Bill not drafted by TLC or Senate E&E.
Line and page numbers may not match official copy.
By Berlanga H.B. No. 2846
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the practice of advanced practice nurses and physician
1-3 assistants in collaborative practice with a physician.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subdivision (5)(D), Subsection (d), Section 3.06,
1-6 Medical Practice Act (Article 4495b, Vernon's Texas Civil Statutes)
1-7 is amended to read as follows:
1-8 (D) Physician supervision shall be adequate if a
1-9 delegating physician:
1-10 (i) is responsible for the formulation or
1-11 approval of such physician's orders, standing medical orders,
1-12 standing delegation orders, or other orders or protocols and
1-13 periodically reviews such orders and the services provided patients
1-14 under such orders;
1-15 (ii) is on site at least once [a week]
1-16 every ten business days to provide medical direction and
1-17 consultation.
1-18 (iii) receives a daily status report from
1-19 the registered nurse or physician assistant on any problems or
1-20 complications encountered; and
1-21 (iv) is available through direct
1-22 telecommunication for consultation, assistance with medical
1-23 emergencies, or patient referral.
1-24 SECTION 2. Subdivision (5), Subsection (d), Section 3.06,
2-1 Medical Practice Act (Article 4495b, Vernon's Texas Civil
2-2 Statutes), is amended by adding a Paragraph (I) to read as follows:
2-3 (I) The Board, for good cause shown, may grant a
2-4 waiver of one or more of the physician supervision requirements set
2-5 out in Paragraph (D) of this Subdivision. In granting the waiver,
2-6 the Board shall consider:
2-7 (i) the adequacy of the collaborative
2-8 relationship between the physician and the Advanced Practice Nurse
2-9 or Physician Assistant;
2-10 (ii) the mechanism to be established to
2-11 ensure adequate physician supervision and patient care;
2-12 (iii) that compliance with the
2-13 requirements causes undue burden without corresponding benefit to
2-14 patient care; and
2-15 (iv) other provisions established by the
2-16 Board by rule.
2-17 The Board may withdraw the waiver after notice and hearing
2-18 and a waiver must be renewed every three years in accordance with
2-19 rules established by the Board.
2-20 SECTION 3. Subdivision (6)(G)(iii), Subsection (d), Section
2-21 3.06, Medical Practice Act (Article 4495b, Vernon's Texas Civil
2-22 Statutes), is amended to read as follows:
2-23 (iii) "Primary practice site" means:
2-24 (a) the practice location
2-25 where the physician spends the majority of the physician's time;
2-26 (b) a licensed hospital, a
2-27 licensed long-term care facility, and a licensed adult care center
2-28 where both the physician and the Physician Assistant or Advanced
2-29 Practice Nurse are authorized to practice, a clinic operated by or
2-30 associated with a public school district for the purpose of
3-1 providing care to the students of that district and their siblings
3-2 or an established patient's residence; or
3-3 (c) where the physician is
3-4 physically present with the physician assistant or advanced nurse
3-5 practitioner
3-6 SECTION 4. Section 14, Texas Health Maintenance Organization
3-7 Act (Article 20A.14, Vernon's Texas Civil Statutes) is amended by
3-8 adding a subsection (i) to read as follows:
3-9 (i) If an advanced practice nurse or physician assistant has
3-10 been authorized to provide care pursuant to Section 3.06(d)(5) or
3-11 (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
3-12 Statutes), by a physician participating in a health maintenance
3-13 organization's provider network, the health maintenance
3-14 organization may not refuse a request by the physician and
3-15 physician assistant or advanced practice nurse for the physician
3-16 assistant or advanced practice nurse also to be identified on its
3-17 provider network except on the basis that the physician assistant
3-18 or advanced practice nurse fails to meet the pre-established
3-19 quality of care standards of the health maintenance organization
3-20 for participation by advanced practice nurses and physician
3-21 assistants.
3-22 SECTION 5. Chapter 3, Insurance Code, is amended by adding
3-23 Article 3.70-3C to read as follows:
3-24 Art. 3.70-3C.
3-25 Sec. 1. In this article:
3-26 (1) "Preferred Provider" means a physician, advanced
3-27 practice nurse, physician assistant or other health care provider
3-28 or an organization of physicians or health care providers, who
3-29 contracts with an insurer to provide medical care or health care to
3-30 insureds covered by a health insurance policy, certificate or
4-1 contract.
4-2 (2) "Preferred Provider Benefit Plan" means a benefit
4-3 plan in which an insurer provides, through its health insurance
4-4 policy, for the payment of a level of coverage which is different
4-5 from the basic level of coverage provided by the health insurance
4-6 policy if the insured uses a preferred provider.
4-7 Sec. 2. If an advanced practice nurse or physician assistant
4-8 has been authorized to provide care pursuant to Section 3.06(d)(5)
4-9 or (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
4-10 Statutes), by a physician included as a preferred provider in a
4-11 preferred provider benefit plan, the plan may not refuse a request
4-12 by the physician and physician assistant or advanced practice nurse
4-13 for the physician assistant or advanced practice nurse also to be
4-14 included as a preferred provider by the plan except on the basis
4-15 that the physician assistant or advanced practice nurse fails to
4-16 meet the pre-established quality of care standards of the preferred
4-17 provider benefit plan for participation by advanced practice nurses
4-18 and physician assistants.
4-19 SECTION 6. Subsection (B), Section 2, Chapter 397, Acts of
4-20 the 54th Legislature, 1955, (Article 3.70-2, Vernon's Texas
4-21 Insurance Code) is amended to read as follows:
4-22 (B) No policy of accident and sickness insurance
4-23 shall make benefits contingent upon treatment or examination by a
4-24 particular practitioner or by particular practitioners of the
4-25 healing arts hereinafter designated unless such policy contains a
4-26 provision designating the practitioner or practitioners who will be
4-27 recognized by the insurer and those who will not be recognized by
4-28 the insurer. Such provision may be located in the "Exceptions" or
4-29 "Exceptions and Reductions" provisions, or elsewhere in the policy,
4-30 or by endorsement attached to the policy, at the insurer's option.
5-1 In designating the practitioners who will and will not be
5-2 recognized, such provision shall use the following terms: Doctor
5-3 of Medicine, Doctor of Osteopathy, Doctor of Dentistry, Doctor of
5-4 Chiropractic, Doctor of Optometry, Doctor of Podiatry, Licensed
5-5 Audiologist, Licensed Speech-language Pathologist, Doctor in
5-6 Psychology, Licensed Master Social Worker--Advanced Clinical
5-7 Practitioner, Licensed Dietitian, Licensed Professional Counselor,
5-8 Licensed Marriage and Family Therapist, Licensed Chemical
5-9 Dependency Counselor, Licensed Hearing Aid Fitter and Dispenser,
5-10 and Licensed Psychological Associate.
5-11 For purposes of this Act, such designations shall have the
5-12 following meanings:
5-13 Doctor of Medicine: One licensed by the Texas State Board of
5-14 Medical Examiners on the basis of the degree "Doctor of Medicine";
5-15 Doctor of Osteopathy: One licensed by the Texas State Board
5-16 of Medical Examiners on the basis of the degree of "Doctor of
5-17 Osteopathy";
5-18 Doctor of Dentistry: One licensed by the State Board of
5-19 Dental Examiners;
5-20 Doctor of Chiropractic: One licensed by the Texas Board of
5-21 Chiropractic Examiners;
5-22 Doctor of Optometry: One licensed by the Texas Optometry
5-23 Board;
5-24 Doctor of Podiatry: One licensed by the Texas State Board of
5-25 Podiatric Medical Examiners;
5-26 Licensed Audiologist: One with a master's or doctorate
5-27 degree in audiology from an accredited college or university and
5-28 who is licensed as an audiologist by the State Committee of
5-29 Examiners for Speech-Language Pathology and Audiology;
5-30 Licensed Speech-language Pathologist: One with a master's or
6-1 doctorate degree in speech pathology or speech-language pathology
6-2 from an accredited college or university and who is licensed as a
6-3 speech-language pathologist by the State Committee of Examiners for
6-4 Speech-Language Pathology and Audiology;
6-5 Doctor in Psychology: One licensed by the Texas State Board
6-6 of Examiners of Psychologists and certified as a Health Service
6-7 Provider;
6-8 Licensed Master Social Worker--Advanced Clinical
6-9 Practitioner: One licensed by the Texas State Board of Social
6-10 Worker Examiners as a Licensed Master Social Worker with the order
6-11 of recognition of Advanced Clinical Practitioner;
6-12 Licensed Dietitian: One licensed by the Texas State Board of
6-13 Examiners of Dietitians;
6-14 Licensed Professional Counselor: One licensed by the Texas
6-15 State Board of Examiners of Professional Counselors;
6-16 Licensed Marriage and Family Therapist: One licensed by the
6-17 Texas State Board of Examiners of Marriage and Family Therapists;
6-18 Licensed Chemical Dependency Counselor: One licensed by the
6-19 Texas Commission on Alcohol and Drug Abuse;
6-20 Licensed Hearing Aid Fitter and Dispenser: One licensed by
6-21 the Texas Board of Examiners in the Fitting and Dispensing of
6-22 Hearing Aids; [and]
6-23 Licensed Psychological Associate: One licensed by the Texas
6-24 State Board of Examiners of Psychologists and practicing under the
6-25 supervision of a licensed psychologist;
6-26 Advanced Practice Nurse: One licensed by the Board of Nurse
6-27 Examiners as a registered nurse and recognized by that board as an
6-28 advanced practice nurse; and
6-29 Physician Assistant: One licensed by the Texas State Board
6-30 of Physician Assistants.
7-1 SECTION 7. Section 1, Article 21.52, Insurance Code, is
7-2 amended to read as follows:
7-3 Sec. 1. Definitions. As used in this article:
7-4 (a) "health insurance policy" means any individual, group,
7-5 blanket, or franchise insurance policy, insurance agreement, or
7-6 group hospital service contract, providing benefits for medical or
7-7 surgical expenses incurred as a result of an accident or sickness;
7-8 (b) "doctor of podiatric medicine" includes D.P.M.,
7-9 podiatrist, doctor of surgical chiropody, D.S.C. and chiropodist;
7-10 (c) "doctor of optometry" includes optometrist, doctor of
7-11 optometry, and O.D.;
7-12 (d) "doctor of chiropractic" means a person who is licensed
7-13 by the Texas Board of Chiropractic Examiners to practice
7-14 chiropractic;
7-15 (e) "licensed dentist" means a person who is licensed to
7-16 practice dentistry by the State Board of Dental Examiners;
7-17 (f) "licensed audiologist" means a person who has received a
7-18 master's or doctorate degree in audiology from an accredited
7-19 college or university and is licensed as an audiologist by the
7-20 State Committee of Examiners for Speech-Language Pathology and
7-21 Audiology;
7-22 (g) "licensed speech-language pathologist" means a person
7-23 who has received a master's or doctorate degree in speech-language
7-24 pathology from an accredited college or university and is licensed
7-25 as a speech-language pathologist by the State Committee of
7-26 Examiners for Speech-Language Pathology and Audiology;
7-27 (h) "licensed master social worker--advanced clinical
7-28 practitioner" means a person who is licensed by the Texas State
7-29 Board of Social Worker Examiners as a licensed master social worker
7-30 with the order of recognition of advanced clinical practitioner;
8-1 (i) "licensed dietitian" means a person who is licensed by
8-2 the Texas State Board of Examiners of Dietitians;
8-3 (j) "licensed professional counselor" means a person who is
8-4 licensed by the Texas State Board of Examiners of Professional
8-5 Counselors;
8-6 (k) "psychologist" means a person licensed to practice
8-7 psychology by the Texas State Board of Examiners of Psychologists;
8-8 (l) "licensed marriage and family therapist" means a person
8-9 who is licensed by the Texas State Board of Examiners of Marriage
8-10 and Family Therapists;
8-11 (m) "licensed chemical dependency counselor" means a person
8-12 who is licensed by the Texas Commission on Alcohol and Drug Abuse;
8-13 [and]
8-14 (n) "licensed hearing aid fitter and dispenser" means a
8-15 person who is licensed by the Texas Board of Examiners in the
8-16 Fitting and Dispensing of Hearing Aids;
8-17 ([n] o) "licensed psychological associate" means a person
8-18 who is licensed by the Texas State Board of Examiners of
8-19 Psychologists and who practices under the supervision of a licensed
8-20 psychologist;
8-21 (p) "advanced practice nurse" means a person licensed by the
8-22 Board of Nurse Examiners and recognized by that board as an
8-23 advanced practice nurse; and
8-24 (q) "physician assistant" means a person licensed by the
8-25 Texas State Board of Physician Assistants.
8-26 SECTION 8. Section 3, Article 21.52, Insurance Code, is
8-27 amended to read as follows:
8-28 Sec. 3. (a) Selection of Practitioners. Any person who is
8-29 issued, who is a party to, or who is a beneficiary under any health
8-30 insurance policy delivered, renewed, or issued for delivery in this
9-1 state by any insurance company, association, or organization to
9-2 which this article applies may select a licensed doctor of
9-3 podiatric medicine, a licensed dentist, or a doctor of chiropractic
9-4 to perform the medical or surgical services or procedures scheduled
9-5 in the policy which fall within the scope of the license of that
9-6 practitioner, a licensed doctor of optometry to perform the
9-7 services or procedures scheduled in the policy which fall within
9-8 the scope of the license of that doctor of optometry, a licensed
9-9 audiologist to measure hearing for the purpose of determining the
9-10 presence or extent of a hearing loss and to provide aural
9-11 rehabilitation services to a person with a hearing loss if those
9-12 services or procedures are scheduled in the policy, a licensed
9-13 speech-language pathologist to evaluate speech and language and to
9-14 provide habilitative and rehabilitative services to restore speech
9-15 or language loss or to correct a speech or language impairment if
9-16 those services or procedures are scheduled in the policy, a
9-17 licensed master social worker--advanced clinical practitioner to
9-18 provide the services that fall within the scope of the license of
9-19 such certified practitioner and which are specified as services
9-20 within the terms of the policy of insurance, including the
9-21 provision of direct, diagnostic, preventive, or clinical services
9-22 to individuals, families, and groups whose functioning is
9-23 threatened or affected by social or psychological stress or health
9-24 impairment, if those services or procedures are scheduled in the
9-25 policy, a licensed dietitian including a provisional licensed
9-26 dietitian under a licensed dietitian's supervision to provide the
9-27 services that fall within the scope of the license of that
9-28 dietitian if those services are scheduled in the policy, a licensed
9-29 professional counselor to provide the services that fall within the
9-30 scope of the license of that professional if those services are
10-1 scheduled in the policy, a licensed marriage and family therapist
10-2 to provide the services that fall within the scope of the license
10-3 of that professional if those services are scheduled in the policy,
10-4 a psychologist to perform the services or procedures scheduled in
10-5 the policy that fall within the scope of the license of that
10-6 psychologist, a licensed chemical dependency counselor to perform
10-7 the services or procedures scheduled in the policy that fall within
10-8 the scope of the license of that practitioner, a licensed hearing
10-9 aid fitter and dispenser to provide the services or procedures
10-10 scheduled in the policy that fall within the scope of the license
10-11 of that practitioner, or a licensed psychological associate to
10-12 provide the services that fall within the scope of the license of
10-13 that professional if those services are scheduled in the policy.
10-14 The services of a licensed master social worker--advanced clinical
10-15 practitioner, licensed professional counselor, or licensed marriage
10-16 and family therapist that are included in this Act may require a
10-17 professional recommendation by a doctor of medicine or doctor of
10-18 osteopathy unless the health insurance policy terms do not require
10-19 such a recommendation. The payment or reimbursement by the
10-20 insurance company, association, or organization for those services
10-21 or procedures in accordance with the payment schedule or the
10-22 payment provisions in the policy shall not be denied because the
10-23 same were performed by a licensed doctor of podiatric medicine, a
10-24 licensed doctor of optometry, a licensed doctor of chiropractic, a
10-25 licensed dentist, a licensed audiologist, a licensed
10-26 speech-language pathologist, a licensed master social
10-27 worker--advanced clinical practitioner, a licensed dietitian, a
10-28 licensed professional counselor, a licensed marriage and family
10-29 therapist, a psychologist, a licensed chemical dependency
10-30 counselor, a licensed psychological associate, or a licensed
11-1 hearing aid fitter and dispenser. There shall not be any
11-2 classification, differentiation, or other discrimination in the
11-3 payment schedule or the payment provisions in a health insurance
11-4 policy, nor in the amount or manner of payment or reimbursement
11-5 thereunder, between scheduled services or procedures when performed
11-6 by a doctor of podiatric medicine, a doctor of optometry, a doctor
11-7 of chiropractic, a licensed dentist, a licensed audiologist, a
11-8 licensed speech-language pathologist, a licensed master social
11-9 worker--advanced clinical practitioner, a licensed dietitian, a
11-10 licensed professional counselor, a licensed marriage and family
11-11 therapist, a psychologist, a licensed psychological associate, a
11-12 licensed chemical dependency counselor, or a licensed hearing aid
11-13 fitter and dispenser which fall within the scope of the license or
11-14 certification and the same services or procedures when performed by
11-15 any other practitioner of the healing arts whose services or
11-16 procedures are covered by the policy. Any provision in a health
11-17 insurance policy contrary to or in conflict with the provisions of
11-18 this article shall, to the extent of the conflict, be void, but
11-19 such invalidity shall not affect the validity of the other
11-20 provisions of this policy. Any presently approved policy form
11-21 containing any provision in conflict with the requirements of this
11-22 Act shall be brought into compliance with this Act by the use of
11-23 riders and endorsements which have been approved by the State Board
11-24 of Insurance or by the filing of new or revised policy forms for
11-25 approval by the State Board of Insurance.
11-26 (b) Advanced practice nurses and physician assistants
11-27 performing services or procedures scheduled in the policy which
11-28 fall within the scope of the license of the advanced practice nurse
11-29 or physician assistant or which the advanced practice nurse or
11-30 physician assistant may perform under the authority of Section
12-1 3.06(d)(5) or (6), Medical Practice Act (Article 4495b, Vernon's
12-2 Texas Civil Statutes), shall be considered to be practitioners
12-3 listed in Subsection (a) for all purposes except that a health
12-4 insurance policy may differentiate in its payment schedule or
12-5 payment provisions or in its amount of payment or manner of payment
12-6 or reimbursement for scheduled services or procedures when
12-7 performed by a physician and when performed by an advanced practice
12-8 nurse or physician assistant based on reasonable differences in the
12-9 costs between a physician providing those services or procedures
12-10 and an advanced practice nurse or physician assistant providing
12-11 them.
12-12 SECTION 9. Section 241.003, Health and Safety Code, is
12-13 amended to read as follows:
12-14 Sec. 241.003. Definitions. In this chapter:
12-15 (1) "Advanced practice nurse" means a registered nurse
12-16 recognized as an advanced practice nurse by the Board of Nurse
12-17 Examiners.
12-18 (2) ("Board" means the Texas Board of Health.
12-19 (3) [(2)] "Council" means the Hospital Licensing
12-20 Advisory Council.
12-21 (4) [(3)] "Department" means the Texas Department of
12-22 Health.
12-23 (5) [(4)] "General hospital" means an establishment
12-24 that:
12-25 (A) offers services, facilities, and beds for
12-26 use for more than 24 hours for two or more unrelated individuals
12-27 requiring diagnosis, treatment, or care for illness, injury,
12-28 deformity, abnormality, or pregnancy; and
12-29 (B) regularly maintains, at a minimum, clinical
12-30 laboratory services, diagnostic X-ray services, treatment
13-1 facilities including surgery or obstetrical care or both, and other
13-2 definitive medical or surgical treatment of similar extent.
13-3 (6) [(5)] "Governmental unit" means a political
13-4 subdivision of the state, including a hospital district, county, or
13-5 municipality, and any department, division, board, or other agency
13-6 of a political subdivision.
13-7 (7) [(6)] "Hospital" includes a general hospital and a
13-8 special hospital.
13-9 (8) [(7)] "Medical staff" means a physician or group
13-10 of physicians, and a podiatrist or group of podiatrists, who by
13-11 action of the governing body of a hospital are privileged to work
13-12 in and use the facilities of a hospital for or in connection with
13-13 the observation, care, diagnosis, or treatment of an individual who
13-14 is, or may be, suffering from a mental or physical disease or
13-15 disorder or a physical deformity or injury.
13-16 (9) [(8)] "Person" means an individual, firm,
13-17 partnership, corporation, association, or joint stock company, and
13-18 includes a receiver, trustee, assignee, or other similar
13-19 representative of those entities.
13-20 (10) [(9)] "Physician" means a physician licensed by
13-21 the Texas State Board of Medical Examiners.
13-22 (11) "Physician Assistant" means a physician assistant
13-23 licensed by the Texas State Board of Physician Assistant Examiners.
13-24 (12) [(10)] "Podiatrist" means a podiatrist licensed
13-25 by the Texas State Board of Podiatry Examiners.
13-26 (13) [(11)] "Special hospital" means an establishment
13-27 that:
13-28 (A) offers services, facilities, and beds for
13-29 use for more than 24 hours for two or more unrelated individuals
13-30 who are regularly admitted, treated, and discharged and who require
14-1 services more intensive than room, board, personal services, and
14-2 general nursing care;
14-3 (B) has clinical laboratory facilities,
14-4 diagnostic X-ray facilities, treatment facilities, or other
14-5 definitive medical treatment;
14-6 (C) has a medical staff in regular attendance;
14-7 and
14-8 (D) maintains records of the clinical work
14-9 performed for each patient.
14-10 SECTION 10. Chapter 241, Health and Safety Code, is amended
14-11 by adding a Section 241.105 to read as follows:
14-12 Sec. 241.105. HOSPITAL PRIVILEGES FOR ADVANCED PRACTICE
14-13 NURSES AND PHYSICIAN ASSISTANTS. (a) The governing body of a
14-14 hospital is authorized to establish polices concerning the granting
14-15 of medical staff or other clinical privileges to advanced practice
14-16 nurses or physician assistants, including the application process,
14-17 qualifications for privileges and the process for modification or
14-18 revocation of privileges.
14-19 (b) If the governing body of a hospital has adopted a policy
14-20 of extending medical staff or other clinical privileges to advanced
14-21 practice nurses or physician assistants, an individual advanced
14-22 practice nurse or physician assistant who qualifies for privileges
14-23 under that policy shall be entitled to certain due process rights,
14-24 as determined by the hospital board, when an application for
14-25 privileges is submitted to the hospital. At a minimum, any policy
14-26 adopted shall specify a reasonable time period for the processing
14-27 and consideration of the application and shall provide for written
14-28 notification of the applicant of any final action by the hospital
14-29 on the application, including any reason for denial or restriction
14-30 of the privileges requested.
15-1 (c) If an advanced practice nurse or physician assistant has
15-2 been granted medical or other clinical privileges by a hospital,
15-3 that hospital may not modify or revoke those privileges without
15-4 providing certain due process rights, as determined by the hospital
15-5 board, to the advanced practice nurse or physician assistant. At a
15-6 minimum, the hospital shall provide the advanced practice nurse or
15-7 physician assistant with written reasons for the modification or
15-8 revocation of privileges and a mechanism for appeal.
15-9 SECTION 11. This Act takes effect September 1, 1997.
15-10 SECTION 12. The importance of this legislation and the
15-11 crowded condition of the calendars in both houses create an
15-12 emergency and an imperative public necessity that the
15-13 constitutional rule requiring bills to be read on three several
15-14 days in each house be suspended, and this rule is hereby suspended,
15-15 and that this Act take effect and be in force from and after its
15-16 passage, and it is so enacted.