"Advanced registered nursing practice" is defined as the performance of the acts of a registered nurse and the performance of an expanded role in providing health care services recognized by the medical and nursing professions. Advanced registered nurse practitioners (ARNPs) are authorized to perform all activities registered nurses perform, perform specialized and advanced levels of nursing, and prescribe legend drugs and certain controlled substances. An ARNP's scope of practice is defined by the Washington State Board of Nursing and includes: examining and diagnosing patients; admitting, managing, and discharging patients to and from health care facilities; ordering, collecting, performing, and interpreting diagnostic tests; managing health care by identifying, developing, implementing, and evaluating a plan of care and treatment for patients; prescribing therapies and medical equipment; prescribing medications when granted prescriptive authority; and referring patients to other health care practitioners, services, or facilities. In 2024 the title for ARNPs was changed to advanced practice registered nurses (APRNs), but the title change is not in effect until June 30, 2027.
A physician assistant (PA) is a person who is licensed by the Washington Medical Commission to practice medicine under the terms of one or more collaboration agreements. A collaboration agreement is a written agreement that describes the manner in which a PA is supervised by or collaborates with at least one physician, which must be signed by the PA and one or more physicians or the PA's employer. Physician assistants may practice in any area of medicine or surgery as long as the practice is not beyond the scope of expertise and clinical practice of the participating physician or physicians within the department or specialty areas in which the physician assistant practices. The participating physician or the PA's employer and the PA must determine which procedures may be performed and the degree of autonomy under which the procedure is performed.
For private health plans issued or renewed on or after January 1, 2026, a health carrier may not reimburse a contracted APRN or PA in an amount less than the amount that the health carrier would reimburse for the same service if provided by a contracted physician or osteopathic physician in the same service area when an APRN or PA is providing:
A carrier may not pay a contracted physician more by making nonclaims-based payments to physicians that are not also made available to APRNs or PAs for the same service in the same service area. A health carrier may not reduce the reimbursement amount paid to physicians and osteopathic physicians to comply with this requirement.
The Office of the Insurance Commissioner (OIC) must collect data from on the implementation of this requirement beginning January 1, 2026, from health carriers or from other available sources including the all-payer claims database. By July 1, 2027, the OIC must report to the relevant committees of the Legislature on the number of insurers that have changed their reimbursement policy because of these requirements, the number of APRNs or PAs whose reimbursement increased, the number of physicians whose reimbursement decreased, and the cost to insurers to implement these requirements. These requirements do not apply to APRNs or PAs who are employees of a health maintenance organization.
"Service area" means the geographic location area or areas where a specific product is issued and rated, accepts members and enrollees, and covers provided services. A service area must be defined by the county or counties included, unless the commissioner permits limitation of a service area by zip code in rule or an applicable payment methodology uses an alternative service area designation.
(In support) Advanced practice registered nurses provide primary and specialty care across Washington and have done so for over 50 years. The Legislature first required reimbursement for APRNs in the 1980s but did not set rates. Beginning in 2013 most health plans reduced the reimbursement rates for APRNs to 85 percent of what physicians were paid, despite lots of evidence showing APRNs practice safely. This bill restores reimbursement to prior levels.
Health plans do not reimburse premiums by 15 percent to the individuals who see APRNs and PAs. These providers have to care for 100 percent of the person, not 85 percent. These reductions make it difficult for practices to remain financially solvent. All providers have the same administrative costs, and the same costs for rent, supplies, and wages, and the patients pay the same. Quality care and services should be reimbursed the same. These types of providers have the same or better outcomes as physicians and provide more care in rural areas. Health care clinics operated by APRNs provide patient-centered, community care and keep communities strong. This bill increases access to necessary health services. Medicaid also pays APRNs and PAs the same as physicians.
Insurance reimbursement discrimination is against the law, but health carriers continue to do it. Federal law made this discrimination illegal but it is up to states to enforce the law.
(Opposed) Individual market consumers have experienced at least a 10 percent increase per year and so the overall impact on premiums must be considered. Previous versions of the bill applied to plans offered to public and school employees and previous fiscal notes were $23 million. If this bill is passed, the report should include the impact on workforce to see if the policy really accomplished what was intended.
Due to physicians' training and education, they are able to provide more advanced services. These professionals have chosen a different profession than a physician, which comes with different education levels and costs. Physicians undergo significantly more training in medical school and residency, which comes with a much higher cost. If this bill passes there is no financial incentive to pursue the additional training to become a physician. Physicians must go through more exams, boards, and have greater malpractice liability.
Small employers struggle to afford group health plans for their employees and the number of small employers offering health insurance has dropped since 2020. This bill will unnecessarily increase costs and make a bad situation worse. If this bill was narrowed to focus on underserved areas and specific specialties like primary care or mental health and applied more equally it might bear more consideration.
(Other) Labor and Industries (L&I) completed a three-year pilot project that allowed APRNs to fill the role of attending provider in the Worker's Compensation System. When comparing APRNs to physicians, the pilot found that they did not differ on cost or disability measures after one year and that APRNs provided more care in rural areas. Several years later, L&I decided to make payment for APRNs the same as physicians, and since then the number of visits to APRNs has increased.
(In support) Representative Tarra Simmons, prime sponsor; Justin Gill, President, Washington State Nurses Association; Kelli Camp, Washington Association of Nurse Anesthesiology; Dee Bender, Washington Association of Nurse Anesthesiology; Louise Kaplan, PhD, ARNP, FNP-BC, ARNPs United of Washington State (AUWS); Eileen Ravella, PAC, Washington Academy of Physician Assistants (WAPA); Ashley Fedan, CRNA, LCDR, ARNPs United of Washington State (AUWS); Justin Gill, DNP, APRN, RN, Washington State Nurses Association (WSNA); Maddy Wiley, MSN, ARNP, FAANP, ARNPs United of Washington State (AUWS); and MaryAnne Murray, DNP, EdD, PHMNP, Balance Beams Wellness, PLLC.