Important Info for NPs: Waivers, Regulatory, and Policies Related to COVID-19
Thursday, March 19, 2020
Posted by: Erin Cusack
APRN Practice FAQ, COVID-19 Disaster
For guidance on APRN scope of practice and delegation requirements in the context of the COVID-19 declared disaster, please see an FAQ from the BON here.
Out-of-State RN/APRN Licensure
In accordance with Section 418.171 of the Texas Government Code, any out-of-state nurse, including APRNs, may practice in Texas for the purpose of rendering aid, provided the nurse holds a current license in good standing in their home state. Therefore, any out-of-state nurse with a license in good standing* is not required to hold a Texas license in order to practice nursing in a disaster relief effort operation setting. Additionally, Texas is a member state of the Nurse Licensure Compact. As such, any LVN or RN holding an active compact license already holds a privilege to practice in Texas. See BON's announcement here.
Waiving Written Delegation Requirements
Pursuant to Texas Medical Board Rule 172.21, APRNs practicing in the context of a disaster declaration are not required to have a written prescriptive authority agreement (e.g. Prescriptive Authority Agreement or Facility-based protocol) for practice in a disaster relief effort operation setting. Although the written delegation agreement is waived, APRNs are still required by the rule to have some form of delegating physician, and specifically, a delegating physician who: 1) is licensed in Texas; and 2) practiced prior to the date of the emergency. However, the arrangement with this delegating physician is informal and can be made with any physician who meets the two criteria above. See BON's announcement here.
Waiver for Allow Retired/Inactive APRNs
Governor Greg Abbott has waived certain regulations allowing for an expedited licensing reactivation process for Advanced Practice Registered Nurses (APRN) in Texas. Under these waivers, an APRN with a license that has been inactive for more than two years, but less than four years, will not have to pay a reactivation fee, complete continuing education credits, or complete the current practice requirements. For APRNs with a license that has been inactive for more than four years, the reactivation fee and continuing education requirements will be waived. See details on the BON website here.
Regulations to Allow LVNs, RNs, & APRNs a 6-month Grace Period for Licensure Renewal
The Office of the Governor granted a waiver of Texas Occupations Code 301.301(c), (c-1), and (f), 22 Tex. Admin. Code 223.1(a)(5), 22 Tex. Admin. Code 217.6(a), and22 Tex. Admin. Code 216.8(d)(1). As a result of these waived regulations, beginning on March, 23, 2020, Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), and Advanced Practice Registered Nurses (APRNs) will have a grace period until September 30, 2020 to renew the license without any late fees incurred or need to submit evidence of continuing education to meet continuing competency requirements for renewal. This waiver also applies to renewals of prescriptive authority.
Additionally, any nurse whose license expires between March 23 and September 30, 2020 may continue to practice until September 30, 2020. For more information please visit the Board’s COVID-19 Licensing Page here: https://www.bon.texas.gov/COVID-19Licensing.asp.
Continuing Competency Requirements for Licensure Renewal During COVID-19
The Board of Nursing will consider extenuating circumstances on a case-by-case basis regarding the completion of continuing competency requirements for licensure renewal during the COVID-19 Disaster Declaration Period. For more information about continuing competency requirements, please visit the Board’s Frequently Asked Questions for Continuing Education & Competency. If a licensee needs to request a waiver of continuing competency requirements, please email a request to the following address: Mark.Majek@bon.texas.gov. In the request, include your name, dated of birth and license number. Once received, the BON will allow an online renewal.
Changes to the APRN Application/Licensure Process
To ensure timely processing of APRN applications, the BON will now allow exceptions to the submission requirements of the Verification of Completion (Part II) form and graduate level transcripts. The BON will now accept electronic versions of the Part II form. As a courtesy, the BON staff has reached out to various APRN programs throughout the state to provide an interactive PDF of the Verification of Completion form. The BON will also accept electronic transcripts. See more information on these application requirement accommodations and waivers here.
Temporary Licensure Permits for Nursing Students, Retired and Inactive Nurses
Governor Greg Abbott has waived several regulations to help meet Texas’ growing need for nurses as the state responds to the COVID-19 virus. Please note: at this time, these specific waivers apply to RNs only, and not APRNs. For more details, see the BON website here.
The Governor’s actions will expand Texas’ active nursing workforce by doing the following:
- Allowing temporary permit extensions to practice for graduate nurses and graduate vocational nurses who have yet to take the licensing exam.
- Allowing students in their final year of nursing school to meet their clinical objectives by exceeding the 50% limit on simulated experiences.
- Allowing nurses with inactive licenses or retired nurses to reactivate their licenses.
Telehealth/Telemedicine, State Exceptions and Waivers
Please see an FAQ on the use of telehealth/telemedicine during the COVID-19 disaster here.
- Allowing Phone Consults. Telemedicine, including the use of telephone only, may be used to establish a physician-patient relationship (see Texas Medical Board announcement here). This expanded use of telemedicine may be used for diagnosis, treatment, ordering of tests, and prescribing for all conditions. The standard of care must be met in all instances.
- Reimbursement for State-Regulated Health Insurance Plans: The Texas Department of Insurance filed an emergency rule requiring insurers to pay the same amount for telemedicine services, including covered mental health services, as they do for in-person services. Please see an FAQ on the emergency rule here. The rule applies to in-network services for state-regulated health plans. State-regulated plans cover about 15% of the Texas market, including plans purchased through Healthcare.gov. The insurance cards for state-regulated plans have either “DOI” (for department of insurance) or “TDI” (Texas Department of Insurance) printed on them.
Use of Telemedicine to Treat Chronic Pain:
The Office of the Governor granted a waiver of the Texas Board of Nursing Rule 217.24(e)(1) that limits the APRN's ability to issue prescriptions for controlled substances for chronic pain via telemedicine. A waiver from this prohibition for refilling controlled substances for chronic pain patients evaluated via telemedicine was granted and is in effect until April 10, 2020. The waiver is only applicable to those APRNs whose delegating physicians agree to permit them to issue refills for these patients via telemedicine. The standard of care must be met, the APRN must exercise appropriate professional judgement, and all documentation requirements must be met. For APRNs, the waiver is limited to refills of controlled substances in schedules III through V. The waiver does not expand the APRN's authority to order or prescribe schedule II drugs
The Centers for Medicare and Medicaid Services, Telehealth Changes
The Centers for Medicare and Medicaid Services (CMS) have announced significant short term changes to Medicare telehealth policy. They will reimburse for telehealth visits to Medicare patients starting March 6, regardless of location, to patients in facilities or in homes. Please see an FAQ on the Medicare telehealth changes here.
Medicare, Codes for Telehealth/Telemedicine Reimbursement
CMS released an additional list of Medicare codes that are eligible for telemedicine and telehealth payment. Please read the announcement here, which also contains a link to a spreadsheet with all of the codes.
Controlled Substances/Ryan Haight and Telemedicine
The Drug Enforcement Administration (DEA) has announced that telemedicine can now be used under the conditions outlined in the Controlled Substances Act under the public health emergency telemedicine exception to Ryan Haight. DEA-registered prescribers may issue prescriptions for controlled substances via telemedicine without a prior in-person evaluation if the prescription is for a legitimate medical purpose, real-time two-way audio-video is used, and the practitioner is acting in accordance with state law. See more information on their coronavirus page under "telemedicine."
The Department of Health and Human Services Office for Civil Rights (HHS OCR) has issued a notification of Enforcement Discretion indicating that OCR will not enforce certain HIPAA regulations during this emergency in order to ease access to telehealth services. Please review their release here.
Medicare, Expedited Provider Enrollment
For up-to-date info on expedited provider enrollment in Medicare, please see a newly released FAQ from CMS here.