the former Nebraska governor on the last day of
the 2014 legislative session, preventing lawmakers
from overriding the veto.
3
In Maryland, lawmakers removed the requirement
that NPs maintain "attestation agreements" with
physicians as a prerequisite for licensure and prac-
tice.
4
Attestation agreements, which indicate the
physician with whom an NP will collaborate if nec-
essary, were instituted as a compromise in 2010
when the Maryland legislature retired the collabora-
tion requirement. Attestation was problematic be-
cause insurance companies and managed care or-
ganizations (MCOs) required the physician listed on
the attestation to be credentialed by the insurance
company in order for the NPs to be reimbursed; this
meant that many NPs with Medicaid MCO patients
could not be credentialed.
5
Passage of the law is ex-
pected to greatly improve access to care for persons
living in rural and underserved areas.
Gaining Momentum
In the past four years, five other states have eliminated
the requirement for physician involvement in NP prac-
tice: North Dakota and Vermont (2011), Nevada (2013),
and Minnesota and Connecticut (2014). This trend is
continuing in 2015. Currently, several states, including
Florida (HB 547), Texas (HB 1885/SB 751), Kansas (HB
2122/SB 69), and South Carolina (H 3078/S 246), have
introduced bills that would remove mandated collabo-
rative agreement requirements.
6
Part of the impetus
for these recent changes is the Affordable Care Act,
which highlighted the need for quality primary care
providers. Underlying these changes and the ACA it-
self, however, is the longstanding issue of lack of ac-
cess to high-quality care across many regions of the
country. States are increasingly realizing that NPs, with
their focus on health promotion and disease preven-
NP Scope of Practice
Continued on page 5