CRNA Opt-Out States: The 2026 List

An opt-out state is one whose governor has told CMS to exempt its hospitals from Medicare's rule that CRNAs be supervised by a physician. As of October 2026, 27 states plus the District of Columbia (and Guam) have opted out.

Opting out removes a federal Medicare condition. It does not, by itself, change state scope of practice law or a hospital's own policies.

The federal supervision rule

Medicare sets "conditions of participation" that hospitals must meet to be paid. For anesthesia, the hospital rule is 42 CFR 482.52.

Unless the state is exempt, it says a CRNA must be supervised. The supervisor is "the operating practitioner or ... an anesthesiologist who is immediately available if needed." So under the federal rule, the supervisor can be the surgeon or other operating practitioner.

Parallel rules apply to critical access hospitals (42 CFR 485.639) and ambulatory surgery centers (42 CFR 416.42).

How a state opts out

CMS created the opt-out in a final rule published November 13, 2001. To opt out, the governor sends CMS a letter attesting that:

1. The governor consulted the state boards of medicine and nursing about access to and quality of anesthesia care.
2. Opting out is in the best interests of the state's residents.
3. The opt-out is consistent with state law.

The request takes effect when it is submitted. A state can also withdraw it at any time.

States that have opted out

This list follows the AANA fact sheet updated September 2026.

Guam also opted out in June 2016.

Partial opt-outs

Two states have opted out only for some hospitals:

• Utah: critical access hospitals and specified rural hospitals.
• Wyoming: critical access hospitals and hospitals with 25 or fewer licensed beds.

Colorado started with a partial opt-out in 2010 and moved to a full opt-out in October 2023.

The newest opt-outs

Vermont (Governor Scott) and Ohio (Governor DeWine) both opted out in July 2026. The District of Columbia followed in September 2026, for all hospitals.

The table on this page may also show each state's status alongside its board of nursing and compact membership.

What opting out means for CRNAs

It removes one federal layer

In an opt-out state, hospitals no longer need physician supervision of CRNAs to meet Medicare's conditions. CMS leaves the decision to state law and the facility.

State law still decides your scope

Scope of practice comes from state nurse practice acts, board rules and other state laws. These differ from state to state, including in opt-out states.

The governor's letter must say the opt-out is consistent with state law. So an opt-out confirms state law allows it. It does not expand state law.

Facilities set their own policies

Hospitals and surgery centers set anesthesia staffing through bylaws, credentialing and privileging. A facility in an opt-out state may still choose a care team model with anesthesiologists.

When you interview, ask how anesthesia is staffed. Ask who you report to, and whether CRNAs practice independently at that site.

Rural hospitals

The partial opt-outs in Utah and Wyoming apply only to critical access and small or specified rural hospitals. Colorado's first opt-out in 2010 had the same focus.

If you want rural or independent practice, opt-out states are a useful starting filter. Then check the state's practice act and the facility's model.

Payment rules are separate

The opt-out deals with Medicare conditions of participation. How Medicare and other payers reimburse anesthesia services is set by separate billing rules. Billing questions belong with the facility's billing team or a qualified advisor.

Non-opt-out states

In states that have not opted out, hospitals must meet the federal supervision condition. Remember that the operating practitioner can be the supervisor, so a surgeon or dentist may fill that role.

State law can be stricter or looser than the federal rule. Check the board of nursing in the state where you plan to work.

Find each board on our board of nursing page. For pay by state, see CRNA salary by state, and for openings, see CRNA jobs.

FAQ

How many states have opted out in 2026?

27 states plus the District of Columbia, according to the AANA fact sheet updated September 2026. Guam has also opted out.

Which states opted out most recently?

Vermont and Ohio in July 2026, and the District of Columbia in September 2026.

Does opt-out mean CRNAs can practice independently?

Not by itself. It removes Medicare's physician supervision condition. State law and facility policy still set how you practice.

Can a state reverse an opt-out?

Yes. The rule lets a governor withdraw the request at any time. Montana reversed its opt-out in 2005 and restored it the same year.

This page is general information, not legal advice. Confirm your scope of practice with your state board of nursing.

Sources

• AANA: Fact Sheet Concerning State Opt-Outs (updated September 2026)
• AANA: Vermont opts out of physician supervision of CRNAs
• AANA: Ohio opts out of physician supervision for CRNAs
• eCFR: 42 CFR 482.52, Anesthesia services (hospitals)
• eCFR: 42 CFR 485.639, Surgical services (critical access hospitals)
• eCFR: 42 CFR 416.42, Surgical services (ambulatory surgical centers)