OHIO LEGISLATIVE SERVICE COMMISSION
Office of Research Legislative Budget
www.lsc.ohio.gov and Drafting Office
H.B. 221 Bill Analysis
134th General Assembly
Click here for H.B. 221’s Fiscal Note
Version: As Introduced
Primary Sponsor: Reps. Brinkman and Gross
Effective Date:
Elizabeth Molnar, Attorney
SUMMARY
Grants an advanced practice registered nurse (APRN) who is a certified nurse
practitioner, clinical nurse specialist, or certified nurse-midwife the option to practice
without a standard care arrangement and collaborating practitioner if the APRN has
practiced in a clinical setting for the longer of 2,000 hours or 12 months.
Permits an APRN’s collaborating practitioner to be not only a physician or podiatrist as
under current law, but also an APRN who is not practicing with another collaborator.
Makes conforming changes to the laws governing APRNs and other health professionals,
including the law regarding youth athletics and concussions.
Eliminates the express prohibition against a certified nurse-midwife treating an
abnormal condition, but otherwise maintains the current law list of activities the nurse-
midwife may not perform.
Names the bill the “Better Access, Better Care Act.”
DETAILED ANALYSIS
Advanced practice registered nurse independent practice
H.B. 221 grants an advanced practice registered nurse (APRN) who is a certified nurse
practitioner, clinical nurse specialist, or certified nurse-midwife the option to practice without a
standard care arrangement and collaborating practitioner if the nurse has practiced as an APRN
in a clinical setting for the longer of 2,000 hours or 12 months.
For an APRN who has not yet reached 2,000 hours or 12 months of clinical practice, the
bill maintains the requirement that the nurse enter into a standard care arrangement and
practice with a collaborating practitioner. The bill also permits an APRN who has completed
2,000 hours or 12 months of practice in a clinical setting to continue practicing under a
May 13, 2022
Office of Research and Drafting LSC Legislative Budget Office
standard care arrangement with one or more collaborating practitioners if the nurse so
chooses.1
Documentation of clinical practice
An APRN who seeks to practice without a standard care arrangement and collaborating
practitioner is required by the bill to submit to the Board of Nursing documentation
demonstrating that the nurse did both of the following for the longer of 2,000 hours or
12 months:
Collaborated with one or more collaborating practitioners under a standard care
arrangement;
Practiced in a clinical setting.2
In the case of an APRN who, immediately prior to the bill’s effective date, completed
2,000 hours or 12 months of clinical practice under a standard care arrangement with a
collaborating physician or podiatrist, the bill directs the Board to consider the nurse as having
met the bill’s requirements for independent practice. To be eligible for this consideration, the
APRN must submit to the Board documentation to that effect not later than six months after
the bill’s effective date.3
Licensure by endorsement
In the case of an APRN who obtained a license by endorsement, the bill directs the
Board to accept clinical practice completed in another jurisdiction if the Board determines that
the nurse practiced in that jurisdiction in a manner equivalent to practicing under a standard
care arrangement with a collaborating practitioner.
Rulemaking
The bill requires the Board to adopt rules as necessary to implement its provisions,
including rules specifying the documentation that must be submitted in order to obtain
authority to practice independently. The rules are to be adopted in accordance with the
Administrative Procedure Act.4
Collaborating practitioner
Existing law requires an APRN to practice in collaboration with a physician or podiatrist
with whom the nurse has entered into a standard care arrangement.5 For those APRNs required
or authorized by the bill to practice with a collaborator, the bill permits a collaborating
1 R.C. 4723.43, 4723.431, and 4723.437.
2 R.C. 4723.437.
3 Section 4.
4 R.C. 4723.487(C); R.C. Chapter 119, not in the bill.
5 R.C. 4723.43.
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As Introduced
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practitioner to include not just a physician or podiatrist, but also an APRN who is not practicing
with another collaborator.6
Current law defines “collaboration” to mean that the collaborating physician or
podiatrist is continuously available to communicate with the nurse either in person or by
electronic communication. The bill modifies the definition to accommodate its inclusion of
independently practicing APRNs as collaborating practitioners.7
Standard care arrangements
Under existing law, an APRN must practice in accordance with a standard care
arrangement, a written, formal guide for planning and evaluating a patient’s health care that is
developed by one or more collaborating physicians or podiatrists and the APRN.8 It must
contain certain information, including the following:
Criteria for referral of a patient by the nurse to a collaborating physician or podiatrist;
A process for the nurse to obtain a consultation with a collaborating physician or
podiatrist or another physician or podiatrist;
A plan for coverage in instances of emergency or planned absences of either the nurse
or collaborating physician or podiatrist;
The process for resolving disagreements between the nurse and a collaborating
physician or podiatrist regarding matters of patient management.9
The bill maintains these requirements, but makes the following three changes to the law
governing standard care arrangements. First, it eliminates provisions that allow an APRN to
continue to practice under an arrangement without a collaborating practitioner for a period of
120 days in cases where the collaborator terminates the arrangement or the arrangement
terminates due to the collaborator’s death.10 However, in eliminating such provisions, the bill
does not address APRNs who are required or authorized by the bill to practice with a
collaborator.
Second, it repeals the requirement that the Board of Nursing establish, by rule, criteria
specifying an acceptable travel time between the location where the APRN prescribes and the
collaborator’s location.11
6 R.C. 4723.01(M).
7 R.C. 4723.01.
8 R.C. 4723.01 and 4723.431.
9 R.C. 4723.431.
10 R.C. 4723.431 and 4731.27.
11 R.C. 4723.50.
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As Introduced
Office of Research and Drafting LSC Legislative Budget Office
Third, the bill eliminates provisions that permit an APRN who specializes in psychiatric or
mental health care to enter into an arrangement with a collaborating physician specializing in
pediatrics, primary care, or family practice.12 Current law generally requires the collaborating
physician or podiatrist to practice in a specialty that is the same as or similar to the APRN’s.13
Consequently, under the bill, a psychiatric or mental health APRN could enter into an
arrangement only with a psychiatrist or a psychiatric or mental health APRN who is not
practicing with another collaborator.
Quality assurance standards
Existing law requires the Board of Nursing to adopt rules establishing quality assurance
standards for all APRNs, including certified registered nurse anesthetists.14 The bill instead
directs the Board to set by rule quality assurance standards only for certified nurse
practitioners, clinical nurse specialists, or certified nurse midwives with less than 2,000 hours or
12 months of clinical practice. Accordingly, under the bill, the Board is not required to establish
in rule quality assurance standards for either of the following: APRNs who choose to continue
practicing with collaboration or certified registered nurse anesthetists.
Youth concussions – assessments and clearances
When a student or individual exhibits symptoms consistent with a concussion that is
sustained while playing in or practicing for an athletic event sponsored by a school district or
youth sports organization, current law requires the student or individual to be removed from
play or practice.15 The student or individual cannot return to play or practice until he or she has
been (1) assessed by a physician or another licensed health care professional authorized by the
school district or youth sports organization to conduct such assessments and (2) cleared to
return to play or practice by the physician or other licensed health care professional.
Under current law, a school district or youth sports organization may authorize a
licensed health care professional other than a physician to conduct assessments and grant
clearances only if the professional acts as follows: (1) in consultation with a physician,
(2) pursuant to a physician’s referral, (3) in collaboration with a physician, or (4) under the
physician’s supervision. In the case of a certified nurse practitioner or clinical nurse specialist
who is either practicing without a standard care arrangement or eligible to practice without
one, the bill removes the condition that the nurse act in collaboration with a physician. Under
law unchanged by the bill, a licensed health care professional is an individual, other than a
physician, who is authorized under Ohio law to practice a health care profession.16
12 R.C. 4723.431.
13 R.C. 4723.431.
14 R.C. 4723.07.
15 R.C. 3313.539 and 3707.511.
16 R.C. 3707.511(A)(2).
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As Introduced
Office of Research and Drafting LSC Legislative Budget Office
Other changes
Because the bill grants an APRN who is a certified nurse practitioner, clinical nurse
specialist, or certified nurse-midwife the option to practice without a collaborating practitioner,
it makes various conforming changes to the laws governing nurses and other health
professionals.17
The bill also addresses the law authorizing an APRN to admit a patient to a hospital,
which was in effect at the time of the bill’s introduction. However, because the law regarding
hospital admissions has been repealed as part of H.B. 110, the biennial budget enacted by the
134th General Assembly, an amendment is needed to remove these now obsolete provisions
from the bill.18
The bill repeals another obsolete provision of statutory law, in particular, the law under
which any person holding, as of 1988, a certificate to practice nurse-midwifery issued by the
State Medical Board is deemed to be certified by the Board of Nursing.19 Under law in effect
before 1988, nurse-midwives were regulated by the Medical Board.
The bill also repeals the law regarding the division of Medicaid payments between a
collaborating physician or podiatrist and an APRN.20
Certified nurse-midwives – scope of practice
In the case of a certified nurse-midwife, the bill eliminates the express prohibition
against treating an abnormal condition, while maintaining the current law list of activities a
certified nurse-midwife may not perform. These include delivering breech or face presentation,
performing version, using forceps, or performing any obstetric operation.21
Advanced pharmacology – course of study
At present, an applicant for a license to practice as a certified nurse practitioner, clinical
nurse specialist, or certified nurse-midwife must submit evidence of successfully completing a
course of study in advanced pharmacology that is approved by the Board of Nursing in
17 R.C. 1751.67 (insurance and maternity benefits), 2133.211 (do-not-resuscitate orders and legal
immunity), 3923.233 (insurance reimbursement for services performed by a certified nurse-midwife),
3923.301 (insurance reimbursement for services performed by a certified nurse-midwife), 3923.63
(insurance and maternity benefits), 3923.64 (insurance and maternity benefits), 4723.28 (Board of
Nursing disciplinary actions), 4723.42 (APRN license renewals), 4723.44 (unauthorized practice),
4723.481 (APRN prescriptive authority), 4723.50 (Board rules regarding prescriptive authority), 4731.27
(physicians and standard care arrangements), 4761.17 (respiratory care supervision), and 5164.07
(Medicaid and maternity benefits).
18 R.C. 3727.06.
19 R.C. 4723.45.
20 R.C. 5164.73.
21 R.C. 4723.43.
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As Introduced
Office of Research and Drafting LSC Legislative Budget Office
accordance with standards established by the Board in rule. While the bill maintains the
requirement that an applicant complete the course of study, it eliminates the condition that it
be completed within the five years before the application for licensure is filed.22
Board of Nursing quorum
Under current law, seven Board of Nursing members, including at least four registered
nurses (RNs) and one licensed practical nurse, constitute a quorum. The bill requires that, of the
four RN members needed for a quorum, at least one must be an APRN.23
Electronic notice – change of address and intent to practice
The bill authorizes the holder of a nursing license to give the Board of Nursing electronic
notice when informing the Board of a change of address or the nurse’s intent not to practice in
Ohio.24 Existing law provides only for written notice.
HISTORY
Action Date
Introduced 03-17-21
ANHB0221IN-134/ks
22 R.C. 4723.482.
23 R.C. 4723.02.
24 R.C. 4723.24.
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As Introduced
Statutes affected: As Introduced: 1751.67, 2133.211, 3313.539, 3707.511, 3727.06, 3923.233, 3923.301, 3923.63, 3923.64, 4723.01, 4723.02, 4723.06, 4723.07, 4723.24, 4723.28, 4723.41, 4723.42, 4723.43, 4723.431, 4723.44, 4723.46, 4723.481, 4723.482, 4723.483, 4723.493, 4723.50, 4731.27, 4761.17, 5164.07, 4723.45, 5164.73, 4723.437