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HB 2391

Modifies provisions relating to advanced practice registered nurses

2026 Regular Session Introduced by Bill Irwin and 4 co-sponsors

HB 2391 would allow APRNs to practice independently after 2,000 hours of collaborative practice or endorsement, expand prescriptive authority (with limits), and phase out geographi

Referred: Emerging Issues(H)
#drugsandcontrolledsubstances #healthcareprofessionals #nurses #physicians #professionalregistrationandlicensing
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Bill Summary · HB 2391

Overview

  • Bill: HB 2391
  • Session: 2026
  • Jurisdiction: Missouri

  • Topic: Modifies provisions relating to advanced practice registered nurses (APRNs)

  • Sponsor: Representative Murray (with several co-sponsors)

  • Status: Referred to Emerging Issues (as of May 15, 2026)

  • Fiscal note: Projects a net positive general revenue impact of $34,020 in FY 2027 (one-time IT system modification by DHSS/BNDD); no ongoing state cost anticipated beyond FY 2027.

1) Purpose and Intent

The bill aims to modify the regulatory framework governing advanced practice registered nurses in Missouri. Its core objectives are:
- Remove geographic proximity requirements between APRNs and collaborating physicians.
- Eliminate the mandatory one-month direct-supervision period for APRNs before practicing independently when not in the immediate presence of the collaborating physician.
- Create a pathway for certain APRNs (non-certified registered nurse anesthetists) to practice without a collaborative practice arrangement after meeting specified hours-of-practice criteria.
- Expand APRN prescriptive authority to include a broader scope of medications and treatment under collaborative practice, with limitations on certain controlled substances (notably Schedule II hydrocodone and certain Schedule III–IV–V meds).
- Establish explicit administrative and oversight provisions for collaborative practice arrangements, including documentation, chart reviews, and supervisory requirements.
- Clarify implementation timelines and rulemaking responsibilities, and provide a transitional framework regarding geographic proximity waivers.

2) Key Provisions and Changes

  • 195.070 (Controlled substances prescribing)

    • APRNs with a certificate of controlled-substance prescriptive authority may prescribe Schedule III–V and possibly Schedule II (hydrocodone) under collaborative arrangements; may have restricted Schedule II authority for hospice patients.
    • Restrictions include a 120-hour (5 days) supply cap for Schedule II hydrocodone prescriptions and Schedule III narcotics without refills.
    • Prohibits APRNs from prescribing for personal use; no self or family prescribing.

  • 334.104 (Collaborative practice arrangements)

    • Physicians may enter written collaborative practice agreements with registered nurses, including APRNs.
    • APRNs in collaborative arrangements may administer, dispense, or prescribe drugs within their scope; APN authority to prescribe controlled substances (Schedules II–V) included, with limitations (see above).
    • For hospice: APRNs may be delegated Schedule II (hydrocodone) for hospice patients, under certain conditions.
    • Requires written agreements, protocols, and standing orders detailing collaboration, lists of certifications, and disclosure to patients about rights to see the collaborating physician.
    • Establishes detailed reporting and documentation requirements, including:
    • Names and contact information of collaborating physician and APRN.
    • Geographic coverage and other practice locations.
    • Disclosure statements for patients.
    • Manner of collaboration and how supervision will occur.
    • Descriptions of controlled substance authority and chart-review protocols (minimum chart-review percentages every two weeks; 10% of charts must be reviewed by the physician for non-controlled prescriptions; 20% for controlled-substance prescribing).
    • Provisions for patient care continuity in physician absence or emergencies.
    • Duration and scope of the collaborative agreement.
    • Adds a geographic proximity framework with complex waivers and contingencies (see subsection 8 below). However, the bill also strips enforcement of geographic proximity rules by some boards after a transition period.
    • Requires supervision and periodic chart reviews; presence requirements for acutely/chronically ill patients, with at least biweekly physician oversight.

  • 335.016 (Definitions)

    • Defines APRN scope to include certified clinical nurse specialist, certified nurse midwife, certified nurse practitioner, and certified registered nurse anesthetist (CRNA).
    • Clarifies licensing terms and professional roles.

  • 335.019 (APRN prescriptive authority)

    • Establishes prescriptive authority for APRNs, including the ability to prescribe, dispense, and administer medications (scheduled and nonscheduled) within their practice.
    • Allows non-scheduled samples to be provided to patients at no charge (under definitions of non-scheduled legend drugs).
    • Requires a Board of Nursing grant of a certificate of controlled-substance prescriptive authority if certain qualifications are met (see below).
    1. (New exemptions for eligible APRNs)
    • An APRN who has:
    • Maintained a license in good standing and accumulated 2,000 documented hours in collaborative practice with a physician, or
    • Achieved licensure by endorsement with 2,000 hours of documented practice, may practice without a collaborative practice arrangement.
    • Eligible APRNs are not required to enter or remain in a collaborative arrangement to practice in the state.

  • 7–9. Additional operational provisions

    • CRNAs may provide anesthesia services without a collaborative arrangement if supervised by an immediately available physician, surgeon, or other qualifying provider, but such arrangement may still be pursued if desired.
    • Caps and thresholds for number of APRNs per collaborating physician (no more than six FTE APRNs/physician assistants/assistant physicians per physician, with exceptions for hospital inpatient care or CRNAs under direct supervision).

  • Rulemaking and enforcement

    • The boards of nursing and the healing arts would jointly promulgate rules governing collaborative practice arrangements, including treatment methods and required reviews, and would oversee prescribing authority delegation.
    • Geographic proximity rules would not be enforced after August 28, 2026; previously existing rules would be superseded, and waivers would be handled by the two boards with a 45-day review window (deemed approved if no action taken).

  • Records and disciplinary actions

    • The healing arts board may not take disciplinary action against physicians for health care services delegated to APRNs if requirements are met.
    • Physicians may request removal of disciplinary records related to older collaborative arrangements under certain conditions from previous records.

3) Who or What Would Be Affected

  • Advanced Practice Registered Nurses (APRNs):

    • Could practice without a collaborative arrangement after meeting 2,000 hours of collaborative practice or endorsement-based experience.
    • Expanded prescriptive authority to Schedule II–V drugs in certain contexts (with limits).
    • Subject to new chart review and supervision requirements under collaborative arrangements (unless exempt).

  • Collaborating Physicians:

    • Relationship management with APRNs remains, but geographic proximity restrictions would be removed after transition; some oversight and documentation requirements remain.
    • Responsibility for chart reviews (minimum percentages every two weeks) and ensuring safe delegation of duties.

  • Hospitals and Hospice Providers:

    • Geographical and supervisory requirements are altered; hospice APRNs may have specific authority to prescribe Schedule II hydrocodone within hospice settings.
    • Inpatient and emergency care protocols continue under hospital licensing standards, with potential alignment to new rules.

  • Regulatory Bodies:

    • Missouri Board of Nursing and the State Board of Registration for the Healing Arts to jointly regulate and adopt rules for collaborative practice arrangements.
    • Potential impact on IT systems (BNDD/BNDD database) to accommodate exemptions for APRNs without requiring physician data.

  • Patients and Public:

    • Increased access to APRN-driven care, especially in rural or underserved areas, subject to the safeguards of collaborative practice arrangements and prescribing controls.
    • Clear disclosures regarding patient rights to see the collaborating physician.

4) Procedural and Timeline Considerations

  • Geographic proximity requirements:

    • Provisions would phase out geographic proximity restrictions by August 28, 2026.
    • Rules allowing or waiving proximity would be nullified or deemed unenforceable after the transition.

  • Supervision and chart reviews:

    • Ongoing requirements for physician review of APRN-delivered care (minimum chart review percentages) would be codified in the written collaborative agreements.

  • Hospice and telemedicine:

    • Provisions allow for remote collaboration and telehealth as part of the arrangement, with documentation requirements.

  • Waiver process:

    • Boards would review waiver applications for exceptions to proximity on a case-by-case basis, with a 45-day review period; if no action, waivers are deemed approved.

  • Effective date and implementation:

    • The bill outlines a structured transition from current practice to the new framework, with the August 2026 transition milestone and related regulatory changes.

5) Fiscal Impact

  • General Revenue:

    • One-time cost of $34,020 in FY 2027 for DHSS/ITSD to modify a BNDD database to allow exempt APRNs (not requiring a physician data entry).

  • Ongoing costs/revenues:

    • No ongoing general revenue costs projected; no anticipated impact on other state funds or federal funds.
    • Local government impact: none expected.
    • Small business notes: some medical practices may experience implementation costs.

6) Practical Implications

  • Accessibility: Could improve access to care by enabling more APRNs to practice independently after meeting experience thresholds, particularly in underserved areas.
  • Safety and oversight: Maintains patient safety through structured collaborative practice agreements, chart reviews, and supervisory requirements; imposes explicit caps and supervision standards for controlled substances.
  • Professional autonomy: Expands APRN scope and reduces mandatory proximity constraints, balanced by reporting and governance mechanisms.

If you’d like, I can provide a side-by-side comparison of current law vs. HB 2391 excerpts, or a one-page briefing for stakeholders (providers, patients, and policymakers).

Compiled from official sources — confirm details with the bill’s official record.

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