Nurse practitioners (NPs), also referred to as Advanced Practice Registered Nurses (APRNs) in some states, are seeing changes to the scope of their practice. Some of these changes grant full practice authority, which removes the need for nurse practitioners to collaborate with a physician to own and run a medical practice. Often this authority is granted only after the completion of certain hourly requirements. Full practice authority for nurse practitioners has been associated with better quality of patient care, especially in underserved communities. Over half of the states now give full practice authority to NPs.
In April, Lengea reached out to its clients and email subscribers with an urgent update when a recent law was approved in New York, effecting changes to the ownership structure for many medical spas in the state. Last year, we were monitoring the journey of a similar bill as it made its way through California state Congress and we are happy to inform you that it is in effect as of January 1, 2023.
Bill AB-890
In September 2020, a bill was passed in CA granting full practice authority to NPs. The bill, AB-890, was signed into law by the governor and set to go into effect beginning January 2023, through the use of additional explanatory regulations that were still pending at the time of signing.
The law has altered the NP structure, dividing NPs into two different types. The first falls under the category of Section 103 NPs. To be classified as 103, an individual must complete the following requirements:
- Have passed a national nurse practitioner board certification examination and, if applicable, any supplemental examination required.
- Hold a certification as a nurse practitioner from a national certifying body accredited by the National Commission for Certifying Agencies or the American Board of Nursing Specialties and recognized by the board
- Provide documentation that educational training was consistent with standards established by the board; and
- Have completed a transition to practice in California of a minimum of three full-time equivalent years of practice or 4600 hours.
Having completed the above requirements, an individual will be classified as a section 103 NP. With this classification, NPs will work under the provisions outlined in the Business and Profession Code Section 2837.103. They will work in a group setting with at least one physician and surgeon within the population focus of their National Certification.
The second classification is the category of Section 104 NPs. To be classified as a 104 NP, one must be a currently licensed 103 NP and meet the following criteria:
- Holds a valid and active license as a registered nurse in California and a master’s degree in nursing or a clinical field related to nursing or a doctoral degree in nursing.
- Has practiced as a nurse practitioner in good standing for at least three years, not inclusive of the transition to practice required pursuant to subparagraph (D) of paragraph (1) of subdivision (a) of Section 2837.103. The board may, at its discretion, lower this requirement for a nurse practitioner holding a Doctorate of Nursing Practice degree (DNP) based on practice experience gained in the course of doctoral education experience.
Once a 103 NP meets the above requirements, they can apply for 104 NP status. Once that status is granted, the 104 NP may work independently within the population focus of their National Certification under the provisions outlined in Business and Profession Code Section 2837.104. As it stands, all currently licensed NPs will be classified as 103 NPs following an application process. However, the three-year practice rule following 103 NP status applies equally to all. Regardless of how many years one has been a licensed NP up until this point, no one will be eligible to apply for 104 NP status until 2026.
Feedback from the Nurse Practitioner Community
Expanding practice authority is generally seen as a positive step forward for nurses, and many NPs celebrate the passing of the bill. However, other NP professionals were dissatisfied. The main objection was that in contrast to other state versions, the California law required a state-based certification system instead of the national testing standards. NPs thought the licensing exams may not include everything needed to practice, and that the bill did not do enough to clear a path for NPs to open their own practices.
The American Association of Nurse Practitioners (AANP) agreed, responding by stating that the organization did not support the original version of the law. In its view, the legislation included too many unnecessary amendments and regulations, making it restrictive and confusing, and it did too little to address high healthcare costs and lack of access to primary care.
Current Law: BPC Article 8.5
The California state legislature has updated its code to incorporate the change. NPs who completed their transition hours and are in practice as of January 1, 2023, may now apply for practicing as a Section 103 professional without standardized procedures. When they complete three years of working after the change in the law, they can achieve 104 status. This means that the earliest they can apply is 2026 when the state will see the first group of Section 104 NPs who can finally practice without a physician involved. An electronic 103 online application is being built on the Board’s website and an email will be sent to certified NPs when it is available.
There are also NPs who are certified graduates of NP programs and may call themselves APRNs still working towards the earlier transition hours. These professionals are not eligible to apply for Section 103 status yet and must complete those initial three years in which they work using standardized procedures for supervision before they join the pathway to practicing without standardized procedures and with expanded practice authority.
However, the long-awaited final changes to the administrative rules which expound on the law are also now in effect and published on the Board of Nursing website (though the changes do not appear in the full online administrative code yet). These rules state that there are six types of NPs recognized in California focusing on different populations: Family/individual, Adult-gerontology, Neonatal, Pediatrics, Women’s health/gender-related, and Psychiatric-Mental Health. Practitioners who have obtained a license as a registered nurse, a state certification as a nurse practitioner, hold an accepted certification in one of the focus categories, have completed three years of transition hours, and have passed an acceptable board certification examination are eligible to apply for 103 status.
These NPs may work without standardized procedures as 103 NPs if they are working in a group setting and are working only within the NP field in which they are certified. Eventually, after three more years, these NPs will be able to work independently in any practice setting, as long as they are still working within their population focus.
Once an NP becomes allowed to have expansive authority as a 104 NP, they have 90 days to provide a written protocol for consultation and a written plan for referrals that must be made available to patients on request. With that, they may essentially run their own practice.
Takeaways
The long journey for a change in NP practice has resulted in a new system that will allow NPs to eventually own and run independent practices. However, the road to that point is quite long, requiring adherence to many laws and rules that are not easily navigated, many years of education, training experience, and examinations, and an obstacle course of application materials, which differentiate between those educated and certified outside of California. Ultimately, it is good news that NPs will be able to expand access to care, and the years of training are presumably to ensure an adequate standard of it.
Most notably, the final rules do not require the passage of a California NP examination and allow passage of the Board’s national nurse practitioner Board certification examination. It is unclear yet which of the two recognized national certification examinations, given by the AANP and ANCC, will be allowed. This is a big win for the advocacy groups involved in the rulemaking process.
It is important to keep in mind that the scope of practice for NPs is defined, and there is a list of activities that are allowed for NPs written into the law. At all levels of the process, regardless of the level of physician supervision required, NPs may only work within their scope of practice and may never practice medicine or hold themselves out to be medical doctors. All NPs may only prescribe and dispense drugs if they obtain a California furnishing number, and for controlled substances, a federal DEA number.
Confusingly, Advanced nursing specialist categories still exist for certification of registered nurses as Clinical Nurse Specialists (CNS), Nurse Anesthetists (NA), Nurse-Midwives (NMW), Psychiatric/Mental Health Nurses, and (PMH) Public Health Nurses (PHN). These types of nurses are categories of RNs and not NPs, of which there are now six types of certifications and three tiers of practice authority.
So, may an NP own a medical spa in California without an MSO? Not yet, but be on the lookout for the newly minted 104 NPs ready for practice in 2026.
*This blog post is for informational purposes only and does not constitute legal, financial, or medical advice, or the forging of an attorney-client relationship. Please retain the services of an attorney licensed in California to receive counseling on the ways the law applies to your business.