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A Comparison of Changes in the Professional Practice of Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives: 1992 and 2000
- Printer-friendly (Acrobat/pdf) (11.33MB)
This page: Appendix F. New CNM Scope Index Calculations
Appendix F. New CNM Scope Index Calculations
This appendix contains a table that documents the detailed calculations used to compute the new professional practice index for CNMs for each of the 50 States plus the District of Columbia.
Legal Status (Maximum = 35)
Title protection indicates acceptance and acknowledgement of the skills required to practice as a professional. Legal protection provides a safeguard for both the public and the practicing professional.
CNMs are licensed, certified, or approved in all fifty States and the District of Columbia. Licensure as a nurse midwife provides recognition of the status of the profession. CNMs are frequently regulated as a category of Advanced Practice Nurse (APN). They are sometimes addressed as a separate category within the statutes and regulations which speak to professional practice, licensure requirements, and prescriptive authority. In some States, Midwives or CNMs are considered independently from other nurses and are regulated as a separate profession from APNs.
Regulation by the Board of Nursing is the most common structure when CNMs are considered to be APNs. Separate regulation by a Board of Midwifery is considered ideal since a separate board can best represent the interests and the orientation of midwives. When midwives are regulated by a separate entity, non-nurse midwives may be included in the rules.
Gynecological care in statute or regulation suggests that midwives are viewed as practicing in an expanded role. Limiting midwives to care in pregnancy and at birth does not fully use their professional competencies.
The nature of midwifery practice demands a relationship with a physician. Complicated pregnancies and deliveries require the availability of specialty physicians with the skills to provide needed patient care. Practice as a self-employed (autonomous) midwife is an option in several States, but the need for a collaborating physician is universal. Practice agreements and review of records that are left to the discretion of the midwife and the physician acknowledge the competency and skill of each profession and the ability of both to safely meet patient need.
Temporary permits allow nurse midwives awaiting the results of the certification examination to practice.
Inactive or retired status allows non-practicing CNMs to use their title.
The profession of Midwifery philosophically supports non-nurse midwives who are properly trained and regulated. The roots of midwifery practice are in the care of women during pregnancy and childbirth in communities where other medical resources are limited. Requiring a masters degree, although elevating to a profession, limits the ability of non-nurse midwives (also referred to as direct entry or lay midwives) to provide care. Rather, professional midwifery associations support adequate skill and competency in midwifery and have opened their certification examinations to these midwives.
Hospital privileges permit a nurse midwife to admit a patient without a supervising physician and provide autonomy to the professional. Signing birth certificates and the ability to directly refer indicate recognition of the professional ability of the midwife.
Reimbursement (Maximum = 35)
In 1997, the Balanced Budget Act, expanded the locations at which CNM could be reimbursed for services. Since this was a progression in reimbursement from 1992, a score was awarded to every State for direct Medicare payment.
State reimbursement policy for payment of services rendered to Medicaid-eligible patients varies considerably by State and by profession.
The legal right to be reimbursed for services provided is critical to the autonomy of CNMs. Although services may be provided totally by the CNM, the inability to bill third parties for payment as an identified provider can be a barrier to the provision of care.
Direct access legislation allows women to choose well care services from a nurse midwife. Legislation enabling that independent choice acknowledges the skill of the CNM and suggests the roles that CNMs can play in healthcare delivery.
Prescriptive Authority (Maximum = 30)
When prescriptive authority is granted as part of the licensure process for nurse midwives, it is recognition of confidence in the education and skill of the CNM. The necessity of a separate application for prescriptive privilege suggests special requirements for the authority not fundamental to the didactic and clinical preparation of the midwife.
Although DEA numbers are a requirement for prescribing controlled substances, a separate score was allotted to emphasize the importance of the privilege of writing scripts for scheduled drugs.
Definition of the prescriptive privilege in law rather than by individual physicians suggests full recognition of the capability of the professional. Dependence for prescriptive authority on physician delegation limits the nurse midwife by creating barriers to efficient practice. Review with another health professional of patient needs and ordering of appropriate medications is a necessary part of practice. However, the circumstances under which that consultation occurs may best be determined by the midwife and may not need to be detailed in law or in a cooperative agreement.
The ability to receive and distribute sample medications, to independently sign a prescription and to prescribe medical devices are suggestive of recognition of the expertise of nurse midwives.
Continuing education requirements maintain the skill of the professional and update competencies.
The actual point allocations for the 50 States are presented below.
| Table F-1Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000New Index for AL, AK, AZ, AR, CA, and CO | |||||||||||||||
| Scoring Category | Points |
Optimal Score |
fn |
State |
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
AL |
AK |
AZ |
AR |
CA |
CO |
||||||||||
Legal
Status |
|||||||||||||||
| Title protected | 3 |
3 |
a |
3 |
a |
a |
3 |
a |
3 |
a |
3 |
||||
| Type of recognition: | b |
b |
|||||||||||||
|
3 |
3 |
3 |
||||||||||||
|
2 |
2 |
2 |
b |
2 |
b |
2 |
b |
2 |
b |
|||||
| Regulated How: | c |
||||||||||||||
|
2 |
2 |
2 |
||||||||||||
|
1 |
1 |
1 |
1 |
c |
1 |
1 |
||||||||
| Regulated By: | d |
||||||||||||||
|
3 |
3 |
|||||||||||||
|
2 |
2 |
d |
||||||||||||
|
1 |
1 |
1 |
||||||||||||
|
1 |
1 |
1 |
||||||||||||
|
0 |
0 |
d |
||||||||||||
| Scope Defined: | e |
||||||||||||||
|
3 |
3 |
3 |
3 |
3 |
3 |
|||||||||
|
2 |
2 |
2 |
||||||||||||
|
1 |
||||||||||||||
|
0 |
||||||||||||||
| Gynecological care in SOP defined | 1 |
1 |
f |
1 |
1 |
1 |
1 |
1 |
|||||||
| Masters degree required | 0 |
g |
0 |
0 |
g |
0 |
g |
||||||||
| National Certification | 1 |
1 |
h |
1 |
1 |
1 |
1 |
1 |
1 |
||||||
| Autonomous practice possible | 5 |
5 |
I |
5 |
I |
5 |
5 |
5 |
I |
||||||
| Relationships with Physicians: | j |
||||||||||||||
|
3 |
3 |
3 |
j |
|||||||||||
|
2 |
2 |
2 |
j |
2 |
2 |
2 |
j |
|||||||
|
1 |
||||||||||||||
| Temporary Permit, or not necessary | 1 |
1 |
k |
1 |
1 |
k |
1 |
1 |
k |
1 |
|||||
| Inactive or Retired Status Available | 1 |
1 |
l |
1 |
1 |
1 |
|||||||||
| Practice Agreements: | m |
||||||||||||||
|
3 |
3 |
3 |
||||||||||||
|
2 |
2 |
m |
2 |
|||||||||||
|
1 |
1 |
1 |
m |
1 |
m |
|||||||||
| Practice permissible for lay or direct entry midwives | 1 |
1 |
n |
1 |
n |
1 |
n |
1 |
n |
1 |
n |
1 |
n |
1 |
n |
| Review of Records by Physician: | o |
||||||||||||||
|
2 |
2 |
2 |
2 |
2 |
2 |
2 |
||||||||
|
1 |
1 |
o |
||||||||||||
|
0 |
||||||||||||||
| Hospital Privileges in legislation | 1 |
1 |
p |
1 |
p |
1 |
p |
||||||||
| CNMs can sign birth certificates | 1 |
1 |
q |
1 |
1 |
1 |
1 |
q |
1 |
1 |
|||||
| Can refer directly for other health services | 1 |
1 |
r |
1 |
r |
1 |
r |
1 |
1 |
r |
1 |
r |
|||
| Subtotals Legal | 35 |
19 |
25 |
25 |
28 |
23 |
26 |
||||||||
Reimbursement |
|||||||||||||||
| Medicare | 5 |
5 |
s |
5 |
5 |
5 |
s |
5 |
5 |
5 |
|||||
| Medicaid % x 10 | 0-10 |
10 |
t |
8 |
10 |
6 |
8 |
10 |
10 |
||||||
| Language that permits reimb by 3rd party/HMO | 15 |
15 |
u |
15 |
u |
15 |
15 |
15 |
|||||||
| Any "direct access" legislation for women | 5 |
5 |
v |
5 |
v |
||||||||||
| Subtotals Reimbursement | 35 |
13 |
35 |
26 |
13 |
30 |
30 |
||||||||
Prescriptive
Authority |
|||||||||||||||
| How received: | w |
||||||||||||||
|
4 |
4 |
|||||||||||||
|
2 |
2 |
2 |
2 |
2 |
w |
2 |
2 |
|||||||
| Own DEA number | 3 |
3 |
x |
3 |
3 |
3 |
3 |
||||||||
| CNM name on Rx pad | 1 |
1 |
y |
1 |
1 |
1 |
1 |
1 |
|||||||
| Extent of Authority: | z |
||||||||||||||
|
16 |
16 |
16 |
z |
16 |
z |
16 |
z |
|||||||
|
12 |
12 |
|||||||||||||
|
8 |
||||||||||||||
|
4 |
||||||||||||||
|
1 |
1 |
1 |
z |
|||||||||||
| Authority through: | ^ |
||||||||||||||
|
4 |
4 |
4 |
4 |
^ |
||||||||||
|
3 |
3 |
3 |
^ |
|||||||||||
|
2 |
2 |
|||||||||||||
|
1 |
1 |
|||||||||||||
|
0 |
||||||||||||||
| Durable medical equipment or devices | 1 |
1 |
# |
1 |
1 |
1 |
1 |
||||||||
| Continuing Ed requirements | 1 |
1 |
$ |
1 |
1 |
1 |
1 |
1 |
1 |
||||||
| Subtotals Prescriptive Authority | 30 |
6 |
28 |
28 |
23 |
7 |
26 |
||||||||
| TOTAL POINTS | 100 |
38 |
88 |
79 |
64 |
60 |
82 |
||||||||
FOOT NOTES
ALABAMA:
b) Certification of Qualification
d) One midwife on Joint Practice Committee
n) Lay midwives with permit may practice but DOH has no present method
for issuing permits; the statute is inactive (ACNM)
o) Plan for review of records required in regulations
r) Referral in definition of practice
ALASKA:
a) ANP title only,includes CNM
I,j,m) Procedures for consultation referral must be filed with BON but
no direct relationship required
n) Certified Direct Entry (CDEMs) Midwives regulated by Board Of Certified
Direct Entry Midwives (ACNM)
r) Referral to other health care professionals
u) Any Willing Provider Law
v) No managed care in Alaska, direct access implied by independent nature
of practice
z) Dispensing authority as of 1994
ARIZONA:
a) RNP title protected includes CNMS
b) Certified to practice
c) Category of RNP
g) After 2001
j) All acts performed must be in collaboration with a physician
k) RN temporary license
n) Midwifery regulated by DOH Nurse Midwives by BON
p) Scope of practice in statute includes admitting patients to hospitals
s) Arizona has an innovative managed care plan called Arizona Health Cost
Containment System that covers medicaid eligibles, pregnant women etc.
RNPs can contract with the plan
z) Prescribe and dispense -limits on refills
^) No physician collaboration required on Application for Authority
ARKANSAS:
a) CNM
m) For intrapartum care and prescriptive authority only
n) Lay midwives regulated by state DOH (ACNM)
q) Licensed midwifery statute provides this privilege
r) Referrals in definition of practice
w) Granted a certificate of prescriptive authority
CALIFORNIA:
a) Holding oneself out as CNM without certification is grounds for discipline
b) Certificate to practice
d) BON with Midwifery Committee
k) Not necessary because of various avenues available for certificates
to practice
m) Standardized procedures which are protocols for medical acts including
prescribing provide guidelines for practice
n) Licensed midwives are regulated by Division of Licensing of Medical
Board since 1993 (ACNM)
p) RNs may be granted expanded role privilege in hospitals
z) Medically delegated
COLORADO:
b) Registration
g) For prescriptive authority and beginning 7/1/2008 required
I) Direct entry midwives are licensed and regulated under Colorado Medical
Practice Act
J) 2000 legislation changed language to collaboration
n) Supervisory language for medical functions, collaborative language
for prescriptive authority
r) In definition of collaborative agreement
z) Dispensing limited to prepackaged samples, prescriptive authority limited
to acute self limiting condition, chronic condition, terminal comfort
care
^) Name of at least one collaborating physician required
REFERENCES
Main Resources
American College
of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and
Regulations 2000, Washington, DC, 2000.
Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen
Publications, Gaithersburg, Maryland, 1999.
Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting,
April 2001, Washington, DC.
Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers,
Intergovernmental Health Policy Project, The George Washington University,
February 1994.
Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for
Advanced Practice Registered Nurses, Primary Care Resource Center, Intergovernmental
Health Policy Project, The George Washington University, December 1995.
Henderson T, Norris S, National Conference of State Legislators, Inc.
National Council of State Boards of Nursing, http://www.ncsbn.org.
National Council of State Boards of Nursing, The Regulation of Advanced
Practice Registered Nurses 1997, Chicago, IL, 1998.
Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative
Issues Affecting Advanced Nursing Practice, The Nurse Practitioner 26(1):7-57.
US Department of Justice, Drug Enforcement Administration, Diversion Control
Program, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html.
Washburn University School of Law, http://www.washlaw.edu
ALABAMA
Alabama Board of Nursing, http://www.abn.state.al.us
ALASKA
Alaska Legislature Online, http://www.legis.state.ak.us
Alaska Division of Occupational Licensing: Board of Nursing, http://www.dced.state.ak.us/occ
ARIZONA
Arizona Health Care Cost Containment System, http://www.ahccs.state.az.us
Arizona State Board of Nursing, http://www.azboard
of nursing.org
ARKANSAS
Arkansas State Board of Nursing , http://www.accessarkansas.org/nurse
CALIFORNIA
State of California-State and Consumer Services Agency, Board
of Registered Nursing, http://www.rn.ca.gov
National Council of State Boards of Nursing, http://www.ncsbn.org
American College of Nurse Midwives, http://www.acnm.org
COLORADO
Colorado Department of Regulatory Agencies, http://www.dora.state.co.us/Nursing
| Table F-1, continuedProfessional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000New Index for CT, DE, DC, FL, GA, and HI | |||||||||||||||
| Scoring Category | Points | Optimal Score |
fn | State | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CT | DE | DC | FL | GA | HI | ||||||||||
Legal
Status |
|||||||||||||||
| Title protected | 3 | 3 | a | 3 | a | 3 | a | 3 | a | ||||||
| Type of recognition: | b | ||||||||||||||
|
3 | 3 | 3 | 3 | 3 | ||||||||||
|
2 | 2 | b | 2 | b | 2 | b | ||||||||
| Regulated How: | c | ||||||||||||||
|
2 | 2 | 2 | c | |||||||||||
|
1 | 1 | 1 | 1 | 1 | 1 | |||||||||
| Regulated By: | d | ||||||||||||||
|
3 | 3 | |||||||||||||
|
2 | ||||||||||||||
|
1 | ||||||||||||||
|
1 | 1 | 1 | 1 | |||||||||||
|
0 | 0 | d | 0 | d | 0 | d | ||||||||
| Scope Defined: | e | ||||||||||||||
|
3 | 3 | 3 | 3 | 3 | 3 | 3 | ||||||||
|
2 | ||||||||||||||
|
1 | 1 | |||||||||||||
|
0 | ||||||||||||||
| Gynecological care in SOP definition | 1 | 1 | f | 1 | 1 | 1 | 1 | 1 | 1 | ||||||
| Masters degree required | 0 | g | 0 | g | 0 | 0 | g | 0 | g | 0 | g | ||||
| National Certification | 1 | 1 | h | 1 | 1 | 1 | 1 | h | 1 | 1 | h | ||||
| Autonomous practice possible | 5 | 5 | I | 5 | I | 5 | 5 | 5 | I | 5 | I | ||||
| Relationships with Physicians: | j | ||||||||||||||
|
3 | 3 | 3 | ||||||||||||
|
2 | 2 | j | 2 | 2 | j | |||||||||
|
1 | 1 | j | 1 | j | ||||||||||
| Temporary Permit, or not necessary | 1 | 1 | k | 1 | 1 | 1 | 1 | 1 | k | ||||||
| Inactive or Retired Status Available | 1 | 1 | l | 1 | 1 | 1 | |||||||||
| Practice Agreements: | m | ||||||||||||||
|
3 | 3 | 3 | m | 3 | ||||||||||
|
2 | 2 | 2 | m | |||||||||||
|
1 | 1 | m | 1 | |||||||||||
| Practice permissible for lay or direct entry midwives | 1 | 1 | n | 1 | n | 1 | n | 1 | n | 1 | n | 1 | n | ||
| Review of Records by Physician: | o | ||||||||||||||
|
2 | 2 | 2 | 2 | 2 | 2 | |||||||||
|
1 | 1 | 1 | o | |||||||||||
|
0 | ||||||||||||||
| Hospital Privileges in legislation | 1 | 1 | p | 1 | 1 | 1 | p | ||||||||
| CNMs can sign birth certificates | 1 | 1 | q | 1 | 1 | 1 | 1 | 1 | 1 | ||||||
| Can refer directly for other health services | 1 | 1 | r | 1 | r | 1 | 1 | 1 | |||||||
| Subtotals Legal | 35 | 24 | 26 | 32 | 21 | 20 | 23 | ||||||||
Reimbursement |
|||||||||||||||
| Medicare | 5 | 5 | s | 5 | 5 | 5 | 5 | 5 | 5 | ||||||
| Medicaid % x 10 | 0-10 | 10 | t | 9 | 10 | 10 | t | 8 | 10 | 7.5 | |||||
| Language that permits reimb by 3rd party/HMO | 15 | 15 | u | 15 | 15 | 15 | u | u | 15 | ||||||
| Any "direct access" legislation for women | 5 | 5 | v | 5 | |||||||||||
| Subtotals Reimbursement | 35 | 34 | 30 | 15 | 28 | 15 | 27.5 | ||||||||
Prescriptive
Authority |
|||||||||||||||
| How received: | w | ||||||||||||||
|
4 | 4 | 4 | 4 | 4 | ||||||||||
|
2 | 2 | 2 | ||||||||||||
| Own DEA number | 3 | 3 | x | 3 | 3 | 3 | |||||||||
| CNM name on Rx pad | 1 | 1 | y | 1 | 1 | 1 | 1 | 1 | |||||||
| Extent of Authority: | z | ||||||||||||||
|
16 | 16 | 16 | z | 16 | z | 16 | z | |||||||
|
12 | ||||||||||||||
|
8 | ||||||||||||||
|
4 | ||||||||||||||
|
1 | 1 | z | 1 | z | 1 | |||||||||
| Authority through: | ^ | ||||||||||||||
|
4 | 4 | 4 | ||||||||||||
|
3 | 3 | 3 | ^ | |||||||||||
|
2 | 2 | 2 | ^ | |||||||||||
|
1 | 1 | ^ | ||||||||||||
|
0 | ||||||||||||||
| Durable medical equipment or devices | 1 | 1 | # | 1 | 1 | 1 | |||||||||
| Continuing Ed requirements | 1 | 1 | $ | 1 | 1 | 1 | $ | 1 | 1 | $ | |||||
| Subtotals Prescriptive Authority | 30 | 28 | 27 | 25 | 9 | 8 | 7 | ||||||||
| TOTAL POINTS | 100 | 86 | 83 | 72 | 58 | 43 | 57.5 | ||||||||
FOOT NOTES
CONNECTICUT:
c) Midwifery Practice Act
d) Department of Public Health and Addiction Services, a committee of
3 CNMs
serves as advisory panelI) Clinical practice relationship with OB/GYN
required
j) Services "directed" by a qualified OB/GYN however, statute indicates
this is not to be construed as supervision
m) Protocols for prescriptive authority filed with DOH
n) Unlicensed midwives who practice independently of physicians are allowed
to practice (ACNM)
z) May prescribe, dispense, administer
DELAWARE:
a) APN title protection only
m) Name of collaborating physician on application for licensure
n) Traditional midwives practice under a special waiver of the regulation
(ACNM)
r) Initiating referrals in definition of scope
z) Prescribing medications and treatments independently - can dispense
^) A copy of the collaborative agreement must be submitted to the Joint
Practice Committee
DISTRICT OF COLUMBIA:
n) Persons previously licensed under now deleted provisions
may continue to practice, other "midwives unregulated but legal" (ACNM)
t) Managed care system
z) No refills on controlled substances
FLORIDA:
a) ARNP title only
b) Certified
d) Joint Practice Committee BON with BOM with two APN members
g) Included in list of options in rules for certification
h) For initial certification only
I) Limited practice in licensed midwifery
j) Supervision with protocols, collaborative language
n) Council of Licensed Midwifery regulates practice of other midwives
since 1992 (ACNM)
u) Any Willing Provider law
z) Dispensing allowed but special application for privilege is required
$) RN requirement
GEORGIA:
b) Authorization to practice
g) Effective 1/1/99
j) SOP collaborative, prescriptive authority is supervisory and delegatory
p) Hospitals must provide due process rights to licensed medical professionals
u) Georgia has an Any Willing Provider law but APRNs do not seem to qualify
under the definitions
z) Controlled substances and legend drugs may be prescribed and dispensed
if included in protocol but location of practice, where this is allowed,
is restricted to clinic and government settings
^) Written protocols define privilege, on delegated medical authority
of physicians
HAWAII:
a) APRN title only
b) Recognized
d) BON but BOME involved with prescriptive authority, Department of Commerce
and Consumer Affairs approves prescriptive authority
g) For prescriptive authority
h) Certification or masters
j) No particular relationship specified except for prescriptive authority
k) Not necessary if a nurse has a masters degree
m) For prescriptive authority the name of physician must be submitted
n) Midwifery practice appears to be legal (ACNM)
o) Joint and periodic evaluation
^) Prescribing, administering, dispensing and distribution of drugs
$) For prescriptive authority
REFERENCES
Main Resources
American College
of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and
Regulations 2000, Washington, DC, 2000.
Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen
Publications, Gaithersburg, Maryland, 1999.
Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting,
April 2001, Washington, DC.
Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers,
Intergovernmental Health Policy Project, The George Washington University,
February 1994.
Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for
Advanced Practice Registered Nurses, Primary Care Resource Center, Intergovernmental
Health Policy Project, The George Washington University, December 1995.
Henderson T, Norris S, National Conference of State Legislators, Inc.
National Council of State Boards of Nursing, http://www.ncsbn.org.
National Council of State Boards of Nursing, The Regulation of Advanced
Practice Registered Nurses 1997, Chicago, IL, 1998.
Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative
Issues Affecting Advanced Nursing Practice, The Nurse Practitioner 26(1):7-57.
US Department of Justice, Drug Enforcement Administration, Diversion Control
Program, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html.
Washburn University School of Law, http://www.washlaw.edu
CONNECTICUT
Connecticut Department of Public Health, http://www.state.ct.us/dph
DELAWARE
State of Delaware, Delaware Administrative Code, http://www.state.de.us
DISTRICT OF COLUMBIA
Lexis Nexis, http://198.187.128.12/dc
FLORIDA
Online Sunshine, State of Florida, http://www.leg.state.fl.us
GEORGIA
State Government of Georgia, http://www.ganet.org
HAWAII
Hawaii State Legislature, http://www.capitol.hawaii.gov
Hawaii State Government, Department of Commerce and Consumer Affairs,
http://www.state.hi.us
| Table F-1, continued Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 New Index for ID, IL, IN, IA, KS, and KY | |||||||||||||||
| Scoring Category | Points |
Optimal Score |
fn |
State |
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
ID |
IL |
IN |
IA |
KS |
KY |
||||||||||
Legal
Status |
|||||||||||||||
| Title protected | 3 |
3 |
a |
3 |
3 |
3 |
3 |
a |
3 |
a |
|||||
| Type of recognition: | b |
||||||||||||||
|
3 |
3 |
3 |
b |
3 |
3 |
b |
||||||||
|
2 |
2 |
b |
2 |
b |
2 |
b |
||||||||
| Regulated How: | c |
||||||||||||||
|
2 |
2 |
|||||||||||||
|
1 |
1 |
1 |
1 |
c |
1 |
1 |
1 |
c |
||||||
| Regulated By: | d |
||||||||||||||
|
3 |
3 |
|||||||||||||
|
2 |
||||||||||||||
|
1 |
1 |
d |
1 |
d |
1 |
d |
||||||||
|
1 |
1 |
1 |
1 |
|||||||||||
|
0 |
||||||||||||||
| Scope Defined: | e |
||||||||||||||
|
3 |
3 |
3 |
3 |
3 |
3 |
3 |
||||||||
|
2 |
2 |
|||||||||||||
|
1 |
||||||||||||||
|
0 |
||||||||||||||
| Gynecological care in SOP | 1 |
1 |
f |
1 |
1 |
1 |
1 |
1 |
1 |
||||||
| Masters degree required | 0 |
g |
0 |
g |
0 |
g |
0 |
g |
|||||||
| National Certification | 1 |
1 |
h |
1 |
1 |
1 |
1 |
h |
1 |
||||||
| Autonomous practice possible | 5 |
5 |
I |
5 |
I |
5 |
I |
5 |
I |
5 |
I |
||||
| Relationships with Physicians: | j |
||||||||||||||
|
3 |
3 |
3 |
||||||||||||
|
2 |
2 |
j |
2 |
j |
2 |
j |
2 |
j |
||||||
|
1 |
1 |
j |
||||||||||||
| Temporary Permit, or not necessary | 1 |
1 |
k |
1 |
k |
k |
1 |
1 |
|||||||
| Inactive or Retired Status Available | 1 |
1 |
l |
1 |
|||||||||||
| Practice Agreements: | m |
||||||||||||||
|
3 |
3 |
3 |
||||||||||||
|
2 |
2 |
2 |
m |
2 |
||||||||||
|
1 |
1 |
m |
1 |
m |
||||||||||
| Practice permissible for lay or direct entry midwives | 1 |
1 |
n |
1 |
n |
1 |
n |
n |
1 |
n |
1 |
n |
|||
| Review of Records by Physician: | o |
||||||||||||||
|
2 |
2 |
2 |
2 |
o |
||||||||||
|
1 |
1 |
o |
1 |
o |
1 |
o |
1 |
o |
||||||
|
0 |
||||||||||||||
| Hospital Privileges in legislation | 1 |
1 |
p |
1 |
p |
||||||||||
| CNMs can sign birth certificates | 1 |
1 |
q |
1 |
1 |
1 |
1 |
q |
1 |
1 |
|||||
| Can refer directly for other health services | 1 |
1 |
r |
1 |
1 |
1 |
r |
1 |
1 |
1 |
|||||
| Subtotals Legal | 35 |
27 |
20 |
20 |
26 |
22 |
27 |
||||||||
Reimbursement |
|||||||||||||||
| Medicare | 5 |
5 |
s |
5 |
5 |
5 |
5 |
5 |
5 |
||||||
| Medicaid % x 10 | 0-10 |
10 |
t |
10 |
7 |
7.5 |
8 |
7.5 |
7.5 |
||||||
| Language that permits reimb by 3rd party/HMO | 15 |
15 |
u |
15 |
u |
15 |
u |
15 |
15 |
15 |
u |
||||
| Any "direct access" legislation for women | 5 |
5 |
v |
||||||||||||
| Subtotals Reimbursement | 35 |
30 |
12 |
27.5 |
28 |
27.5 |
27.5 |
||||||||
Prescriptive
Authority |
|||||||||||||||
| How received: | w |
||||||||||||||
|
4 |
4 |
4 |
4 |
4 |
w |
|||||||||
|
2 |
2 |
w |
2 |
2 |
||||||||||
| Own DEA number | 3 |
3 |
x |
3 |
3 |
3 |
3 |
3 |
|||||||
| CNM name on Rx pad | 1 |
4 |
y |
2 |
2 |
2 |
4 |
4 |
4 |
||||||
| Extent of Authority: | z |
||||||||||||||
|
16 |
16 |
16 |
z |
16 |
16 |
z |
16 |
|||||||
|
12 |
||||||||||||||
|
8 |
||||||||||||||
|
4 |
4 |
z |
||||||||||||
|
1 |
1 |
z |
||||||||||||
| Authority through: | ^ |
||||||||||||||
|
4 |
4 |
4 |
||||||||||||
|
3 |
3 |
3 |
3 |
|||||||||||
|
2 |
2 |
^ |
||||||||||||
|
1 |
||||||||||||||
|
0 |
||||||||||||||
| Durable medical equipment or devices | 1 |
1 |
# |
1 |
1 |
1 |
1 |
||||||||
| Continuing Ed requirements | 1 |
1 |
$ |
1 |
1 |
1 |
1 |
$ |
1 |
||||||
| Subtotals Prescriptive Authority | 30 |
24 |
11 |
26 |
30 |
27 |
14 |
||||||||
| TOTAL POINTS | 100 |
81 |
43 |
73.5 |
84 |
76.5 |
68.5 |
||||||||
FOOT NOTES
IDAHO:
b) Licensed as a CNM, authorized as a prescriber
d) BON with Advisory Committee on APNs
j) " Shall consult and collaborate with other members of health care team"
"autonomy… of the practice category " but "practice with supervision"
n) A direct entry midwife could practice legally in the state under certain
restrictions (ACNM)
o) BOM regulations for supervising physician require periodic review of
a representative sample
u) Any Willing Provider law includes CNMs
w) " May be part of initial licensure by separate application"
z) " Prescribe, deliver, distribute and dispense" -- limits on controlled
substances
ILLINOIS:
d) APN Board
g) 2001
o) Periodic
z) Schedule III -V but delegated only
INDIANA:
b) "Limited license"
c) Addressed separately in rules for SOP but jointly with NPs for prescriptive
authority
i) Performs as an independent and interdependent member of the health
care team
j) In collaboration with a "licensed practitioner", specific exclusion
for collaboration with other APNs
k) No temporary permit under any circumstance
m) For prescriptive authority only
n) Not regulated but appears to be legal (ACNM)
o) Periodic and joint evaluation chart reviews within 7 days with prescriptive
authority
r) Refer clients to other health care providers as appropriate
u) Discrimination prohibited in law
IOWA:
b) Registered
g) Optional
I) Referred to as "solo practitioners", practice occurs within an interdisciplinary
health care team which provides for consultation, collaboration, referral
j) Collaborative agreement reflects both independent and cooperative decision
making
m) Required with respect to " delegated medical function"
n) A Bill for the establishment of a Midwifery Advisory Council in the
Department of Public Health which would issue certificate to qualified
midwives was introduced but not passed (ACNM)
p) Hospital Fairness Act 1999
q) By designation of institution or out of hospital
z) Prescribe, deliver, distribute or dispense
KANSAS:
a) APRN title only
b) Certificate of qualification
g) After 2002
h) Optional
I,j) Physician's involvement with prescriptive practice only, ARNPs function
independently, "collegial relationship with physicians and other health
professionals", "interdependent member of physicians directed team with
mutually adopted protocols"
n) Lay midwife must have an arrangement with a licensed physician to handle
complications (ACNM)
o) Periodic and joint evaluation of services rendered
^) Protocol for prescribing, administering or supplying ( no dispensing
except samples)
$) Requirement for RN licensure
KENTUCKY:
a) "Use of ARNP or any other words, letters..to indicate"
b) Registration and designation
c) Nurse midwives who held a permit to practice from the State Cabinet
of Human Resources prior to 1986 have option to practice as nurse midwife
( not ARNP)
d) Advanced Registered Nurse Practice Council including nurse midwives
I) May practice independently but "established protocol required"
j) Protocol defined as similar to national standard of practice, consultation
and referral language
m) For prescriptive authority
n) Lay midwifery regulated and legal (ACNM)
o) Not defined
u) Any Willing Provider law
w) No application process
z) " Issue prescriptions for and dispense" ( samples only)
REFERENCES
Main Resources
American College
of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and
Regulations 2000, Washington, DC, 2000.
Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen
Publications, Gaithersburg, Maryland, 1999.
Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting,
April 2001, Washington, DC.
Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers,
Intergovernmental Health Policy Project, The George Washington University,
February 1994.
Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for
Advanced Practice Registered Nurses, Primary Care Resource Center, Intergovernmental
Health Policy Project, The George Washington University, December 1995.
Henderson T, Norris S, National Conference of State Legislators, Inc.
National Council of State Boards of Nursing, http://www.ncsbn.org.
National Council of State Boards of Nursing, The Regulation of Advanced
Practice Registered Nurses 1997, Chicago, IL, 1998.
Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative
Issues Affecting Advanced Nursing Practice, The Nurse Practitioner 26(1):7-57.
US Department of Justice, Drug Enforcement Administration, Diversion Control
Program, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html.
Washburn University School of Law, http://www.washlaw.edu
IDAHO
Idaho State Board of Nursing, http://www2.state.id.us/adm
ILLINOIS
Illinois General Assembly, http://www.legis.state.il.us
Illinois Bar Journal, http://www.illinoisbar.org
National Council of State Boards of Nursing, http://www.ncsbn.or/files/npa/wholenpas/ilnpa.asp
INDIANA
Indiana Health Professions Bureau, http://www.IN.gov/hpb/boards
Indiana State Board of Nursing, http://www.state.in.us/hpb/boards
IOWA
Iowa Board of Nursing, http://www.state.ia.us/nursing
KANSAS
Kansas Legislative Services, http://www.accesskansas.org/legislative
KENTUCKY
Kentucky Legislature, http://www.lrc.state.ky.us/kar
Kentucky Board of Nursing, http://www.kbn.state.ky.us
| Table F-1, continued Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 New Index for LA, ME, MD, MA, MI, and MN | |||||||||||||||
| Scoring Category |
Points |
Optimal
Score |
fn |
State
|
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
LA |
ME |
MD |
MA |
MI |
MN |
||||||||||
Legal
Status |
|||||||||||||||
| Title protected | 3 |
3 |
a |
a |
3 |
a |
3 |
3 |
a |
3 |
3 |
||||
| Type of recognition: | b |
||||||||||||||
|
3 |
3 |
3 |
||||||||||||
|
2 |
2 |
b |
2 |
b |
2 |
b |
2 |
b |
2 |
b |
||||
| Regulated How: | c |
||||||||||||||
|
2 |
2 |
2 |
||||||||||||
|
1 |
1 |
1 |
c |
1 |
c |
1 |
1 |
|||||||
| Regulated By: | d |
||||||||||||||
|
3 |
3 |
|||||||||||||
|
2 |
2 |
2 |
||||||||||||
|
1 |
||||||||||||||
|
1 |
||||||||||||||
|
0 |
0 |
d |
0 |
d |
0 |
d |
0 |
d |
||||||
| Scope Defined: | e |
||||||||||||||
|
3 |
3 |
3 |
3 |
3 |
3 |
3 |
e |
|||||||
|
2 |
||||||||||||||
|
1 |
||||||||||||||
|
0 |
0 |
e |
||||||||||||
| Gynecological care in SOP definition | 1 |
1 |
f |
1 |
1 |
1 |
1 |
1 |
|||||||
| Masters degree required | 0 |
g |
0 |
g |
0 |
g |
|||||||||
| National Certification | 1 |
1 |
h |
1 |
1 |
1 |
1 |
1 |
1 |
||||||
| Autonomous practice possible | 5 |
5 |
I |
5 |
5 |
I |
5 |
||||||||
| Relationships with Physicians: | j |
||||||||||||||
|
3 |
3 |
3 |
3 |
|||||||||||
|
2 |
2 |
2 |
2 |
j |
2 |
|||||||||
|
1 |
||||||||||||||
| Temporary Permit, or not necessary | 1 |
1 |
k |
1 |
1 |
1 |
1 |
1 |
|||||||
| Inactive or Retired Status Available | 1 |
1 |
l |
1 |
l |
||||||||||
| Practice Agreements: | m |
||||||||||||||
|
3 |
3 |
3 |
3 |
|||||||||||
|
2 |
2 |
|||||||||||||
|
1 |
1 |
m |
1 |
|||||||||||
| Practice permissible for lay or direct entry midwives | 1 |
1 |
n |
1 |
n |
n |
1 |
n |
1 |
n |
1 |
n |
|||
| Review of Records by Physician: | o |
o |
|||||||||||||
|
2 |
2 |
2 |
o |
2 |
o |
2 |
0 |
|||||||
|
1 |
1 |
o |
1 |
1 |
o |
|||||||||
|
0 |
||||||||||||||
| Hospital Privileges in legislation | 1 |
1 |
p |
||||||||||||
| CNMs can sign birth certificates | 1 |
1 |
q |
1 |
1 |
1 |
1 |
1 |
1 |
||||||
| Can refer directly for other health services | 1 |
1 |
r |
1 |
1 |
1 |
1 |
1 |
1 |
||||||
| Subtotals Legal | 35 |
17 |
28 |
19 |
20 |
25 |
26 |
||||||||
Reimbursement |
s |
||||||||||||||
| Medicare | 5 |
5 |
t |
5 |
5 |
5 |
5 |
5 |
5 |
||||||
| Medicaid % x 10 | 0-10 |
10 |
u |
10 |
10 |
10 |
10 |
10 |
10 |
||||||
| Language that permits reimb by 3rd party/HMO | 15 |
15 |
v |
15 |
u |
15 |
15 |
15 |
15 |
u |
15 |
u |
|||
| Any "direct access" legislation for women | 5 |
5 |
5 |
5 |
v |
||||||||||
| Subtotals Reimbursement | 35 |
30 |
35 |
35 |
30 |
30 |
30 |
||||||||
Prescriptive
Authority |
|||||||||||||||
| How received: | w |
||||||||||||||
|
4 |
4 |
4 |
4 |
|||||||||||
|
2 |
2 |
2 |
2 |
w |
2 |
w |
||||||||
| Own DEA number | 3 |
3 |
x |
3 |
3 |
3 |
3 |
3 |
|||||||
| CNM name on Rx pad | 1 |
1 |
y |
1 |
1 |
1 |
1 |
||||||||
| Extent of Authority: | z |
||||||||||||||
|
16 |
16 |
16 |
z |
16 |
z |
16 |
16 |
z |
||||||
|
12 |
||||||||||||||
|
8 |
||||||||||||||
|
4 |
4 |
z |
||||||||||||
|
1 |
1 |
z |
||||||||||||
| Authority through: | ^ |
||||||||||||||
|
4 |
4 |
4 |
^ |
4 |
||||||||||
|
3 |
3 |
|||||||||||||
|
2 |
2 |
2 |
||||||||||||
|
1 |
1 |
|||||||||||||
|
0 |
||||||||||||||
| Durable medical equipment or devices | 1 |
1 |
# |
1 |
1 |
1 |
|||||||||
| Continuing Ed requirements | 1 |
1 |
$ |
1 |
1 |
1 |
1 |
$ |
1 |
1 |
|||||
| Subtotals Prescriptive Authority | 30 |
9 |
28 |
26 |
24 |
14 |
28 |
||||||||
| TOTAL POINTS | 100 |
56 |
91 |
80 |
74 |
69 |
84 |
||||||||
FOOT NOTES
LOUISIANA:
a) APRN protection only under" violation" section in statute
d) Joint Administrative Committee on Prescriptive Authority; BON with
BOM governs prescribing by APRNs
g) 1996
l) For prescriptive authority
n) Licensed midwives regulated by BOME with Advisory Committee on Midwifery
within Department of Health and Hospitals (ACNM)
o) Frequency determined by APRN and collaborating physician
u) Any Willing Provider Law
z) The Board may make exceptions and broaden authority on an individual
review of APRN qualifications
MAINE:
a) "Or the title designated by national certifying body" , also CNM
b) Approval
c) Statutes classify as APRN, separate rules
d) Joint Practice Council on APRN composed of BON, BOME and BOO makes
recommendations on prescriptive authority and other matters
g) 2006
n) Unclear (ACNM)
o) Not defined
z) Prescription and dispensing (prescribe, administer, dispense or distribute)
^) Formulary, referred to in rules, is a very broad guideline
MARYLAND:
b) Certified
d) Joint Committee of BON and BOPQA ( Board Of Physicians Quality Assurance)
approves applications
l) Illegal - also has Midwife Peer Review Advisory Committee
v) Bill in 2000-- provides for direct access to nurse midwives
z) Dispensing, limited to practice in non profit, government and public
facilities
MASSACHUSETTS:
a) No person may use any letters, words suggesting expanded role
b) Authorization, endorsement
c) Addressed separately in rules
d) An Advisory Committee to BON for each class of nurse practitioners
in "expanded role", Board of Registration and Discipline in Medicine approves
BON regulations and Department of Public Health approves prescriptive
authority
j) Collaborative language in SOP, supervisory language in prescriptive
authority and in SOP
n) Not prohibited (ACNM)
o) At least every three months
w) Registration with Massachusetts Department of Public Health
$) RN Requirement
MICHIGAN:
b) Certification
e) Scope of Practice not defined
I) No relationship with health professionals is described except for prescriptive
authority which is delegated
n) Midwifery practice not regulated but not prohibited (ACNM)
o) Not defined
u) Attorney General Opinion
z) Schedule II - V may be prescribed but only as a delegated medical act
MINNESOTA:
b) Certification
e) "Functioning as direct care providers"
n) Licensed traditional midwives regulated by Board of Medical Practice
(ACNM)
o) Not defined
u) Mandated but only if NP(CNM) is working under supervision of physician
w) 1999 law requires fee and proof that criteria for prescribing are met
z) Prescribe and dispense( authority more liberal for CNMs than NPs)
$) RN requirement
REFERENCES
Main Resources
American College
of Nurse Midwives, Nurse Midwifery Today, A Handbook of State Laws and
Regulations 2000, Washington, DC, 2000.
Buppert C, Nurse Practitioner’s Business Practice & Legal Guide, Aspen
Publications, Gaithersburg, Maryland, 1999.
Cooper RA, Multidisciplinary Healthcare Workforce Data Consortium, Meeting,
April 2001, Washington, DC.
Henderson T, Chovan T , Removing Practice Barriers of NonPhysician Providers,
Intergovernmental Health Policy Project, The George Washington University,
February 1994.
Henderson T, Fox-Grage W, Lewis S, Scope of Practice & Reimbursement for
Advanced Practice Registered Nurses, Primary Care Resource Center, Intergovernmental
Health Policy Project, The George Washington University, December 1995.
Henderson T, Norris S, National Conference of State Legislators, Inc.
National Council of State Boards of Nursing, http://www.ncsbn.org.
National Council of State Boards of Nursing, The Regulation of Advanced
Practice Registered Nurses 1997, Chicago, IL, 1998.
Pearson LJ. Annual Legislative Update: How Each State Stands on Legislative
Issues Affecting Advanced Nursing Practice, The Nurse Practitioner 26(1):7-57.
US Department of Justice, Drug Enforcement Administration, Diversion Control
Program, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html.
Washburn University School of Law, http://www.washlaw.edu
LOUISIANA
Louisiana State Board of Nursing, http://www.lsbn.state.la.us
MAINE
Maine Legislature, http://janus.state.me.us/legis
MARYLAND
Maryland General Assembly, http://mlis.state.md.us
Maryland Board of Nursing, http://dhmh.state.md.us
MASSACHUSETTS
Commonwealth of Massachusetts, http://www.state.ma.us/legis
MICHIGAN
National Council of State Boards of Nursing, http://www.michiganlegislature.org/law
Michigan Legislature, http://www.michiganlegislature.org/law
MINNESOTA
State of Minnesota Board of Nursing , http://www.nursingboard.state.mn.us
Minnesota Office of the Revisor of Statutes, http://www.revisor.leg.state.mn.us
| Table F-1, continued Professional Practice Index Scoring Criteria for Certified Nurse Midwives in 2000 New Index for MS, MO, MT, NE, NV, and NH | |||||||||||||||
| Scoring Category | Points |
Optimal Score |
fn |
State |
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
MS |
MO |
MT |
NE |
NV |
NH |
||||||||||
Legal
Status |
|||||||||||||||
| Title protected | 3 |
3 |
a |
3 |
3 |
3 |
3 |
3 |
a |
a |
|||||
| Type of recognition: | b |
||||||||||||||
|
3 |
3 |
3 |
||||||||||||
|
2 |
2 |
b |
2 |
b |
2 |
b |
2 |
b |
2 |
b |
||||
| Regulated How: | c |
||||||||||||||
|
2 |
2 |
2 |
||||||||||||
|
1 |
1 |
1 |
1 |
1 |
1 |
|||||||||
| Regulated By: | d |
||||||||||||||
|
3 |
3 |
|||||||||||||
|
2 |
||||||||||||||
|
1 |
||||||||||||||
|
1 |
1 |
d |
||||||||||||
|
0 |
0 |
d |
0 |
d |
0 |
d |
0 |
d |
0 |
d |
||||
| Scope Defined: | e |
||||||||||||||
|
3 |
3 |
3 |
3 |
3 |
||||||||||
|
2 |
2 |
e |
2 |
e |
||||||||||
|
1 |
||||||||||||||
|
0 |
0 |
e |
||||||||||||
| Gynecological care in SOP | 1 |
1 |
f |
1 |
1 |
1 |
|||||||||
| Masters degree required | 0 |
g |
0 |
0 |
g |
0 |
g |
0 |
g |
||||||
| National Certification | 1 |
1 |
h |
1 |
1 |
1 |
1 |
1 |
1 |
||||||
| Autonomous practice possible | 5 |
5 |
I |
5 |
5 |
||||||||||
| Relationships with Physicians: | j |
||||||||||||||
|
3 |
3 |
3 |
j |
3 |
j |
|||||||||
|
2 |
2 |
j |
2 |
j |
2 |
j |
2 |
|||||||
|
1 |
||||||||||||||
| Temporary Permit, or not necessary | 1 |
1 |
k |
1 |
1 |
1 |
1 |
1 |
k |
1 |
|||||
| Inactive or Retired Status Available | 1 |
1 |
l |
1 |
1 |
||||||||||
| Practice Agreements: | m |
||||||||||||||
|
3 |
3 |
3 |
m |
3 |
||||||||||
|
2 |
2 |
|||||||||||||
|
1 |
1 |
1 |
m |
1 |
||||||||||
| Practice permissible for lay or direct entry midwives | 1 |
1 |
n |
1 |
n |
1 |
n |
1 |
n |
1 |
n |
||||
| Review of Records by Physician: | o |
||||||||||||||
|
2 |
2 |
2 |
o |
2 |
o |
2 |
o |
|||||||
|
1 |
1 |
o |
1 |
o |
||||||||||
|
0 |
0 |
o |
||||||||||||
| Hospital Privileges in legislation | 1 |
1 |
p |
||||||||||||
| CNMs can sign birth certificates | 1 |
1 |
q |
1 |
1 |
1 |
1 |
q |
1 |
1 |
|||||
| Can refer directly for other health services | 1 |
1 |
r |
1 |
1 |
1 |
1 |
1 |
1 |
||||||
| Subtotals Legal | 35 |
16 |
19 |
27 |
20 |
17 |
26 |
||||||||
Reimbursement |
s |
||||||||||||||
| Medicare | 5 |
5 |
t |
5 |
5 |
5 |
5 |
5 |
5 |
||||||
| Medicaid % x 10 | 0-10 |
10 |
u |
9 |
10 |
8 |
10 |
8.5 |
t |
10 |
|||||
| Language that permits reimb by 3rd party/HMO | 15 |
15 |
v |
15 |
u |
15 |
u |
15 |
u |
15 |
15 |
||||
| Any "direct access" legislation for women | 5 |
5 |
|||||||||||||
| Subtotals Reimbursement | 35 |
29 |
30 |
28</ | |||||||||||