By: Madla S.B. No. 1575
Line and page numbers may not match official copy.
Bill not drafted by TLC or Senate E&E.
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 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Subdivision (5)(D), Subsection (d), Section 3.06,
1-5 Medical Practice Act (Article 4495b, Vernon's Texas Civil Statutes)
1-6 is amended to read as follows:
1-7 (D) Physician supervision shall be adequate if a
1-8 delegating physician:
1-9 (i) is responsible for the formulation or
1-10 approval of such physician's orders, standing medical orders,
1-11 standing delegation orders, or other orders or protocols and
1-12 periodically reviews such orders and the services provided patients
1-13 under such orders;
1-14 (ii) is on site at least once [a week]
1-15 every ten business days to provide medical direction and
1-16 consultation;
1-17 (iii) receives a daily status report from
1-18 the registered nurse or physician assistant on any problems or
1-19 complications encountered; and
1-20 (iv) is available through direct
1-21 telecommunication for consultation, assistance with medical
2-1 emergencies, or patient referral.
2-2 SECTION 2. Subdivision (5), Subsection (d), Section 3.06,
2-3 Medical Practice Act (Article 4495b, Vernon's Texas Civil
2-4 Statutes), is amended by adding a Paragraph (I) to read as follows:
2-5 (I) The Board, for good cause shown, may grant a
2-6 waiver of one or more of the physician supervision requirements set
2-7 out in Paragraph (D) of this Subdivision. In granting the waiver,
2-8 the Board shall consider:
2-9 (i) the adequacy of the collaborative
2-10 relationship between the physician and the Advanced Practice Nurse
2-11 or Physician Assistant;
2-12 (ii) the mechanism to be established to
2-13 ensure adequate physician supervision and patient care;
2-14 (iii) that compliance with the
2-15 requirements causes undue burden without corresponding benefit to
2-16 patient care; and
2-17 (iv) other provisions established by the
2-18 Board by rule.
2-19 The Board may withdraw the waiver after notice and hearing
2-20 and a waiver must be renewed every three years in accordance with
2-21 rules established by the Board.
2-22 SECTION 3. Subdivision (6)(G)(iii), Subsection (d), Section
2-23 3.06, Medical Practice Act (Article 4495b, Vernon's Texas Civil
2-24 Statutes), is amended to read as follows:
2-25 (iii) "Primary practice site" means:
3-1 (a) the practice location where the physician spends the
3-2 majority of the physician's time;
3-3 (b) a licensed hospital, a licensed long-term care facility,
3-4 and a licensed adult care center where both the physician and the
3-5 Physician Assistant or Advanced Practice Nurse are authorized to
3-6 practice, a clinic operated by or associated with a public school
3-7 district for the purpose of providing care to the students of that
3-8 district and their siblings or an established patient's residence;
3-9 or
3-10 (c) where the physician is physically present with the
3-11 physician assistant or advanced nurse practitioner.
3-12 SECTION 4. Section 14, Texas Health Maintenance Organization
3-13 Act (Article 20A.14, Vernon's Texas Civil Statutes) is amended by
3-14 adding a Subsection (i) to read as follows:
3-15 (i) If an advanced practice nurse or physician assistant has
3-16 been authorized to provide care pursuant to Section 3.06(d)(5) or
3-17 (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
3-18 Statutes), by a physician participating in a health maintenance
3-19 organization's provider network, the health maintenance
3-20 organization may not refuse a request by the physician and
3-21 physician assistant or advanced practice nurse for the physician
3-22 assistant or advanced practice nurse also to be identified on its
3-23 provider network except on the basis that the physician assistant
3-24 or advanced practice nurse fails to meet the pre-established
3-25 quality of care standards of the health maintenance organization
4-1 for participation by advanced practice nurses and physician
4-2 assistants.
4-3 SECTION 5. Chapter 3, Insurance Code, is amended by adding
4-4 Article 3.70-3C to read as follows:
4-5 Art. 3.70-3C.
4-6 Sec. 1. In this article:
4-7 (1) "Preferred Provider" means a physician, advanced
4-8 practice nurse, physician assistant or other health care provider
4-9 or an organization of physicians or health care providers, who
4-10 contracts with an insurer to provide medical care or health care to
4-11 insureds covered by a health insurance policy, certificate or
4-12 contract.
4-13 (2) "Preferred Provider Benefit Plan" means a benefit
4-14 plan in which an insurer provides, through its health insurance
4-15 policy, for the payment of a level of coverage which is different
4-16 from the basic level of coverage provided by the health insurance
4-17 policy if the insured uses a preferred provider.
4-18 Sec. 2. If an advanced practice nurse or physician assistant
4-19 has been authorized to provide care pursuant to Section 3.06(d)(5)
4-20 or (6), Medical Practice Act (Article 4495b, Vernon's Texas Civil
4-21 Statutes), by a physician included as a preferred provider in a
4-22 preferred provider benefit plan, the plan may not refuse a request
4-23 by the physician and physician assistant or advanced practice nurse
4-24 for the physician assistant or advanced practice nurse also to be
4-25 included as a preferred provider by the plan except on the basis
5-1 that the physician assistant or advanced practice nurse fails to
5-2 meet the pre-established quality of care standards of the preferred
5-3 provider benefit plan for participation by advanced practice nurses
5-4 and physician assistants.
5-5 SECTION 6. Subsection (B), Section 2, Chapter 397, Acts of
5-6 the 54th Legislature, 1955, (Article 3.70-2, Vernon's Texas
5-7 Insurance Code) is amended to read as follows:
5-8 (B) No policy of accident and sickness insurance shall make
5-9 benefits contingent upon treatment or examination by a particular
5-10 practitioner or by particular practitioners of the healing arts
5-11 hereinafter designated unless such policy contains a provision
5-12 designating the practitioner or practitioners who will be
5-13 recognized by the insurer and those who will not be recognized by
5-14 the insurer. Such provision may be located in the "Exceptions" or
5-15 "Exceptions and Reductions" provisions, or elsewhere in the policy,
5-16 or by endorsement attached to the policy, at the insurer's option.
5-17 In designating the practitioners who will and will not be
5-18 recognized, such provision shall use the following terms: Doctor
5-19 of Medicine, Doctor of Osteopathy, Doctor of Dentistry, Doctor of
5-20 Chiropractic, Doctor of Optometry, Doctor of Podiatry, Licensed
5-21 Audiologist, Licensed Speech-language Pathologist, Doctor in
5-22 Psychology, Licensed Master Social Worker--Advanced Clinical
5-23 Practitioner, Licensed Dietitian, Licensed Professional Counselor,
5-24 Licensed Marriage and Family Therapist, Licensed Chemical
5-25 Dependency Counselor, Licensed Hearing Aid Fitter and Dispenser,
6-1 and Licensed Psychological Associate.
6-2 For purposes of this Act, such designations shall have the
6-3 following meanings:
6-4 Doctor of Medicine: One licensed by the Texas State Board of
6-5 Medical Examiners on the basis of the degree "Doctor of Medicine";
6-6 Doctor of Osteopathy: One licensed by the Texas State Board
6-7 of Medical Examiners on the basis of the degree of "Doctor of
6-8 Osteopathy";
6-9 Doctor of Dentistry: One licensed by the State Board of
6-10 Dental Examiners;
6-11 Doctor of Chiropractic: One licensed by the Texas Board of
6-12 Chiropractic Examiners;
6-13 Doctor of Optometry: One licensed by the Texas Optometry
6-14 Board;
6-15 Doctor of Podiatry: One licensed by the Texas State Board of
6-16 Podiatric Medical Examiners;
6-17 Licensed Audiologist: One with a master's or doctorate
6-18 degree in audiology from an accredited college or university and
6-19 who is licensed as an audiologist by the State Committee of
6-20 Examiners for Speech-Language Pathology and Audiology;
6-21 Licensed Speech-language Pathologist: One with a master's or
6-22 doctorate degree in speech pathology or speech-language pathology
6-23 from an accredited college or university and who is licensed as a
6-24 speech-language pathologist by the State Committee of Examiners for
6-25 Speech-Language Pathology and Audiology;
7-1 Doctor in Psychology: One licensed by the Texas State Board
7-2 of Examiners of Psychologists and certified as a Health Service
7-3 Provider;
7-4 Licensed Master Social Worker--Advanced Clinical
7-5 Practitioner: One licensed by the Texas State Board of Social
7-6 Worker Examiners as a Licensed Master Social Worker with the order
7-7 of recognition of Advanced Clinical Practitioner;
7-8 Licensed Dietitian: One licensed by the Texas State Board of
7-9 Examiners of Dietitians;
7-10 Licensed Professional Counselor: One licensed by the Texas
7-11 State Board of Examiners of Professional Counselors;
7-12 Licensed Marriage and Family Therapist: One licensed by the
7-13 Texas State Board of Examiners of Marriage and Family Therapists;
7-14 Licensed Chemical Dependency Counselor: One licensed by the
7-15 Texas Commission on Alcohol and Drug Abuse;
7-16 Licensed Hearing Aid Fitter and Dispenser: One licensed by
7-17 the Texas Board of Examiners in the Fitting and Dispensing of
7-18 Hearing Aids; [and]
7-19 Licensed Psychological Associate: One licensed by the Texas
7-20 State Board of Examiners of Psychologists and practicing under the
7-21 supervision of a licensed psychologist;
7-22 Advanced Practice Nurse: One licensed by the Board of Nurse
7-23 Examiners as a registered nurse and recognized by that board as an
7-24 advanced practice nurse; and
7-25 Physician Assistant: One licensed by the Texas State Board
8-1 of Physician Assistants.
8-2 SECTION 7. Section 1, Article 21.52, Insurance Code, is
8-3 amended to read as follows:
8-4 Sec. 1. DEFINITIONS. As used in this article:
8-5 (a) "health insurance policy" means any individual, group,
8-6 blanket, or franchise insurance policy, insurance agreement, or
8-7 group hospital service contract, providing benefits for medical or
8-8 surgical expenses incurred as a result of an accident or sickness;
8-9 (b) "doctor of podiatric medicine" includes D.P.M.,
8-10 podiatrist, doctor of surgical chiropody, D.S.C. and chiropodist;
8-11 (c) "doctor of optometry" includes optometrist, doctor of
8-12 optometry, and O.D.;
8-13 (d) "doctor of chiropractic" means a person who is licensed
8-14 by the Texas Board of Chiropractic Examiners to practice
8-15 chiropractic;
8-16 (e) "licensed dentist" means a person who is licensed to
8-17 practice dentistry by the State Board of Dental Examiners;
8-18 (f) "licensed audiologist" means a person who has received a
8-19 master's or doctorate degree in audiology from an accredited
8-20 college or university and is licensed as an audiologist by the
8-21 State Committee of Examiners for Speech-Language Pathology and
8-22 Audiology;
8-23 (g) "licensed speech-language pathologist" means a person
8-24 who has received a master's or doctorate degree in speech-language
8-25 pathology from an accredited college or university and is licensed
9-1 as a speech-language pathologist by the State Committee of
9-2 Examiners for Speech-Language Pathology and Audiology;
9-3 (h) "licensed master social worker--advanced clinical
9-4 practitioner" means a person who is licensed by the Texas State
9-5 Board of Social Worker Examiners as a licensed master social worker
9-6 with the order of recognition of advanced clinical practitioner;
9-7 (i) "licensed dietitian" means a person who is licensed by
9-8 the Texas State Board of Examiners of Dietitians;
9-9 (j) "licensed professional counselor" means a person who is
9-10 licensed by the Texas State Board of Examiners of Professional
9-11 Counselors;
9-12 (k) "psychologist" means a person licensed to practice
9-13 psychology by the Texas State Board of Examiners of Psychologists;
9-14 (l) "licensed marriage and family therapist" means a person
9-15 who is licensed by the Texas State Board of Examiners of Marriage
9-16 and Family Therapists;
9-17 (m) "licensed chemical dependency counselor" means a person
9-18 who is licensed by the Texas Commission on Alcohol and Drug Abuse;
9-19 [and]
9-20 (n) "licensed hearing aid fitter and dispenser" means a
9-21 person who is licensed by the Texas Board of Examiners in the
9-22 Fitting and Dispensing of Hearing Aids;
9-23 [(n)] (o) "licensed psychological associate" means a person
9-24 who is licensed by the Texas State Board of Examiners of
9-25 Psychologists and who practices under the supervision of a licensed
10-1 psychologist;
10-2 (p) "advanced practice nurse" means a person licensed by the
10-3 Board of Nurse Examiners and recognized by that board as an
10-4 advanced practice nurse; and
10-5 (q) "physician assistant" means a person licensed by the
10-6 Texas State Board of Physician Assistants.
10-7 SECTION 8. Section 3, Article 21.52, Insurance Code, is
10-8 amended to read as follows:
10-9 Sec. 3. (a) Selection of Practitioners. Any person who is
10-10 issued, who is a party to, or who is a beneficiary under any health
10-11 insurance policy delivered, renewed, or issued for delivery in this
10-12 state by any insurance company, association, or organization to
10-13 which this article applies may select a licensed doctor of
10-14 podiatric medicine, a licensed dentist, or a doctor of chiropractic
10-15 to perform the medical or surgical services or procedures scheduled
10-16 in the policy which fall within the scope of the license of that
10-17 practitioner, a licensed doctor of optometry to perform the
10-18 services or procedures scheduled in the policy which fall within
10-19 the scope of the license of that doctor of optometry, a licensed
10-20 audiologist to measure hearing for the purpose of determining the
10-21 presence or extent of a hearing loss and to provide aural
10-22 rehabilitation services to a person with a hearing loss if those
10-23 services or procedures are scheduled in the policy, a licensed
10-24 speech-language pathologist to evaluate speech and language and to
10-25 provide habilitative and rehabilitative services to restore speech
11-1 or language loss or to correct a speech or language impairment if
11-2 those services or procedures are scheduled in the policy, a
11-3 licensed master social worker--advanced clinical practitioner to
11-4 provide the services that fall within the scope of the license of
11-5 such certified practitioner and which are specified as services
11-6 within the terms of the policy of insurance, including the
11-7 provision of direct, diagnostic, preventive, or clinical services
11-8 to individuals, families, and groups whose functioning is
11-9 threatened or affected by social or psychological stress or health
11-10 impairment, if those services or procedures are scheduled in the
11-11 policy, a licensed dietitian including a provisional licensed
11-12 dietitian under a licensed dietitian's supervision to provide the
11-13 services that fall within the scope of the license of that
11-14 dietitian if those services are scheduled in the policy, a licensed
11-15 professional counselor to provide the services that fall within the
11-16 scope of the license of that professional if those services are
11-17 scheduled in the policy, a licensed marriage and family therapist
11-18 to provide the services that fall within the scope of the license
11-19 of that professional if those services are scheduled in the policy,
11-20 a psychologist to perform the services or procedures scheduled in
11-21 the policy that fall within the scope of the license of that
11-22 psychologist, a licensed chemical dependency counselor to perform
11-23 the services or procedures scheduled in the policy that fall within
11-24 the scope of the license of that practitioner, a licensed hearing
11-25 aid fitter and dispenser to provide the services or procedures
12-1 scheduled in the policy that fall within the scope of the license
12-2 of that practitioner, or a licensed psychological associate to
12-3 provide the services that fall within the scope of the license of
12-4 that professional if those services are scheduled in the policy.
12-5 The services of a licensed master social worker--advanced clinical
12-6 practitioner, licensed professional counselor, or licensed marriage
12-7 and family therapist that are included in this Act may require a
12-8 professional recommendation by a doctor of medicine or doctor of
12-9 osteopathy unless the health insurance policy terms do not require
12-10 such a recommendation. The payment or reimbursement by the
12-11 insurance company, association, or organization for those services
12-12 or procedures in accordance with the payment schedule or the
12-13 payment provisions in the policy shall not be denied because the
12-14 same were performed by a licensed doctor of podiatric medicine, a
12-15 licensed doctor of optometry, a licensed doctor of chiropractic, a
12-16 licensed dentist, a licensed audiologist, a licensed
12-17 speech-language pathologist, a licensed master social
12-18 worker--advanced clinical practitioner, a licensed dietitian, a
12-19 licensed professional counselor, a licensed marriage and family
12-20 therapist, a psychologist, a licensed chemical dependency
12-21 counselor, a licensed psychological associate, or a licensed
12-22 hearing aid fitter and dispenser. There shall not be any
12-23 classification, differentiation, or other discrimination in the
12-24 payment schedule or the payment provisions in a health insurance
12-25 policy, nor in the amount or manner of payment or reimbursement
13-1 thereunder, between scheduled services or procedures when performed
13-2 by a doctor of podiatric medicine, a doctor of optometry, a doctor
13-3 of chiropractic, a licensed dentist, a licensed audiologist, a
13-4 licensed speech-language pathologist, a licensed master social
13-5 worker--advanced clinical practitioner, a licensed dietitian, a
13-6 licensed professional counselor, a licensed marriage and family
13-7 therapist, a psychologist, a licensed psychological associate, a
13-8 licensed chemical dependency counselor, or a licensed hearing aid
13-9 fitter and dispenser which fall within the scope of the license or
13-10 certification and the same services or procedures when performed by
13-11 any other practitioner of the healing arts whose services or
13-12 procedures are covered by the policy. Any provision in a health
13-13 insurance policy contrary to or in conflict with the provisions of
13-14 this article shall, to the extent of the conflict, be void, but
13-15 such invalidity shall not affect the validity of the other
13-16 provisions of this policy. Any presently approved policy form
13-17 containing any provision in conflict with the requirements of this
13-18 Act shall be brought into compliance with this Act by the use of
13-19 riders and endorsements which have been approved by the State Board
13-20 of Insurance or by the filing of new or revised policy forms for
13-21 approval by the State Board of Insurance.
13-22 (b) Advanced practice nurses and physician assistants
13-23 performing services or procedures scheduled in the policy which
13-24 fall within the scope of the license of the advanced practice nurse
13-25 or physician assistant or which the advanced practice nurse or
14-1 physician assistant may perform under the authority of Section
14-2 3.06(d)(5) or (6), Medical Practice Act (Article 4495b, Vernon's
14-3 Texas Civil Statutes), shall be considered to be practitioners
14-4 listed in Subsection (a) for all purposes except that a health
14-5 insurance policy may differentiate in its payment schedule or
14-6 payment provisions or in its amount of payment or manner of payment
14-7 or reimbursement for scheduled services or procedures when
14-8 performed by a physician and when performed by an advanced practice
14-9 nurse or physician assistant based on reasonable differences in the
14-10 costs between a physician providing those services or procedures
14-11 and an advanced practice nurse or physician assistant providing
14-12 them.
14-13 SECTION 9. Section 241.003, Health and Safety Code, is
14-14 amended to read as follows:
14-15 Sec. 241.003. Definitions. In this chapter:
14-16 (1) "Advanced practice nurse" means a registered nurse
14-17 recognized as an advanced practice nurse by the Board of Nurse
14-18 Examiners.
14-19 (2) "Board" means the Texas Board of Health.
14-20 (3) [(2)] "Council" means the Hospital Licensing
14-21 Advisory Council.
14-22 (4) [(3)] "Department" means the Texas Department of
14-23 Health.
14-24 (5) [(4)] "General hospital" means an establishment
14-25 that:
15-1 (A) offers services, facilities, and beds for
15-2 use for more than 24 hours for two or more unrelated individuals
15-3 requiring diagnosis, treatment, or care for illness, injury,
15-4 deformity, abnormality, or pregnancy; and
15-5 (B) regularly maintains, at a minimum, clinical
15-6 laboratory services, diagnostic X-ray services, treatment
15-7 facilities including surgery or obstetrical care or both, and other
15-8 definitive medical or surgical treatment of similar extent.
15-9 (6) [(5)] "Governmental unit" means a political
15-10 subdivision of the state, including a hospital district, county, or
15-11 municipality, and any department, division, board, or other agency
15-12 of a political subdivision.
15-13 (7) [(6)] "Hospital" includes a general hospital and a
15-14 special hospital.
15-15 (8) [(7)] "Medical staff" means a physician or group
15-16 of physicians, and a podiatrist or group of podiatrists, who by
15-17 action of the governing body of a hospital are privileged to work
15-18 in and use the facilities of a hospital for or in connection with
15-19 the observation, care, diagnosis, or treatment of an individual who
15-20 is, or may be, suffering from a mental or physical disease or
15-21 disorder or a physical deformity or injury.
15-22 (9) [(8)] "Person" means an individual, firm,
15-23 partnership, corporation, association, or joint stock company, and
15-24 includes a receiver, trustee, assignee, or other similar
15-25 representative of those entities.
16-1 (10) [(9)] "Physician" means a physician licensed by
16-2 the Texas State Board of Medical Examiners.
16-3 (11) "Physician Assistant" means a physician assistant
16-4 licensed by the Texas State Board of Physician Assistant Examiners.
16-5 (12) [(10)] "Podiatrist" means a podiatrist licensed
16-6 by the Texas State Board of Podiatry Examiners.
16-7 (13) [(11)] "Special hospital" means an establishment
16-8 that:
16-9 (A) offers services, facilities, and beds for
16-10 use for more than 24 hours for two or more unrelated individuals
16-11 who are regularly admitted, treated, and discharged and who require
16-12 services more intensive than room, board, personal services, and
16-13 general nursing care;
16-14 (B) has clinical laboratory facilities,
16-15 diagnostic X-ray facilities, treatment facilities, or other
16-16 definitive medical treatment;
16-17 (C) has a medical staff in regular attendance;
16-18 and
16-19 (D) maintains records of the clinical work
16-20 performed for each patient.
16-21 SECTION 10. Chapter 241, Health and Safety Code, is amended
16-22 by adding a Section 241.105 to read as follows:
16-23 Sec. 241.105. Hospital Privileges for Advanced Practice
16-24 Nurses and Physician Assistants. (a) The governing body of a
16-25 hospital is authorized to establish policies concerning the
17-1 granting of medical staff or other clinical privileges to advanced
17-2 practice nurses or physician assistants, including the application
17-3 process, qualifications for privileges and the process for
17-4 modification or revocation of privileges.
17-5 (b) If the governing body of a hospital has adopted a policy
17-6 of extending medical staff or other clinical privileges to advanced
17-7 practice nurses or physician assistants, an individual advanced
17-8 practice nurse or physician assistant who qualifies for privileges
17-9 under that policy shall be entitled to certain due process rights,
17-10 as determined by the hospital board, when an application for
17-11 privileges is submitted to the hospital. At a minimum, any policy
17-12 adopted shall specify a reasonable time period for the processing
17-13 and consideration of the application and shall provide for written
17-14 notification of the applicant of any final action by the hospital
17-15 on the application, including any reason for denial or restriction
17-16 of the privileges requested.
17-17 (c) If an advanced practice nurse or physician assistant has
17-18 been granted medical or other clinical privileges by a hospital,
17-19 that hospital may not modify or revoke those privileges without
17-20 providing certain due process rights, as determined by the hospital
17-21 board, to the advanced practice nurse or physician assistant. At a
17-22 minimum, the hospital shall provide the advanced practice nurse or
17-23 physician assistant with written reasons for the modification or
17-24 revocation of privileges and a mechanism for appeal.
17-25 SECTION 11. This Act takes effect September 1, 1997.
18-1 SECTION 12. The importance of this legislation and the
18-2 crowded condition of the calendars in both houses create an
18-3 emergency and an imperative public necessity that the
18-4 constitutional rule requiring bills to be read on three several
18-5 days in each house be suspended, and this rule is hereby suspended,
18-6 and that this Act take effect and be in force from and after its
18-7 passage, and it is so enacted.