CRNA Supervision Opt-Out States: The 2026 List

The short answer: as of October 2026, 27 states and Guam have opted out of the Medicare rule that a nurse anesthetist (CRNA) be supervised by a physician, according to the American Association of Nurse Anesthesiology. The most recent are Vermont and Ohio, both in July 2026. Two, Utah and Wyoming, are partial, limited to critical access and certain rural or small hospitals. Opting out removes a federal condition on the hospital or surgery center; it does not change state scope-of-practice law, a facility’s own bylaws, or how anesthesia is billed.

The federal rule being opted out of

Medicare’s conditions for facilities require a CRNA to work under supervision:

• Hospitals: supervision by the operating practitioner, or by an anesthesiologist who is immediately available (42 CFR 482.52).
• Critical access hospitals: supervision by the operating practitioner (42 CFR 485.639).
• Ambulatory surgery centers: supervision by the operating physician (42 CFR 416.42).

Supervision under these rules does not require an anesthesiologist. In a state that has not opted out, the surgeon performing the procedure can be the supervising physician.

Since a 2001 rule change, a state can be exempted. The governor sends CMS a letter attesting that the state’s boards of medicine and nursing were consulted about access to and quality of anesthesia care, that opting out is in the best interests of the state’s residents, and that it is consistent with state law. The opt-out takes effect when the letter is submitted, and a later governor can withdraw it.

States that have opted out

CMS’s own web page on opt-outs is out of date: it still lists 19 states and Guam as of November 2020. The District of Columbia has changed its own law on CRNA practice but has not filed a federal opt-out.

What opting out does not change

• State law. Nurse practice acts and other state rules on CRNA practice still apply, and they vary.
• The facility’s own rules. A hospital or surgery center in an opt-out state can still require anesthesiologist involvement through its bylaws, credentialing and anesthesia department policies, and some do.
• Billing. Medicare payment depends on whether a case was medically directed, not on the state. A CRNA working without medical direction bills QZ in any state; medical direction still requires the anesthesiologist to meet all seven conditions. See how the modifiers pay.
• Anesthesiologist assistants. The opt-out covers CRNAs only. Anesthesiologist assistants still work under an anesthesiologist.

No federal rule change to the supervision requirement was proposed or finalized between 2024 and October 2026, though the nurse anesthetists’ association continues to ask CMS to drop it nationally. The temporary nationwide waiver issued during the COVID-19 emergency ended on May 11, 2023.

What it means for a hospital’s anesthesia model

An opt-out widens the choice of coverage models: CRNA-only coverage at a small or rural site, fewer anesthesiologists covering more rooms, or a mixed model by location. It does not make any of them cheaper by itself. The comparison still turns on local pay, which varies more for CRNAs than for anesthesiologists (2026 pay by state); on how much of the schedule depends on locums; and on payer policy, since Cigna, Anthem in some states and UnitedHealthcare now pay CRNA claims without medical direction at 85% (the 85% rule). A model that looks cheaper on staffing can collect less on the same cases.

Sources

• American Association of Nurse Anesthesiology, Fact Sheet Concerning State Opt-Outs (July 2026).
• 42 CFR 482.52 (hospitals), 485.639 (critical access hospitals) and 416.42 (ambulatory surgery centers).
• CMS, Conditions of Participation spotlight (opt-out list as of November 2020).