Changes in Federal and State Law That Have Expanded Medical Assistants’ Scope of Service

By Donald A. Balasa, JD, MBA, CEO and House Legal Counsel, American Association of Medical Assistants (AAMA)

Medical assistants continue to be some of the most versatile and vital allied health professionals in the American workforce. The COVID-19 pandemic has necessitated medical assistants learning new skills and working in nontraditional settings such as hospitals and vaccination clinics. In addition, changes in federal and state law (and in nongovernmental national standards) have given medical assistants unprecedented opportunities to work to the fullest extent of their education and certification. The following are some of the most significant changes in laws and standards that have empowered medical assistants to go the extra mile and band together with their fellow health professionals to respond to one of the most serious health crises in the last one hundred years.

The CDC and Telemedicine/Telehealth

In June 2020, the Centers for Disease Control and Prevention (CDC) updated its telehealth policy to permit health care personnel (e.g., a nurse or a medical assistant) physically with the patient to use “peripheral medical equipment (e.g., digital stethoscopes, otoscopes, ultrasounds) … while the consulting medical provider conducts a remote evaluation.”¹ The remote physiologic monitoring services of the medical assistant are reimbursable incident to the services of the overseeing and delegating licensed provider. Although not necessarily signaling a return to house calls, this change in federal policy has enabled a significant number of homebound patients to receive the health care they needed during the pandemic.

American Medical Association

In its Telehealth Implementation Playbook,² the American Medical Association (AMA) addresses specific ways in which medical assistants help physicians before and during a telehealth visit. The AMA has urged physicians to use medical assistants to the greatest extent permitted by law to provide safe and effective health care in the most efficient manner. This division of labor allows physicians to focus on diagnosing diseases and treating patients.

Medication Reconciliation

Medical assistants are not mentioned by name in the medication reconciliation measures³ of the National Committee for Quality Assurance (NCQA)—a national standard-setting body whose indicators and metrics are recognized by federal agencies. As a result, there has been ambiguity about whether medical assistants are permitted to do medication reconciliation that is counted toward meeting the NCQA threshold. NCQA eliminated this ambiguity by issuing the following statement in July 2021:

NCQA recognizes the supervising physician as providing the service when they have signed off on the medical record/documentation. It is our understanding many licensed practical nurses (LPNs) and medical assistants work with physicians and registered nurses (RNs). With this in mind, medication reconciliation provided by the medical assistant and signed off by a physician, [nurse practitioner, physician assistant, or clinical pharmacist with prescribing privileges], or RN may be counted toward NCQA Medication Reconciliation indicators as the signature indicates additional clinical oversight for this work.

Colorado

On November 2, 2021, the Colorado Department of Regulatory Agencies issued emergency rules permitting medical assistants to work under the authority of physicians, registered nurses, advanced practice registered nurses (including certified nurse-midwives, clinical nurse specialists, certified registered nurse anesthetists, and nurse practitioners), and physician assistants in a hospital or inpatient facility.⁴ This is the first instance of any state law specifically authorizing medical assistants to work in inpatient facilities and demonstrates the versatility and adaptability of medical assistants that have  become more apparent during the pandemic.

Texas

The Texas Medical Board has taken the position that physicians are permitted to delegate to knowledgeable and competent unlicensed professionals such as medical assistants the initiation and discontinuation of IVs (Texas Medical Board, email, March 25, 2021). Some licensed providers in Texas and other states have expressed their interest in delegating to medical assistants the starting of IVs. Patient safety requires that medical assistants must have additional education and training to be able to initiate and discontinue IVs.

Utah

On March 10, 2022, the Utah legislature amended Section 58-67-102 of the Utah statutes to permit medical assistants to administer vaccines under general physician supervision rather than indirect supervision. Note the following definition of general supervision from the Utah law:

(c) “General supervision” means that the supervising [licensed provider]:

(i) has authorized the work to be performed by the person being supervised;

(ii) is available for consultation with the person being supervised by personal face-to-face contact, or direct voice contact by telephone, radio or some other means, without regard to whether the supervising [licensed provider] is located on the same premises as the person being supervised; and

(iii) can provide any necessary consultation within a reasonable period of time and personal contact is routine.⁵

The Utah Department of Commerce Division of Occupational and Professional Licensing issued regulations that permit medical assistants to complete a formal or on-the-job dispensing training program and become dispensing medical practitioner (DMP) designees. Note the following excerpt from this regulation:

(3) The duties of the consulting pharmacist, [pharmacist-in-charge], [remote dispensing pharmacist-in-charge], or [dispensing medical practitioner in charge] shall include:

(a) assuring that a pharmacist, pharmacy intern, [dispensing medical practitioner], or [dispensing medical practitioner] designee dispenses drugs or devices, including:

(i) packaging, preparation, compounding and labeling; and

(ii) ensuring that drugs are dispensed safely and accurately as prescribed⁶

Washington

The 2021 Washington legislature authorized medical assistants to perform duties without a supervising health care practitioner present in the facility. The new statutory language includes the following:

(b) The health care practitioner does not need to be present during procedures to withdraw blood, but must be immediately available [by telephone].

(c) During a telemedicine visit, supervision over a medical assistant assisting a health care practitioner with the telemedicine visit may be provided through interactive audio and video telemedicine technology.⁷

Maryland

Legislation was passed by the Maryland legislature in 2021 that would allow medical assistants working under nurse practitioner supervision to perform tasks not permitted under previous law.⁸ Among these additional tasks is the administration of certain types of injections. The legislation was supported by the Maryland Board of Nursing, the Nurse Practitioner Association of Maryland, and the Maryland Society of Medical Assistants.

District of Columbia

The District of Columbia Department of Health amended its regulations to authorize medical assistants with required training who are functioning under the supervision of a licensed health professional to administer COVID-19 vaccinations and other immunizations.⁹ This amendment was prompted by the need for additional vaccinators in the District of Columbia and the realization that adequately trained medical assistants are capable of serving as vaccinators under licensed independent practitioners.

Questions may be directed to the author at dbalasa@aama-ntl.org.

References

1. Using telehealth to expand access to essential health services during the COVID-19 pandemic. Centers for Disease Control and Prevention. Updated June 10, 2020. Accessed April 12, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html
2. American Medical Association. Telehealth Implementation Playbook. 2020. Accessed April 12, 2022. https://www.ama-assn.org/system/files/2020-04/ama-telehealth-playbook.pdf
3. National Committee for Quality Assurance. Quality ID #46 (NQF 0097): Medication Reconciliation Post-Discharge. Accessed April 12, 2022. https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2019_Measure_046_MedicarePartBClaims.pdf
4. Code Colo. Regs. § 3 CCR 716-1. Accessed April 14, 2022. https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=10095&fileName=3%20CCR%20716-1
5. Utah Admin. Code r. 156-1. Accessed April 14, 2022. https://utrules.elaws.us/uac/r156-1
6. Utah Admin. Code r. 156-17b-603. Accessed April 14, 2022. https://casetext.com/regulation/utah-administrative-code/commerce/title-r156-occupational-and-professional-licensing/rule-r156-17b-pharmacy-practice-act-rule/section-r156-17b-603-operating-standards-consulting-pharmacist-pharmacist-in-charge-remote-dispensing-pharmacist-in-charge-or-dispensing-medical-practitioner-in-charge
7. HR 1378, 67th Leg (Wash. 2021). April 2021. Accessed April 12, 2022. https://lawfilesext.leg.wa.gov/biennium/2021-22/Pdf/Bills/House%20Passed%20Legislature/1378.PL.pdf?q=20210611091714
8. Health Occupations – Nurses – Delegation of Tasks, HB95 (Md. 2021). Accessed April 14, 2022. https://legiscan.com/MD/text/HB95/id/2416136
9. District of Columbia Register. August 6, 2021;68(32). Accessed April 14, 2022. https://www.dcregs.dc.gov/Common/DCR/Issues/IssueDetailPage.aspx?issueID=886