Ohio became the 27th state to eliminate the federal Medicare requirement that a physician supervise Certified Registered Nurse Anesthetists (CRNAs), after Gov. Mike DeWine sent CMS an opt-out attestation letter on July 10, 2026, one week after Vermont became the 26th state to do the same on July 2, 2026, according to Becker's ASC (September 8, 2026). Both states join a list that now spans more than half the country, built on a Nov. 13, 2001 CMS rule that lets a governor exempt their state from the federal physician-supervision condition simply by sending CMS a letter of attestation, with no legislative action required at the federal level.
The opt-out is narrower than it may sound. It removes only the federal Medicare condition tied to physician supervision of CRNAs. It does not, on its own, grant CRNAs authority to practice beyond what state law already allows. Ohio paired its federal opt-out with a state law change. House Bill 52, effective June 8, 2026, moved Ohio CRNAs from a physician "supervision" standard to a "collaboration" model with physicians, dentists, or podiatrists, which is what made the federal opt-out relevant in Ohio's case.
For ambulatory surgery centers, the expanding opt-out list turns anesthesia staffing into more of a strategic choice than a fixed compliance cost. Becker's ASC cites Seattle-based Proliance Surgeons, which moved to a CRNA-only staffing model in 2025 and reported no patient care delays or cases redirected to hospitals over provider-availability concerns. The source does not cite a quantified dollar savings figure for that shift, or for any other facility, a distinction worth holding onto before using this as a hard cost-savings data point with clients.
Key Takeaways
27th state opts out. Ohio Gov. Mike DeWine sent CMS an opt-out attestation letter on July 10, 2026, one week after Vermont's Gov. Phil Scott did the same on July 2, 2026 (the 26th state).
The mechanism dates to 2001. A Nov. 13, 2001 CMS rule allows a governor to exempt their state from the federal physician-supervision condition of participation via a single attestation letter to CMS.
Scope of practice is still set by state law. An opt-out would not permit a CRNA to practice outside the scope of authority granted by state law. Most opt-out states, including Ohio, pair the federal move with a state scope-of-practice change (Ohio's House Bill 52, effective June 8, 2026).
No verified dollar savings figure. Becker's ASC references Proliance Surgeons' 2025 shift to CRNA-only staffing (no reported patient delays or hospital redirections) but cites no specific cost-savings amount for that facility or the sector generally.
Source and date. Becker's ASC, September 8, 2026, by Cameron Cortigiano.
What Exactly Changed, and What Didn't
The opt-out applies to a single federal rule, the Medicare condition of participation requiring physician supervision of CRNAs. States opt out by having the governor send CMS a signed attestation confirming they have consulted with the state's medical and nursing boards and concluded the opt-out serves patients' access to and quality of anesthesia care. Vermont's Gov. Phil Scott used that exact language in his July 2, 2026 letter. No act of Congress, and in most cases no act of the state legislature, is required for the federal opt-out itself.
What the opt-out does not do is override state law. In states where CRNAs are still required by state statute to practice under physician supervision or direction, that state requirement remains in force regardless of the federal opt-out. That is why nearly every state opt-out in recent years, Ohio and Vermont included, has arrived alongside, or shortly after, a change to the state's own nurse anesthesia practice law.
Why This Matters for Specialty Practices
Anesthesia staffing cost is one of the largest and least predictable line items for ambulatory surgery centers, particularly in orthopedics, pain management, gastroenterology, and other high-volume ASC specialties where anesthesia is required for nearly every case. As more states remove the federal supervision mandate, ASCs gain more latitude to evaluate whether their case mix genuinely requires a physician anesthesiologist on every case, a CRNA operating under a collaborative agreement, or an all-CRNA model. That is a staffing and contracting decision with direct billing implications: the anesthesia provider model on a claim (physician-only, medical direction, medical supervision, or CRNA-only) determines which billing rules and modifiers apply and how the claim is reimbursed.
For anesthesia and ASC practices specifically, this is also a reminder that staffing-model flexibility is expanding faster in some states than others. A practice operating across multiple states needs a clear, state-by-state view of both the federal opt-out status and the underlying state scope-of-practice law before changing its anesthesia staffing or billing model.
What This Means for Your Practice
Anesthesia billing already carries some of the most state- and payer-specific rules in revenue cycle management, and a change in staffing model, whether prompted by cost pressure, provider availability, or a new state opt-out, can quietly change how claims should be coded and reimbursed. Cosentus supports the specialties most exposed to this shift, including anesthesia, orthopedics, pain management, and ASCs, and our investment in Accreda Healthcare Management gives our anesthesia clients dedicated, anesthesia-exclusive RCM expertise for exactly this kind of staffing-model and billing-rule change.
Before adjusting an anesthesia staffing model based on a state's opt-out status, we recommend confirming the underlying state scope-of-practice law, reviewing payer-specific billing rules for the provider model under consideration, and modeling the reimbursement impact by procedure mix, rather than assuming savings that have not been verified for your specific payer contracts and case volume.
Frequently Asked Questions
Does the federal opt-out mean CRNAs can now practice independently in all 27 states?
No. The federal opt-out removes only the Medicare physician-supervision condition of participation. Whether a CRNA can practice without physician supervision or collaboration still depends entirely on that state's own scope-of-practice law.
Which states most recently opted out, and when?
Vermont opted out on July 2, 2026 (the 26th state), and Ohio opted out on July 10, 2026 (the 27th state), according to Becker's ASC and the states' respective gubernatorial announcements.
Is there a verified cost-savings figure for switching to a CRNA-only anesthesia model?
Not in this source. Becker's ASC cites Proliance Surgeons' 2025 shift to a CRNA-only model in Seattle, with no reported patient care delays or hospital redirections, but no dollar figure for savings is given. Any specific savings estimate should be modeled against your own payer contracts and case mix, not assumed from this example.
How does an anesthesia staffing change affect billing?
The anesthesia provider model on a case, whether physician-only, medical direction, medical supervision, or CRNA-only, determines which billing modifiers and reimbursement rules apply. A staffing model change should be reviewed against payer-specific anesthesia billing rules before it is implemented.
Talk to Cosentus
Anesthesia staffing rules are shifting state by state. What you can control is how precisely your practice bills and collects for the anesthesia services you already provide, whatever staffing model you use. Talk to our team at cosentus.com/contact or call +1 (877) 266-9040.