Filling the Gaps and Navigating Fine Lines: Licensure Considerations for Medical Spas

The Rhode Island Medical Spas Safety Act (RI MSSA) was signed into law by Governor Daniel McKee on June 30, 2025, and is the latest example of the increasing regulation of medical spas. Despite their growth in popularity across the United States, there is considerable ambiguity about what precisely “medical spas” are, the services they provide, and their regulation. The RI MSSA defines a “medical spa” as an establishment that performs “cosmetic medical procedures,” which is “any procedure that does not require sedation that is performed on a person and is directed at improving the person’s appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease.” This can include procedures such as microneedling, cosmetic injections, chemical peels, laser treatments, and permanent fat removal, among numerous others. The ever-changing variety of procedures offered by medical spas makes it challenging for medical spas to navigate and assess whether certain regulatory requirements are applicable to their services.

This blog post is the first in a series exploring key regulatory and transactional issues that current and prospective medical spa owners, employees, and investors should be aware of as state legislatures and agencies continue to propose and enact legislation and regulations that directly affect their operations. In this post, we discuss different licensure considerations for both medical spa entities and their employees, highlight the requirements of the RI MSSA, and compare such requirements to existing state laws and regulations as well as model legislation that seems to have influenced the RI MSSA’s language and could serve as a guiding point for other states looking to regulate medical spas.

Licensure and Regulation of Medical Spa Facilities 

One regulatory issue that states are grappling with is how best to regulate medical spa establishments. While certain states, like Rhode Island, have taken the approach of formal health care facility licensure, other states, like Texas, source their regulatory framework through professional licensing boards and narrowly tailored legislation addressing the services medical spas provide. This section explores how different states are defining and regulating medical spas, highlighting evolving standards for medical spa ownership, facility licensure, and scope of practice.

Rhode Island 

Under the RI MSSA, medical spas are required to be licensed by the Rhode Island Department of Health (RI DOH). No later than July 1, 2026, RI DOH must promulgate rules and regulations to provide for the licensing of medical spas as health care facilities. The RI MSSA does explicitly exempt medical spas from a “determination of need” requirement to which other health care facilities are subject. 

RI DOH issued a Guidance Document Regarding the Operation of Medical Spas and intravenous (IV) Therapy Business (Guidance Document) in July 2024. The Guidance Document indicated that where a medical spa has an owner with a certain professional license, such as a physician, a professional services corporation can be formed for purposes of operating the medical spa. However, if the owner of the medical spa does not hold a professional license or does not qualify for a professional service corporation exemption, it must obtain an organized ambulatory care facility license. Furthermore, if a medical spa provides direct nursing services outside of its brick-and-mortar establishment, such as to a clientele’s place of residence, it is required to obtain a home nursing care provider license. Now, under the RI MSSA, RI DOH is expected to provide medical spas with clear guidance and a more streamlined approach to obtaining licensure as a health care facility.

Texas 

In Texas, who can own a medical spa and how a medical spa is licensed is entirely dependent on the types of services offered at the medical spa. For example, a medical spa that offers traditional esthetic services—such as facials, eyelash extensions, and temporary hair removal using wax or tweezers—all of which may be performed by a licensed esthetician or cosmetologist, may be owned by an individual holding either of those licenses. On the other hand, if a medical spa in Texas offers services such as laser hair removal, skin resurfacing, teeth whitening, Botox, or lip fillers—services that are considered medical procedures—then the medical spa must be owned by a licensed physician.

The Texas Department of Licensing & Regulation (TDLR), which regulates estheticians and cosmetologists, acknowledges that services offered at medical spas vary and often are not regulated by the same regulatory bodies. For example, TDLR regulates cosmetology, massage therapy, and laser hair removal and details the types of licenses and permits needed to provide these services in a Texas medical spa. TDLR acknowledges that it does not have authority to regulate medical spa services that are medical procedures requiring medical professional performance or oversight. There is a fine line between what constitutes a cosmetic procedure that can be performed by an esthetician or cosmetologist versus what can be performed by a physician. This is particularly evident in microdermabrasion procedures where TDLR states that more advanced levels of microdermabrasion ( e.g. deeper treatments that contact or penetrate the dermis) exceed the scope of licensure for an esthetician and cosmetologist and must therefore be performed by a physician.

In March 2025, House Bill 3749 was introduced to the Texas Legislature. Originally titled “An Act relating to the regulation of the practice of medicine, including the performance of cosmetic medical procedures and the provision of elective intravenous therapy,” the bill sought to regulate both medical spas and facilities that administered elective intravenous (IV) therapy to clientele. If the introduced version of House Bill 3749 had passed, it would have defined a medical spa as a “medical practice setting,” imposed medical spa director requirements on facilities, and implemented physician training and delegation requirements with respect to cosmetic medical procedure performance. However, on June 20, 2025, the Texas Legislature enacted a revised version of House Bill 3749 that exclusively focuses on the provision of elective IV therapy – all references to medical spas were removed. This law, which is set to take effect on September 1, 2025, places limitations on who may prescribe, order, and administer elective IV therapy in non-traditional medical settings providing that only physician assistants and advanced practice registered nurses (APRNs) acting under appropriate physician supervision may do so. This law's sole focus on elective IV therapy demonstrates the patchwork nature in which states are attempting to regulate medical spas.

Licensure and Regulation of the “Practice of Medicine” at Medical Spas 

As medical spas increasingly offer services that straddle the line between beauty and medicine, states are refining their regulatory frameworks to ensure that those performing procedures in these entities are doing so within their scope of practice. Illinois, for instance, has adopted a more medical-centric model, clearly delineating services that constitute the “practice of medicine” and restricting performance of them to licensed medical professionals. These restrictions also translate to restrictions on organization, ownership, and oversight of medical spas in the state. To contrast, Arizona has taken a more tiered approach, allowing a broader range of licensed professionals – including licensed cosmetologists, licensed aestheticians, and certified laser technologists – to perform certain aesthetic procedures on a sliding scale. These contrasting approaches underscore how differently states are defining professional boundaries and structuring access to aesthetic care.

Illinois 

On December 2, 2024, the Illinois Department of Financial and Professional Regulation (IDFPR) published the Issue Memo Regarding Medical Spas (Issue Memo) to address regulatory and compliance requirements under IDFPR and Illinois Department of Public Health (IDPH) regulations. The Issue Memo explicitly discusses certain services that could be offered at a medical spa as constituting the “practice of medicine” and outside the scope of practice of a cosmetologist or esthetician. These services include, but are not limited to, Botox, chemical peels, collagen injections, liposuction, certain forms of microdermabrasion, dermaplaning, and microblading. IDFPR issued a Statement on Prohibited Practices that outline these and other procedures that cosmetologists and estheticians are prohibited from performing. The Statement of Prohibited Practices also instructs that even where the above procedures are delegated by a licensed physician, an individual cannot represent themselves to be a cosmetologist or esthetician while performing that procedure.

The Issue Memo also discusses ownership and entity restrictions for medical spas under the Illinois Medical Practice Act and the Illinois Nurse Practice Act. In Illinois, physicians may own and operate a medical spa, and are permitted to organize the medical spa under the Medical Corporation Act, the Professional Service Corporation Act, or the Professional Limited Liability Act. In certain instances, APRNs are also permitted to own and operate medical spas, and can organize under the Professional Service Corporation Act or the Professional Limited Liability Act. The Issue Memo also details that corporate entities operated by physicians, notwithstanding certain limited exceptions, may only have physicians as shareholders or members, officers, directors, or managers. Likewise, corporate entities owned and operated by an APRN must only have APRNs as shareholders or members, officers, directors, or managers. 

Of note, the Issue Memo distinguishes medical spas from the facilities that cosmetologists and estheticians are permitted to own and operate in Illinois. If a facility provides cosmetology and/or esthetics services, they must obtain an IDFPR shop or salon registration, and it is not permitted to use a business name that includes medical terminology. IDFPR regulations state that if this terminology is used in a business name, it implies that the salon or shop offers a service that cannot be legally offered to consumers. Furthermore, entities that are licensed as medical spas may only provide medical services; it cannot provide a hybrid of medical services with cosmetology or esthetics services in the same entity. 

Arizona 

In January 2025, the Arizona State Board of Nursing revised its advisory opinion, Medical Aesthetics Procedures Performed by Licensed Nurses, Licensed Cosmetologists, Licensed Aestheticians, and Certified Laser Technologists (Advisory Opinion). According to the Advisory Opinion, certain medical aesthetics procedures can be performed by registered nurses (RNs), licensed practical nurses (LPNs), APRNs, licensed cosmetologists, licensed aestheticians, and certified laser technologists. However, these procedures must be performed under the supervision of a licensed independent practitioner that has medical or surgical training and possess specific knowledge, skills, and abilities in medical aesthetic procedures. The Advisory Opinion also explicitly states that therapeutic medical procedures are outside the scope of practice of RNs, LPNs, APRNs, licensed cosmetologists, licensed aestheticians, and certified laser technologists, and those procedures must be performed by an appropriate medical professional.

The Advisory Opinion also discusses a three-tiered system of classification to define the scope of practice for RNs, LPNs, APRNs, licensed cosmetologists, licensed aestheticians, and certified laser technologists:

• A “Level I” procedure is a procedure that is “basic cosmetic/aesthetic in nature” that requires training and certification for performance but does not require a licensed practitioner order or indirect supervision. 
• A “Level II” procedure is described as “intermediate in nature” and requires an order and indirect supervision. If a certified laser technologist is performing non-ablating treatment of the skin, the certified laser technologist must be supervised by a licensed practitioner and must possess specific training and certification or licensure for the procedure being performed. 
• A “Level III” procedure refers to an advanced aesthetic procedure requiring specific training, demonstrated clinical competence, and certification or licensure for the procedure being performed. These procedures must be performed under the medical supervision of a specifically trained licensed practitioner who possesses the knowledge, skills, and ability for the aesthetic procedure.

Finally, the Advisory Opinion advises that an APRN can serve as a medical director for aesthetics facilities, and oversee the care and treatment provided. However, the APRN is responsible for (a) providing health care services within the scope of their practice, such as prescribing and dispensing, (b) maintaining up-to-date education and certification for all procedures, and (c) offering leadership, training, and guidance to staff. Additionally, the APRN medical director must ensure that written policies for all procedures are reviewed, approved, and maintained, be available to staff during business hours, and meet all state requirements for an outpatient facility.

Conclusion 

Over the last decade, medical spas have become commonplace. State regulatory bodies are only now beginning to catch up with the rapid growth of medical spas and are starting to implement guardrails around which procedures may be performed in these settings and by whom. This patchwork regulatory scheme is fraught with risk for providers of services in medical spa settings. For individuals seeking to open a medical spa, it is imperative that one closely examines the types of services to be provided and who is to provide such services alongside the various regulations, if any, of the state in which the medical spa is located. This close examination and analysis is necessary to ensure that your medical spa is properly classified as a medical spa and that you have employed the correct individuals to perform the services offered at your medical spa.

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