Twenty-seven states have opted out of the federal requirement that a physician supervise CRNAs administering anesthesia, according to the American Association of Nurse Anesthesiology’s most recent fact sheet, updated in July 2026.
Vermont and Ohio became the 26th and 27th states to opt out, making the move in July 2026. The full list stretches back more than two decades, and for ASC leaders dealing with anesthesia staffing costs, where a state falls on that list is directly relevant to how much flexibility they have to restructure anesthesia coverage.
What opting out actually means
The opt-out applies to a single, specific rule: the federal condition, tied to Medicare reimbursement, that a physician supervise CRNAs. It dates to a Nov. 13, 2001, CMS rule that let governors exempt their states from that requirement by sending CMS a letter of attestation. The opt-out takes effect as soon as it’s submitted — no legislature or rulemaking process required.
However, that letter doesn’t automatically override state law. A state can opt out of the federal Medicare rule and still require physician supervision under its own nursing or medical practice act. AANA’s fact sheet is explicit that an opt-out “would not permit a CRNA to practice outside the scope of authority granted by state law.”
The opt-out also doesn’t bind individual facilities. Hospitals and ASCs can still choose to require physician supervision as a matter of internal policy, regardless of what the state or federal government allows.
In practice, most opt-out states have paired the move with state-level scope changes — moving from “supervision” to a “collaboration” model, as Ohio did through House Bill 52 this year.
The full list of 27 states, in order of when each opted out
- Iowa: December 2001
- Nebraska: February 2002
- Idaho: March 2002
- Minnesota: April 2002
- New Hampshire: June 2002
- New Mexico: November 2002
- Kansas: March 2003
- North Dakota: October 2003
- Washington: October 2003
- Alaska: October 2003
- Oregon: December 2003
- Montana: January 2004
- South Dakota: March 2005
- Wisconsin: June 2005
- California: July 2009
- Colorado: September 2010 (partial); full opt-out October 2023
- Kentucky: April 2012
- Arizona: March 2020
- Oklahoma: August 2020
- Utah: February 2022 (partial)
- Michigan: May 2022
- Arkansas: May 2022
- Wyoming: May 2023 (partial)
- Delaware: June 2023
- Massachusetts: June 2024
- Vermont: July 2, 2026
- Ohio: July 10, 2026
Notes: Colorado, Utah and Wyoming initially opted out only for critical access hospitals and specified rural facilities before later moves toward full opt-outs. Colorado later moved to a full opt-out in October 2023; Utah and Wyoming remain partial opt-outs. Montana’s governor briefly reversed the state’s opt-out in 2005 before restoring it the same year.
The ASC angle: staffing flexibility and stipend economics
In opt-out states — provided state law and facility policy also allow it — ASCs have more room to build CRNA-based staffing model models. Seattle-based Proliance Surgeons moved to a CRNA-only staffing model in 2025 after the anesthesiology group it was partnered with decided not to renew its contract. After switching the new model, the organization reported no patient care delays and no cases redirected to hospitals over provider-availability concerns.
That’s just one case study, but as more states move away from the federal supervision requirement, the staffing-model conversation for ASCs is likely to keep shifting from “how much do we pay for anesthesiologist coverage” to “do we need anesthesiologist coverage for this case mix at all.”
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