Bill not drafted by TLC or Senate E&E.
Line and page numbers may not match official copy.
By: Madla S.B. No. 1244
A BILL TO BE ENTITLED
AN ACT
1-1 relating to the practice of advanced practice nurses and physician
1-2 assistants in collaborative practice with a physician.
1-3 SECTION 1. Subdivision (5)(D), Subsection (d), Section 3.06,
1-4 Medical Practice Act (Article 4495b, Vernon's Texas Civil Statutes)
1-5 is amended to read as follows:
1-6 (D) Physician supervision shall be adequate if a delegating
1-7 physician:
1-8 (i) is responsible for the formulation or approval of
1-9 such physician's orders, standing medical orders, standing
1-10 delegation orders, or other orders or protocols and periodically
1-11 reviews such orders and the services provided patients under such
1-12 orders;
1-13 (ii) is on site at least once [a week] every ten
1-14 business days to provide medical direction and consultation.
1-15 (iii) receives a daily status report from the
1-16 registered nurse or physician assistant on any problems or
1-17 complications encountered; and
1-18 (iv) is available through direct telecommunication for
1-19 consultation, assistance with medical emergencies, or patient
1-20 referral.
1-21 SECTION 2. Subdivision (5), Subsection (d), Section 3.06,
1-22 Medical Practice Act (Article 4495b, Vernon's Texas Civil
1-23 Statutes), is amended by adding a Paragraph (I) to read as follows:
2-1 (I) The Board, for good cause shown, may grant a waiver of
2-2 one or more of the physician supervision requirements set out in
2-3 Paragraph (D) of this Subdivision. In granting the waiver, the
2-4 Board shall consider:
2-5 (i) the adequacy of the collaborative relationship
2-6 between the physician and the Advanced Practice Nurse or Physician
2-7 Assistant;
2-8 (ii) the mechanism to be established to ensure
2-9 adequate physician supervision and patient care;
2-10 (iii) that compliance with the requirements causes
2-11 undue burden without corresponding benefit to patient care; and
2-12 (iv) other provisions established by the Board by
2-13 rule.
2-14 The Board may withdraw the waiver after notice and hearing
2-15 and a waiver must be renewed every three years in accordance with
2-16 rules established by the Board.
2-17 SECTION 3. Subdivision (6)(G)(iii), Subsection (d), Section
2-18 3.06, Medical Practice Act (Article 4495b, Vernon's Texas Civil
2-19 Statutes), is amended to read as follows:
2-20 (iii) "Primary practice site" means:
2-21 (a) the practice location where the physician spends
2-22 the majority of the physician's time;
2-23 (b) a licensed hospital, a licensed long-term care
2-24 facility, and a licensed adult care center where both the physician
2-25 and the Physician Assistant or Advanced Practice Nurse are
3-1 authorized to practice, a clinic operated by or associated with a
3-2 public school district for the purpose of providing care to the
3-3 students of that district and their siblings or an established
3-4 patient's residence; or
3-5 (c) where the physician is physically present with the
3-6 physician assistant or advanced nurse practitioner.
3-7 SECTION 4. Section 14, Texas Health Maintenance Organization
3-8 Act (Article 20A.14, Vernon's Texas Civil Statutes) is amended by
3-9 adding a subsection (i) to read as follows:
3-10 (i) If an advanced practice nurse or physician assistant has
3-11 been authorized to provide care pursuant to Section 3.06(d)(5) or
3-12 (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
3-13 Statutes), by a physician participating in a health maintenance
3-14 organization's provider network, the health maintenance
3-15 organization may not refuse a request by the physician and
3-16 physician assistant or advanced practice nurse for the physician
3-17 assistant or advanced practice nurse also to be identified on its
3-18 provider network except on the basis that the physician assistant
3-19 or advanced practice nurse fails to meet the pre-established
3-20 quality of care standards of the health maintenance organization
3-21 for participation by advanced practice nurses and physician
3-22 assistants.
3-23 SECTION 5. Chapter 3, Insurance Code, is amended by adding
3-24 Article 3.70-3C to read as follows:
3-25 Art. 3.70-3C.
4-1 Sec. 1. In this article:
4-2 (1) "Preferred Provider" means a physician, advanced
4-3 practice nurse, physician assistant or other health care provider
4-4 or an organization of physicians or health care providers, who
4-5 contracts with an insurer to provide medical care or health care to
4-6 insureds covered by a health insurance policy, certificate or
4-7 contract.
4-8 (2) "Preferred Provider Benefit Plan" means a benefit
4-9 plan in which an insurer provides, through its health insurance
4-10 policy, for the payment of a level of coverage which is different
4-11 from the basic level of coverage provided by the health insurance
4-12 policy if the insured uses a preferred provider.
4-13 Sec. 2. If an advanced practice nurse or physician assistant
4-14 has been authorized to provide care pursuant to Section 3.06(d)(5)
4-15 or (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
4-16 Statutes), by a physician included as a preferred provider in a
4-17 preferred provider benefit plan, the plan may not refuse a request
4-18 by the physician and physician assistant or advanced practice nurse
4-19 for the physician assistant or advanced practice nurse also to be
4-20 included as a preferred provider by the plan except on the basis
4-21 that the physician assistant or advanced practice nurse fails to
4-22 meet the pre-established quality of care standards of the preferred
4-23 provider benefit plan for participation by advanced practice nurses
4-24 and physician assistants.
4-25 SECTION 6. Subsection (B), Section 2, Chapter 397, Acts of
5-1 the 54th Legislature, 1955, (Article 3.70-2, Vernon's Texas
5-2 Insurance Code) is amended to read as follows:
5-3 (B) No policy of accident and sickness insurance shall make
5-4 benefits contingent upon treatment or examination by a particular
5-5 practitioner or by particular practitioners of the healing arts
5-6 hereinafter designated unless such policy contains a provision
5-7 designating the practitioner or practitioners who will be
5-8 recognized by the insurer and those who will not be recognized by
5-9 the insurer. Such provision may be located in the "Exceptions" or
5-10 "Exceptions and Reductions" provisions, or elsewhere in the policy,
5-11 or by endorsement attached to the policy, at the insurer's option.
5-12 In designating the practitioners who will and will not be
5-13 recognized, such provision shall use the following terms: Doctor
5-14 of Medicine, Doctor of Osteopathy, Doctor of Dentistry, Doctor of
5-15 Chiropractic, Doctor of Optometry, Doctor of Podiatry, Licensed
5-16 Audiologist, Licensed Speech-language Pathologist, Doctor in
5-17 Psychology, Licensed Master Social Worker--Advanced Clinical
5-18 Practitioner, Licensed Dietitian, Licensed Professional Counselor,
5-19 Licensed Marriage and Family Therapist, Licensed Chemical
5-20 Dependency Counselor, Licensed Hearing Aid Fitter and Dispenser,
5-21 and Licensed Psychological Associate.
5-22 For purposes of this Act, such designations shall have the
5-23 following meanings:
5-24 Doctor of Medicine: One licensed by the Texas State Board of
5-25 Medical Examiners on the basis of the degree "Doctor of Medicine";
6-1 Doctor of Osteopathy: One licensed by the Texas State Board
6-2 of Medical Examiners on the basis of the degree of "Doctor of
6-3 Osteopathy";
6-4 Doctor of Dentistry: One licensed by the State Board of
6-5 Dental Examiners;
6-6 Doctor of Chiropractic: One licensed by the Texas Board of
6-7 Chiropractic Examiners;
6-8 Doctor of Optometry: One licensed by the Texas Optometry
6-9 Board;
6-10 Doctor of Podiatry: One licensed by the Texas State Board of
6-11 Podiatric Medical Examiners;
6-12 Licensed Audiologist: One with a master's or doctorate
6-13 degree in audiology from an accredited college or university and
6-14 who is licensed as an audiologist by the State Committee of
6-15 Examiners for Speech-Language Pathology and Audiology;
6-16 Licensed Speech-language Pathologist: One with a master's or
6-17 doctorate degree in speech pathology or speech-language pathology
6-18 from an accredited college or university and who is licensed as a
6-19 speech-language pathologist by the State Committee of Examiners for
6-20 Speech-Language Pathology and Audiology;
6-21 Doctor in Psychology: One licensed by the Texas State Board
6-22 of Examiners of Psychologists and certified as a Health Service
6-23 Provider;
6-24 Licensed Master Social Worker--Advanced Clinical
6-25 Practitioner: One licensed by the Texas State Board of Social
7-1 Worker Examiners as a Licensed Master Social Worker with the order
7-2 of recognition of Advanced Clinical Practitioner;
7-3 Licensed Dietitian: One licensed by the Texas State Board of
7-4 Examiners of Dietitians;
7-5 Licensed Professional Counselor: One licensed by the Texas
7-6 State Board of Examiners of Professional Counselors;
7-7 Licensed Marriage and Family Therapist: One licensed by the
7-8 Texas State Board of Examiners of Marriage and Family Therapists;
7-9 Licensed Chemical Dependency Counselor: One licensed by the
7-10 Texas Commission on Alcohol and Drug Abuse;
7-11 Licensed Hearing Aid Fitter and Dispenser: One licensed by
7-12 the Texas Board of Examiners in the Fitting and Dispensing of
7-13 Hearing Aids; [and]
7-14 Licensed Psychological Associate: One licensed by the Texas
7-15 State Board of Examiners of Psychologists and practicing under the
7-16 supervision of a licensed psychologist;
7-17 Advanced Practice Nurse: One licensed by the Board of Nurse
7-18 Examiners as a registered nurse and recognized by that board as an
7-19 advanced practice nurse; and
7-20 Physician Assistant: One licensed by the Texas State Board
7-21 of Physician Assistants.
7-22 SECTION 7. Section 1, Article 21.52, Insurance Code, is
7-23 amended to read as follows:
7-24 Sec. 1. Definitions. As used in this article:
7-25 (a) "health insurance policy" means any individual, group,
8-1 blanket, or franchise insurance policy, insurance agreement, or
8-2 group hospital service contract, providing benefits for medical or
8-3 surgical expenses incurred as a result of an accident or sickness;
8-4 (b) "doctor of podiatric medicine" includes D.P.M.,
8-5 podiatrist, doctor of surgical chiropody, D.S.C. and chiropodist;
8-6 (c) "doctor of optometry" includes optometrist, doctor of
8-7 optometry, and O.D.;
8-8 (d) "doctor of chiropractic" means a person who is licensed
8-9 by the Texas Board of Chiropractic Examiners to practice
8-10 chiropractic;
8-11 (e) "licensed dentist" means a person who is licensed to
8-12 practice dentistry by the State Board of Dental Examiners;
8-13 (f) "licensed audiologist" means a person who has received a
8-14 master's or doctorate degree in audiology from an accredited
8-15 college or university and is licensed as an audiologist by the
8-16 State Committee of Examiners for Speech-Language Pathology and
8-17 Audiology;
8-18 (g) "licensed speech-language pathologist" means a person
8-19 who has received a master's or doctorate degree in speech-language
8-20 pathology from an accredited college or university and is licensed
8-21 as a speech-language pathologist by the State Committee of
8-22 Examiners for Speech-Language Pathology and Audiology;
8-23 (h) "licensed master social worker--advanced clinical
8-24 practitioner" means a person who is licensed by the Texas State
8-25 Board of Social Worker Examiners as a licensed master social worker
9-1 with the order of recognition of advanced clinical practitioner;
9-2 (i) "licensed dietitian" means a person who is licensed by
9-3 the Texas State Board of Examiners of Dietitians;
9-4 (j) "licensed professional counselor" means a person who is
9-5 licensed by the Texas State Board of Examiners of Professional
9-6 Counselors;
9-7 (k) "psychologist" means a person licensed to practice
9-8 psychology by the Texas State Board of Examiners of Psychologists;
9-9 (l) "licensed marriage and family therapist" means a person
9-10 who is licensed by the Texas State Board of Examiners of Marriage
9-11 and Family Therapists;
9-12 (m) "licensed chemical dependency counselor" means a person
9-13 who is licensed by the Texas Commission on Alcohol and Drug Abuse;
9-14 [and]
9-15 (n) "licensed hearing aid fitter and dispenser" means a
9-16 person who is licensed by the Texas Board of Examiners in the
9-17 Fitting and Dispensing of Hearing Aids;
9-18 ([n] o) "licensed psychological associate" means a person
9-19 who is licensed by the Texas State Board of Examiners of
9-20 Psychologists and who practices under the supervision of a licensed
9-21 psychologist;
9-22 (p) "advanced practice nurse" means a person licensed by the
9-23 Board of Nurse Examiners and recognized by that board as an
9-24 advanced practice nurse; and
9-25 (q) "physician assistant" means a person licensed by the
10-1 Texas State Board of Physician Assistants.
10-2 SECTION 8. Section 3, Article 21.52, Insurance Code, is
10-3 amended to read as follows:
10-4 Sec. 3. (a) Selection of practitioners. Any person who is
10-5 issued, who is a party to, or who is a beneficiary under any health
10-6 insurance policy delivered, renewed, or issued for delivery in this
10-7 state by any insurance company, association, or organization to
10-8 which this article applies may select a licensed doctor of
10-9 podiatric medicine, a licensed dentist, or a doctor of chiropractic
10-10 to perform the medical or surgical services or procedures scheduled
10-11 in the policy which fall within the scope of the license of that
10-12 practitioner, a licensed doctor of optometry to perform the
10-13 services or procedures scheduled in the policy which fall within
10-14 the scope of the license of that doctor of optometry, a licensed
10-15 audiologist to measure hearing for the purpose of determining the
10-16 presence or extent of a hearing loss and to provide aural
10-17 rehabilitation services to a person with a hearing loss if those
10-18 services or procedures are scheduled in the policy, a licensed
10-19 speech-language pathologist to evaluate speech and language and to
10-20 provide habilitative and rehabilitative services to restore speech
10-21 or language loss or to correct a speech or language impairment if
10-22 those services or procedures are scheduled in the policy, a
10-23 licensed master social worker--advanced clinical practitioner to
10-24 provide the services that fall within the scope of the license of
10-25 such certified practitioner and which are specified as services
11-1 within the terms of the policy of insurance, including the
11-2 provision of direct, diagnostic, preventive, or clinical services
11-3 to individuals, families, and groups whose functioning is
11-4 threatened or affected by social or psychological stress or health
11-5 impairment, if those services or procedures are scheduled in the
11-6 policy, a licensed dietitian including a provisional licensed
11-7 dietitian under a licensed dietitian's supervision to provide the
11-8 services that fall within the scope of the license of that
11-9 dietitian if those services are scheduled in the policy, a licensed
11-10 professional counselor to provide the services that fall within the
11-11 scope of the license of that professional if those services are
11-12 scheduled in the policy, a licensed marriage and family therapist
11-13 to provide the services that fall within the scope of the license
11-14 of that professional if those services are scheduled in the policy,
11-15 a psychologist to perform the services or procedures scheduled in
11-16 the policy that fall within the scope of the license of that
11-17 psychologist, a licensed chemical dependency counselor to perform
11-18 the services or procedures scheduled in the policy that fall within
11-19 the scope of the license of that practitioner, a licensed hearing
11-20 aid fitter and dispenser to provide the services or procedures
11-21 scheduled in the policy that fall within the scope of the license
11-22 of that practitioner, or a licensed psychological associate to
11-23 provide the services that fall within the scope of the license of
11-24 that professional if those services are scheduled in the policy.
11-25 The services of a licensed master social worker--advanced clinical
12-1 practitioner, licensed professional counselor, or licensed marriage
12-2 and family therapist that are included in this Act may require a
12-3 professional recommendation by a doctor of medicine or doctor of
12-4 osteopathy unless the health insurance policy terms do not require
12-5 such a recommendation. The payment or reimbursement by the
12-6 insurance company, association, or organization for those services
12-7 or procedures in accordance with the payment schedule or the
12-8 payment provisions in the policy shall not be denied because the
12-9 same were performed by a licensed doctor of podiatric medicine, a
12-10 licensed doctor of optometry, a licensed doctor of chiropractic, a
12-11 licensed dentist, a licensed audiologist, a licensed
12-12 speech-language pathologist, a licensed master social
12-13 worker--advanced clinical practitioner, a licensed dietitian, a
12-14 licensed professional counselor, a licensed marriage and family
12-15 therapist, a psychologist, a licensed chemical dependency
12-16 counselor, a licensed psychological associate, or a licensed
12-17 hearing aid fitter and dispenser. There shall not be any
12-18 classification, differentiation, or other discrimination in the
12-19 payment schedule or the payment provisions in a health insurance
12-20 policy, nor in the amount or manner of payment or reimbursement
12-21 thereunder, between scheduled services or procedures when performed
12-22 by a doctor of podiatric medicine, a doctor of optometry, a doctor
12-23 of chiropractic, a licensed dentist, a licensed audiologist, a
12-24 licensed speech-language pathologist, a licensed master social
12-25 worker--advanced clinical practitioner, a licensed dietitian, a
13-1 licensed professional counselor, a licensed marriage and family
13-2 therapist, a psychologist, a licensed psychological associate, a
13-3 licensed chemical dependency counselor, or a licensed hearing aid
13-4 fitter and dispenser which fall within the scope of the license or
13-5 certification and the same services or procedures when performed by
13-6 any other practitioner of the healing arts whose services or
13-7 procedures are covered by the policy. Any provision in a health
13-8 insurance policy contrary to or in conflict with the provisions of
13-9 this article shall, to the extent of the conflict, be void, but
13-10 such invalidity shall not affect the validity of the other
13-11 provisions of this policy. Any presently approved policy form
13-12 containing any provision in conflict with the requirements of this
13-13 Act shall be brought into compliance with this Act by the use of
13-14 riders and endorsements which have been approved by the State Board
13-15 of Insurance or by the filing of new or revised policy forms for
13-16 approval by the State Board of Insurance.
13-17 (b) Advanced practice nurses and physician assistants
13-18 performing services or procedures scheduled in the policy which
13-19 fall within the scope of the license of the advanced practice nurse
13-20 or physician assistant or which the advanced practice nurse or
13-21 physician assistant may perform under the authority of Section
13-22 3.06(d)(5) or (6), Medical Practice Act (Article 4495b, Vernon's
13-23 Texas Civil Statutes), shall be considered to be practitioners
13-24 listed in Subsection (a) for all purposes except that a health
13-25 insurance policy may differentiate in its payment schedule or
14-1 payment provisions or in its amount of payment or manner of payment
14-2 or reimbursement for scheduled services or procedures when
14-3 performed by a physician and when performed by an advanced practice
14-4 nurse or physician assistant based on reasonable differences in the
14-5 costs between a physician providing those services or procedures
14-6 and an advanced practice nurse or physician assistant providing
14-7 them.
14-8 SECTION 9. Section 241.003, Health and Safety Code, is
14-9 amended to read as follows:
14-10 Sec. 241.003. DEFINITIONS. In this chapter:
14-11 (1) "Advanced practice nurse" means a registered nurse
14-12 recognized as an advanced practice nurse by the Board of Nurse
14-13 Examiners.
14-14 (2) ("Board" means the Texas Board of Health.
14-15 (3) [(2)] "Council" means the Hospital Licensing
14-16 Advisory Council.
14-17 (4) [(3)] "Department" means the Texas Department of
14-18 Health.
14-19 (5) [(4)] "General hospital" means an establishment
14-20 that:
14-21 (A) offers services, facilities, and beds for
14-22 use for more than 24 hours for two or more unrelated individuals
14-23 requiring diagnosis, treatment, or care for illness, injury,
14-24 deformity, abnormality, or pregnancy; and
14-25 (B) regularly maintains, at a minimum, clinical
15-1 laboratory services, diagnostic X-ray services, treatment
15-2 facilities including surgery or obstetrical care or both, and other
15-3 definitive medical or surgical treatment of similar extent.
15-4 (6) [(5)] "Governmental unit" means a political
15-5 subdivision of the state, including a hospital district, county, or
15-6 municipality, and any department, division, board, or other agency
15-7 of a political subdivision.
15-8 (7) [(6)] "Hospital" includes a general hospital and a
15-9 special hospital.
15-10 (8) [(7)] "Medical staff" means a physician or group
15-11 of physicians, and a podiatrist or group of podiatrists, who by
15-12 action of the governing body of a hospital are privileged to work
15-13 in and use the facilities of a hospital for or in connection with
15-14 the observation, care, diagnosis, or treatment of an individual who
15-15 is, or may be, suffering from a mental or physical disease or
15-16 disorder or a physical deformity or injury.
15-17 (9) [(8)] "Person" means an individual, firm,
15-18 partnership, corporation, association, or joint stock company, and
15-19 includes a receiver, trustee, assignee, or other similar
15-20 representative of those entities.
15-21 (10) [(9)] "Physician" means a physician licensed by
15-22 the Texas State Board of Medical Examiners.
15-23 (11) "Physician Assistant" means a physician assistant
15-24 licensed by the Texas State Board of Physician Assistant Examiners.
15-25 (12) [(10)] "Podiatrist" means a podiatrist licensed
16-1 by the Texas State Board of Podiatry Examiners.
16-2 (13) [(11)] "Special hospital" means an establishment
16-3 that:
16-4 (A) offers services, facilities, and beds for
16-5 use for more than 24 hours for two or more unrelated individuals
16-6 who are regularly admitted, treated, and discharged and who require
16-7 services more intensive than room, board, personal services, and
16-8 general nursing care;
16-9 (B) has clinical laboratory facilities,
16-10 diagnostic X-ray facilities, treatment facilities, or other
16-11 definitive medical treatment;
16-12 (C) has a medical staff in regular attendance;
16-13 and
16-14 (D) maintains records of the clinical work
16-15 performed for each patient.
16-16 SECTION 10. Chapter 241, Health and Safety Code, is amended
16-17 by adding a Section 241.105 to read as follows:
16-18 Sec. 241.105. Hospital Privileges for Advanced Practice
16-19 Nurses and Physician Assistants.
16-20 (a) The governing body of a hospital is authorized to
16-21 establish policies concerning the granting of medical staff or
16-22 other clinical privileges to advanced practice nurses or physician
16-23 assistants, including the application process, qualifications for
16-24 privileges and the process for modification or revocation of
16-25 privileges.
17-1 (b) If the governing body of a hospital has adopted a policy
17-2 of extending medical staff or other clinical privileges to advanced
17-3 practice nurses or physician assistants, an individual advanced
17-4 practice nurse or physician assistant who qualifies for privileges
17-5 under that policy shall be entitled to certain due process rights,
17-6 as determined by the hospital board, when an application for
17-7 privileges is submitted to the hospital. At a minimum, any policy
17-8 adopted shall specify a reasonable time period for the processing
17-9 and consideration of the application and shall provide for written
17-10 notification of the applicant of any final action by the hospital
17-11 on the application, including any reason for denial or restriction
17-12 of the privileges requested.
17-13 (c) If an advanced practice nurse or physician assistant has
17-14 been granted medical or other clinical privileges by a hospital,
17-15 that hospital may not modify or revoke those privileges without
17-16 providing certain due process rights, as determined by the hospital
17-17 board, to the advanced practice nurse or physician assistant. At a
17-18 minimum, the hospital shall provide the advanced practice nurse or
17-19 physician assistant with written reasons for the modification or
17-20 revocation of privileges and a mechanism for appeal.
17-21 SECTION 11. This Act takes effect September 1, 1997.
17-22 SECTION 12. The importance of this legislation and the
17-23 crowded condition of the calendars in both houses create an
17-24 emergency and an imperative public necessity that the
17-25 constitutional rule requiring bills to be read on three several
18-1 days in each house be suspended, and this rule is hereby suspended,
18-2 and that this Act take effect and be in force from and after its
18-3 passage, and it is so enacted.