CRNA Full Practice Authority States (2026 Update)

Introduction

Certified Registered Nurse Anesthetists (CRNAs) are advanced practice nurses trained to administer anesthesia. In states with full practice authority, CRNAs may practice and prescribe without mandated physician supervision. Federal "opt-out" provisions also allow CRNAs in eligible states to administer anesthesia for Medicare patients without a physician present. As of 2026, 23 states plus Washington, DC allow CRNAs to practice without direct physician oversight. In fact, 25 states, DC, and Guam have formally "opted out" of the federal supervision requirement.

State-by-State Full Practice Authority Table

The table below summarizes each full-practice state's CRNA scope (physician supervision required, prescriptive authority, special provisions).

Table Notes: "No" in the Supervision column means CRNAs practice independently (no mandatory on-site physician). "Prescriptive Authority: Yes" indicates CRNAs may order and administer anesthesia-related medications as APRNs (most states allow at least this). Some states (e.g. Kentucky) still require a collab agreement for non-anesthesia prescriptions. Special provisions (e.g. rural-only opt-outs in Utah/Wyoming) are noted.

State Scope of Practice Details

Iowa

CRNAs are licensed as Advanced Registered Nurse Practitioners who "practice independently" and "have authority to prescribe medications used before, during, and after anesthesia." Iowa opted out of federal supervision in 2001, and today CRNAs work autonomously, collaborating only with surgeons or other providers as needed.

Kentucky

In 2018–2020 Kentucky became the last "opt-out" state. The CRNA scope law explicitly removed any supervision requirement; CRNAs "may administer anesthesia care under their education, licensure, and certification" without physician presence. Kentucky APRNs (including CRNAs) have full prescriptive authority for anesthesia-related drugs. Under KBN guidance, a CRNA need not enter a collaborative agreement to prescribe drugs when practicing anesthesia, but would require a collab agreement (CAPA) to prescribe outside perioperative care.

Massachusetts

Effective June 2024, Governor Healey signed an opt-out letter for CRNAs. This removes the Medicare mandate for physician supervision. Massachusetts law did not previously require physician direction for CRNAs under state statute, so this opt-out confirms CRNAs' independent status. Massachusetts CRNAs have had de facto autonomy in practice; the opt-out simply codifies it for federal purposes.

Delaware

In June 2023, Delaware's governor formally opted out of the federal physician-supervision requirement. State law already recognized CRNAs as independent providers, so Delaware CRNAs today can furnish anesthesia without on-site anesthesiologists. CRNAs in Delaware, like other APRNs, can write orders and manage medications as permitted by their training.

West Virginia

Prior to 2025, West Virginia required "supervision" or "collaboration" by a physician for CRNAs. On April 30, 2025, WV passed SB 810 to remove "in the presence and under the supervision" language, replacing it with a team "cooperation" model. Under SB 810, CRNAs may "administer anesthesia in cooperation with a physician." This means CRNAs work with physicians (or dentists/podiatrists) in a team, but no longer need direct physical supervision. WV CRNAs retain full authority to perform anesthesia services and manage anesthesia medications under this cooperative practice framework.

Kansas

Kansas historically allowed CRNAs to practice in nurse-led teams, and it opted out of Medicare supervision. In 2025, Kansas enacted Senate Bill 67 to explicitly add prescriptive authority for CRNAs. K.S.A. §65‑1158 was amended to allow CRNAs to prescribe any drugs "consistent with the education, training, and qualifications of a nurse anesthetist." Importantly, Kansas CRNAs have long practiced without a required physician present (either via opt-out or earlier law), and SB 67 simply affirms their autonomy and adds prescribing of anesthesia medications and durable medical equipment. A DEA registration is required for controlled substances, as for all prescribers.

Michigan

Michigan eliminated its supervision requirement in 2021–2022. An executive order in 2020 and a law (HB 4359, July 2021) permanently removed all CRNA supervision in state law. CRNAs in Michigan now have full independent practice. Under Michigan law, CRNA scope includes developing anesthesia care plans, performing assessments, and "selection, ordering, or prescribing and the administration of anesthesia and analgesic agents", including prescription drugs and controlled substances, within the perioperative period. Thus Michigan CRNAs can prescribe and administer anesthesia medications during the case without a physician, though like most states they may not prescribe these drugs for patient use outside the perioperative encounter.

Alabama

In April 2022 Alabama enacted Act 2022-276. This law removed a previous requirement that CRNAs practice only "in coordination with an anesthesiologist." Instead, CRNAs may now provide anesthesia "in coordination with a physician, podiatrist or dentist." The law also explicitly permits CRNAs to order medications and tests related to anesthesia care. In practice, Alabama CRNAs can manage anesthesia cases under a physician's broad coordination, but no longer need the physician in the room at all times. (Full autonomy, i.e. no required physician collaboration at all, has not been granted.)

Oklahoma

Oklahoma removed supervision in 2019. SB 1 (2019) amended the Nurse Practice Act so that CRNAs "may administer anesthesia in collaboration with a physician" instead of "under the supervision of a physician." This legislative change allowed Oklahoma CRNAs to work entirely independently as long as they collaborate with (not supervised by) a physician. CRNAs in OK also have prescriptive authority for anesthesia drugs.

Oregon

Oregon law long recognized CRNAs as independent APRNs. In 2021, Oregon repealed outdated statutes and reaffirmed the state Board of Nursing's authority to set CRNA scope. No state requirement for physician supervision exists. Oregon CRNAs may furnish anesthesia and related medications in any setting, and they have full APRN prescribing rights within the anesthesia context.

Colorado

Colorado's governor opted out of the CMS requirement in 2010 (for rural and CAHs) and the state has no physician-supervision law for CRNAs. Colorado courts (2012) upheld CRNA independence as consistent with state law. CRNAs "are now allowed to independently administer anesthesia" without supervision. In practice, Colorado CRNAs operate autonomously in all settings.

California

California has never required physician supervision of CRNAs. In fact, CRNA independence was validated by a 2012 appellate court decision. AB 876 (signed October 2025) later codified this status, reaffirming that CRNAs have independent authority. California CRNAs have full prescriptive authority as APRNs. (They are also required to hold a dentist permit to practice anesthesia in dental offices, per state law.)

Other Full-Practice States

Alaska, Idaho, Minnesota, Nebraska, North Dakota, South Dakota, Vermont, Washington, Wisconsin, New Hampshire, New Mexico, Montana, Arkansas, and Maine have no statutory physician supervision requirement for CRNAs. In each of these states, CRNAs are licensed as independent APRNs. For example, Alaska's board explicitly treats APRNs as licensed independent practitioners. Maine long ago exempted CRNAs from supervision (Maine's governor opted out of CMS in 1976). Arkansas fully opted out in 2022, making all CRNA practice independent.

Partial Opt-Out States: Wyoming and Utah

• Wyoming's 2023 law applies only to small hospitals (≤25 beds)
• Utah's 2022 opt-out applies in rural/Critical Access settings

In those states, CRNAs in rural hospitals can practice without physicians, but larger facilities may still have state-imposed collaboration rules.

Legislative Changes (2022–2025)

Recent years have seen key expansions of CRNA authority:

In general, physician supervision laws are being repealed; by 2025, 44 state legislatures had eliminated statutory supervision requirements.

States to Watch

Several states are actively considering CRNA practice reform:

Florida (High Impact) - Competing bills in 2025 (e.g. HB 375, HB 649) would create autonomous CRNA licensure - Large employment market regardless of outcomes - Strong hospital opposition remains a factor

Texas (Large Market) - Considered (but did not pass) CRNA independence bills in 2023 (SB 1700, HB 4071) - Would be massive impact if passed - Ongoing advocacy efforts

Virginia - Introduced legislation (e.g. SB33) to clarify CRNA practice - As of 2025, Virginia law still requires physician supervision - Watch for future legislative sessions

Other States - **Tennessee, Mississippi, North Carolina, and South Carolina** have not removed supervision, but professional associations report discussions toward expanded CRNA roles - **Illinois, Florida, and New York** continue strict supervision - **Wyoming and Utah** may expand their partial opt-outs to broader coverage

Stakeholders (AANA, state CRNA associations) are lobbying for change in these "laggard" states, often citing workforce shortages and rural access needs.

Impact on CRNA Jobs

Why FPA Matters

Salary Comparison

Note: Many factors affect salary beyond practice authority.

How Practice Authority Changes

The Federal Opt-Out Process

Under Medicare, states can "opt out" of federal supervision requirements:

1. Governor requests opt-out from CMS
2. Requires written agreement about quality of care
3. Applies to Medicare patients initially
4. State can extend to all patients

State Legislative Process

For broader full practice authority:

1. Bill introduced in legislature
2. Committee hearings and testimony
3. Floor votes in both chambers
4. Governor signature
5. Implementation period

Key Advocacy Organizations

• AANA (American Association of Nurse Anesthetists) — National advocacy
• State CRNA associations — Local advocacy and lobbying
• NCSBN — National Council for nursing regulation

Choosing a State

For New Graduates

• FPA states offer more direct, independent opportunities
• But don't avoid supervised states—experience is valuable
• Consider mentorship and case volume first
• Rural FPA states often provide best early-career experience

For Experienced CRNAs

• FPA states: Private practice, ownership options, partnership opportunities
• Supervised states: Often higher salary urban markets
• Consider lifestyle factors beyond practice authority
• Leadership roles increasingly available in FPA states

Frequently Asked Questions

A: As of 2026, 23 states plus Washington, DC allow CRNAs to practice without direct physician oversight. Additionally, 25 states, DC, and Guam have formally opted out of the federal Medicare supervision requirement.

A: The federal opt-out allows state governors to exempt CRNAs from Medicare's physician supervision requirement. When a state opts out, CRNAs can administer anesthesia to Medicare patients without an anesthesiologist present. The governor must submit a written request to CMS affirming quality of care standards.

A: Recent expansions include: Delaware and Wyoming (2023 opt-outs), Massachusetts (June 2024 opt-out), Kansas (2025 prescriptive authority via SB 67), West Virginia (2025 cooperative practice model via SB 810), and California (2025 reaffirmation via AB 876). Arkansas, Alabama, Maryland, and Utah also expanded authority in 2022.

A: Prescriptive authority allows CRNAs to order and administer anesthesia-related medications as APRNs. In most full practice authority states, CRNAs can prescribe within their anesthesia scope. Some states like Kentucky require a collaborative agreement (CAPA) only for prescriptions outside perioperative care.

A: On average, yes. CRNAs in full practice authority states earn approximately $220,000+ annually compared to $210,000 in collaborative states and $205,000 in restricted states. However, many factors beyond practice authority affect salary including location, facility type, and experience.

A: Florida has active legislation (HB 375, HB 649 in 2025) to create autonomous CRNA licensure. Texas continues advocacy efforts after bills in 2023 did not pass. Virginia has introduced legislation (SB33), and Wyoming/Utah may expand their partial opt-outs to all facilities.

Conclusion

As of 2026, CRNA full practice authority is the norm in the majority of states. 23 states plus DC (and Guam) explicitly allow CRNAs to practice independently of physicians. In these jurisdictions, CRNAs are licensed as APRNs with the right to manage anesthesia cases and associated medications without an anesthesiologist on site.

The remaining states generally still require some level of physician supervision or written agreement, though legislative momentum favors independence. Recent laws in Delaware, Massachusetts, Kansas, and West Virginia significantly expanded autonomy.

State boards of nursing and legislatures continue to update regulations, so CRNAs and healthcare leaders should monitor developments closely. Verify current regulations before making career decisions via the state Board of Nursing or legislative sources.

Information current as of January 2026. Sources include AANA press releases, state Board of Nursing guidance, Becker's Healthcare, state legislative materials, NCSL, and published regulatory fact sheets.