House Study Bill 20 - Introduced HOUSE FILE _____ BY (PROPOSED COMMITTEE ON HUMAN RESOURCES BILL BY CHAIRPERSON MILLER) A BILL FOR An Act establishing an interstate medical licensure compact. 1 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: 2 TLSB 1270YC (2) 86 tr/nh

H.F. _____ Section 1. NEW SECTION . 148G.1 Interstate medical licensure 1 compact. 2 1. Purpose. 3 a. In order to strengthen access to health care, and in 4 recognition of the advances in the delivery of health care, 5 the member states of the interstate medical licensure compact 6 have allied in common purpose to develop a comprehensive 7 process that complements the existing licensing and regulatory 8 authority of state medical boards and provides a streamlined 9 process that allows physicians to become licensed in multiple 10 states, thereby enhancing the portability of a medical license 11 and ensuring the safety of patients. The compact creates 12 another pathway for licensure and does not otherwise change 13 a state’s existing medical practice act. The compact also 14 adopts the prevailing standard for licensure and affirms that 15 the practice of medicine occurs where the patient is located 16 at the time of the physician-patient encounter, and therefore, 17 requires the physician to be under the jurisdiction of the 18 state medical board where the patient is located. 19 b. State medical boards that participate in the compact 20 retain the jurisdiction to impose an adverse action against 21 a license to practice medicine in that state issued to a 22 physician through the procedures in the compact. 23 2. Definitions. In this compact: 24 a. “Bylaws” means those bylaws established by the interstate 25 commission pursuant to subsection 11 for its governance, or for 26 directing and controlling its actions and conduct. 27 b. “Commissioner” means the voting representative appointed 28 by each member board pursuant to subsection 11. 29 c. “Conviction” means a finding by a court that 30 an individual is guilty of a criminal offense through 31 adjudication, or entry of a plea of guilt or no contest to the 32 charge by the offender. Evidence of an entry of a conviction 33 of a criminal offense by the court shall be considered final 34 for purposes of disciplinary action by a member board. 35 -1- LSB 1270YC (2) 86 tr/nh 1/ 23

H.F. _____ d. “Expedited license” means a full and unrestricted medical 1 license granted by a member state to an eligible physician 2 through the process set forth in the compact. 3 e. “Interstate commission” means the interstate commission 4 created pursuant to this section. 5 f. “License” means authorization by a state for a physician 6 to engage in the practice of medicine, which would be unlawful 7 without the authorization. 8 g. “Medical practice act” means laws and regulations 9 governing the practice of allopathic and osteopathic medicine 10 within a member state. 11 h. “Member board” means a state agency in a member state 12 that acts in the sovereign interests of the state by protecting 13 the public through licensure, regulation, and education of 14 physicians as directed by the state government. 15 i. “Member state” means a state that has enacted the 16 compact. 17 j. “Offense” means a felony, gross misdemeanor, or crime of 18 moral turpitude. 19 k. “Physician” means any person who satisfies all of the 20 following: 21 (1) Is a graduate of a medical school accredited by the 22 liaison committee on medical education, the commission on 23 osteopathic college accreditation, or a medical school listed 24 in the international medical education directory or its 25 equivalent. 26 (2) Passed each component of the United States medical 27 licensing examination or the comprehensive osteopathic medical 28 licensing examination within three attempts, or any of its 29 predecessor examinations accepted by a state medical board as 30 an equivalent examination for licensure purposes. 31 (3) Successfully completed graduate medical education 32 approved by the accreditation council for graduate medical 33 education or the American osteopathic association. 34 (4) Holds specialty certification or a time-unlimited 35 -2- LSB 1270YC (2) 86 tr/nh 2/ 23

H.F. _____ specialty certificate recognized by the American board of 1 medical specialties or the American osteopathic association’s 2 bureau of osteopathic specialists. 3 (5) Possesses a full and unrestricted license to engage in 4 the practice of medicine issued by a member board. 5 (6) Has never been convicted, received adjudication, 6 deferred adjudication, community supervision, or deferred 7 disposition for any offense by a court of appropriate 8 jurisdiction. 9 (7) Has never held a license authorizing the practice of 10 medicine subjected to discipline by a licensing agency in any 11 state, federal, or foreign jurisdiction, excluding any action 12 related to nonpayment of fees related to a license. 13 (8) Has never had a controlled substance license or permit 14 suspended or revoked by a state or the United States drug 15 enforcement administration. 16 (9) Is not under active investigation by a licensing agency 17 or law enforcement authority in any state, federal, or foreign 18 jurisdiction. 19 l. “Practice of medicine” means the clinical prevention, 20 diagnosis, or treatment of human disease, injury, or condition 21 requiring a physician to obtain and maintain a license in 22 compliance with the medical practice act of a member state. 23 m. “Rule” means a written statement by the interstate 24 commission promulgated pursuant to subsection 12 that is of 25 general applicability, implements, interprets, or prescribes 26 a policy or provision of the compact, or an organizational, 27 procedural, or practice requirement of the interstate 28 commission, and has the force and effect of statutory law in a 29 member state, and includes the amendment, repeal, or suspension 30 of an existing rule. 31 n. “State” means any state, commonwealth, district, or 32 territory of the United States. 33 o. “State of principal license” means a member state where 34 a physician holds a license to practice medicine and which 35 -3- LSB 1270YC (2) 86 tr/nh 3/ 23

H.F. _____ has been designated as such by the physician for purposes of 1 registration and participation in the compact. 2 3. Eligibility. 3 a. A physician must meet the eligibility requirements as 4 defined in subsection 2, paragraph “k” , to receive an expedited 5 license under the terms and provisions of the compact. 6 b. A physician who does not meet the requirements of 7 subsection 2, paragraph “k” , may obtain a license to practice 8 medicine in a member state if the individual complies with all 9 laws and requirements, other than the compact, relating to the 10 issuance of a license to practice medicine in that state. 11 4. Designation of state of principal license. 12 a. A physician shall designate a member state as the state 13 of principal license for purposes of registration for expedited 14 licensure through the compact if the physician possesses a full 15 and unrestricted license to practice medicine in that state, 16 and the state is: 17 (1) The state of primary residence for the physician, or 18 (2) The state where at least twenty-five percent of the 19 practice of medicine occurs, or 20 (3) The location of the physician’s employer, or 21 (4) If no state qualifies under subparagraph (1), 22 subparagraph (2), or subparagraph (3), the state designated as 23 state of residence for purposes of federal income tax. 24 b. A physician may redesignate a member state as the state 25 of principal license at any time, as long as the state meets 26 the requirements in paragraph “a” . 27 c. The interstate commission is authorized to develop rules 28 to facilitate redesignation of another member state as the 29 state of principal license. 30 5. Application and issuance of expedited licensure. 31 a. A physician seeking licensure through the compact shall 32 file an application for an expedited license with the member 33 board of the state selected by the physician as the state of 34 principal license. 35 -4- LSB 1270YC (2) 86 tr/nh 4/ 23

H.F. _____ b. Upon receipt of an application for an expedited 1 license, the member board within the state selected as 2 the state of principal license shall evaluate whether the 3 physician is eligible for expedited licensure and issue a 4 letter of qualification, verifying or denying the physician’s 5 eligibility, to the interstate commission. 6 (1) Static qualifications, which include verification of 7 medical education, graduate medical education, results of any 8 medical or licensing examination, and other qualifications as 9 determined by the interstate commission through rule, shall 10 not be subject to additional primary source verification where 11 already primary source-verified by the state of principal 12 license. 13 (2) The member board within the state selected as the 14 state of principal license shall, in the course of verifying 15 eligibility, perform a criminal background check of an 16 applicant, including the use of the results of fingerprint or 17 other biometric data checks compliant with the requirements 18 of the federal bureau of investigation, with the exception 19 of federal employees who have suitability determination in 20 accordance with 5 C.F.R. §731.202. 21 (3) Appeal on the determination of eligibility shall be made 22 to the member state where the application was filed and shall 23 be subject to the law of that state. 24 c. Upon verification in paragraph “b” , physicians eligible 25 for an expedited license shall complete the registration 26 process established by the interstate commission to receive a 27 license in a member state selected pursuant to paragraph “a” , 28 including the payment of any applicable fees. 29 d. After receiving verification of eligibility under 30 paragraph “b” and any fees under paragraph “c” , a member board 31 shall issue an expedited license to the physician. This 32 license shall authorize the physician to practice medicine in 33 the issuing state consistent with the medical practice act and 34 all applicable laws and regulations of the issuing member board 35 -5- LSB 1270YC (2) 86 tr/nh 5/ 23

H.F. _____ and member state. 1 e. An expedited license shall be valid for a period 2 consistent with the licensure period in the member state and in 3 the same manner as required for other physicians holding a full 4 and unrestricted license within the member state. 5 f. An expedited license obtained through the compact shall 6 be terminated if a physician fails to maintain a license in 7 the state of principal license for a nondisciplinary reason, 8 without redesignation of a new state of principal license. 9 g. The interstate commission is authorized to develop rules 10 regarding the application process, including payment of any 11 applicable fees, and the issuance of an expedited license. 12 6. Fees for expedited licensure. 13 a. A member state issuing an expedited license authorizing 14 the practice of medicine in that state may impose a fee for a 15 license issued or renewed through the compact. 16 b. The interstate commission is authorized to develop rules 17 regarding fees for expedited licenses. 18 7. Renewal and continued participation. 19 a. A physician seeking to renew an expedited license granted 20 in a member state shall complete a renewal process with the 21 interstate commission if the physician satisfies the following: 22 (1) Maintains a full and unrestricted license in a state of 23 principal license. 24 (2) Has not been convicted, received adjudication, deferred 25 adjudication, community supervision, or deferred disposition 26 for any offense by a court of appropriate jurisdiction. 27 (3) Has not had a license authorizing the practice of 28 medicine subject to discipline by a licensing agency in any 29 state, federal, or foreign jurisdiction, excluding any action 30 related to nonpayment of fees related to a license. 31 (4) Has not had a controlled substance license or permit 32 suspended or revoked by a state or the United States drug 33 enforcement administration. 34 b. Physicians shall comply with all continuing professional 35 -6- LSB 1270YC (2) 86 tr/nh 6/ 23

H.F. _____ development or continuing medical education requirements for 1 renewal of a license issued by a member state. 2 c. The interstate commission shall collect any renewal fees 3 charged for the renewal of a license and distribute the fees 4 to the applicable member board. 5 d. Upon receipt of any renewal fees collected in paragraph 6 “c” , a member board shall renew the physician’s license. 7 e. Physician information collected by the interstate 8 commission during the renewal process will be distributed to 9 all member boards. 10 f. The interstate commission is authorized to develop rules 11 to address renewal of licenses obtained through the compact. 12 8. Coordinated information system. 13 a. The interstate commission shall establish a database of 14 all physicians licensed, or who have applied for licensure, 15 under subsection 5. 16 b. Notwithstanding any other provision of law, member boards 17 shall report to the interstate commission any public action 18 or complaints against a licensed physician who has applied or 19 received an expedited license through the compact. 20 c. Member boards shall report disciplinary or investigatory 21 information determined as necessary and proper by rule of the 22 interstate commission. 23 d. Member boards may report any nonpublic complaint, 24 disciplinary, or investigatory information not required by 25 paragraph “c” to the interstate commission. 26 e. Member boards shall share complaint or disciplinary 27 information about a physician upon request of another member 28 board. 29 f. All information provided to the interstate commission or 30 distributed by member boards shall be confidential, filed under 31 seal, and used only for investigatory or disciplinary matters. 32 g. The interstate commission is authorized to develop rules 33 for mandated or discretionary sharing of information by member 34 boards. 35 -7- LSB 1270YC (2) 86 tr/nh 7/ 23

H.F. _____ 9. Joint investigations. 1 a. Licensure and disciplinary records of physicians are 2 deemed investigative. 3 b. In addition to the authority granted to a member board by 4 its respective medical practice Act or other applicable state 5 law, a member board may participate with other member boards 6 in joint investigations of physicians licensed by the member 7 boards. 8 c. A subpoena issued by a member state shall be enforceable 9 in other member states. 10 d. Member boards may share any investigative, litigation, or 11 compliance materials in furtherance of any joint or individual 12 investigation initiated under the compact. 13 e. Any member state may investigate actual or alleged 14 violations of the statutes authorizing the practice of medicine 15 in any other member state in which a physician holds a license 16 to practice medicine. 17 10. Disciplinary actions. 18 a. Any disciplinary action taken by any member board against 19 a physician licensed through the compact shall be deemed 20 unprofessional conduct which may be subject to discipline 21 by other member boards, in addition to any violation of the 22 medical practice Act or regulations in that state. 23 b. If a license granted to a physician by the member board 24 in the state of principal license is revoked, surrendered, 25 or relinquished in lieu of discipline, or suspended, then 26 all licenses issued to the physician by member boards shall 27 automatically be placed, without further action necessary by 28 any member board, on the same status. If the member board 29 in the state of principal license subsequently reinstates 30 the physician’s license, a license issued to the physician 31 by any other member board shall remain encumbered until that 32 respective member board takes action to reinstate the license 33 in a manner consistent with the medical practice Act of that 34 state. 35 -8- LSB 1270YC (2) 86 tr/nh 8/ 23

H.F. _____ c. If disciplinary action is taken against a physician by a 1 member board not in the state of principal license, any other 2 member board may deem the action conclusive as to matter of law 3 and fact decided and either: 4 (1) Impose the same or lesser sanctions against the 5 physician so long as such sanctions are consistent with the 6 medical practice Act of that state, or 7 (2) Pursue separate disciplinary action against the 8 physician under its respective medical practice Act, regardless 9 of the action taken in other member states. 10 d. If a license granted to a physician by a member board is 11 revoked, surrendered, or relinquished in lieu of discipline, 12 or suspended, then any licenses issued to the physician by 13 any other member boards shall be suspended, automatically and 14 immediately without further action necessary by the other 15 member boards, for ninety days upon entry of the order by the 16 disciplining board, to permit the member boards to investigate 17 the basis for the action under the medical practice Act of that 18 state. A member board may terminate the automatic suspension 19 of the license it issued prior to the completion of the 20 ninety-day suspension period in a manner consistent with the 21 medical practice Act of that state. 22 11. Interstate medical licensure compact commission. 23 a. The member states hereby create the interstate medical 24 licensure compact commission. 25 b. The purpose of the interstate commission is the 26 administration of the interstate medical licensure compact, 27 which is a discretionary state function. 28 c. The interstate commission shall be a body corporate 29 and joint agency of the member states and shall have all the 30 responsibilities, powers, and duties set forth in the compact, 31 and such additional powers as may be conferred upon it by a 32 subsequent concurrent action of the respective legislatures of 33 the member states in accordance with the terms of the compact. 34 d. The interstate commission shall consist of two voting 35 -9- LSB 1270YC (2) 86 tr/nh 9/ 23

H.F. _____ representatives appointed by each member state who shall serve 1 as commissioners. In states where allopathic and osteopathic 2 physicians are regulated by separate member boards, or if 3 the licensing and disciplinary authority is split between 4 multiple member boards within a member state, the member state 5 shall appoint one representative from each member board. A 6 commissioner shall be one of the following: 7 (1) An allopathic or osteopathic physician appointed to a 8 member board. 9 (2) An executive director, executive secretary, or similar 10 executive of a member board. 11 (3) A member of the public appointed to a member board. 12 e. The interstate commission shall meet at least once each 13 calendar year. A portion of this meeting shall be a business 14 meeting to address such matters as may properly come before 15 the commission, including the election of officers. The 16 chairperson may call additional meetings and shall call for a 17 meeting upon the request of a majority of the member states. 18 f. The bylaws may provide for meetings of the interstate 19 commission to be conducted by telecommunication or electronic 20 communication. 21 g. Each commissioner participating at a meeting of the 22 interstate commission is entitled to one vote. A majority of 23 commissioners shall constitute a quorum for the transaction 24 of business, unless a larger quorum is required by the bylaws 25 of the interstate commission. A commissioner shall not 26 delegate a vote to another commissioner. In the absence of its 27 commissioner, a member state may delegate voting authority for 28 a specified meeting to another person from that state who shall 29 meet the requirements of paragraph “d” . 30 h. The interstate commission shall provide public notice 31 of all meetings and all meetings shall be open to the public. 32 The interstate commission may close a meeting, in full or 33 in portion, where it determines by a two-thirds vote of the 34 commissioners present that an open meeting would be likely to 35 -10- LSB 1270YC (2) 86 tr/nh 10/ 23

H.F. _____ result in one or more of the following: 1 (1) Relate solely to the internal personnel practices and 2 procedures of the interstate commission. 3 (2) Discuss matters specifically exempted from disclosure 4 by federal statute. 5 (3) Discuss trade secrets, commercial, or financial 6 information that is privileged or confidential. 7 (4) Involve accusing a person of a crime, or formally 8 censuring a person. 9 (5) Discuss information of a personal nature where 10 disclosure would constitute a clearly unwarranted invasion of 11 personal privacy. 12 (6) Discuss investigative records compiled for law 13 enforcement purposes. 14 (7) Specifically relate to the participation in a civil 15 action or other legal proceeding. 16 i. The interstate commission shall keep minutes which shall 17 fully describe all matters discussed in a meeting and shall 18 provide a full and accurate summary of actions taken, including 19 record of any roll call votes. 20 j. The interstate commission shall make its information 21 and official records, to the extent not otherwise designated 22 in the compact or by its rules, available to the public for 23 inspection. 24 k. The interstate commission shall establish an executive 25 committee, which shall include officers, members, and others as 26 determined by the bylaws. The executive committee shall have 27 the power to act on behalf of the interstate commission, with 28 the exception of rulemaking, during periods when the interstate 29 commission is not in session. When acting on behalf of the 30 interstate commission, the executive committee shall oversee 31 the administration of the compact including enforcement and 32 compliance with the provisions of the compact, its bylaws and 33 rules, and other such duties as necessary. 34 l. The interstate commission may establish other committees 35 -11- LSB 1270YC (2) 86 tr/nh 11/ 23

H.F. _____ for governance and administration of the compact. 1 12. Powers and duties of the interstate commission. The 2 interstate commission shall have power to perform the following 3 functions: 4 a. Oversee and maintain the administration of the compact. 5 b. Promulgate rules which shall be binding to the extent and 6 in the manner provided for in the compact. 7 c. Issue, upon the request of a member state or 8 member board, advisory opinions concerning the meaning or 9 interpretation of the compact, its bylaws, rules, and actions. 10 d. Enforce compliance with compact provisions, the rules 11 promulgated by the interstate commission, and the bylaws, using 12 all necessary and proper means, including but not limited to 13 the use of judicial process. 14 e. Establish and appoint committees including but not 15 limited to an executive committee as required by subsection 11, 16 which shall have the power to act on behalf of the interstate 17 commission in carrying out its powers and duties. 18 f. Pay, or provide for the payment of, the expenses related 19 to the establishment, organization, and ongoing activities of 20 the interstate commission. 21 g. Establish and maintain one or more offices. 22 h. Borrow, accept, hire, or contract for services of 23 personnel. 24 i. Purchase and maintain insurance and bonds. 25 j. Employ an executive director who shall have such 26 powers to employ, select, or appoint employees, agents, or 27 consultants, and to determine their qualifications, define 28 their duties, and fix their compensation. 29 k. Establish personnel policies and programs relating 30 to conflicts of interest, rates of compensation, and 31 qualifications of personnel. 32 l. Accept donations and grants of money, equipment, 33 supplies, materials, and services, and to receive, utilize, and 34 dispose of the same in a manner consistent with the conflict of 35 -12- LSB 1270YC (2) 86 tr/nh 12/ 23

H.F. _____ interest policies established by the interstate commission. 1 m. Lease, purchase, accept contributions or donations of, or 2 otherwise to own, hold, improve, or use, any property, real, 3 personal, or mixed. 4 n. Sell, convey, mortgage, pledge, lease, exchange, abandon, 5 or otherwise dispose of any property, real, personal, or mixed. 6 o. Establish a budget and make expenditures. 7 p. Adopt a seal and bylaws governing the management and 8 operation of the interstate commission. 9 q. Report annually to the legislatures and governors of 10 the member states concerning the activities of the interstate 11 commission during the preceding year. Such reports shall also 12 include reports of financial audits and any recommendations 13 that may have been adopted by the interstate commission. 14 r. Coordinate education, training, and public awareness 15 regarding the compact, its implementation, and its operation. 16 s. Maintain records in accordance with the bylaws. 17 t. Seek and obtain trademarks, copyrights, and patents. 18 u. Perform such functions as may be necessary or appropriate 19 to achieve the purposes of the compact. 20 13. Finance powers. 21 a. The interstate commission may levy on and collect an 22 annual assessment from each member state to cover the cost of 23 the operations and activities of the interstate commission and 24 its staff. The total assessment must be sufficient to cover 25 the annual budget approved each year for which revenue is not 26 provided by other sources. The aggregate annual assessment 27 amount shall be allocated upon a formula to be determined 28 by the interstate commission, which shall promulgate a rule 29 binding upon all member states. 30 b. The interstate commission shall not incur obligations of 31 any kind prior to securing the funds adequate to meet the same. 32 c. The interstate commission shall not pledge the credit of 33 any of the member states, except by, and with the authority of, 34 the member state. 35 -13- LSB 1270YC (2) 86 tr/nh 13/ 23

H.F. _____ d. The interstate commission shall be subject to a yearly 1 financial audit conducted by a certified or licensed public 2 accountant and the report of the audit shall be included in the 3 annual report of the interstate commission. 4 14. Organization and operation of the interstate commission. 5 a. The interstate commission shall, by a majority of 6 commissioners present and voting, adopt bylaws to govern its 7 conduct as may be necessary or appropriate to carry out the 8 purposes of the compact within twelve months of the first 9 interstate commission meeting. 10 b. The interstate commission shall elect or appoint annually 11 from among its commissioners a chairperson, a vice chairperson, 12 and a treasurer, each of whom shall have such authority and 13 duties as may be specified in the bylaws. The chairperson, 14 or in the chairperson’s absence or disability, the vice 15 chairperson, shall preside at all meetings of the interstate 16 commission. 17 c. Officers selected in paragraph “b” shall serve without 18 remuneration from the interstate commission. 19 d. The officers and employees of the interstate commission 20 shall be immune from suit and liability, either personally or 21 in their official capacity, for a claim for damage to or loss 22 of property or personal injury or other civil liability caused 23 or arising out of, or relating to, an actual or alleged act, 24 error, or omission that occurred, or that such person had a 25 reasonable basis for believing occurred, within the scope of 26 interstate commission employment, duties, or responsibilities, 27 provided that such person shall not be protected from suit or 28 liability for damage, loss, injury, or liability caused by the 29 intentional or willful and wanton misconduct of such person. 30 (1) The liability of the executive director and employees of 31 the interstate commission or representatives of the interstate 32 commission, acting within the scope of such person’s employment 33 or duties for acts, errors, or omissions occurring within such 34 person’s state, may not exceed the limits of liability set 35 -14- LSB 1270YC (2) 86 tr/nh 14/ 23

H.F. _____ forth under the constitution and laws of that state for state 1 officials, employees, and agents. The interstate commission 2 is considered to be an instrumentality of the states for 3 the purposes of any such action. Nothing in this paragraph 4 “d” shall be construed to protect such person from suit or 5 liability for damage, loss, injury, or liability caused by the 6 intentional or willful and wanton misconduct of such person. 7 (2) The interstate commission shall defend the executive 8 director, its employees, and subject to the approval of 9 the attorney general or other appropriate legal counsel of 10 the member state represented by an interstate commission 11 representative, shall defend such interstate commission 12 representative in any civil action seeking to impose liability 13 arising out of an actual or alleged act, error, or omission 14 that occurred within the scope of interstate commission 15 employment, duties, or responsibilities, or that the defendant 16 had a reasonable basis for believing occurred within the 17 scope of interstate commission employment, duties, or 18 responsibilities, provided that the actual or alleged act, 19 error, or omission did not result from intentional or willful 20 and wanton misconduct on the part of such person. 21 (3) To the extent not covered by the state involved, member 22 state, or the interstate commission, the representatives or 23 employees of the interstate commission shall be held harmless 24 in the amount of a settlement or judgment, including attorney 25 fees and costs, obtained against such persons arising out of 26 an actual or alleged act, error, or omission that occurred 27 within the scope of interstate commission employment, duties, 28 or responsibilities, or that such persons had a reasonable 29 basis for believing occurred within the scope of interstate 30 commission employment, duties, or responsibilities, provided 31 that the actual or alleged act, error, or omission did not 32 result from intentional or willful and wanton misconduct on the 33 part of such persons. 34 15. Rulemaking functions of the interstate commission. 35 -15- LSB 1270YC (2) 86 tr/nh 15/ 23

H.F. _____ a. The interstate commission shall promulgate reasonable 1 rules in order to effectively and efficiently achieve the 2 purposes of the compact. Notwithstanding the foregoing, in 3 the event the interstate commission exercises its rulemaking 4 authority in a manner that is beyond the scope of the purposes 5 of the compact, or the powers granted hereunder, then such an 6 action by the interstate commission shall be invalid and have 7 no force or effect. 8 b. Rules deemed appropriate for the operations of the 9 interstate commission shall be made pursuant to a rulemaking 10 process that substantially conforms to the model state 11 administrative procedure Act of 2010, and subsequent amendments 12 thereto. 13 c. Not later than thirty days after a rule is promulgated, 14 any person may file a petition for judicial review of the 15 rule in the United States district court for the District 16 of Columbia or the federal district where the interstate 17 commission has its principal offices, provided that the filing 18 of such a petition shall not stay or otherwise prevent the 19 rule from becoming effective unless the court finds that the 20 petitioner has a substantial likelihood of success. The 21 court shall give deference to the actions of the interstate 22 commission consistent with applicable law and shall not find 23 the rule to be unlawful if the rule represents a reasonable 24 exercise of the authority granted to the interstate commission. 25 16. Oversight of interstate compact. 26 a. The executive, legislative, and judicial branches 27 of state government in each member state shall enforce the 28 compact and shall take all actions necessary and appropriate to 29 effectuate the compact’s purposes and intent. The provisions 30 of the compact and the rules promulgated hereunder shall have 31 standing as statutory law but shall not override existing state 32 authority to regulate the practice of medicine. 33 b. All courts shall take judicial notice of the compact and 34 the rules in any judicial or administrative proceeding in a 35 -16- LSB 1270YC (2) 86 tr/nh 16/ 23

H.F. _____ member state pertaining to the subject matter of the compact 1 which may affect the powers, responsibilities, or actions of 2 the interstate commission. 3 c. The interstate commission shall be entitled to receive 4 all service of process in any such proceeding, and shall have 5 standing to intervene in the proceeding for all purposes. 6 Failure to provide service of process to the interstate 7 commission shall render a judgment or order void as to the 8 interstate commission, the compact, or promulgated rules. 9 17. Enforcement of interstate compact. 10 a. The interstate commission, in the reasonable exercise of 11 its discretion, shall enforce the provisions and rules of the 12 compact. 13 b. The interstate commission may, by majority vote of 14 the commissioners, initiate legal action in the United 15 States district court for the District of Columbia, or, at 16 the discretion of the interstate commission, in the federal 17 district where the interstate commission has its principal 18 offices, to enforce compliance with the provisions of the 19 compact, and its promulgated rules and bylaws, against a 20 member state in default. The relief sought may include 21 both injunctive relief and damages. In the event judicial 22 enforcement is necessary, the prevailing party shall be awarded 23 all costs of such litigation including reasonable attorney 24 fees. 25 c. The remedies herein shall not be the exclusive remedies 26 of the interstate commission. The interstate commission may 27 avail itself of any other remedies available under state law or 28 the regulation of a profession. 29 18. Default procedures. 30 a. The grounds for default include but are not limited 31 to failure of a member state to perform such obligations or 32 responsibilities imposed upon it by the compact, or the rules 33 and bylaws of the interstate commission promulgated under the 34 compact. 35 -17- LSB 1270YC (2) 86 tr/nh 17/ 23

H.F. _____ b. If the interstate commission determines that a member 1 state has defaulted in the performance of its obligations 2 or responsibilities under the compact, or the bylaws or 3 promulgated rules, the interstate commission shall do the 4 following: 5 (1) Provide written notice to the defaulting state and other 6 member states of the nature of the default, the means of curing 7 the default, and any action taken by the interstate commission. 8 The interstate commission shall specify the conditions by which 9 the defaulting state must cure its default. 10 (2) Provide remedial training and specific technical 11 assistance regarding the default. 12 c. If the defaulting state fails to cure the default, the 13 defaulting state shall be terminated from the compact upon an 14 affirmative vote of a majority of the commissioners and all 15 rights, privileges, and benefits conferred by the compact shall 16 terminate on the effective date of termination. A cure of the 17 default does not relieve the offending state of obligations or 18 liabilities incurred during the period of the default. 19 d. Termination of membership in the compact shall be imposed 20 only after all other means of securing compliance have been 21 exhausted. Notice of intent to terminate shall be given by 22 the interstate commission to the governor, the majority and 23 minority leaders of the defaulting state’s legislature, and 24 each of the member states. 25 e. The interstate commission shall establish rules and 26 procedures to address licenses and physicians that are 27 materially impacted by the termination of a member state, or 28 the withdrawal of a member state. 29 f. The member state which has been terminated is responsible 30 for all dues, obligations, and liabilities incurred through 31 the effective date of termination including obligations, the 32 performance of which extends beyond the effective date of 33 termination. 34 g. The interstate commission shall not bear any costs 35 -18- LSB 1270YC (2) 86 tr/nh 18/ 23

H.F. _____ relating to any state that has been found to be in default or 1 which has been terminated from the compact, unless otherwise 2 mutually agreed upon in writing between the interstate 3 commission and the defaulting state. 4 h. The defaulting state may appeal the action of the 5 interstate commission by petitioning the United States district 6 court for the District of Columbia or the federal district 7 where the interstate commission has its principal offices. The 8 prevailing party shall be awarded all costs of such litigation 9 including reasonable attorney fees. 10 19. Dispute resolution. 11 a. The interstate commission shall attempt, upon the request 12 of a member state, to resolve disputes which are subject to 13 the compact and which may arise among member states or member 14 boards. 15 b. The interstate commission shall promulgate rules 16 providing for both mediation and binding dispute resolution as 17 appropriate. 18 20. Member states, effective date, and amendment. 19 a. Any state is eligible to become a member state of the 20 compact. 21 b. The compact shall become effective and binding upon 22 legislative enactment of the compact into law by no less than 23 seven states. Thereafter, it shall become effective and 24 binding on a state upon enactment of the compact into law by 25 that state. 26 c. The governors of nonmember states, or their designees, 27 shall be invited to participate in the activities of the 28 interstate commission on a nonvoting basis prior to adoption 29 of the compact by all states. 30 d. The interstate commission may propose amendments to the 31 compact for enactment by the member states. No amendment shall 32 become effective and binding upon the interstate commission and 33 the member states unless and until it is enacted into law by 34 unanimous consent of the member states. 35 -19- LSB 1270YC (2) 86 tr/nh 19/ 23

H.F. _____ 21. Withdrawal. 1 a. Once effective, the compact shall continue in force and 2 remain binding upon each and every member state, provided that 3 a member state may withdraw from the compact by specifically 4 repealing the statute which enacted the compact into law. 5 b. Withdrawal from the compact shall be by the enactment 6 of a statute repealing the same, but shall not take effect 7 until one year after the effective date of such statute and 8 until written notice of the withdrawal has been given by the 9 withdrawing state to the governor of each other member state. 10 c. The withdrawing state shall immediately notify the 11 chairperson of the interstate commission in writing upon the 12 introduction of legislation repealing the compact in the 13 withdrawing state. 14 d. The interstate commission shall notify the other member 15 states of the withdrawing state’s intent to withdraw within 16 sixty days of its receipt of notice provided under paragraph 17 “c” . 18 e. The withdrawing state is responsible for all dues, 19 obligations, and liabilities incurred through the effective 20 date of withdrawal, including obligations, the performance of 21 which extend beyond the effective date of withdrawal. 22 f. Reinstatement following withdrawal of a member state 23 shall occur upon the withdrawing state reenacting the compact 24 or upon such later date as determined by the interstate 25 commission. 26 g. The interstate commission is authorized to develop 27 rules to address the impact of the withdrawal of a member 28 state on licenses granted in other member states to physicians 29 who designated the withdrawing member state as the state of 30 principal license. 31 22. Dissolution. 32 a. The compact shall dissolve effective upon the date of 33 the withdrawal or default of the member state which reduces the 34 membership in the compact to one member state. 35 -20- LSB 1270YC (2) 86 tr/nh 20/ 23