Multi-State Licensure and Nurse Licensure Compact

Click Here For Printable Version of Multi-State Licensure in Case Management Position Statement

POSITION STATEMENT:
MULTISTATE NURSING LICENSURE IN CASE MANAGEMENT

Revised: 11/04/2005 | Updated: 07/21/2009 | Revised October 2010

Purpose:

CMSA is frequently asked by its members how they should approach licensure to comply with
state nurse licensure laws when conducting case management outside their state of
residence. The purpose of this statement is to clarify CMSA’s position as it applies to
the issue of multistate nurse licensure and the Nurse Licensure Compact (NLC).

Summary:

Nurse licensure is regulated on a state-by-state basis with State Boards of Nursing requiring
nurse case managers to be licensed in the states where patients reside when case
manager-patient telephonic or on-site interactions occur. In general, nurses are required to be
licensed in the state in which they are practicing and in which their patients reside. The 1997
Policy Statement by the National Council of State Boards of Nursing (NCSBN) defines
“telenursing” as the practice of nursing and asserts that it is regulated by state boards of
nursing.
This statement is limited specifically to nursing licensure as there are unique qualifications
associated specifically to nursing. Other professional specialties perform case management
services and will be guided by their specific regulatory requirements.
This statement will address three related questions:

1) Which activities performed by licensed nurse case managers are defined as the
practice of nursing and, thus, fall under regulatory control?
2) Do CMSA Standards of Practice for Case Management, Revised, 2010 address the
issue of multistate nurse case manager licensure?
3) What action can case managers take to support reasonable licensure requirements
to practice in today’s telephonic care world?

Facts:

A license is a legal document that permits the holder to offer special skills and knowledge to the
public in a particular jurisdiction, where such practice would otherwise be unlawful. To offer
nurse case management services, the case manager must have proper state licensure,
recognized endorsement, or statutory waiver (typically limited to those working with the
Veterans Administration or military service). Without such legal permission, a professional may
not be adhering to state of residence licensure requirements or the licensure requirements
of the state in which the patient to whom they are providing services resides.
All registered nursing graduates must take the US qualifying exam, National Council Licensure
Exam-RN (NCLEX) in order to obtain licensure. Many states “endorse” licenses from other
states. For example, a nurse licensed in one state can submit paperwork and receive a license

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© CMSA, Little Rock, AR 2009 All Rights Reserved.

in another state without re-taking the NCLEX. The NCLEX is currently also available to nurses
outside the US. Therefore, nurses educated in foreign countries can demonstrate equivalency
by passing of the NCLEX exam.

The Issue:

When nurses provide case management services telephonically or on site without a license to
practice in the state of the patient’s residence, he/she may be violating the law. The violation is
punishable variably in states with some penalties of up to $1,000, permanent loss of licensure,
and up to 1 year in jail. Of additional concern to nurse case managers is the fact that no
professional liability insurance carrier will cover an improperly licensed or non-licensed nurse in
the event of actions which are deemed damaging to the patient. Therefore, case managers
would be personally responsible for payment of damages if there are damages assessed.

As one might imagine, licensure in all non-Compact states and the District of Columbia would
be financially and administratively burdensome to an individual or organization. With pressure to
demonstrate cost containment, current practice for some large organizations is to self insure the
risk of incurring a damage assessment and to direct nurses to proceed whether licensed
properly or not. This practice leaves the nurse vulnerable to being named in a lawsuit for
damages without recourse to professional liability insurance.

Goal:

The goal of the CMSA position statement is not to create an administrative nightmare or to
add additional costs to organizations or the US healthcare system. The purpose of the
CMSA position statement is to alert and encourage individuals and organizations to
aggressively urge non-Compact State Boards of Nursing to join the Nurse Licensure Compact,
and to advance legislation mandating recognition of nurse licensure across state lines just as
drivers licenses are recognized.

Nurse Licensure Compact States as of June 2010

Through the National Council of State Boards of Nursing, 24 states have entered into a compact
to recognize other states’ licensing of nurses. The remaining 26 states and the District of
Columbia do not currently participate in the compact. A listing of participating states (as of June
2010) is included below. The compact is tied to the nurse’s state of residence, not the state of
practice or the patient’s location. Therefore, if a nurse resides in and is licensed in a state that
participates in the Nurse Licensure Compact, the nurse’s licensure will be recognized by other
states participating in the Compact. The nurse should check with his/her State Board of Nursing
for appropriate procedures and guidelines for licensure.

Nurse Licensure Compact Implementation (Excerpt from www.ncsbn.org)
The following tables and map indicate which states have enacted the RN and LPN/VN Nurse
Licensure Compact.
Last Updated: [June 2010]

Nurse Licensure Compact States

Arizona 7/1/2002
Arkansas 7/1/2000
Colorado 10/1/2007
Delaware 7/1/2000

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© CMSA, Little Rock, AR 2009 All Rights Reserved.

Idaho 7/1/2001
Iowa 7/1/2000
Kentucky 6/1/2007
Maine 7/1/2001
Maryland 7/1/1999
Mississippi 7/1/2001
Missouri 6/1/2010
Nebraska 1/1/2001
New Hampshire 1/1/2006
New Mexico 1/1/2004
North Carolina 7/1/2000
North Dakota 1/1/2004
Rhode Island 7/1/2008
South Carolina 2/1/2006
South Dakota 1/1/2001
Tennessee 7/1/2003
Texas 1/1/2000
Utah 1/1/2000
Virginia 1/1/2005
Wisconsin 1/1/2000

If you are seeking Compact licensure, please contact your state board of nursing for primary
state of residence requirements. For state board of nursing contact information, go to
www.ncsbn.org.
States Pending NLC Implementation (these dates could be subject to change)
PENDING COMPACT STATES STATUS: Currently no states are pending NLC implementation

Nurse Licensure Compact Map
(Conclusion of Excerpt)

Which activities performed by licensed nurse case managers are defined as the practice
of nursing and, thus fall under regulatory control?

The practice of nursing is defined in state law, and therefore varies by state. The 1997 NCSBN
policy statement noted that some common functions of nursing practice include interacting with
an individual client, receiving individual health-status data, initiating and transmitting therapeutic
interventions and regimens, and monitoring and reporting client response and nursing care
outcomes.

In 2004 and 2005, CMSA conducted a survey of all 50 State Boards of Nursing and the District
of Columbia Board of Nursing to determine if case management as defined by CMSA’s
Standards of Practice is seen as the practice of nursing. The survey results indicated that in all
50 states and D.C., case management is considered the practice of nursing when practiced by
a RN.

The NCSBN policy statement recognizes that states consider telenursing conducted by health
call centers, telephonic disease management and case management to be the practice of
nursing. Utilization management has made an active argument that it falls under the category of
administrative oversight, and is not nursing practice. However, previously silo’d UM, CM, and

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© CMSA, Little Rock, AR 2009 All Rights Reserved.

DM services are now being integrated which reopens the issue of licensure.

Nurse case managers are governed by laws regulating nursing practice in the patient’s state of
residence. In the instance of nurse case managers working with patients in several states,
licensure is necessary in each state. Should a patient reside in a Compact state AND the nurse
case manager reside in and be licensed in a Compact state, the nursing licensure would be
mutually recognized. Should a patient reside in a non-Compact state OR should the nurse case
manager reside in and be licensed in a non-Compact state, the nurse case manager would
need to comply with state law by obtaining nursing licensure in the state where the patient
resides.

In August, 2005, the Case Management Leadership Coalition recognized the Nurse Licensure
Compact and recommended to participating organizations that they aggressively support the
Compact.

The Compact is currently supported and regulated by NCSBN and the Nurse Licensure
Compact Administrators. For further information, go to https://www.ncsbn.org.
NCL supporting organizations include:

  • Association of Camp Nurses (ACN)

  • American Nephrology Nurses Association (ANNA)

  • American Telemedicine Association's nursing special interest group

  • American Telemedicine Association (ATA)

  • The American Association of Occupational Health Nurses (AAOHN)

  • The American Organization of Nurse Executives (AONE)

  • Case Management Leadership Coalition (CMLC)

  • Case Management Society of America (CMSA)

    • Case Management Society of New England

    • Case Management Society of Atlanta

    • Case Management Society of St. Louis

    • Case Management Society of Chicago

    • Disease Management Association of America

  • Emergency Nurses Association (ENA)

  • Many state nursing associations have expressed support for the NLC, and have worked to help adopt it (i.e., Arkansas Nurses Association, Idaho Nurses Association, Texas Nurses Association).

  • Several state hospital associations have supported the NLC and also have worked to adopt it in their states

  • U.S. Department of Commerce, which supported the NLC in speech to the American Telemedicine Association in 2003 and formally recognized NLC in its report to Congress titled "Innovation, Demand and Investment in Telehealth" (February 2004)

  • The Center for Telehealth and E-Health Law

  • The Telehealth Leadership Council

  • Citizens Advocacy Center (CAC)

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© CMSA, Little Rock, AR 2009 All Rights Reserved.

CMSA Position:

CMSA’s Position is clearly stated by CMSA’s Standards of Practice for Case Management,
Revised 2010© which state that:
“The case manager should adhere to applicable local, state, and federal laws. as well as
employer policies, governing all aspects of case management practice…….It is the
responsibility of the case manager to work within the scope of his/her license”.

1. CMSA encourages case managers and case manager employers to work aggressively with
State Boards of Nursing to encourage entry and compliance with the Nurse Licensure Compact
so that multi-state nursing licensure might continue appropriately and cost
effectively.
2. CMSA encourages the enactment of legislation mandating the
recognition of nurse licensure in all states, territories and the District of Columbia.
3. CMSA has added its name to the growing list of those organizations supporting and
endorsing the Nurse Licensure Compact.

RESOURCES:
Case Management Leadership Coalition meeting, August, 2005
Code of Professional Conduct for Case Managers with Disciplinary Rules, Procedures,
and Penalties, 1996 revised, June, 2001
2001 Report to Congress on Telemedicine, last updated May 16, 2002 Office for the
advancement of Telehealth, 5600 Fishers Lane, Room 11A-55, Rockville, MD 20857 Phone
(301)443-0447

AAOHN Multistate Practice Advisory available for a fee from American Association of
Occupational Health Nursing, 2920 Brandywine Road, Suite 100, Atlanta GA 30341

Center for Telemedicine Law – issued its findings and recommendations on interstate
licensure on February 12, 1997. Their detailed report can be obtained by contacting the Center
at (202) 775-5722

CMSA’s Standards of Practice for Case Management, Revised 2010©

Available at www.cmsa.org or from CMSA, 6301 Ranch Drive, Little Rock, AR 72223-4623

Interstate Practice in the Age of Informatics and E-Technology,

Deborah DiBenedetto, AAOHN Journal, Sept, 2003 Vol. 51, No. 9, pp. 367-369

National Council of State Boards of Nursing http://www.ncsbn.org
Case Management Society of America
6301 Ranch Drive
Little Rock, Arkansas 72223-4623

www.cmsa.org

501-225-2229
Revised by the CMSA Public Policy Committee, October 2010

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© CMSA, Little Rock, AR 2009 All Rights Reserved.