Restrictions to Care:

How Collaborative Practice Agreements for Advanced Practice Registered Nurses and Certified Nurse-Midwives Limit Patient Access

By Caitlin Styrsky, Donna Matias, and Jaimie Cavanaugh

Advanced practice registered nurses (APRNs) are among the most qualified and versatile health practitioners. APRNs have education and training in a specialized medical field that allows them to perform tasks beyond the scope of a registered nurse, such as diagnosing and treating patients or prescribing medications.

APRNs play a critical role in increasing patient access to care through their work in community settings and rural areas. A 2022 report from the Medicare Payment Advisory Commission finds that APRNs and physician assistants make up half of the primary care workforce in rural areas and one-third of the primary care workforce overall. ¹Medicare Payment Advisory Commission, Medicare and the Health Care Delivery System, 2022. As of 2024, the United States had a shortage of an estimated 124,000 physicians, ²IHS Markit Ltd, The Complexities of Physician Supply and Demand: Projections from 2019 to 2034 (Washington, DC: Association of American Medical Colleges, 2021). making the work of APRNs in rural and community settings—especially communities with low socioeconomic health status—pivotal to increasing patient access to care. ³Matthew A. Davis et al., “Supply of Healthcare Providers in Relation to County Socioeconomic and Health Status,” Journal of General Internal Medicine 33 (2018): 412–14.

While some states allow APRNs to practice independently, other states require APRNs to enter into a collaborative practice agreement (CPA) or a similar supervisory relationship with a physician. CPA restrictions, such as limiting an APRN’s practice to a group or hospital setting, can prove frustrating for entrepreneurial APRNs seeking to practice independently. This research in brief compares CPA requirements throughout the United States for APRNs, focusing on nurse practitioners (NPs) and certified nurse-midwives (CNMs). In addition, it analyzes the effect of these requirements on healthcare competition and patient access to care.

A CPA is a legally binding contract between a health professional, such as an APRN, and a licensed physician that outlines the parameters of the health professional’s practice and the physician’s role. While an APRN’s scope of practice is generally defined by state statutes or regulations, CPAs and similar supervisory relationships can further constrain an APRN’s practice authority by stipulating practice settings, permitted medical functions, or prescriptive authority. These agreements may also establish physician supervision requirements, such as consultations and patient record reviews. ⁴Tracy Yee et al., “Primary Care Workforce Shortages: Nurse Practitioner Scope-of-Practice Laws and Payment Policies” (research brief no. 13, National Institute for Health Care Reform, Detroit, MI, February 2013).

For APRNs, the specific structure of CPAs varies by state. Some states require comprehensive agreements covering all aspects of APRN practice, while other states limit required agreements to prescribing authority or other specific functions. ⁵Barbara Resnick and Sandra Nettina, “Should a Written Collaborative Practice Agreement with a Physician Be Required for Nurse Practitioner Practice?,” Journal for Nurse Practitioners 6, no. 3 (2010): 199–200. CPAs may also provide a path to independent practice once an APRN completes a mandated number of supervised clinical hours. California law, for example, requires NPs who desire independent practice to complete 4,600 “transition to practice” hours. Doing so earns them the title “103 NP.” These 103 NPs are free to work without a CPA but may only do so in a group setting. While some might choose to remain in this setting, those NPs who wish to become fully independent—called “104 NPs”—must complete another 4,600 clinical hours in a group setting.

In other cases, CPAs control where APRNs are allowed to practice. Nebraska law, for example, prevents CNMs from practicing outside of hospitals or group settings, making it illegal for CNMs to attend home births. Such variations influence the degree of oversight and autonomy APRNs have within their specialized fields. ⁶Ankur Garg, Peter I. Buerhaus, and Joanne Spetz, “How Collaborative Practice Agreements Impede the Provision of Vital Behavioral Health Services,” Journal of Behavioral Health Services and Research 48, no. 3 (2021): 390–97.

CPA advocates argue that the agreements serve as a regulatory tool to streamline supervision, interdisciplinary collaboration, and liability management. ⁷Andrew B. Smith and James C. Williams, “Nurse Practitioner State-Required CPA Agreements: A Cross-Sectional Case Study in Florida,” Journal of Nursing Regulation 12, no. 1 (2021): 35–43. CPAs, according to this view, formalize the working relationship and responsibilities between APRNs and physicians, ⁸Resnick and Nettina, “Should a Written Collaborative Practice Agreement with a Physician Be Required?” provide a mentorship framework for newly certified APRNs, ⁹Julia T. Harrison and Katherine L. Peters, “Collaborative Practice Agreements between Nurse Practitioners and Pharmacists: Barriers and Opportunities,” American Journal of Pharmacy Law 44, no. 2 (2020): 22–29. and reduce liability risk. ¹⁰Rebecca P. Johnson, Paul T. Greene, and Kelly L. Peters, “Collaboration: Foundation for a Successful Practice,” Geriatric Nursing 42, no. 2 (2021): 435–440.

State CPA requirements for NPs and CNMs fall into five categories:

• CPA not required. NPs and CNMs can practice independently, and a CPA is not required.
• CPA required. NPs and CNMs must have a CPA in place to practice. Independent practice is not permitted.
• CPA with transition to independent practice. NPs and CNMs are required to have a CPA for a specific period. After working a number of hours under physician supervision, APRNs can practice independently.
• CPA required only for prescriptive authority. NPs and CNMs are required to have a CPA in place to prescribe certain medications or controlled substances.
• CPA for prescriptive authority with transition to independent practice. NPs and CNMs must have a CPA for prescriptive authority during the initial supervisory period. Once these APRNs satisfy the supervisory period, they may practice and prescribe independently.

Although NPs and CNMs are most often regulated in the same way, a handful of states have separate requirements for CNMs. Figure 1 shows the CPA requirements in each state and shows which states have different CPA requirements for CNMs.

Figure 1. Collaborative Practice Agreements for Nurse Practitioners by State

Note: CNM = certified nurse-midwife. CPA = collaborative practice agreement. NP = nurse practitioner.
Source: See Appendix A.

Thirty-five states and the District of Columbia allow APRNs to practice independently. Of these states, 17 require an initial CPA or similar supervisory relationship that transitions to independent practice authority after the APRN satisfies a specified hourly requirement under physician supervision. The hourly requirement ranges from 1,000 hours for CNMs in Virginia to 6,240 hours for NPs in Arkansas. Of the states that offer a path to independent practice, 13 have full CPA requirements, and four have CPA requirements for prescriptive authority only.

Sixteen states require APRNs to practice under a CPA. Of these states, 13 require a CPA for full practice, and three require a CPA for prescriptive authority only.

While most states demonstrate alignment between CPA requirements for NPs and CNMs, 12 have different CPA requirements for each. Table 1 identifies the states with these differences and the specific requirements for NPs and CNMs.

Table 1. Requirements for Certified Nurse-Midwife and Nurse Practitioner Collaborative Practice Agreements (in States Where Those Requirements Differ)

Source: See Appendix A.

Despite their purported benefits, CPAs can have several negative policy implications that undermine their intended purpose, including limiting healthcare options for patients and restricting entrepreneurial opportunities for nurses seeking to earn a living independently.

The challenges associated with establishing and maintaining CPAs can create significant professional barriers for APRNs. The difficulties in finding a collaborating physician and maintaining the agreement can disincentivize entrepreneurial APRNs from establishing their own practices. Moreover, some nurses have reported interruptions in their practices when a physician relocates, retires, or decides to no longer participate in a CPA. These situations can leave APRNs scrambling to find new partnering physicians and establish new agreements, and this process often hinders patient access to care.

A 2020 survey of mental health APRNs, for example, finds that more than one-third of nurses had experienced a disruption in their CPA. ¹¹Brendan Martin and Kyrani Reneau, “How Collaborative Practice Agreements Impede the Administration of Vital Women’s Health Services,” Journal of Midwifery and Women’s Health 65, no. 4 (2020): 445–586. In situations in which patients form strong trust bonds with their providers, this can be distressing. In rural areas where healthcare options are already limited, CPA interruptions can further reduce provider options.

The fees that APRNs must pay physicians to establish or maintain a CPA can further disincentivize entrepreneurial APRNs from working in states with CPA requirements. A 2019 survey of APRNs across 29 states finds that the one-time fees required to establish a new CPA averaged $650, ranging from as low as $10 to as high as $50,000. On top of the initial establishment fee, the additional monthly fees required to maintain the CPA averaged $500, ranging from $4 to more than $4,000. These fees create financial obstacles for many APRNs seeking to enter independent practice, raising prices and limiting healthcare options for patients. ¹²Brendan Martin and Maryann Alexander, “The Economic Burden and Practice Restrictions Associated with Collaborative Practice Agreements: A National Survey of Advanced Practice Registered Nurses,” Journal of Nursing Regulation 9, no. 4 (2019): 22–30.

Despite charging substantial fees, not all supervising physicians provide APRNs with meaningful oversight, raising questions about the quality and necessity of CPA supervision. Forty to fifty percent of respondents to the 2019 survey had irregular communication with their supervising provider and received no formal review of their medical records. ¹³Martin and Alexander, “The Economic Burden.” The paperwork and administrative burdens of maintaining a CPA, moreover, take time away from practitioners’ provision of patient care and add unnecessary complexity to healthcare services. ¹⁴Martin and Reneau, “Collaborative Practice Agreements.” A 2017 study, for example, finds that independent practice authority for NPs increases the amount of time physicians spend providing patient care, suggesting that eliminating CPA administrative burdens allows multiple types of providers to devote more time to patients. ¹⁵Jeffrey Traczynski and Victoria Udalova, “Nurse Practitioner Independence, Health Care Utilization, and Health Outcomes,” Journal of Health Economics 58 (2018): 90–109. And a 2023 study finds that rather than increasing malpractice claims, relaxed practice restrictions on APRNs result in a 21–24 percent reduction in physician malpractice rates, with no increase in NP malpractice claims. ¹⁶Sara Markowitz and Andrew J. D. Smith, “Nurse Practitioner Scope of Practice and Patient Harm: Evidence from Medical Malpractice Cases and Adverse Action Reports” (working paper no. 31109, National Bureau of Economic Research, Cambridge, MA, April 2023).

CPAs can create additional barriers to entry, particularly for entrepreneurial CNMs. Nebraska, for example, not only requires a CPA but also mandates that CNMs practice only in hospitals or settings authorized by their collaborating physician. This limits the ability of highly skilled CNMs to provide services to women seeking alternative or home birth options.

CPAs are correlated with smaller APRN workforces, higher costs, and reduced patient access to care. ¹⁷Martin and Reneau, “Collaborative Practice Agreements.” These agreements add an additional layer of bureaucratic oversight to the APRN profession, which is already regulated by state boards of nursing. ¹⁸Resnick and Nettina, “Should a Written Collaborative Practice Agreement with a Physician Be Required?” Through fees, practice restrictions, and administrative burdens, CPAs ultimately limit healthcare delivery, especially in rural and underserved areas.

APRNs in independent practice have patient outcomes comparable to those of physicians, experience high levels of satisfaction among their patients, and increase access to healthcare in underserved communities. ¹⁹Martin and Alexander, “The Economic Burden.” States that grant APRNs full practice authority show increased access to healthcare and more cost-effective treatment. ²⁰Katy B. Kozhimannil, Carrie Henning-Smith, and Peiyin Hung, “The Practice of Midwifery in Rural US Hospitals,” Journal of Midwifery and Women’s Health 61, no. 4 (2016): 411–18. A 2017 study finds that patients in states with independent NPs reported more convenient appointment scheduling, reduced travel times, and increased access to a consistent care provider. ²¹Traczynski and Udalova, “Nurse Practitioner Independence.” The same study estimates that the increased availability of NPs in medically underserved communities would result in a 30 percent increase in access to primary care services. ²²Traczynski and Udalova. In addition, walk-in clinics offering non-emergency care, known as retail clinics, are often staffed by NPs and have lower associated costs per visit than visits to emergency rooms or hospitals. A 2013 study finds even lower costs for visits to retail clinics staffed by NPs in states in which NPs had independent practice authority. The study estimates $1.8 billion in cost savings through retail clinic visits and an additional $810 million in savings if all states were to allow for independent NP practice. ²³Joanne Spetz et al., “Scope-of-Practice Laws for Nurse Practitioners Limit Cost Savings That Can Be Achieved in Retail Clinics,” Health Affairs 32, no. 11 (2013): 1977–84.

The counties along the Maryland–Pennsylvania border show the effects of independent NP practice authority on patient access to care. NPs in Maryland have had independent practice authority since 2015, whereas NPs in Pennsylvania must practice under physician supervision. A 2022 report from the Commonwealth Foundation finds that Maryland’s transition to independent NP practice resulted in statistically significant increases in NP provider density per 100,000 residents. The report concludes that transitioning to independent NP practice in Pennsylvania could increase access to primary care by 1,792 patients per week and reduce the number of medically underserved communities in the state. ²⁴Kihwan Bae et al., How Full Practice Authority Can Increase Access and Improve Outcomes (Harrisburg, PA: Commonwealth Foundation, 2022), 21–22. A similar study from the Knee Regulatory Research Center from 2024 examines healthcare access in North Carolina after Virginia allowed NPs to practice independently in 2018. The study finds that many North Carolina NPs chose to work instead in neighboring Virginia, resulting in a 20 percent decline in NPs per 100,000 residents in interior North Carolina counties and an increase in poor resident health. ²⁵Conor Norris et al., Nurse Practitioner Full Practice Authority and Access to Primary Care in North Carolina (Morgantown, WV: Knee Regulatory Research Center, 2024), 12.

Full practice authority for CNMs improves women’s access to care and supports birth options outside hospital settings. Like APRNs more broadly, independent CNMs have patient outcomes comparable with those of physicians. ²⁶Lauren Hoehn-Velasco et al., “Health Outcomes and Provider Choice under Full Practice Authority for Certified Nurse-Midwives,” Journal of Health Economics 92 (2023): 1-26. Full practice authority for CNMs has also contributed to a rise in CNM-attended births. Because many CNMs attend births in home settings and birth centers outside of hospitals, allowing CNMs to practice independently increases women’s access to birth options, with no negative impact on health or safety. Granting full practice authority for CNMs has had little impact on maternal mortality, obstetric outcomes, or neonatal mortality. ²⁷Hoehn-Velasco et al., “Health Outcomes.” CNMs offer more cost-effective services and lower-intensity obstetric care, reducing interventions and complications. ²⁸Sukriti Beniwal, Lauren Hoehn-Velasco, and Diana R. Jolles, “Public Health Insurance Expansions and Non-Physician Providers: Evidence from Certified Nurse Midwives” (preprint, submitted June 3, 2024), https://ssrn.com/abstract=4851919. One study found a 7.5 percent reduction in C-section rates for women in states where CNMs have independent practice authority, suggesting potential nationwide savings of more than $101 million a year. ²⁹Sara Markowitz et al., “Competitive Effects of Scope of Practice Restrictions: Public Health or Public Harm?,” Journal of Health Economics 55 (2017): 201–18. In fact, many wealthy countries, including Australia, Canada, the Netherlands, and the United Kingdom, have midwifery-led models of care that demonstrate high patient satisfaction rates and improved health outcomes. ³⁰Roosa Tikkanen et al., Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries (New York: Commonwealth Fund, 2020).

Research into the behavioral health sector has reached similar conclusions, finding positive patient outcomes for mental health and psychiatric APRNs and bolstering support for independent practice authority. A 2017 analysis of community health center data from the National Ambulatory Medical Care Survey, for example, concludes that mental health APRNs were likelier than physicians to offer care to rural communities and special populations, including women, minorities, and individuals with disabilities. ³¹Bo Kyum Yang et al., “Nurse Practitioner Independent Practice Authority and Mental Health Service Delivery in U.S. Community Health Centers,” Psychiatric Services 68, no. 10 (2017): 1032–38. A separate study finds that adults with major depression treated by psychiatric APRNs reported being highly satisfied with the care they received. ³²Mary Casey et al., “An Overview of the Outcomes and Impact of Specialist and Advanced Nursing and Midwifery Practice on Quality of Care, Cost, and Access to Services: A Narrative Review,” Nurse Education Today 56 (2017): 35–40. In states with full practice authority, mental health APRNs play a pivotal role in expanding access to care in rural and underserved areas. ³³Martin and Reneau, “Collaborative Practice Agreements.”

In Nebraska, CNM Heather Swanson is, with the help of the Pacific Legal Foundation, challenging a state law that mandates a CPA with the strictest provisions in the country. CNMs in Nebraska must practice under physician supervision and can only practice within hospitals or settings authorized by their collaborating physician, unlike other types of midwives, who typically have less training but can work outside of hospitals. These restrictions not only limit the ability of CNMs to earn a living in the state but also prevent pregnant women from having formally trained medical professionals attend their home births. In Swanson v. Hilgers, ³⁴“Nebraska Midwife Entrepreneur Fights Unjust Ban on Her Profession,” Pacific Legal Foundation, accessed April 17, 2025, https://pacificleg1stg.wpenginepowered.com/case/swanson-cnm-midwife-ban-nebraska/. Swanson argued that the law mandating a CPA violates the Due Process Clause, the Equal Protection Clause, and the Privileges and Immunities Clause of the Fourteenth Amendment by arbitrarily restricting the rights of Nebraska CNMs to provide in-home childbirth care to expectant mothers.

In California, NPs Kerstin Helgason and Jamie Sorenson care for vulnerable mental health patients in solo practices that nonetheless require a CPA with a physician by law. The two NPs are, with the help of the Pacific Legal Foundation, challenging the State Board of Registered Nursing’s interpretation of a 2020 California law that effectively eliminates their ability to continue their solo practices if they hope to transition to independent practice. The path to independent practice established by the law entails practicing for three years in a group setting, such as a hospital, forcing Helgason and Sorenson to leave their existing solo practices and disrupt their patients’ care, only to open back up once they have achieved independent status. In Helgason v. California Board of Registered Nursing, ³⁵“California Nurse Practitioners Fight for Their Right to Provide Much-Needed Mental Health Care,” Pacific Legal Foundation, accessed April 17, 2025, https://pacificleg1stg.wpenginepowered.com/case/california-nursing-mental-health-practitioners/. Helgason and Sorenson argue that the board’s interpretation of the law violates the Equal Protection Clause and the Due Process Clause of the Fourteenth Amendment by preventing qualified APRNs from pursuing their chosen profession free from unreasonable government interference.

Whereas more than half of states allow for independent practice or provide a path to independent practice for APRNs, 16 states still mandate CPAs that decrease competition and patient access to care. By reducing CPA requirements, these states could boost innovation, healthcare access, and entrepreneurship among APRNs.

Acknowledgment

The authors thank Olivia Hodge for her contribution to the research and data in this brief.

Appendix A

Alabama

• Ala. Admin. Code r. 540-X-8-.08 (1995).
• “Collaboration,” Alabama Board of Medical Examiners & Medical Licensure Commission, accessed April 28, 2025, https://www.albme.gov/licensing/crnp-cnm/collaboration.
• “FAQS,” Alabama Board of Nursing, accessed April 28, 2025, https://www.abn.alabama.gov/licensing/advanced-practice/faqs/.

Alaska

• Alaska Admin. Code tit. 12, § 44.440, .445 (n.d.).
• Department of Commerce, Community, and Economic Development, Nursing Statutes and Regulations, April 2025, https://www.commerce.alaska.gov/web/Portals/5/pub/NursingStatutes.pdf.

Arizona

• Ariz. Admin. Code § 4-19-508(B)(1.), (4.) (n.d.).
• Ariz. Rev. Stat. Ann. § 32-1601(5), (7) (n.d.).

Arkansas

• Ark. Code Ann. § 17-87-102, 301, 314–315 (2023).
• Ark. Admin. Code 067.00.16-004 § VII(B)(6) (2024).
• “ASBN – Adv Practice RN Initial,” Arkansas Department of Health, accessed April 28, 2025, https://healthy.arkansas.gov/boards-commissions/boards/nursing-arkansas-state-board/examination/adv-practice-rn-initial.
• “ASBN – Fees,” Arkansas Department of Health, accessed April 28, 2025, https://healthy.arkansas.gov/boards-commissions/boards/nursing-arkansas-state-board/fees/.
• “ASBN – Prescriptive Authority,” Arkansas Department of Health, accessed April 28, 2025, https://healthy.arkansas.gov/boards-commissions/boards/nursing-arkansas-state-board/advanced-practice/collaborative-practice/.

California

• Cal. Bus. & Prof. Code § 2746.5 (2024).
• “Nurse Practitioner,” California Board of Registered Nursing, accessed April 28, 2025, https://www.rn.ca.gov/practice/np.shtml.
• California Board of Registered Nursing, Initial Statement of Reasons, September 1, 2022, https://www.rn.ca.gov/pdfs/regulations/isor-ab890.pdf.
• California Nurse-Midwives Association, SB 1237: The Justice and Equity in Maternity Care Act, n.d., https://www.cnma.org/_files/ugd/1f2263_006e804f66ad47baa5bb9ada844f09bf.pdf.

Colorado

• Colo. Code Regs. §§ 3 713-37, 716-1.1 (n.d.).
• “Colorado Medical Board: Advanced Practice Nurse Prescriptive Authority,” Colorado Department of Regulatory Agencies, accessed April 28, 2025, https://dpo.colorado.gov/Medical/APNPrescriptiveAuthority.

Connecticut

• Conn. Gen. Stat. §§ 20-86, -87a (2024).
• “State Overview: Connecticut,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/connecticut.
• “Midwife Licensure Requirements,” Connecticut Department of Public Health, accessed April 28, 2025, https://portal.ct.gov/dph/practitioner-licensing–investigations/midwife/midwife-licensure-requirements.

Delaware

• Del. Code Ann. tit. 24 § 1936 (2020).
• Justin Gero, “Delaware Becomes the Latest Full Practice Authority State,” Full Practice Authority, August 5, 2021.

District of Columbia

• Reza Ghafoorian, “Expanding Autonomy for APRNs and CRNAs in Washington, DC: A New Era in Advanced Practice Nursing,” G2Z Law Group, November 12, 2024, https://www.g2zlaw.com/publications/aprns-scope-of-practice-dc.

Florida

• Fla. Stat. §§ 464.003, .0123 (2024).
• “Autonomous Advanced Practice Registered Nurse,” Florida Board of Nursing, accessed April 28, 2025, https://floridasnursing.gov/licensing/autonomous-advanced-practice-registered-nurse/.
• “State Overview: Florida,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/florida.

Georgia

• GA. Code Ann. §§ 43-26-3, 34-25 (2023).
• “APRN Protocol Registration Forms,” Georgia Composite Medical Board, accessed April 28, 2025, https://medicalboard.georgia.gov/licensure-information/aprn-protocol-registration-forms.

Hawaii

• Haw. Rev. Stat. § 457-8.5 (2024).
• Hawaii Health Partners, Nurse Practitioner Credentialing Policy, June 26, 2013.

Idaho

• Idaho Admin. Code 24.34.01.000–999 (2024).
• “Nurse Practitioner Scope of Practice: Idaho,” ThriveAP (blog), accessed April 28, 2025, https://provider.thriveap.com/blog/nurse-practitioner-scope-practice-idaho.

Illinois

• 225 Comp. Stat. 65 / 65 (2024).
• Illinois Primary Health Care Association, Advanced Practice Registered Nurse and Physician Assistant: Illinois Overview and Supervision Requirements, n.d.

Indiana

• Ind. Code § 16-42-19-5 (2024).
• Ind. Code §§ 25-23-1-19.4(b), 19.5 (2024).
• “State Overview: Indiana,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/indiana.

Iowa

• Iowa Admin. Code 655-7.1 (152) (2025).
• “State Overview: Iowa,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/iowa.
• “Advanced Registered Nurse Practitioner Role and Scope,” Iowa Department of Inspections, Appeals, and Licensing, accessed April 28, 2025, https://dial.iowa.gov/i-need/licenses/medical/nursing-professional-midwifery/nursing-practice/arnp-role-and-scope.

Kansas

• Kan. Admin. Regs. § 68-7-22 (2024).
• B. 2279, 2021–2022 Reg. Sess. (Kan. 2022).
• “APRN FAQ on the New 2022 Kansas Statute Changes,” Kansas Medical Society, last updated September 17, 2022, https://kmsonline.org/resources/practice-operations/3259-aprn-faq-2022.
• Vicky Diaz-Camacho, “Kansas Joins 25 Other States by Expanding Access to Nurse Practitioners,” Flatland, April 19, 2022.

Kentucky

• Rev. Stat. Ann. § 314.011 (2025).
• 201 Admin. Reg. 20:057 (2024).
• Kentucky Coalition of Nurse Practitioners and Nurse Midwives, Certified Nurse Midwives, January 5, 2015, https://cdn.ymaws.com/www.kcnpnm.org/resource/dynamic/blogs/20150105_194032_16324.pdf.
• Kentucky Coalition of Nurse Practitioners and Nurse Midwives, “Nurse Practitioners and Nurse Midwives Provide Quality, Cost-Effective Care, but Barriers to Their Practice Decrease Patient Access to Care,” Kentucky Association of Nurse Practitioners and Nurse-Midwives, https://www.kcnpnm.org/page/white_paper.

Louisiana

• Admin. Code tit. 46, pt. XLVII, § 4513P (2024).
• Stat. Ann. § 37:913 (2024).

Maine

• 02-380-8 Me. Code R. § 8 (2024).
• Leonel Cabrera, “Nurse Practitioner Scope of Practice: Maryland,” ThriveAP (blog), accessed April 28, 2025, https://provider.thriveap.com/blog/nurse-practitioner-scope-practice-maryland.

Maryland

• Code Ann., Health Occ. § 8-302 (2024).
• Code Regs. 10.27.05.01, .06 (2024).
• 45 Md. Reg. 96 (January 19, 2018).
• “Nurse Practitioner Full Practice Authority Act of 2015 SB 723/HB 999,” accessed April 28, 2025, https://www.npamonline.org/page/FullPracticeAuthorit/Nurse-Practitioner-Full-Practice-Authority-Act-of-2015-SB-723-HB-999.htm.

Massachusetts

• Gen. Laws ch. 112, § 80G (2025).
• 244 Code Regs. 4.00 (2021).
• Sasha Albert, “Certified Nurse Midwives and Maternity Care in Massachusetts” (PowerPoint, Massachusetts Health Policy Commission, Boston, MA, October 6, 2021), https://www.mass.gov/doc/certified-nurse-midwives-and-maternity-care-in-massachusetts-1062021/download.
• “Learn About Advanced Practice Registered Nurses (APRN),” Massachusetts Department of Public Health, accessed April 28, 2025, https://www.mass.gov/info-details/learn-about-advanced-practice-registered-nurses-aprn.
• “Apply for APRN Prescriptive Authority,” Massachusetts Department of Public Health, accessed April 28, 2025, https://www.mass.gov/how-to/apply-for-aprn-prescriptive-authority.

Michigan

• Comp. Laws §§ 333.17101–17123, 17201–17242 (2025).
• Michigan Council of Nurse Practitioners, Collaborative Agreement Sample and FAQ, n.d., https://cdn.ymaws.com/micnp.org/resource/resmgr/resources_&_links/micnp_collaborative_agreemen.pdf.
• “Midwifery Routes,” Michigan Midwives Association, accessed April 28, 2025, https://www.michiganmidwives.org/midwifery-routes.
• “Nurse-Midwifery,” University of Michigan Medical School, accessed April 28, 2025, https://medschool.umich.edu/departments/obstetrics-gynecology/divisions/nurse-midwifery.

Minnesota

• Stat. §§ 148.171, 211 (2024).
• “Advanced Practice Registered Nurse (APRN) License General Information,” Minnesota Board of Nursing, accessed April 28, 2025, https://mn.gov/boards/nursing/advanced-practice/advanced-practice-registered-nurse-(aprn)-licensure-general-information/.
• “State Overview: Minnesota,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/minnesota.

Mississippi

• Code Ann. § 73-15-20 (2017).
• Moira K. McGhee, “2023 State-by-State Scope of Practice: Nurse Practitioner,” Vivian, August 1, 2022, https://hire.vivian.com/blog/2022-state-by-state-scope-of-practice-nurse-practitioner.

Missouri

• Rev. Stat. § 334.104 (2023).
• Code Regs. Ann. tit. 20, § 2200-4.200 (2024).
• Christina Moore and Sydney Miller, “Stop, Collaborate, and Listen: Missouri Requirements regarding Collaboration with and Supervision of Advance Practice Nurses,” Missouri Medicine 120, no. 4 (2023): 250–255.
• Marcus L. Kearns, “Independent Practice for Missouri APRNs,” Nursing CE Central, February 16, 2024.

Montana

• Admin. R. 24.159.1406 (2025).
• “Doctor of Nursing Practice (DNP) Degree – Nurse-Midwifery Option,” Montana State University, accessed March 27, 2025, https://www.montana.edu/nursing/graduate/DNP_NurseMidwiferyOption.html.
• “State Overview: Montana,” National Conference of State Legislatures, accessed March 27, 2025, https://scopeofpracticepolicy.org/states/mt/.

Nebraska

• Rev. Stat. §§ 38-613, 2322 (2025).
• Nebraska Department of Health and Human Services, Statutes Relating to Certified Nurse Midwifery Practice Act, 2021.

Nevada

• “State Overview: Nevada,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/nevada.
• Jennifer Vanderlaan, “NRS 449.1923 and AB287: Update From Nevada’s Nurse-Midwives,” Nevada State Board of Nursing News (Spring 2022): 6–8.
• Nevada State Board of Nursing, Licensure Requirements for Advanced Practice Registered Nurse, October 2019.

New Hampshire

• H. Rev. Stat. Ann. § 326-B:11.III (2024).
• “State Overview: New Hampshire,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/new-hampshire.

New Jersey

• J. Admin. Code § 13:35-2A (2024).
• “State Overview: New Jersey,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/new-jersey.
• “Advanced Practice Nurse Certification,” New Jersey Division of Consumer Affairs, last modified October 2, 2024, https://www.njconsumeraffairs.gov/nur/Pages/APN-Certification.aspx.

New Mexico

• M. Code R. § 16.11.2 (2024).
• “Regulations Governing APRN Practice,” New Mexico Nurse Practitioner Council, accessed April 28, 2025, https://www.nmnpc.org/page/PracticeRegs.
• “State Overview: New Mexico,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/new-mexico.
• Susanne J. Phillips, “37th Annual APRN Legislative Update: Past, Present, and Future,” Nurse Practitioner Journal 50, no. 1 (2025): 15–47.

New York

• Y. Educ. Law §§ 6902, 6950–58 (McKinney 2024).
• “License Application Forms: Nurse Practitioner,” New York State Education Department, last updated February 9, 2021, https://www.op.nysed.gov/professions/nurse-practitioners/license-application-forms.
• “Practice Requirements for Nurse Practitioners,” New York State Education Department, accessed April 28, 2025, https://www.op.nysed.gov/professions/nurse-practitioners/professional-practice/practice-requirements.

North Carolina

• C. Gen. Stat. § 90-178.3 (2025).
• 21 C. Admin. Code 32M.0101, 36.0804, 36.0809 (2025).
• Rose Hoban, “After a Decades-Long Stalemate, Nurse Midwives Can Now Practice without Physician Supervision,” North Carolina Health News, June 5, 2023.
• “State Overview: North Carolina,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/north-carolina.
• “Finding a Collaborating Physician in North Carolina,” Zivian, January 31, 2025, https://www.zivianhealth.com/blog/finding-a-collaborating-physician-in-north-carolina.
• “Certified Nurse Midwife,” North Carolina Board of Nursing, last updated December 10, 2024, https://www.ncbon.com/certified-nurse-midwife-0.

North Dakota

• D. Cent. Code § 43-12.1 (2025).
• “State Overview: North Dakota,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/north-dakota.

Ohio

• Ohio Admin. Code 4723-8-04 (2025)
• Ohio Board of Nursing, APRN Licensure and Practice in Ohio, n.d.
• “State Overview: Ohio,” National Conference of State Legislatures, accessed April 29, 2025, https://www.ncsl.org/scope-of-practice-policy/state/ohio.

Oklahoma

• Stat. tit. 59, § 567.3a (2024).
• “Understanding the Scope of Practice for Certified Nurse Practitioners,” Oklahoma Board of Nursing Newsletter (December 2014).
• “APRN Prescription News,” Oklahoma Board of Nursing Newsletter (December 2014).
• Oklahoma Board of Nursing, Agreement for Physician Supervising Advanced Practice Prescriptive Authority, November 28, 2022.
• Oklahoma Board of Nursing, Instructions for Prescriptive Authority Recognition for the APRN-CNP, APRN-CNS, APRN-CNM, October 8, 2024.

Oregon

• Oregon State Board of Nursing, Advanced Practice Registered Nurse FAQ Guide, June 12, 2024.

Pennsylvania

• 49 Code §§ 18.1–18.9 (2025).
• “Scope of Practice,” Pennsylvania Coalition of Nurse Practitioners, accessed April 28, 2025, https://www.pacnp.org/page/ScopeofPractice.
• “State Overview: Pennsylvania,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/pennsylvania.
• “Certified Nurse Midwife Licensure Requirements Snapshot,” Pennsylvania Department of State, accessed April 28, 2025, https://www.pa.gov/agencies/dos/department-and-offices/bpoa/boards-commissions/medicine/certified-nurse-midwife-licensure-snapshot.html.

Rhode Island

• 5 R.I. Gen. Laws 5-34-44 (2024).
• 216 40 R.I. Code R. 5 (2022).
• “CNM Independent Practice Map,” National Council of State Boards of Nursing, last updated September 7, 2022, https://www.ncsbn.org/nursing-regulation/practice/aprn/aprn-consensus-implementation-status/cnm-independent-practice-map.page.

South Carolina

• C. Code Ann. § 40-33 (2025).
• “Finding a Collaborating Physician in South Carolina,” Zivian, February 22, 2025, https://www.zivianhealth.com/blog/finding-a-collaborating-physician-in-south-carolina.
• “State Overview: South Carolina,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/south-carolina.

South Dakota

• D. Codified Laws § 36-9A-1 (2025).
• “CNP,” South Dakota Board of Nursing, last updated August 8, 2024, https://www.sdbon.org/Practice/CNP.asp.
• “State Overview: South Dakota,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/south-dakota.

Tennessee

• Code Ann. §§ 63-7-123, 126 (2025).
• Comp. R. & Regs. 0880-06-.02, 1000-04-.08 (2025).
• “State Overview: Tennessee,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/tennessee.

Texas

• 22 Admin. Code §§ 221.13, 222.5 (2025).
• Occ. Code Ann. § 301 (2025).
• “State Overview: Texas,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/texas.
• “Frequently Asked Questions: Advanced Practice Registered Nurse,” Texas Board of Nursing, accessed April 28, 2025, https://www.bon.texas.gov/faq_practice_aprn.asp.html.

Utah

• Utah Admin. Code § 58-31b-102 (2025).
• Utah Admin. Code § 156-31b (2025).
• Gayle Morris, “Utah Nurse Practitioners Granted Full-Practice Authority,” NurseJournal, March 21, 2023.

Vermont

• Stat. Ann. tit. 26, §§ 1571–1648 (2024).

Virginia

• Code Ann. § 54.1-2957, -2900 (2025).
• “State Overview: Virginia,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/virginia.

Washington

• Admin. Code §§ 246-840-010, -300 (2025).
• “Limitations of Practice as a Nurse Practitioner in Washington – 2025,” Nurse Practitioner License, last updated February 12, 2024, https://www.nursepractitionerlicense.com/nurse-practitioner-licensing-guides/limitations-of-practice-as-a-nurse-practitioner-in-washington/.

West Virginia

• Va. Code R. §§ 30-7-1, -15b (2025).
• “State Overview: West Virginia,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/west-virginia.

Wisconsin

• Stat. § 441.15 (2025).
• Admin. Code N § 8.06(3)(c) (2025).
• “State Overview: Wisconsin,” National Conference of State Legislatures, accessed April 28, 2025, https://www.ncsl.org/scope-of-practice-policy/state/wisconsin.
• American College of Nurse-Midwives, Midwifery Fact Sheet: Wisconsin, n.d., https://web.archive.org/web/20240302111813/https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000009121/Wisconsin.pdf.

Wyoming

• Stat. Ann. § 33-21-120 (2024).
• “Practice,” Wyoming State Board of Nursing, accessed April 28, 2025, https://wsbn.wyo.gov/practice.