities, and substance abuse services experience. The qualifications for a Qualified Substance Abuse Prevention Professional are that they may be a community college graduate with an associate degree in the human services field and two years of full-time or pre- or post-associate degree accumulated supervised experience in addictions and recovery prevention. Also requires that the experience accepted for a Qualified Substance Abuse Prevention Professional include accumulated supervised experience in substance abuse prevention prior to the completion of a bachelor's degree.

Requires the Commission to implement a staff definitions rule until the effective date of the permanent rule required by the act. Specifies that the permanent rule will be subject to the legislative review and delayed effective dates provisions of GS 150B-21.3(b1)-(b2). Allows the Commission to make any other conforming rule changes necessary to implement the provisions of the act.

Contains a sunset provision expiring when permanent rules are adopted by the Commission.

Part X.

Amends GS 90-270.56 by now requiring (was, allowing) the North Carolina Marriage and Family Therapy Licensure Board (Board) to issue a license as a marriage and family therapist (was, marriage and family therapist or associate) by reciprocity to any person who applies for the license as prescribed by the Board and meets the additional requirements at all times during the application process.

Amends the additional requirements in the following ways: requires the applicant have been licensed and actively practicing for at least two continuous years and currently licensed as a marriage and family therapist in another state (was, licensed for five continuous years and currently licensed as a marriage and family therapist or marriage and family therapy associate in another state); and allows an applicant to show that they have passed either the National Marriage and Family Therapy examination or the clinical examination required by California’s licensing board regulating marriage and family therapy in that state (was, only the National Marriage and Family Therapy examination).

Amends GS 90-270.63 to make conforming changes. Permits the Board to adopt rules to implement provisions of this act.

Effective October 1, 2025, and applies to applications on or after that date.

Part XI.

Enacts new Article 52, Limitations on Agreements with Health Care Professionals, in GS Chapter 66, providing as follows. Defines health care professional as a licensed physician, physician assistant, advanced practice registered nurse, or registered nurse. Also defines hospital, medical staff bylaws, nondisclosure agreement, and non-compete clause. Requires a nondisclosure agreement entered into with a health care professional to include a statement that it does not restrict them from reporting safety concerns, ethical violations, or illegal activities. Prohibits requiring a health care professional from entering into a nondisclosure agreement that would: (1) prevent the health care professional from discussing patient safety concerns with licensing agencies, accrediting bodies, or other regulatory or oversight entities; or (2) restrict the health care professional's ability to report to the appropriate authorities violations of law, medical ethics, or medical staff bylaws. Prohibits an employment contract for a health care professional employed by a hospital from containing a non-compete clause. Also prohibits any policy or contractual agreement with a health care professional from providing new practice information upon patient request, and if available, requires the information to be provided by the person receiving the request. Voids any nondisclosure agreement or non-compete clause that violates the Article. Entitles a health care professional who prevails in an action under this Article to damages plus reasonable attorneys' fees and costs.

Allows the North Carolina Board of Medicine to adopt rules to implement the provision of this Part that pertain to physicians and physician assistants and for the Board of Nursing to adopt rules implementing provisions that apply to advanced practice registered nurses and registered nurses.

Effective October 1, 2025, and applies to contract entered into, modified, or renewed on or after that date.

Senate committee substitute to the 2nd edition adds the following new Part IV. Makes organizational changes. Makes conforming changes to act’s effective date and its short and long titles. Clarifies that except as otherwise provided in Parts I-IV, the act is effective when it becomes law.

Part IV.

Deletes the limitation in GS 115C-111.2 (contract with private service providers) which directed that the local educational agencies are only able to contract with private special education facilities or providers when the local entity is unable to provide the service, so that local educational agencies may contract with private providers for any service. Defines nursing services. Adds new GS 115C-111.2(b) specifying the following conditions that must be met before a local education agency must make available a parent’s choice of nurse when providing nursing services under an Individualized Education Plan (IEP): (1) the IEP requires nursing services; (2) the child received nursing services from the nurse (i) prior to the nursing services being required by the child's IEP or (ii) prior to the child enrolling in his or her current school; (3) the parent's choice of nurse is employed by a nursing agency and willing to provide the nursing services required by the child's IEP; (4) the nursing agency employing the parent's choice of nurse meets all standard contract terms required for any other nursing agency contracted by the local educational agency, including licensing and liability requirements; and (5) the contracted rate is equal to or less than the contracted rate of other nurses contracted by the local educational agency. Specifies that GS 115C-111.2 should not be construed to limit the local education agency’s responsibility to provide free public education. Applies beginning with the 2025-26 school year.

Senate committee substitute to the 1st edition replaces the previous edition with the following. Makes conforming changes to the act’s long and short titles.

Contains whereas clauses.

Section 1.

Makes the following changes to Article 11B of GS Chapter 131E. Organizes the Article into two parts, Part I, consisting of the Health Care Cost Reduction and Transparency Act of 2013 (2013 Act) and Part II, pertaining to Transparency in Healthcare Provider Billing Practices (discussed in Section 2 below). Makes clarifying, technical, and conforming changes.

Makes the following changes to the 2013 Act. Adds terms CPT (current procedural terminology), HCPCS (the Healthcare Common Procedure Coding System), DRG, and statewide data processor to the definitions pertaining to the 2013 Act. Requires hospitals to submit quarterly reports (currently, annual report) on the most frequently reported admissions by DRG’s (diagnostic related groups) for inpatients, to the statewide data processor (currently, DHHS), as described, and adds new calculation required by the act on how to determine the amount that will be charged to each patient for each DRG. Removes outdated language. Requires quarterly reports (currently, annual reports) to the statewide data processor (currently, DHHS) by hospitals and ambulatory surgical facilities as described on the total costs for the most common surgical and imaging procedures as described and including costs of each billable item and service regardless of whether it was performed by a physician or non-physician practitioner. 

Requires the NC Medical Care Commission (Commission) to adopt rules to accomplish the four listed directives, including: (1) establishing and defining no fewer than ten quality measures for licensed hospitals and licensed ambulatory surgical facilities; (2) providing the methodology that hospitals or ambulatory surgical facilities should use to determine the most common DRG’s for inpatients or common surgical and imaging procedures, as appropriate; and (3) establishing procedures for the statewide data processor to receive the quarterly data required by GS 131E-214.13 for publication on DHHS’s website.

Enacts new GS 131E-214.18 imposing a civil penalty for failure to comply with the Act, including penalties to be assessed for each violation day in the amounts described. Requires DHHS to remit the clear proceeds of any civil penalty to the Civil Penalty and Forfeiture Fund (Fund).

Makes conforming changes to GS 131E-214.4 (duties of the statewide data processor).

Effective on the later of January 1, 2026, or the date the rules adopted by the Commission take effect. Directs that GS 131E-214.18, as enacted by the act, applies to acts occurring on or after that date. Requires the Commission to notify the Revisor of Statutes (Revisor) when the rules required under GS 131E-214.13 take effect.  

Section 2.

Enacts GS 131E-214.30, as follows. Requires at the time a health service facility participating in an insurer's healthcare provider network (1) treats an insured individual for anything other than screening and stabilization; (2) admits an insured individual to receive emergency services; (3) schedules a procedure for non-emergency services for an insured individual; or (4) seeks prior authorization from an insurer for the provision of nonemergency services to an insured individual, to provide the insured individual with a written disclosure pertaining to billing, out-of-network services, and consumer protections, as described.  Requires emergency services facilities to disclose to an insured individual if it does not have a contract for services with the insured’s insurer, and to provide information about consumer protections, as described, as soon as practicable after the facility begins providing emergency services.

Enacts GS 131E-214.31, as follows. Requires at the time a healthcare provider not participating in the insured’s network (1) treats an insured individual for anything other than screening and stabilization; (2) schedules a procedure for non-emergency services for an insured individual; or (3) seeks prior authorization from an insurer for the provision of non-emergency services to an insured individual, to provide the insured individual with a written disclosure that warns the insured that the healthcare provider is not in the insured’s healthcare provider network and provides consumer protection information, as described.

Designates failure to comply with the above requirements as an unfair and deceptive trade practice. Clarifies that nothing in Article 11B of GS Chapter 131E forecloses other remedies available under law or equity.

Repeals the definition of health benefit plan in GS 58-3-200(a)(1) and insurer in GS 58-3-200(a)(2) (definitions section of provisions pertaining to miscellaneous insurance and managed care coverages and networks). Adds definition of terms clinical laboratory, and healthcare provider.

Requires an insurer upon request under GS 58-3-200(d) (services outside provider networks), to determine whether a healthcare provider able to meet the needs of the insured is available to the insured without unreasonable delay by reference to the insured's location and the specific medical needs of the insured.

Applies to healthcare services provided on or after October 1, 2026, and to contracts issued, renewed, or amended or after that date.

Section 3.

Adds new Article 11C to GS Chapter 131E, entitled “Fair Billing and Collection Practices for Hospitals and Ambulatory Surgical Facilities," as follows. Recodifies GS 131E-91(fair billing and collections practices for hospitals and ambulatory surgical facilities) as GS 131E-214.50, and reorganizes that provision into new Article 11C. Requires a hospital or ambulatory surgical facility to first present an itemized list of charges to the patient detailing the specific nature of the charges or expenses incurred by the patient before referring the bill to collection as another required collections practice under new GS 131E-214.50. Enacts new GS 131E-214.52 (patient’s right to a good faith estimate) as part of new Article 11C, as follows. Defines CMS, facility (licensed hospital or ambulatory surgical facility), items and services, service package, and shoppable service (a non-urgent service that can be scheduled by the patient in advance). Requires a facility to provide, upon a patient's request, a good faith estimate for a shoppable service as described. Limits a patient’s final bill from exceeding more than 5% of the good faith estimate. Requires DHHS to adopt rules to implement the statute. Directs DHHS to notify the Revisor when the rules required under GS 131A-214.52 take effect.

Effective on the later of January 1, 2026, or the date the rules adopted by DHHS become effect. Applies to acts occurring after the effective date. 

Section 4.

Adds new GS 131E-214.54 (concerning facility fees) to Article 11C, as follows. Defines ambulatory surgical facility, campus, facility fee (any fee charged or billed by a health care provider for outpatient services provided in a hospital-based facility that is (i) intended to compensate the health care provider for the operational expenses of the health care provider, (ii) separate and distinct from a professional fee, and (iii) charged regardless of the modality through which the health care services were provided), health care provider, health systems, hospital, hospital-based facility, professional fee, and remote location of a hospital.

Places the following limits on facility fees: (1) prevents a health care provider from assessing a charge, bill, or collecting 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 or ambulatory surgical center and (2) regardless of where the services are provided, no health care provider can assess a charge, bill, or collect a facility fee for outpatient evaluation and management services, or any other outpatient, diagnostic, or imaging services identified by DHHS. Requires DHHS to annually identify those services. 

Requires each hospital and health system to submit a report annually to DHHS by July 1st on the six specified matters. Specifies that all violations of the statute are an unfair trade practice. Subjects health care providers that violate the statute to a civil penalty of not more than $1,000 per occurrence.

Requires DHHS to adopt rules to implement new GS 131E-214.54. Effective on the later of January 1, 2026, or the date DHHS adopts the rules discussed above. Requires DHHS to notify the Revisor when the rules adopted under GS 131E-214.54 take effect.

Section 5.

Expands the State Auditor’s responsibilities under GS 147-64.6 to include a periodic review of health service facilities that: (1) receive State funds and (2) are licensed under GS Chapter 122C that are recipients of State funds for information on the prices these facilities charge out-of-network or uninsured patients and their transparency about those prices. Requires that the State Auditor report findings to the specified NCGA committee by April 1, 2026, and periodically thereafter as specified.

Part 6.

Expands the obligations pertaining to non-expedited appeals under GS 58-50-61(k) to include utilization review organizations (currently just insurers). Requires providing contact information for the insurer instead of the coordinator. Makes clarifying and technical changes. Requires an insurer to provide their contact information as part of the written information they `must provide as part of a first-level grievance review (currently have to provide review contact information for the coordinator) and makes technical changes to GS 58-50-62(e) (concerning first-level grievance reviews). Requires the insurer to provide information on how and where to submit written material for a second-level grievance review and contact information for the insurer (currently, just have to provide the coordinator's contact information) in GS 58-50-62(f) (second-level grievance reviews).

Section 7.

Amends GS 131E-176 (the definitions pertaining to certificates of need) so that rehabilitative health services; rehabilitation health service facilities; rehabilitation health service facility beds; rehabilitation facility hospitals for rehabilitation of injured, disabled, or sick persons and nursing provided at a non-inpatient rehabilitation facility for the rehabilitation of sick, injured, or disabled individuals are no longer included in the definitions. Amends term rehabilitation facility so that it means a facility that has been classified and designated as an inpatient rehabilitation facility by the Centers for Medicare and Medicaid Services (currently, means a public or private inpatient facility which is operated for the primary purpose of assisting in the rehabilitation of individuals with disabilities through an integrated program of medical and other services which are provided under competent, professional supervision).

Section 8.

Amends GS 58-50-61 (concerning utilization reviews), as follows. Defines an urgent health care service to mean a health care service (including mental or behavioral health services) with respect to which the application of the time periods for making an urgent care determination that, in the opinion of a healthcare provider with knowledge of the covered person's medical condition, either: (1) could seriously jeopardize the person's life or health or their ability to regain maximum function or (2) would subject the person to severe pain that can't be adequately managed without the care or treatment that is subject to utilization review. Defines prior authorization (process by which insurers and utilization review organizations (URO) determine coverage on the basis of medical necessity and/or covered benefits prior to the rendering of those services) and course of treatment. Now defines health care provider as it defined in GS 90-410.

Creates two different timelines for prospective and concurrent utilization reviews based on the urgency of the healthcare service. Specifies that the current three-business day deadline is for nonurgent healthcare services. For urgent healthcare services, requires the insurer or its utilization review organization (URO) to conduct the review and make the determination or noncertification by not later than 24 hours after receiving the necessary information to conduct the review, unless the reviewer does not have access to the electronic health records of the covered person. Extends the notice obligations pertaining to utilization reviews to URO’s that conduct utilization reviews.   

Sets forth three requirements that apply to an appeals review, including that any appeal not involving a mental health matter be reviewed by a licensed physician meeting the specified criteria, that appeals initiated by a licensed mental health professional be reviewed by a licensed mental health professional rather than a licensed physician and the licensed physician or licensed mental health professional consider all known clinical aspects of the healthcare service under review.  

Requires an insurer to make any current utilization review requirements and restrictions available on its website. Specifies that any new prior authorization requirements or restrictions amendments thereof are not in effect unless and until the insurer’s website has been updated to reflect the new/amended requirements or restrictions. Directs that a claim cannot be denied for failure to obtain a prior authorization if the prior authorization requirement or amended requirement was not in effect on the date of service of the claim.

Sets forth the following requirements that apply to the length of time an approved prior authorization remains valid in certain circumstances:

• If a covered person enrolls in a new health benefit plan offered by the same insurer under which the prior authorization was approved, then the previously approved prior authorization remains valid for the initial 90 days of coverage under the new heath benefit plan. Clarifies that this does not require coverage of a service if it is not a covered service under the new health benefit plan.
• If a healthcare service, other than for in-patient care, requires prior authorization and is for the treatment of a covered person's chronic condition, then the prior authorization shall remain valid for no less than six months from the date the healthcare provider receives notification of the prior authorization approval.

Requires, by January 1, 2028, insurers offering a health benefit plan or a utilization review agent acting on behalf of an insurer offering a health benefit plan, to implement and maintain a prior authorization application programming interface meeting the requirements under 45 C.F.R. § 156.223(b) as it existed on January 1, 2025.

Extends liability for violations of GS 58-50-61 to agents of the insurer. Prevents an insurer from using an artificial intelligence-based algorithm as the sole basis for a utilization review determination.

Applies to insurance contracts, including contracts with URO’s, issued, renewed, or amended on or after October 1, 2026.

Directs the State Treasurer and the Executive Administrator of the State Health Plan to review all practices of the State Health Plan and all contracts with, and practices of, any third party conducting any utilization review on behalf of the State Health Plan to ensure compliance with GS 58-50-61, as amended by the act. 

Section 9.

Specifies that the act is effective when it becomes law, except as otherwise provided.