S1832

An Act concerning graduate physicians, supplementing Title 45 of the Revised Statutes, P.L.1997, c.192 (C.26:2S-1 et seq.), and Title 30 and Title 52 of the Revised Statutes, and amending P.L.2009, c.307 and P.L.2017, c.28.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. (New section) This act shall be known and may be cited as the “Graduate Physician Licensing Act.”

2. (New section) As used in this act:

"Board" means the State Board of Medical Examiners created pursuant to R.S.45:9-1.

"Collaborating physician" means a physician who enters a collaborative practice arrangement with a graduate physician and who assumes responsibility for the oversight of the activities and the primary care services rendered by a graduate physician.

“Collaborative practice arrangement” means an agreement between a physician and a graduate physician established pursuant to the requirements of section 6 of this act.

“Graduate physician” means a health professional who meets the qualifications under this act and holds a current, valid license pursuant to this act.

“Medically underserved area” means an area in this State with a medically underserved population; an area in this State designated by the United States Secretary of Health and Human Services as an area with a shortage of personal health services; a population group designated by the United States Secretary of Health and Human Services as having a shortage of personal health services; an area designated under State or federal law as a medically underserved community; or an area that the Department of Health considers to be medically underserved based on relevant demographic, geographic, and environmental factors.

“Physician” means a person fully licensed to practice medicine and surgery pursuant to chapter 9 of Title 45 of the Revised Statutes.

“Primary care” means physician services in family practice, internal medicine, or pediatrics.

3. (New section) a. The State Board of Medical Examiners shall issue a license as a graduate physician to an applicant who has fulfilled the following requirements:

(1) is at least 18 years of age;

(2) is a graduate of a medical school accredited by the Liaison Committee on Medical Education, the Commission on Osteopathic College Accreditation, or a medical school listed in the International Medical Education Directory or its equivalent;

(3) has successfully completed Step 2 of the United States Medical Licensing Examination, Level 2 of the Comprehensive Osteopathic Medical Licensing Examination, or the equivalent of such step of any other board-approved medical licensing examination;

(4) has not completed an approved postgraduate residency;

(5) has never been convicted, received adjudication, deferred adjudication, community supervision, or deferred disposition for any criminal offense by a court of appropriate jurisdiction;

(6) has never held a license authorizing the practice of medicine that was subjected to discipline by a licensing agency in any state, federal, or foreign jurisdiction, excluding any action related to non-payment of fees related to a license;

(7) has never had a controlled dangerous substance license or permit suspended or revoked by a state or the United States Drug Enforcement Administration; and

(8) is not under active investigation for wrongdoing by a licensing agency or law enforcement authority in any state, federal, or foreign jurisdiction.

b. In addition to the requirements of subsection a. of this section, an applicant for renewal of a license as a graduate physician shall:

(1) execute and submit a sworn statement made on a form provided by the board that neither the license for which renewal is sought nor any similar license or other authority issued by another jurisdiction has been revoked or suspended; and

(2) present satisfactory evidence that any continuing education requirements have been completed as required by this act.

c. A graduate physician shall not be required to complete more hours of continuing education than are required of a physician.

d. The board may accept, in lieu of the requirements of subsection a. of this section, proof that an applicant for licensure holds a current graduate physician license in a state which has standards substantially equivalent to those of this State.

e. The board may deny an application for issuance or renewal of a graduate physician license and the licensure of a graduate physician may be revoked in the same manner as is provided for denial or revocation of a physician license based on a violation of any standards prescribed by State law or by the board for physicians for which the violation merits denial or revocation of a physician license.

4. (New section) a. (1) No person shall practice as a graduate physician or present, call, or represent himself as a graduate physician unless that person is licensed pursuant to section 3 of this act.

(2) Nothing in this act shall be construed to limit, preclude, or otherwise interfere with the practice of any person licensed by an appropriate agency of the State of New Jersey, provided that such duties are consistent with the accepted standards of the person’s profession and the person does not present himself a graduate physician.

b. No person shall assume, represent himself as, or use the title or designation "graduate physician” or any other title or designation which indicates or implies that he is a graduate physician unless that person is licensed pursuant to this act.

c. A graduate physician shall clearly identify himself as a graduate physician. A graduate physician may represent himself as or use the titles or designations of “doctor”, “Dr.”, or “doc.”

5. (New section) a. A graduate physician may practice as a graduate physician provided that:

(1) the practice of the graduate physician is limited to the provision of primary care services in medically underserved areas of the State, and to procedures that are delegated to the graduate physician by a collaborating physician, as authorized under the terms of the collaborative practice arrangement;

(2) the graduate physician conspicuously wears an identification tag using the term "graduate physician" whenever acting in that capacity; and

(3) any entry by a graduate physician in a clinical record is appropriately signed and followed by the designation, "GP".

b. A graduate physician shall not practice or attempt to practice without a collaborative practice arrangement, except in an emergency situation.

c. Any graduate physician who practices in violation of any of the conditions specified in this section shall be deemed to have engaged in professional misconduct.

6. (New section) a. A physician who supervises a graduate physician may maintain a written collaborative practice arrangement with the graduate physician. A graduate physician shall sign a separate written agreement with each physician who delegates the authority to administer or prescribe medications and controlled dangerous substances and provide treatment. The delivery of health care services by a graduate physician shall not exceed the scope of practice of the graduate physician and shall be consistent with that graduate physician's skill, training, and competence and the skill and training of the collaborating physician. Each collaborative practice arrangement shall:

(1) state that the collaborating physician will exercise supervision over the graduate physician in accordance with the provisions of this act and any rules adopted by the board;

(2) contain complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the graduate physician;

(3) list all other offices or locations besides those listed in paragraph (2) of this subsection where the collaborating physician authorizes the graduate physician to practice;

(4) contain a requirement that a prominently displayed disclosure statement, informing patients that they may be seen by a graduate physician and have the right to see the collaborating physician, be posted at every office where the graduate physician is authorized to practice in collaboration with a physician;

(5) list all specialty or board certifications of the collaborating physician and all certifications of the graduate physician;

(6) state the manner of collaboration between the collaborating physician and the graduate physician, including the manner in which the collaborating physician and the graduate physician shall engage in collaborative practice consistent with each professional’s skill, training, education, and competence; and

(b) provide for alternative coverage during absence, incapacity, or infirmity or an emergency;

(7) provide a description of the graduate physician’s prescriptive authority in collaboration with the collaborating physician, including a list of the controlled dangerous substances the collaborating physician authorizes the graduate physician to prescribe, whether the graduate physician will be authorized to authorize qualifying patients for the medical use of cannabis and issue written instructions for medical cannabis pursuant to P.L.2009, c.307 (C.24:6I-1 et al.), and documentation that the graduate physician’s prescriptive authority is consistent with each professional’s education, knowledge, skill, and competence;

(8) contain a list of all other written practice agreements of the collaborating physician and the graduate physician;

(9) provide a description of the time and manner of the collaborating physician’s review of the graduate physician’s delivery of health care services, including requiring the graduate physician to submit a minimum of 10 percent of the charts documenting the graduate physician’s delivery of health care services to the collaborating physician for review by the collaborating physician or any other physician designated in the collaborative practice arrangement, every 14 days;

(10) require that the collaborating physician, or any other physician designated in the collaborative practice arrangement, review every 14 days a minimum of 20 percent of the charts in which the graduate physician prescribes controlled dangerous substances, which charts reviewed under this paragraph may be counted in the number of charts required to be reviewed under paragraph (9) of this subsection;

(11) state the duration of the written practice agreement between the collaborating physician and the graduate physician;

(12) be signed and dated annually by the physician and the graduate physician, and updated as necessary to reflect any changes in the practice or the graduate physician’s role in the practice; and

(13) be kept on file at the practice site.

b. The collaborating physician shall be responsible at all times for the oversight of the activities of, and shall accept responsibility for primary care services rendered by, the graduate physician.

c. The collaborating physician shall determine and document the completion of at least a one-month period of time during which the graduate physician practices in a setting in which the collaborating physician is continuously present before practicing when the collaborating physician is not continuously present.

d. A collaborating physician shall not enter into a collaborative practice arrangement with more than six full-time equivalent graduate physicians, full-time equivalent physician assistants, or full-time equivalent advanced practice nurses, or any combination thereof.

e. A collaborating physician and the graduate physician in a collaborative practice arrangement shall wear identification badges while acting within the scope of their collaborative practice arrangement. The identification badges shall prominently display the licensure status of the collaborating physician and graduate physician.

f. No agreement made under this section shall supersede current hospital licensing regulations governing hospital medication orders under protocols or standing orders for the purpose of delivering inpatient or emergency care within a hospital if such protocols or standing orders have been approved by the hospital’s medical staff and pharmaceutical therapeutics committee.

7. (New section) a. The State Board of Medical Examiners shall promulgate rules and regulations, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), concerning the following:

(1) licensure and license renewal procedures for graduate physicians;

(2) collaborating physician supervision and collaborative practice arrangements;

(3) the establishment of licensing fees; and

(4) any other matter that may be necessary to protect the public and discipline the profession.

b. The board shall promulgate rules concerning the use of collaborative practice arrangements established pursuant to this act. Such rules shall specify:

(1) geographic areas to be covered;

(2) the methods of treatment that may be covered by a graduate physician collaborative practice arrangement;

(3) in conjunction with deans of medical schools and primary care residency program directors in the State, the development and implementation of educational methods and programs undertaken during the collaborative practice service which shall facilitate the advancement of the graduate physician's medical knowledge and capabilities, and which may lead to credit toward a future residency program for programs that deem such documented educational achievements acceptable; and

(4) the requirements for review of services provided under a collaborative practice arrangement, including delegating authority to prescribe medications and controlled dangerous substances.

b. Any rules relating to the dispensing or distribution of medications or devices by prescription or prescription drug orders under this section shall be subject to the approval of the New Jersey State Board of Pharmacy. Any rules relating to the dispensing or distribution of controlled dangerous substances by prescription or prescription drug orders under this section shall be subject to the approval of the Department of Health and the New Jersey State Board of Pharmacy. The board shall promulgate rules applicable to graduate physicians that shall be consistent with guidelines for federally funded clinics.

c. The board shall not promulgate rules that require the collaborating physician to review more than 10 percent of the graduate physician’s patient charts or records during the one-month period provided by subsection c. of section 6 of this act.

d. The board shall not deny, revoke, suspend, or otherwise take disciplinary action against a collaborating physician for health care services delegated to a graduate physician pursuant to the provisions of this section, provided that the rules promulgated pursuant to this section are satisfied.

e. Within 30 days of any change to, and upon each renewal of, a collaborative practice arrangement and upon licensure renewal, the board shall require each physician to identify whether the physician is engaged in any collaborative practice arrangement, including collaborative practice arrangements delegating the authority to prescribe controlled dangerous substances, and also report to the board the name of each graduate physician with whom the physician has entered into such arrangement. The board may make such information available to the public. The board shall track the reported information and may routinely conduct random reviews of such arrangements to ensure that arrangements are carried out for compliance under this act.

8. (New section) a. A graduate physician with a certificate of controlled dangerous substance prescriptive authority as provided pursuant to this act may prescribe any controlled dangerous substance listed in Schedule III, IV, or V, may have restricted authority to prescribe controlled dangerous substances listed in Schedule II, and may authorize qualifying patients for medical cannabis and issue written instructions for medical cannabis to registered qualifying patients pursuant to P.L.2009, c.307 (C.24:6I-1 et al.). Prescriptions for Schedule II controlled dangerous substances prescribed by a graduate physician who has a certificate of controlled dangerous substance prescriptive authority shall be restricted to only those medications containing hydrocodone. A graduate physician may prescribe and dispense narcotic drugs for maintenance treatment or detoxification treatment if the graduate physician has met the training and registration requirements set forth in subsection (g) of 21 U.S.C. s.823 and the collaborative practice arrangement expressly authorizes the graduate physician to prescribe and dispense narcotic drugs for maintenance treatment or detoxification treatment. Authorizations to prescribe controlled dangerous substances under this subsection, authorize qualifying patients for medical cannabis, and issue written instructions for medical cannabis shall be filed with the State Board of Medical Examiners.

b. The collaborating physician shall maintain the right to limit a specific scheduled drug or scheduled drug category that the graduate physician may be permitted to prescribe or otherwise authorize. Any limitations shall be listed in the collaborative practice arrangement.

c. A graduate physician shall not prescribe controlled dangerous substances for himself or members of the graduate physician’s family.

d. Prescriptions for Schedule III controlled dangerous substances and Schedule II medications containing hydrocodone shall be limited to a five-day supply without refill, except that buprenorphine may be prescribed for up to a 30-day supply without refill for patients receiving medication-assisted treatment for substance use disorders under the direction of the collaborating physician.

e. A graduate physician may authorize qualifying patients for the medical use of cannabis and issue written instructions for medical cannabis to registered qualifying patients, subject to the following conditions:

(1) the collaborating physician has authorized the graduate physician to authorize qualifying patients for the medical use of cannabis and issue written instructions for medical cannabis;

(2) the graduate physician signs the graduate physician’s own name to the authorization or written instruction and prints the graduate physician’s name and certification number;

(3) the authorization or written instruction is dated and includes the name of the qualifying patient and the name, address, and telephone number of the collaborating physician;

(4) prior to issuing written instructions for medical cannabis, the graduate physician verifies the patient is a registered qualifying patient; and

(5) the graduate physician complies with the requirements for authorizing qualifying patients for the medical use of cannabis and for issuing written instructions for medical cannabis established pursuant to P.L.2009, c.307 (C.24:6I-1 et al.).

f. A graduate physician who is authorized to prescribe controlled dangerous substances or issue written instructions for medical cannabis under this section shall register with the federal Drug Enforcement Administration and any other appropriate State and federal agencies, and shall include the graduate physician’s Drug Enforcement Administration registration number on prescriptions for controlled dangerous substances and on written instructions for medical cannabis.

g. A collaborating physician shall determine and document the completion of at least 120 hours in a four-month period by the graduate physician during which the graduate physician shall practice with the collaborating physician on-site prior to prescribing controlled dangerous substances, authorizing qualifying patients for medical cannabis, and issuing written instructions for medical cannabis when the collaborating physician is not on-site.

9. (New section) a. No contract or other agreement shall require a physician to act as a collaborating physician for a graduate physician against the physician's will. A physician shall have the right to refuse to act as a collaborating physician, without penalty, for a particular graduate physician. No contract or other agreement shall limit the collaborating physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any graduate physician, but such requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice.

b. No contract or other agreement shall require any graduate physician to serve as a collaborating graduate physician for any collaborating physician against the graduate physician's will. A graduate physician shall have the right to refuse to collaborate, without penalty, with a particular physician.

c. Nothing contained in this act shall be construed to limit the authority of hospitals or hospital medical staff to make employment, credentialing, or privileging decisions.

10. (New section) Each carrier that offers a health benefits plan in this State shall reimburse a graduate physician for the diagnosis, consultation, or treatment of a patient enrolled in the plan on the same basis that the carrier reimburses the service when it is delivered by another comparable mid-level health care provider, including, but not limited to, a physician assistant.

11. (New section) Subject to the receipt of any necessary federal approvals or waivers, the Division of Medical Assistance and Health Services in the Department of Human Services shall ensure that the State Medicaid and NJ FamilyCare programs reimburse a graduate physician for the diagnosis, consultation, or treatment of a Medicaid or NJ FamilyCare enrollee on the same basis that the programs reimburse the service when it is delivered by another comparable mid-level health care provider, including, but not limited to, a physician assistant.

12. (New section) The State Health Benefits Commission and the School Employees' Health Benefits Commission shall ensure that a graduate physician is reimbursed for the diagnosis, consultation, or treatment of a program enrollee on the same basis that the State Health Benefits Program and the School Employees' Health Benefits Program reimburse the service when it is delivered by another comparable mid-level health care provider, including, but not limited to, a physician assistant.

13. Section 3 of P.L.2009, c.307 (C.24:6I-3) is amended to read as follows:

3. As used in P.L.2009, c.307 (C.24:6I-1 et al.) and P.L.2015, c.158 (C.18A:40-12.22 et al.):

"Academic medical center" means (1) an entity located in New Jersey that, on the effective date of P.L.2019, c.153 (C.24:6I-5.1 et al.), has an addiction medicine faculty practice or is in the same health care system as another facility located in New Jersey that offers outpatient medical detoxification services or inpatient treatment services for substance use disorder; has a pain management faculty practice or a facility-based pain management service located in New Jersey; has graduate medical training programs accredited, or pending accreditation, by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association in primary care and medical specialties; is the principal teaching affiliate of a medical school based in the State; and has the ability to conduct research related to medical cannabis. If the entity is part of a system of health care facilities, the entity shall not qualify as an academic medical center unless the health care system is principally located within the State; or

(2) an accredited school of osteopathic medicine that: is located in a state that shares a common border with this State; has an articulation agreement or similar memorandum of understanding, plus an agreement to establish and maintain an apprenticeship program in this State to train workers in the cannabis industry, which training would earn college credit, with any State college or university located in a county of the first class with a college of nursing or nursing degree program accredited by the Commission on Collegiate Nursing Education on the effective date of P.L.2021, c.16 (C.24:6I-31 et al.); and has an institutional review board that has, on the effective date of P.L.2021, c.16 (C.24:6I-31 et al.), previously approved a clinical research study in this State involving medical cannabis; and has the ability and will conduct all research and development in the county in which the partner State college or university is located.

"Adverse employment action" means refusing to hire or employ an individual, barring or discharging an individual from employment, requiring an individual to retire from employment, or discriminating against an individual in compensation or in any terms, conditions, or privileges of employment.

"Cannabis" has the meaning given to "marihuana" in section 2 of the "New Jersey Controlled Dangerous Substances Act," P.L.1970, c.226 (C.24:21-2).

"Clinical registrant" means an entity that has a written contractual relationship with an academic medical center in the region in which it has its principal place of business, which includes provisions whereby the parties will engage in clinical research related to the use of medical cannabis and the academic medical center or its affiliate will provide advice to the entity regarding patient health and safety, medical applications, and dispensing and managing controlled dangerous substances, among other areas.

"Commission" means the Cannabis Regulatory Commission established pursuant to section 31 of P.L.2019, c.153 (C.24:6I-24).

"Commissioner" means the Commissioner of Health.

"Common ownership or control" means:

(1) between two for-profit entities, the same individuals or entities own and control more than 50 percent of both entities;

(2) between a nonprofit entity and a for-profit entity, a majority of the directors, trustees, or members of the governing body of the nonprofit entity directly or indirectly own and control more than 50 percent of the for-profit entity; and

(3) between two nonprofit entities, the same directors, trustees, or governing body members comprise a majority of the voting directors, trustees, or governing body members of both nonprofits.

"Department" means the Department of Health.

"Designated caregiver" means a resident of the State who:

(1) is at least 18 years old;

(2) has agreed to assist with a registered qualifying patient's medical use of cannabis, is not currently serving as a designated caregiver for more than one other qualifying patient, and is not the qualifying patient's health care practitioner;

(3) subject to the provisions of paragraph (2) of subsection c. of section 4 of P.L.2009, c.307 (C.24:6I-4), has never been convicted of possession or sale of a controlled dangerous substance, unless such conviction occurred after the effective date of P.L.2009, c.307 (C.24:6I-1 et al.) and was for a violation of federal law related to possession or sale of cannabis that is authorized under P.L.2009, c.307 (C.24:6I-1 et al.) or P.L.2015, c.158 (C.18A:40-12.22 et al.);

(4) has registered with the commission pursuant to section 4 of P.L.2009, c.307 (C.24:6I-4), and, except in the case of a designated caregiver who is an immediate family member of the patient, has satisfied the criminal history record background check requirement of section 4 of P.L.2009, c.307 (C.24:6I-4); and

(5) has been designated as a designated caregiver by the patient when registering or renewing a registration with the commission or in other written notification to the commission.

"Dispense" means the furnishing of medical cannabis to a registered qualifying patient, designated caregiver, or institutional caregiver by a medical cannabis dispensary or clinical registrant pursuant to written instructions issued by a health care practitioner pursuant to the requirements of P.L.2009, c.307 (C.24:6I-1 et al.). The term shall include the act of furnishing medical cannabis to a medical cannabis handler for delivery to a registered qualifying patient, designated caregiver, or institutional caregiver, consistent with the requirements of subsection i. of section 27 of P.L.2019, c.153 (C.24:6I-20).

"Health care facility" means a general acute care hospital, nursing home, long term care facility, hospice care facility, group home, facility that provides services to persons with developmental disabilities, behavioral health care facility, or rehabilitation center.

"Health care practitioner" means a physician, graduate physician, advanced practice nurse, or physician assistant licensed or certified pursuant to Title 45 of the Revised Statutes who:

(1) possesses active registrations to prescribe controlled dangerous substances issued by the United States Drug Enforcement Administration and the Division of Consumer Affairs in the Department of Law and Public Safety;

(2) is the health care practitioner responsible for the ongoing treatment of a patient's qualifying medical condition, the symptoms of that condition, or the symptoms associated with the treatment of that condition, provided, however, that the ongoing treatment shall not be limited to the provision of authorization for a patient to use medical cannabis or consultation solely for that purpose; and

(3) if the patient is a minor, is a pediatric specialist.

"Immediate family" means the spouse, domestic partner, civil union partner, child, sibling, or parent of an individual, and shall include the siblings, parents, and children of the individual's spouse, domestic partner, or civil union partner, and the parents, spouses, domestic partners, or civil union partners of the individual's parents, siblings, and children.

"Institutional caregiver" means a resident of the State who:

(1) is at least 18 years old;

(2) is an employee of a health care facility;

(3) is authorized, within the scope of the individual's professional duties, to possess and administer controlled dangerous substances in connection with the care and treatment of patients and residents pursuant to applicable State and federal laws;

(4) is authorized by the health care facility employing the person to assist registered qualifying patients who are patients or residents of the facility with the medical use of cannabis, including, but not limited to, obtaining medical cannabis for registered qualifying patients and assisting registered qualifying patients with the administration of medical cannabis;

(5) subject to the provisions of paragraph (2) of subsection c. of section 4 of P.L.2009, c.307 (C.24:6I-4), has never been convicted of possession or sale of a controlled dangerous substance, unless such conviction occurred after the effective date of P.L.2009, c.307 (C.24:6I-1 et al.) and was for a violation of federal law related to possession or sale of cannabis that is authorized under P.L.2009, c.307 (C.24:6I-1 et al.) or P.L.2015, c.158 (C.18A:40-12.22 et al.); and

(6) has registered with the commission pursuant to section 4 of P.L.2009, c.307 (C.24:6I-4).

"Integrated curriculum" means an academic, clinical, or research program at an institution of higher education that is coordinated with a medical cannabis cultivator, medical cannabis manufacturer, or medical cannabis dispensary to apply theoretical principles, practical experience, or both involving the cultivation, manufacturing, dispensing, delivery, or medical use of cannabis to a specific area of study, including, but not limited to, agriculture, biology, business, chemistry, culinary studies, ecology, environmental studies, health care, horticulture, technology, or any other appropriate area of study or combined areas of study. Integrated curricula shall be subject to approval by the commission and the Office of the Secretary of Higher Education.

"Integrated curriculum permit" or "IC permit" means a permit issued to a medical cannabis cultivator, medical cannabis manufacturer, or medical cannabis dispensary that includes an integrated curriculum approved by the commission and the Office of the Secretary of Higher Education.

"Medical cannabis alternative treatment center" or "alternative treatment center" means an organization issued a permit, including a conditional permit, by the commission to operate as a medical cannabis cultivator, medical cannabis manufacturer, medical cannabis dispensary, or clinical registrant. This term shall include the organization's officers, directors, board members, and employees.

"Medical cannabis cultivator" means an organization holding a permit issued by the commission that authorizes the organization to: possess and cultivate cannabis and deliver, transfer, transport, distribute, supply, and sell medical cannabis and related supplies to other medical cannabis cultivators and to medical cannabis manufacturers, clinical registrants, and medical cannabis dispensaries, as well as to plant, cultivate, grow, and harvest medical cannabis for research purposes. A medical cannabis cultivator permit shall not authorize the permit holder to manufacture, produce, or otherwise create medical cannabis products, or to deliver, transfer, transport, distribute, supply, sell, or dispense medical cannabis, medical cannabis products, paraphernalia, or related supplies to qualifying patients, designated caregivers, or institutional caregivers.

"Medical cannabis dispensary" means an organization issued a permit by the commission that authorizes the organization to: purchase or obtain medical cannabis and related supplies from medical cannabis cultivators; purchase or obtain medical cannabis products and related supplies from medical cannabis manufacturers; purchase or obtain medical cannabis, medical cannabis products, and related supplies and paraphernalia from other medical cannabis dispensaries and from clinical registrants; deliver, transfer, transport, distribute, supply, and sell medical cannabis and medical cannabis products to other medical cannabis dispensaries; furnish medical cannabis, including medical cannabis products, to a medical cannabis handler for delivery to a registered qualifying patient, designated caregiver, or institutional caregiver consistent with the requirements of subsection i. of section 27 of P.L.2019, c.153 (C.24:6I-20); and possess, display, deliver, transfer, transport, distribute, supply, sell, and dispense medical cannabis, medical cannabis products, paraphernalia, and related supplies to qualifying patients, designated caregivers, and institutional caregivers. A medical cannabis dispensary permit shall not authorize the permit holder to cultivate medical cannabis, to produce, manufacture, or otherwise create medical cannabis products.

"Medical cannabis manufacturer" means an organization issued a permit by the commission that authorizes the organization to: purchase or obtain medical cannabis and related supplies from a medical cannabis cultivator or a clinical registrant; purchase or obtain medical cannabis products from another medical cannabis manufacturer or a clinical registrant; produce, manufacture, or otherwise create medical cannabis products; and possess, deliver, transfer, transport, distribute, supply, and sell medical cannabis products and related supplies to other medical cannabis manufacturers and to medical cannabis dispensaries and clinical registrants. A medical cannabis manufacturer permit shall not authorize the permit holder to cultivate medical cannabis or to deliver, transfer, transport, distribute, supply, sell, or dispense medical cannabis, medical cannabis products, paraphernalia, or related supplies to registered qualifying patients, designated caregivers, or institutional caregivers.

"Medical use of cannabis" means the acquisition, possession, transport, or use of cannabis or paraphernalia by a registered qualifying patient as authorized by P.L.2009, c.307 (C.24:6I-1 et al.) and P.L.2015, c.158 (C.18A:40-12.22 et al.).

"Minor" means a person who is under 18 years of age and who has not been married or previously declared by a court or an administrative agency to be emancipated.

"Paraphernalia" has the meaning given in N.J.S.2C:36-1.

"Pediatric specialist" means a physician who is a board-certified pediatrician or pediatric specialist, or an advanced practice nurse, graduate physician, or physician assistant who is certified as a pediatric specialist by an appropriate professional certification or licensing entity.

"Primary care" means the practice of family medicine, general internal medicine, general pediatrics, general obstetrics, or gynecology.

"Qualifying medical condition" means seizure disorder, including epilepsy; intractable skeletal muscular spasticity; post-traumatic stress disorder; glaucoma; positive status for human immunodeficiency virus; acquired immune deficiency syndrome; cancer; amyotrophic lateral sclerosis; multiple sclerosis; muscular dystrophy; inflammatory bowel disease, including Crohn's disease; terminal illness, if the patient has a prognosis of less than 12 months of life; anxiety; migraine; Tourette's syndrome; dysmenorrhea; chronic pain; opioid use disorder; or any other medical condition or its treatment that is approved by the commission.

"Qualifying patient" or "patient" means a resident of the State who has been authorized for the medical use of cannabis by a health care practitioner.

"Registration with the commission" means a person has met the qualification requirements for, and has been registered by the commission as, a registered qualifying patient, designated caregiver, or institutional caregiver. The commission shall establish appropriate means for health care practitioners, health care facilities, medical cannabis dispensaries, law enforcement, schools, facilities providing behavioral health services or services for persons with developmental disabilities, and other appropriate entities to verify an individual's status as a registrant with the commission.

"Significantly involved person" means a person or entity who holds at least a five percent investment interest in an entity issued, or applying for a permit to operate as, a medical cannabis cultivator, medical cannabis manufacturer, medical cannabis dispensary, or clinical registrant, or who is a decision making member of a group that holds at least a 20 percent investment interest in an entity issued, or applying for a permit to operate as, a medical cannabis cultivator, medical cannabis manufacturer, medical cannabis dispensary, or clinical registrant, in which no member of that group holds more than a five percent interest in the total group investment interest, and the person or entity makes controlling decisions regarding the operations of the entity issued, or applying for a permit to operate as, a medical cannabis cultivator, medical cannabis manufacturer, medical cannabis dispensary, or clinical registrant.

"Terminally ill" means having an illness or condition with a prognosis of less than 12 months of life.

"Usable cannabis" means the dried leaves and flowers of cannabis, and any mixture or preparation thereof, and does not include the seeds, stems, stalks, or roots of the plant.

(cf: P.L.2021, c.16, s.4)

14. Section 11 of P.L.2017, c.28 (C.24:21-15.2) is amended to read as follows:

11. a. A practitioner shall not issue an initial prescription for an opioid drug which is a prescription drug as defined in section 2 of P.L.2003, c.280 (C.45:14-41) in a quantity exceeding a five-day supply for treatment of acute pain. Any prescription for acute pain pursuant to this subsection shall be for the lowest effective dose of immediate-release opioid drug.

b. Prior to issuing an initial prescription of a Schedule II controlled dangerous substance or any opioid drug which is a prescription drug as defined in section 2 of P.L.2003, c.280 (C.45:14-41) in a course of treatment for acute or chronic pain, a practitioner shall:

(1) take and document the results of a thorough medical history, including the patient's experience with non-opioid medication and non-pharmacological pain management approaches and substance use disorder history;

(2) conduct, as appropriate, and document the results of a physical examination;

(3) develop a treatment plan, with particular attention focused on determining the cause of the patient's pain;

(4) access relevant prescription monitoring information under the Prescription Monitoring Program pursuant to section 8 of P.L.2015, c.74 (C. 45:1-46.1); and

(5) limit the supply of any opioid drug prescribed for acute pain to a duration of no more than five days as determined by the directed dosage and frequency of dosage.

c. No less than four days after issuing the initial prescription pursuant to subsection a. of this subsection, the practitioner, after consultation with the patient, may issue a subsequent prescription for the drug to the patient in any quantity that complies with applicable State and federal laws, provided that:

(1) the subsequent prescription would not be deemed an initial prescription under this section;

(2) the practitioner determines the prescription is necessary and appropriate to the patient's treatment needs and documents the rationale for the issuance of the subsequent prescription; and

(3) the practitioner determines that issuance of the subsequent prescription does not present an undue risk of abuse, addiction, or diversion and documents that determination.

d. Prior to issuing the initial prescription of a Schedule II controlled dangerous substance or any opioid drug which is a prescription drug as defined in section 2 of P.L.2003, c.280 (C.45:14-41) in a course of treatment for acute pain and prior to issuing a prescription at the outset of a course of treatment for chronic pain, a practitioner shall discuss with the patient, or the patient's parent or guardian if the patient is under 18 years of age and is not an emancipated minor, the risks associated with the drugs being prescribed, including but not limited to:

(1) the risks of addiction and overdose associated with opioid drugs and the dangers of taking opioid drugs with alcohol, benzodiazepines and other central nervous system depressants;

(2) the reasons why the prescription is necessary;

(3) alternative treatments that may be available; and

(4) risks associated with the use of the drugs being prescribed, specifically that opioids are highly addictive, even when taken as prescribed, that there is a risk of developing a physical or psychological dependence on the controlled dangerous substance, and that the risks of taking more opioids than prescribed, or mixing sedatives, benzodiazepines or alcohol with opioids, can result in fatal respiratory depression.

The practitioner shall include a note in the patient's medical record that the patient or the patient's parent or guardian, as applicable, has discussed with the practitioner the risks of developing a physical or psychological dependence on the controlled dangerous substance and alternative treatments that may be available. The Division of Consumer Affairs shall develop and make available to practitioners guidelines for the discussion required pursuant to this subsection.

e. Prior to the commencement of an ongoing course of treatment for chronic pain with a Schedule II controlled dangerous substance or any opioid, the practitioner shall enter into a pain management agreement with the patient.

f. When a Schedule II controlled dangerous substance or any prescription opioid drug is continuously prescribed for three months or more for chronic pain, the practitioner shall:

(1) review, at a minimum of every three months, the course of treatment, any new information about the etiology of the pain, and the patient's progress toward treatment objectives and document the results of that review;

(2) assess the patient prior to every renewal to determine whether the patient is experiencing problems associated with physical and psychological dependence and document the results of that assessment;

(3) periodically make reasonable efforts, unless clinically contraindicated, to either stop the use of the controlled substance, decrease the dosage, try other drugs or treatment modalities in an effort to reduce the potential for abuse or the development of physical or psychological dependence and document with specificity the efforts undertaken;

(4) review the Prescription Drug Monitoring information in accordance with section 8 of P.L.2015, c.74 (C. 45:1-46.1); and

(5) monitor compliance with the pain management agreement and any recommendations that the patient seek a referral.

g. As used in this section:

"Acute pain" means pain, whether resulting from disease, accidental or intentional trauma, or other cause, that the practitioner reasonably expects to last only a short period of time. "Acute pain" does not include chronic pain, pain being treated as part of cancer care, hospice or other end of life care, or pain being treated as part of palliative care.

"Chronic pain" means pain that persists or recurs for more than three months.

"Initial prescription" means a prescription issued to a patient who:

(1) has never previously been issued a prescription for the drug or its pharmaceutical equivalent; or

(2) was previously issued a prescription for, or used or was administered the drug or its pharmaceutical equivalent, but the date on which the current prescription is being issued is more than one year after the date the patient last used or was administered the drug or its equivalent.

When determining whether a patient was previously issued a prescription for, or used or was administered a drug or its pharmaceutical equivalent, the practitioner shall consult with the patient and review the patient's medical record and prescription monitoring information.

"Opioid antidote" means any drug, regardless of dosage amount or method of administration, which has been approved by the United States Food and Drug Administration (FDA) for the treatment of an opioid overdose. "Opioid antidote" includes, but is not limited to, naloxone hydrochloride, in any dosage amount, which is administered through nasal spray or any other FDA-approved means or methods.

"Pain management agreement" means a written contract or agreement that is executed between a practitioner and a patient, prior to the commencement of treatment for chronic pain using a Schedule II controlled dangerous substance or any opioid drug which is a prescription drug as defined in section 2 of P.L.2003, c.280 (C.45:14-41), as a means to:

(1) prevent the possible development of physical or psychological dependence in the patient;

(2) document the understanding of both the practitioner and the patient regarding the patient's pain management plan;

(3) establish the patient's rights in association with treatment, and the patient's obligations in relation to the responsible use, discontinuation of use, and storage of Schedule II controlled dangerous substances, including any restrictions on the refill of prescriptions or the acceptance of Schedule II prescriptions from practitioners;

(4) identify the specific medications and other modes of treatment, including physical therapy or exercise, relaxation, or psychological counseling, that are included as a part of the pain management plan;

(5) specify the measures the practitioner may employ to monitor the patient's compliance, including but not limited to random specimen screens and pill counts; and

(6) delineate the process for terminating the agreement, including the consequences if the practitioner has reason to believe that the patient is not complying with the terms of the agreement.

"Practitioner" means a medical doctor, doctor of osteopathy, dentist, optometrist, podiatrist, graduate physician, physician assistant, certified nurse midwife, or advanced practice nurse, acting within the scope of practice of their professional license pursuant to Title 45 of the Revised Statutes.

h. This section shall not apply to a prescription for a patient who is currently in active treatment for cancer, receiving hospice care from a licensed hospice or palliative care, or is a resident of a long term care facility, or to any medications that are being prescribed for use in the treatment of substance use disorder.

i. Every policy, contract or plan delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, and every contract purchased by the School Employees' Health Benefits Commission or State Health Benefits Commission, on or after the effective date of this act, that provides coverage for prescription drugs subject to a co-payment, coinsurance or deductible shall charge a co-payment, coinsurance or deductible for an initial prescription of an opioid drug prescribed pursuant to this section that is either:

(1) proportional between the cost sharing for a 30-day supply and the amount of drugs the patient was prescribed; or

(2) equivalent to the cost sharing for a full 30-day supply of the opioid drug, provided that no additional cost sharing may be charged for any additional prescriptions for the remainder of the 30-day supply.

j. (1) Subject to paragraph (2) of this subsection, if a health care practitioner issues a prescription for an opioid drug which is a controlled dangerous substance to a patient, the prescriber shall additionally issue the patient a prescription for an opioid antidote if any of the following conditions is present:

(a) the patient has a history of substance use disorder;

(b) the prescription for the opioid drug is for a daily dose of more than 90 morphine milligram equivalents; or

(c) the patient holds a current, valid prescription for a benzodiazepine drug that is a Schedule III or Schedule IV controlled dangerous substance.

(2) A practitioner shall not be required to issue more than one prescription for an opioid antidote to a patient under paragraph (1) of this subsection per year.

(3) Nothing in paragraph (2) of this subsection shall be construed to prohibit a practitioner from issuing additional prescriptions for an opioid antidote to a patient upon the patient's request or when the practitioner determines there is a clinical or practical need for the additional prescription.

(cf: P.L.2023, c.177, s.57)

15. (New section) The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of section 11 of this act and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program.

16. This act shall take effect immediately.

STATEMENT

This bill establishes the “Graduate Physician Licensing Act.”

Under this bill, the State Board of Medical Examiners (board) will issue a license as a graduate physician to an applicant who, among other things: 1) is at least 18 years of age; 2) is a medical school graduate; 3) has successfully completed Step 2 of the physician licensing examination; 4) has not completed an approved postgraduate residency; and 5) has no criminal history. Alternatively, the board may accept proof that an applicant holds a current graduate physician license in a state which has standards substantially equivalent to those of New Jersey.

Graduate physicians will be authorized to provide primary care services in medically underserved areas of the State, subject to any restrictions set forth in a collaborative practice arrangement with a collaborating physician, who is responsible for supervising the graduate physician at all times. The delivery of health care services is to be within the scope of practice of the graduate physician and consistent with that graduate physician's skill, training, and competence and the skill and training of the collaborating physician. Graduate physicians may be delegated the authority to prescribe controlled dangerous substances and authorize patients for medical cannabis, subject to certain restrictions.

This bill requires health benefits plans, the Medicaid and NJ FamilyCare programs, and the State Health Benefits Program and the School Employees’ Health Benefits Program, to reimburse a graduate physician for the diagnosis, consultation, or treatment of patients on the same basis that reimbursement is provided for the service when it is delivered by another comparable mid-level health provider including, but not limited to, a physician assistant.