Eight states let physician assistants practice without a supervisory or collaborative agreement with a specific physician: North Dakota, Utah, Wyoming, Iowa, New Hampshire, South Dakota, Oklahoma, and North Carolina.1American Academy of Physician Associates. PA Practice Modernization A handful of additional states, Montana among them, allow the same thing once a PA has logged enough clinical hours. Most of these laws were passed between 2023 and 2025, so the list of states where PAs can practice independently looks very different than it did even two years ago.
The Eight States That Removed the Supervisory Agreement
In these states, a PA no longer needs a named physician to sign a supervisory or collaborative practice agreement in order to see patients:1American Academy of Physician Associates. PA Practice Modernization
- North Dakota
- Utah
- Wyoming
- Iowa
- New Hampshire
- South Dakota
- Oklahoma
- North Carolina
The eight states don’t treat the change identically. Some open independent practice to every licensed PA. Others gate it behind a clinical experience threshold, so a newly graduated PA still works under an agreement until they hit the required hours.
South Dakota
Under a 2025 law, a PA in South Dakota can practice without a collaborative agreement once they hold NCCPA certification and have completed at least 2,080 practice hours. Below that threshold, an agreement is still required. The same law authorizes PAs to bill for and receive direct payment for medically necessary services.2South Dakota Legislature. 2025 House Bill 1071
Oklahoma
Oklahoma’s law took effect in August 2025 and sets the bar at 6,240 clinical hours. Once a PA crosses that threshold, they no longer need a practice agreement and may prescribe Schedule III through V controlled substances independently. PAs still working under a practice agreement gained broader Schedule II prescribing authority under the same law. Independently practicing PAs in Oklahoma remain limited to Schedules III through V; the broader Schedule II authority is tied to keeping a physician agreement in place.
North Carolina
North Carolina’s Healthcare Workforce Reforms bill authorized “team-based practice” for experienced PAs, with most provisions taking effect in 2026.3North Carolina Medical Board. Healthcare Workforce Reforms Bill Will Impact Physician, PA Licensure
The Other Five
North Dakota, Utah, Wyoming, Iowa, and New Hampshire have also removed the supervisory agreement requirement, though the specific experience thresholds and effective dates aren’t detailed in the same public materials as South Dakota, Oklahoma, and North Carolina. Any PA planning a move should verify current requirements with the state’s licensing board before assuming a clean slate on day one.
Montana’s Experience-Gated Independence
Montana isn’t on the AAPA’s list of states that eliminated the agreement outright, but it operates a conditional model worth knowing about. Under a 2023 law, PAs with at least 8,000 hours of postgraduate clinical experience are exempt from any collaborative agreement requirement.4Montana State Legislature. An Act Providing for Independent Practice of Physician Assistants PAs below that threshold must maintain a collaborative agreement with a licensed physician or with a PA who has already reached 8,000 hours.
That 8,000-hour requirement is the highest experience threshold among states offering any form of independent PA practice. For a full-time PA, it means roughly four years of clinical work before qualifying. The Montana Board of Medical Examiners updated its rules to stop requiring supervision agreements for qualifying PAs and will not discipline PAs for practicing without one once they meet the experience standard.5Montana Board of Medical Examiners. Notice of Public Hearing on Proposed Amendment and Repeal Pertaining to Physician Assistants
What Independent Practice Does and Doesn’t Include
Removing a supervisory agreement doesn’t mean PAs stop working with physicians. It means collaboration happens because it makes clinical sense, not because a statute requires a signed document.1American Academy of Physician Associates. PA Practice Modernization Independently practicing PAs still consult specialists, refer complex cases, and work within care teams. No single physician has to be named on paper as a supervisor.
Clinical scope covers what PAs have always been trained for: taking histories, performing physical exams, diagnosing, ordering and interpreting labs and imaging, developing treatment plans, performing procedures, and counseling patients. The most common expansion in independence states is prescriptive authority, particularly for controlled substances.
Prescribing Controlled Substances
Federal law requires any practitioner who prescribes controlled substances to register with the Drug Enforcement Administration.6Office of the Law Revision Counsel. 21 USC 822 – Persons Required to Register The DEA relies on state boards to determine whether a PA is authorized to prescribe and which schedules they can handle.7Diversion Control Division. Registration Q&A A separate DEA registration is needed at each location where a PA dispenses controlled substances. PAs must also satisfy the training requirements from the Consolidated Appropriations Act of 2023 when applying for or renewing their registration.
Which schedules a PA can prescribe depends on state law even after the supervisory agreement is gone. Oklahoma is the clearest example: independent PAs are capped at Schedules III through V, while PAs maintaining a practice agreement have broader Schedule II authority.
Hospital Privileges Are Separate
Independent practice under state law doesn’t automatically translate to hospital privileges. Hospitals credential separately, and the Joint Commission requires PAs to be granted privileges before providing care in accredited facilities, regardless of state-level practice authority.8Joint Commission. Credentialing and Privileging – Requirements for Physician Assistants The hospital’s governing board evaluates each applicant on background, training, competency, and ability to work with others. Where PA privileges were historically tied to a supervising physician’s staff membership, removing the supervisory requirement may open new pathways, but hospital bylaws often lag behind state law changes.
Practice Ownership Is Separate Too
Independence in patient care doesn’t automatically mean a PA can open and own a medical practice. Ownership rules depend on state corporate law, professional service corporation statutes, and the corporate practice of medicine doctrine, all of which vary widely.9American Academy of Physician Associates. Practice Partnership and Ownership Some states let PAs form professional corporations and hold shares. Others restrict medical practice ownership to physicians. Even where PA ownership is allowed, Medicaid and private insurers may set separate rules about reimbursement through a PA-owned entity. Consulting an attorney familiar with both state corporate law and PA practice regulations before investing is the safer path, because the intersection creates traps that aren’t obvious from reading any single statute.
Getting Paid: Medicare Direct Billing
Independent practice is only useful if the PA can actually collect for the work. Since January 1, 2022, PAs have been authorized to bill Medicare directly and receive payment in their own name rather than routing everything through an employer.10CMS. Calendar Year (CY) 2022 Medicare Physician Fee Schedule Final Rule That change was what made solo PA practice financially workable for Medicare patients.
Medicare still reimburses PA services at 85% of the physician rate under the Physician Fee Schedule.11CMS. Physician Assistants (PAs) The 15% haircut applies whether the PA is independent or under an agreement, and whether the service is identical to what a physician would provide.
If state law prohibits PAs from receiving direct payment, Medicare will not override that restriction. Medicaid rules are set separately by each state and may differ from Medicare. Private insurers set their own credentialing and reimbursement policies, and some still require a named supervising physician before they’ll credential a PA on a panel.
Baseline Qualifications Still Apply
Every state requires PAs to graduate from an accredited PA program and pass the Physician Assistant National Certifying Exam (PANCE) administered by the National Commission on Certification of Physician Assistants.12NCCPA. Become Certified NCCPA certification is a licensure prerequisite in all 50 states.13American Academy of Physician Associates. Become a PA – Getting Your Prerequisites and Certification States that grant expanded autonomy layer additional requirements on top: the 2,080-hour threshold in South Dakota, 6,240 in Oklahoma, and 8,000 in Montana. Some states require a PA to file an affidavit or documentation attesting to the completed hours.2South Dakota Legislature. 2025 House Bill 1071
Because the map has shifted quickly and continues to shift with each legislative session, any PA weighing a move or a career change should confirm current status directly with the target state’s licensing board before acting on it.