The positive progress continues!
 
We are pleased to inform you that our reimbursement bills – House Bill 1640 and Senate Bill 1178 – have once again been warmly received by committees in both chambers of the Virginia Legislature!
 
In light of the February 5th “crossover,” all bills passed on the House side during the first half of the General Assembly session are now being considered in the Senate, and vice versa.
 
On Monday, February 11, 2019, HB 1640 was reported from the Senate Commerce & Labor Committee with a vote of 13-0, while SB 1178 passed out of the House Commerce & Labor Committee with another unanimously positive vote of 22-0 on Tuesday, February 12th.
 
Since the two bills were reported without opposition, we anticipate that they will be added to the Uncontested Calendar in the House and the Senate. Ultimately, should this legislation become law, it will go into effect on October 1, 2019.

On January 31st, our reimbursement bills – HB 1640 and SB 1178 – were heard in the Virginia House and Senate Commerce & Labor Committees.
 
SB 1178, sponsored by Sen. Glen Sturtevant, faced no opposition and was passed unanimously by the Senate Commerce & Labor Committee by a vote of 15-0. Similarly, during the House Commerce & Labor Committee meeting this afternoon, the companion bill HB 1640, sponsored by Del. Margaret Ransone, was reported by the Committee 19-0.
 
In both committees, the bill was amended so that the legislation does NOT require a study by the Health Insurance Reform Commission (HIRC) – thereby moving our legislation forward to the House and Senate floors!
 
We are delighted by these positive developments. Since the bills were reported without opposition, we anticipate that they will be added to the Uncontested Calendar in both the House and the Senate. Ultimately, should this legislation become law, it will go into effect on October 1, 2019.

As of January 7th, HB 793 regulations are in effect! Nurse practitioners with five or more years (that is, 9,000 hours or more) of clinical experience are now able to submit their applications for autonomous practice. You may find the attestation form and instructions for applying on the Virginia Board of Nursing website.
 
We will soon be debuting a special FAQ, as well as a “Roadmap to Autonomous Practice” that will outline the application process in an easy-to-read format. Further, don’t forget to register for one of our informative Town Hall webinars! Though the January 10th session is now full, space is still available on January 15 and January 30.

Governor Ralph Northam has officially signed the emergency regulations for HB 793! The regulations will go into effect on Monday, January 7, 2019. Per the Board of Nursing’s update, “[t]he application process will be implemented on or before 1/9/19,” at which point NPs throughout the Commonwealth will be able to apply for autonomous practice licensure.
 
The regulations will be published in the Virginia Register on January 21, 2019, after which a public comment forum will open, remaining open through February 20, 2019. The Board of Nursing has also noted that their staff will provide a report about autonomous practice application process at the February 13th Joint Boards of Nursing and Medicine meeting, which will be open to the public.
 
Though we have not yet seen the attestation form, Jay Douglas, Executive Director of the Board of Nursing, has indicated that the form “will mirror the law and regulations” and will be posted on the Virginia Board of Nursing website in the near future.
 
Questions about the legislation and what autonomous practice licensure means for you? Join us for one of three town hall webinars in January! Click on the date you are interested in for more information and to register:

• Thursday, January 10
• Tuesday, January 15
• Wednesday, January 30

On Thursday, October 18, the Board of Medicine approved the proposed draft regulations that would replace emergency regulations for the prescribing of opioids and buprenorphine by NPs.
 
These regulations are favorable, as they permit SAMHSA-waivered NPs to prescribe buprenorphine outside of a practice agreement, so long as these NPs are autonomous – that is, having completed five years of full-time experience and the attestation process, per the requirements of HB 793.
 
On October 10, the Joint Boards of Medicine and Nursing had unanimously voted to approve these regulations, in spite of organized medicine’s opposition. The draft regulations will now be reviewed and voted on by the Board of Nursing at its November 13th meeting. To view a copy of the latest draft regulations on the prescribing of opioids and buprenorphine, please click here.
 
The Board of Medicine also voted to eliminate the separate license for NP prescriptive authority. The updated regulations repeal 18VAC90-40-50 (“Renewal of prescriptive authority”), as well as 18VAC90-40-60 (“Reinstatement of prescriptive authority”). There will be a one-time, $35 fee for the initial issuance of prescriptive authority. For additional information, please see the relevant Notice of Intended Regulatory Action (NOIRA).

Amended HB 793 Draft Regulations Passed Unanimously

 
At its September 18th meeting, the Board of Nursing voted 12-0 to adopt the HB 793 draft emergency regulations, as amended by the Board of Medicine at its August 3rd meeting. The Board of Nursing did not make any additional changes to the regulations. To view a copy of the updated emergency regulations, as passed, please click here.
 
Since the Board of Medicine and the Board of Nursing have now passed identical draft emergency regulations for HB 793, the regulations will now be reviewed by several state agencies before reaching the Governor’s desk. As soon as the Governor provides his signature, the legislation will go into effect! Per the law, the emergency regulations must be in place by the end of this year at the latest.
 
We are still waiting to learn more about the structure of the attestation form. Board of Nursing Executive Director Jay Douglas has indicated that the Board will keep licensees apprised of the latest developments, and we will continue to send updates as we discover more.
 
Looking forward: The emergency regulations will only remain in effect for 18 months, after which permanent regulations will be promulgated. This will be preceded by a Notice of Intended Regulatory Action (NOIRA) and additional opportunities for public comment.
 

Additional Developments at the Meeting

• The Board voted unanimously to adopt proposed regulations that will eliminate the separate license for NP prescriptive authority. The updated regulations repeal 18VAC90-40-50 (“Renewal of prescriptive authority”), as well as 18VAC90-40-60 (“Reinstatement of prescriptive authority”). There will be a one-time, $35 fee for the initial issuance of prescriptive authority. For additional information, please see the relevant Notice of Intended Regulatory Action (NOIRA).

 

• The Board of Nursing voted unanimously to extend the emergency regulations for the prescribing of opioids by NPs for another six months, beyond the expiration of November 7, 2018. Due to timing concerns, the Boards of Nursing and Medicine would have been unable to ensure the final regulations would take effect before the original expiration date. Please click here for more details about the motion.

 

• The Department of Health Professions (DHP) is in the process of developing a paperless initiative, under which any licenses issued/renewed by the Board of Nursing will be available electronically. The license lookup system will be updated in real time, reflecting any changes as soon as they happen; hard copies of a license may be available only “by request,” for a fee. The paperless initiative will go into effect in the near future, though the exact date is uncertain – all licensees will be notified about these developments via email.

Last Friday, August 3, the Virginia Board of Medicine convened and discussed the draft regulations for the Nurse Practitioner autonomous practice legislation, HB 793. The Committee of the Joint Boards and the Board of Nursing had both passed draft regulations that defined “five years of full-time experience” as 8,000 hours (an average of 1,600 hours/year) at their respective meetings. However, the Board of Medicine decided to amend the draft regulations, changing the definition of “five years of full-time experience” to 9,000 hours. To view the draft of the minutes from the meeting, please click here.
 
The amended regulations will now return to the Board of Nursing for their approval at their September 18th meeting. We will continue to keep VCNP membership apprised of any developments.
 
Thank you to everyone who came to the meeting in support of NPs!

At yesterday morning’s Board of Nursing meeting in Henrico, the Board of Nursing voted unanimously to pass the draft regulations for HB 793, as established at the May 17th meeting of the Joint Boards and advisory committee!
 
During the meeting, Senior Policy Analyst Elaine Yeatts provided a summary of the public commentary period, which included written input from those both supportive of and opposed to the regulations as they stand. The full set of comments may be viewed in the meeting’s agenda, on pages 200-239 of the PDF; a summary of the comments begins on page 240.
 
NEXT STEPS
 
The HB 793 draft regulations will now move on to the Board of Medicine, which will be meeting on August 3 at 8:30 a.m. If you plan to attend the meeting, please be sure to RSVP by clicking HERE; further details can be found on our event calendar.

Last Thursday, May 17, the Committee of the Joint Boards of Nursing and Medicine convened to discuss draft regulations for HB 793. At the beginning of the meeting, representatives from VCNP and organized medicine testified, with each side given just fifteen minutes to make its case. VCNP’s strong presence included attendance and testimonies from VCNP leadership and members, as well as esteemed guests from schools of nursing throughout Virginia. Thank you to everyone who took the time out of their busy schedule to participate! You may view the draft of the official minutes for the meeting by clicking here.
 
The committee reviewed the draft regulations and each of the proposed updates to the Virginia Administrative Code, discussing and voting upon each revision. Important highlights of the draft regulations include:

• 18VAC90-30-20: Fees – An autonomous practice attestation application will be a one-time cost of $100. Please keep in mind that the prescriptive authority fee of $75 and $35 for renewal will soon be eliminated.

 

• 18VAC90-30-86-A-1: Autonomous practice (for nurse practitioners other than certified nurse midwives or certified registered nurse anesthetists) – The Transition to Practice period must include the “completion of the equivalent of five years of full-time clinical experience as a nurse practitioner”. Five years of full-time experience will be defined as a minimum of 1,600 hours/year, for a total of 8,000 hours. This is an average of 32 hours/week, minimum.

 

• 18VAC90-30-86-C: “The nurse practitioner may submit attestations for more than one patient care team physician with whom he practiced during the equivalent of five years of practice, but all attestations shall be submitted to the boards at the same time.”

 

• 18VAC90-30-86-D: “If a nurse practitioner is licensed and certified in more than one category, as specified in 18VAC-90-30-70, a separate fee and attestation that meets the requirements of subsection B shall be submitted for each category. If the hours of practice are applicable to the patient population and in practice areas included within each of the categories of licensure and certification, those hours may be counted towards a second attestation.”

 

• 18VAC90-30-86-E: If an NP’s physician is unwilling to sign the attestation, “The burden shall be on the nurse practitioner to provide sufficient evidence to support the NP’s inability to attain an attestation”. The NP may then provide other evidence that shows they have met the qualifications for attestation.

 

• Much to the benefit of NPs, the draft regulations did NOT include any mention of establishing “core competencies,” as proposed by organized medicine’s original commentary. As we know, NP education and licensing already establishes competency and maintains strong, nationally-recognized standards. Further, the draft regulations ensure that the attestation will be an attestation of TIME, not “quality”.

 
The draft regulations are also posted on the Virginia Regulatory Town Hall site. The regulations for HB 793 are considered “emergency regulations,” which ensures that they must be finalized by the end of the year at the very latest. The regulations will become effective the day they are published.
 
Board of Nursing Executive Director Jay Douglas has assured us that she and her team will develop a “robust communication plan” to ensure that all NP licensees receive notice of the regulations’ progress; and we will continue to keep all VCNP members apprised of the latest developments.

WHAT’S NEXT?

 
Given that the Committee of the Joint Boards was able to effectively work through the draft regulations on Thursday, another Committee meeting is not required. However, the regulations still must pass the Board of Nursing, as well as the Board of Medicine. Should they pass both Boards, they will move on to the Attorney General and Governor for final review. Jay Douglas and her team will handle the implementation phase, which will include developing online resources, crafting the attestation form, and creating a special license format that will distinguish NPs who have attained autonomous practice.
 
A second 30-day Town Hall Forum comment period is scheduled to soon begin. Our goal is now to ensure that the Board of Nursing passes the regulations as they stand. We will send an email with more details about the comment period as soon as the forum is made available.
 
Timeline

• 7/17/18 – Board of Nursing meeting to adopt the emergency regulations
• 8/3/18 – Board of Medicine meeting to adopt the emergency regulations
• Regulations will undergo review by the Attorney General and Governor.
• End of December – Regulations must be complete.

The regulations will become effective the day they are published.
 
HB 793 is ultimately not about an independent practice model – it’s about a NP’s ability to utilize their knowledge, skills, and judgment to provide care without mandated supervision or collaboration from a physician. This will lower barriers to practice, expand access to care. We are excited to continue to work on behalf of NPs throughout the Commonwealth and are thrilled to see the legislation come to fruition!

On Thursday, May 17 at 9:00 a.m., the Committee of the Joint Boards of Nursing and Medicine will be convening in Henrico to promulgate regulations pertaining to HB 793. VCNP leadership and the GR committee, in conjunction with our legal council and lobbyist, have worked fastidiously to compile and submit comments to the Committee of the Joint Boards, in an effort to ensure that the regulations passed will suit the best interests of NPs.
 
Please plan to join us at the May 17th meeting, to be held at 9:00 a.m. at the Perimeter Center, 9960 Mayland Drive, Suite 201, Board Room 2 in Henrico. Just as with the General Assembly Subcommittee and Committee meetings, VISIBILITY is key. During the meeting, the Committee will receive public comment, consider draft regulations, and make recommendations. They may address the issue again at their next meeting in June, as to finalize their recommendations to the Board of Nursing in July and the Board of Medicine in August. Additional information is available on the Virginia Regulatory Town Hall site.
 
A substantial NP presence at the meeting will help demonstrate our dedication to the legislation and belief in its positive impact – which can only be achieved without oppressive regulations.
 
We are collecting the names and contact information of those who plan to attend, as to ascertain how many members and colleagues we may anticipate. Please RSVP by MONDAY, MAY 14 via this form. Be sure to indicate on the form if you are interested in providing testimony at the meeting; we will be in touch with further details about what information, statistics, and personal experience we recommend highlighting.
 
You may view a copy of our comments by clicking here. Organized medicine’s oppositional comments are also available here. See “Concerns with VAFP and MSV’s Comments” below for our reaction to their remarks. The meeting agenda package also includes comments from other organizations and interest groups, including VHHA, ER physicians, and pediatricians.
 
DOWNLOAD THE MEETING AGENDA
 
Concerns with Organized Medicine’s Comments
 
There are numerous issues with the regulations suggested by the Virginia Academy of Family Physicians (VAFP) and the Medical Society of Virginia (MSV):

• The addition of “quality” metrics is NOT a reflection of the legislation – it should be removed. The HB 793 legislation is ONLY concerned with the duration of experience.
• The notion of Core Competencies over and above NP certification is not in the statute – and imposition of such a concept is inappropriate. The 5 year requirement is not a structured training program overseen by an MD; it is simply professional job experience gained by an already licensed NP.
• In regards to the requirements for an attestation: the law does not contain any notion of a physician “approving” an NP or judging quality – the physicians are simply meant to attest to the relationship. The Joint Boards are the only people intending to assure competence and pass judgement on the safety of practitioners.
• Organized medicine appears to fear being designated as an NP’s emergency management plan; but in reality, there is no statutory requirement for a specific physician to be designated or documented. It is the sole responsibility of the NP to have a general plan for referrals and emergencies, should they choose to open their own independent practice.