Changes in practice/regulation of physician assistants

by Gerald Zarlengo, MD, Chairman & CEO, COPIC Insurance Company


Colorado Medical Board (CMB) Rule 400 outlines the rules and regulations regarding the licensure of and practice by PAs.

During the 2019 Colorado legislative session, House Bill 19-1095 was passed, which established requirements for the supervision of PAs in the Medical Practice Act (MPA).

As a result of the passage of HB 19-1095, some sections of CMB Rule 400 regarding supervision and review requirements were removed because they are now included in the MPA.

HB 19-1095 changed the MPA as follows:

  • A licensed physician can be responsible for the direction and supervision of up to eight PAs at any one time.
  • A licensed physician shall not be made responsible for the direction and supervision of more than four PAs unless the physician agrees to assume the responsibility; the physician has sole discretion to assume or refuse such responsibility; and an employer shall not require a licensed physician to assume such responsibility as a condition of employment.
  • The bill increases the number of PAs who sit on the CMB from one to two.

CMB Rule 400 and the MPA are interrelated and should be viewed together for all the requirements for PAs and their supervising physicians.


CMB Rule 400 was revised to state: “The requirements for a Supervisory Plan or a Practice Agreement applies to all supervising physicians and physician assistants as of August 2, 2019.” In other words, a PA must be operating under either a Supervisory Plan (new PAs) or a Practice Agreement (all other PAs).

Within 30 days after a new PA completes 160 working hours, the primary supervising physician must complete an initial performance assessment and a supervisory plan for the PA.

Elements that should be incorporated in a supervisory plan may include, but are not limited to:

  • Nature of the clinical practice (areas of specialty, practice sites, populations served, ambulatory and inpatient expectations, etc.);
  • Specific expectations and duties of the PA;
  • Expectations around physician(s) support, supervision, consultation and back up;
  • Methods and modes of communication, co-management and collaboration;
  • Specific clinical instances in which the PA should ask for physician backup;
  • Plan for ongoing professional education and skills development for the PA;
  • List of secondary supervisors anticipated to participate in the PA’s practice;
  • Schedule of performance assessments and anticipated modalities by which the practice will be assessed and domains that will be assessed;
  • Other pertinent elements of collaborative, team-based practice applicable to the specific practice or individual physician and PA.

The supervision of PAs who have practiced at least 12 months and are new to a practice area or new to Colorado, and all other experienced PAs (those who have practiced in Colorado at least three years) is determined by a practice agreement. The practice agreement must include:

  • A process by which a PA and a supervising physician communicate and make decisions concerning patients’ medical treatment that utilizes the knowledge and skills of the PA and the supervising physician based on their respective education, training, and experience;
  • A protocol for designating an alternative physician for consultation when the supervising physician is unavailable;
  • The signatures of the PA and supervising physician;
  • A termination provision that allows the PA or the supervising physician to terminate the practice agreement after providing written notice of his or her intent to do so at least 30 days before the date of termination. If a practice agreement is terminated, the PA and the PA’s primary supervising physician must create a new practice agreement within 45 days after the date the previous practice agreement was terminated.

In addition to these components, a practice agreement may impose conditions concerning specific duties, procedures or drugs. If the terms or conditions of a practice agreement change, both the PA and the supervising physician must sign and date the updated practice agreement.

Previously, a supervising physician was required to complete a performance assessment for an experienced PA at least annually, but now there must be a “periodic” assessment, with more frequent assessments for new PAs or those new to a practice setting (see chart below). The components of a performance evaluation have not changed in Rule 400.

COPIC has created a guide on Rule 400/supervising PAs that includes this information along with additional details about PA and supervising physician responsibilities, special requirements for acute care hospital settings, and prescription and dispensing of drugs by PAs. You can download this at

Categories: Communications, Colorado Medicine, COPIC Comment