1-1 By: Madla S.B. No. 1131
1-2 (In the Senate - Filed March 10, 1999; March 11, 1999, read
1-3 first time and referred to Committee on Health Services;
1-4 April 6, 1999, reported adversely, with favorable Committee
1-5 Substitute by the following vote: Yeas 4, Nays 0; April 6, 1999,
1-6 sent to printer.)
1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 1131 By: Madla
1-8 A BILL TO BE ENTITLED
1-9 AN ACT
1-10 relating to advanced practice nurses and physician assistants;
1-11 providing penalties.
1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-13 SECTION 1. Section 241.003, Health and Safety Code, is
1-14 amended to read as follows:
1-15 Sec. 241.003. Definitions. In this chapter:
1-16 (1) "Advanced practice nurse" means a registered nurse
1-17 recognized as an advanced practice nurse by the Board of Nurse
1-18 Examiners.
1-19 (2) "Board" means the Texas Board of Health.
1-20 (3) [(2)] "Comprehensive medical rehabilitation
1-21 hospital" means a general hospital that specializes in providing
1-22 comprehensive medical rehabilitation services, including surgery
1-23 and related ancillary services.
1-24 (4) [(2)] "Department" means the Texas Department of
1-25 Health.
1-26 (5) [(3)] "General hospital" means an establishment
1-27 that:
1-28 (A) offers services, facilities, and beds for
1-29 use for more than 24 hours for two or more unrelated individuals
1-30 requiring diagnosis, treatment, or care for illness, injury,
1-31 deformity, abnormality, or pregnancy; and
1-32 (B) regularly maintains, at a minimum, clinical
1-33 laboratory services, diagnostic X-ray services, treatment
1-34 facilities including surgery or obstetrical care or both, and other
1-35 definitive medical or surgical treatment of similar extent.
1-36 (6) [(4)] "Governmental unit" means a political
1-37 subdivision of the state, including a hospital district, county, or
1-38 municipality, and any department, division, board, or other agency
1-39 of a political subdivision.
1-40 (7) [(5)] "Hospital" includes a general hospital and a
1-41 special hospital.
1-42 (8) [(6)] "Medical staff" means a physician or group
1-43 of physicians and a podiatrist or a group of podiatrists who by
1-44 action of the governing body of a hospital are privileged to work
1-45 in and use the facilities of a hospital for or in connection with
1-46 the observation, care, diagnosis, or treatment of an individual who
1-47 is, or may be, suffering from a mental or physical disease or
1-48 disorder or a physical deformity or injury.
1-49 (9) "Pediatric and adolescent hospital" means a
1-50 general hospital that specializes in providing services to children
1-51 and adolescents, including surgery and related ancillary services.
1-52 (10) "Person" means an individual, firm, partnership,
1-53 corporation, association, or joint stock company, and includes a
1-54 receiver, trustee, assignee, or other similar representative of
1-55 those entities.
1-56 (11) "Physician" means a physician licensed by the
1-57 Texas State Board of Medical Examiners.
1-58 (12) "Physician assistant" means a physician assistant
1-59 licensed by the Texas State Board of Physician Assistant Examiners.
1-60 (13) [(12)] "Podiatrist" means a podiatrist licensed
1-61 by the Texas State Board of Podiatric Medical Examiners.
1-62 (14) [(13)] "Premises" means:
1-63 (A) a single building where inpatients receive
1-64 hospital services; or
2-1 (B) multiple buildings where inpatients receive
2-2 hospital services, provided that the following criteria are met:
2-3 (i) all inpatient buildings and inpatient
2-4 services are subject to the control and direction of the governing
2-5 body of the hospital;
2-6 (ii) all inpatient buildings are within a
2-7 30-mile radius of the main address of the licensee;
2-8 (iii) there is integration of the
2-9 organized medical staff of the hospital;
2-10 (iv) there is a single chief executive
2-11 officer who reports directly to the governing body and through whom
2-12 all administrative authority flows and who exercises control and
2-13 surveillance over all administrative activities of the hospital;
2-14 (v) there is a single chief medical
2-15 officer who reports directly to the governing body and who is
2-16 responsible for all medical staff activities of the hospital; and
2-17 (vi) each building that is geographically
2-18 separate from other buildings contains at least one nursing unit
2-19 for inpatients, unless providing only diagnostic or laboratory
2-20 services, or a combination thereof, in the building for hospital
2-21 inpatients.
2-22 (15) [(14)] "Special hospital" means an establishment
2-23 that:
2-24 (A) offers services, facilities, and beds for
2-25 use for more than 24 hours for two or more unrelated individuals
2-26 who are regularly admitted, treated, and discharged and who require
2-27 services more intensive than room, board, personal services, and
2-28 general nursing care;
2-29 (B) has clinical laboratory facilities,
2-30 diagnostic X-ray facilities, treatment facilities, or other
2-31 definitive medical treatment;
2-32 (C) has a medical staff in regular attendance;
2-33 and
2-34 (D) maintains records of the clinical work
2-35 performed for each patient.
2-36 SECTION 2. Subchapter E, Chapter 241, Health and Safety
2-37 Code, is amended by adding Section 241.105 to read as follows:
2-38 Sec. 241.105. HOSPITAL PRIVILEGES FOR ADVANCED PRACTICE
2-39 NURSES AND PHYSICIAN ASSISTANTS. (a) The governing body of a
2-40 hospital is authorized to establish policies concerning the
2-41 granting of clinical privileges to advanced practice nurses and
2-42 physician assistants, including policies relating to the
2-43 application process, reasonable qualifications for privileges, and
2-44 the process for renewal, modification, or revocation of privileges.
2-45 (b) If the governing body of a hospital has adopted a policy
2-46 of granting clinical privileges to advanced practice nurses or
2-47 physician assistants, an individual advanced practice nurse or
2-48 physician assistant who qualifies for privileges under that policy
2-49 shall be entitled to certain procedural rights to provide fairness
2-50 of process, as determined by the governing body of the hospital,
2-51 when an application for privileges is submitted to the hospital.
2-52 At a minimum, any policy adopted shall specify a reasonable period
2-53 for the processing and consideration of the application and shall
2-54 provide for written notification to the applicant of any final
2-55 action on the application by the hospital, including any reason for
2-56 denial or restriction of the privileges requested.
2-57 (c) If an advanced practice nurse or physician assistant has
2-58 been granted clinical privileges by a hospital, the hospital may
2-59 not modify or revoke those privileges without providing certain
2-60 procedural rights to provide fairness of process, as determined by
2-61 the governing body of the hospital, to the advanced practice nurse
2-62 or physician assistant. At a minimum, the hospital shall provide
2-63 the advanced practice nurse or physician assistant written reasons
2-64 for the modification or revocation of privileges and a mechanism
2-65 for appeal to the appropriate committee or body within the
2-66 hospital, as determined by the governing body of the hospital.
2-67 (d) If a hospital extends clinical privileges to an advanced
2-68 practice nurse or physician assistant conditioned on the advanced
2-69 practice nurse or physician assistant having a sponsoring or
3-1 collaborating relationship with a physician and that relationship
3-2 ceases to exist, the advanced practice nurse or physician assistant
3-3 and the physician shall provide written notification to the
3-4 hospital that the relationship no longer exists. Once the hospital
3-5 receives such notice from an advanced practice nurse or physician
3-6 assistant and the physician, the hospital shall be deemed to have
3-7 met its obligations under this section by notifying the advanced
3-8 practice nurse or physician assistant in writing that the advanced
3-9 practice nurse's or physician assistant's clinical privileges no
3-10 longer exist at that hospital.
3-11 (e) Nothing in this section shall be construed as modifying
3-12 the Medical Practice Act (Article 4495b, Vernon's Texas Civil
3-13 Statutes), the Nursing Practice Act (Articles 4513-4528, Revised
3-14 Statutes), the Physician Assistant Licensing Act (Article 4495b-1,
3-15 Vernon's Texas Civil Statutes), or any other law relating to the
3-16 scope of practice of physicians, advanced practice nurses, or
3-17 physician assistants.
3-18 (f) This section does not apply to an employer-employee
3-19 relationship between an advanced practice nurse or physician
3-20 assistant and a hospital.
3-21 SECTION 3. Section 33, Texas Pharmacy Act (Article 4542a-1,
3-22 Vernon's Texas Civil Statutes), is amended by adding Subsection (f)
3-23 to read as follows:
3-24 (f) A person who qualifies as a practitioner's designated
3-25 agent under Section 5(18)(A) or (B) of this Act may be designated
3-26 by the practitioner to communicate prescriptions of an advanced
3-27 practice nurse or physician assistant authorized by the
3-28 practitioner to sign prescription drug orders under Section
3-29 3.06(d)(5) or (6), Medical Practice Act (Article 4495b, Vernon's
3-30 Texas Civil Statutes).
3-31 SECTION 4. Section 483.022, Health and Safety Code, is
3-32 amended by adding Subsection (f) to read as follows:
3-33 (f) A practitioner may designate a person who qualifies as a
3-34 designated agent of the practitioner under Section 483.001(4)(A) or
3-35 (B) to communicate prescriptions of an advanced practice nurse or
3-36 physician assistant authorized by the practitioner to sign
3-37 prescription drug orders under Section 3.06(d)(5) or (6), Medical
3-38 Practice Act (Article 4495b, Vernon's Texas Civil Statutes).
3-39 SECTION 5. Section 31, Chapter 1036, Acts of the 62nd
3-40 Legislature, Regular Session, 1971 (Article 8451a, Vernon's Texas
3-41 Civil Statutes), is amended to read as follows:
3-42 Sec. 31. Health Certificate. (a) Every applicant for an
3-43 original or renewal operator license, instructor license,
3-44 reciprocal license, or specialty certificate must submit a
3-45 certificate of health signed by a licensed physician, licensed
3-46 advanced practice nurse, or licensed physician assistant, showing
3-47 that the applicant is free, as determined by an examination, from
3-48 tuberculosis, hepatitis, or a contagious disease for which the
3-49 applicant is not entitled to protection under the Americans with
3-50 Disabilities Act (42 U.S.C. Section 12101 et seq.).
3-51 (b) Any physician, advanced practice nurse, or physician
3-52 assistant who signs a health certificate required by Subsection (a)
3-53 of this section showing the applicant to be free from a disease
3-54 covered by that subsection without having made the physical
3-55 examination is guilty of a misdemeanor, and on conviction may be
3-56 fined not less than $50 or more than $200.
3-57 SECTION 6. Section 1, Article 21.52, Insurance Code, is
3-58 amended to read as follows:
3-59 Sec. 1. DEFINITIONS. As used in this article:
3-60 (a) "health insurance policy" means any individual, group,
3-61 blanket, or franchise insurance policy, insurance agreement, or
3-62 group hospital service contract, providing benefits for medical or
3-63 surgical expenses incurred as a result of an accident or sickness;
3-64 (b) "doctor of podiatric medicine" includes D.P.M.,
3-65 podiatrist, doctor of surgical chiropody, D.S.C. and chiropodist;
3-66 (c) "doctor of optometry" includes optometrist, doctor of
3-67 optometry, and O.D.;
3-68 (d) "doctor of chiropractic" means a person who is licensed
3-69 by the Texas Board of Chiropractic Examiners to practice
4-1 chiropractic;
4-2 (e) "licensed dentist" means a person who is licensed to
4-3 practice dentistry by the State Board of Dental Examiners;
4-4 (f) "licensed audiologist" means a person who has received a
4-5 master's or doctorate degree in audiology from an accredited
4-6 college or university and is licensed as an audiologist by the
4-7 State Committee of Examiners for Speech-Language Pathology and
4-8 Audiology;
4-9 (g) "licensed speech-language pathologist" means a person
4-10 who has received a master's or doctorate degree in speech-language
4-11 pathology from an accredited college or university and is licensed
4-12 as a speech-language pathologist by the State Committee of
4-13 Examiners for Speech-Language Pathology and Audiology;
4-14 (h) "licensed master social worker--advanced clinical
4-15 practitioner" means a person who is licensed by the Texas State
4-16 Board of Social Worker Examiners as a licensed master social worker
4-17 with the order of recognition of advanced clinical practitioner;
4-18 (i) "licensed dietitian" means a person who is licensed by
4-19 the Texas State Board of Examiners of Dietitians;
4-20 (j) "licensed professional counselor" means a person who is
4-21 licensed by the Texas State Board of Examiners of Professional
4-22 Counselors;
4-23 (k) "psychologist" means a person licensed to practice
4-24 psychology by the Texas State Board of Examiners of Psychologists;
4-25 (l) "licensed marriage and family therapist" means a person
4-26 who is licensed by the Texas State Board of Examiners of Marriage
4-27 and Family Therapists;
4-28 (m) "licensed chemical dependency counselor" means a person
4-29 who is licensed by the Texas Commission on Alcohol and Drug Abuse;
4-30 (n) "licensed hearing aid fitter and dispenser" means a
4-31 person who is licensed by the Texas Board of Examiners in the
4-32 Fitting and Dispensing of Hearing Aids;
4-33 (o) "licensed psychological associate" means a person who is
4-34 licensed by the Texas State Board of Examiners of Psychologists and
4-35 who practices under the supervision of a licensed psychologist;
4-36 (p) "occupational therapist" means a person who is licensed
4-37 to practice occupational therapy by the Texas Board of Occupational
4-38 Therapy Examiners; [and]
4-39 (q) "physical therapist" means a person who practices
4-40 physical therapy and is licensed by the Texas Board of Physical
4-41 Therapy Examiners;
4-42 (r) "advanced practice nurse" means a person licensed by the
4-43 Board of Nurse Examiners and recognized by that board as an
4-44 advanced practice nurse; and
4-45 (s) "physician assistant" means a person licensed by the
4-46 Texas State Board of Physician Assistant Examiners.
4-47 SECTION 7. Section 3, Article 21.52, Insurance Code, as
4-48 amended by Chapter 541, Acts of the 74th Legislature, Regular
4-49 Session, 1995, and as reenacted and amended by Chapter 946, Acts of
4-50 the 75th Legislature, Regular Session, 1997, is amended to read as
4-51 follows:
4-52 Sec. 3. Selection of practitioners. (a) Any person who is
4-53 issued, who is a party to, or who is a beneficiary under any health
4-54 insurance policy delivered, renewed, or issued for delivery in this
4-55 state by any insurance company, association, or organization to
4-56 which this article applies may select:
4-57 (1) a licensed doctor of podiatric medicine, a
4-58 licensed dentist, or a doctor of chiropractic to perform the
4-59 medical or surgical services or procedures scheduled in the policy
4-60 which fall within the scope of the license of that practitioner;
4-61 (2) [,] a licensed doctor of optometry to perform the
4-62 services or procedures scheduled in the policy which fall within
4-63 the scope of the license of that doctor of optometry;
4-64 (3) [,] an occupational therapist to provide the
4-65 services scheduled in the policy which fall within the scope of the
4-66 license of that occupational therapist;
4-67 (4) [,] a physical therapist to provide the services
4-68 scheduled in the policy which fall within the scope of the license
4-69 of that physical therapist;
5-1 (5) [,] a licensed audiologist to measure hearing for
5-2 the purpose of determining the presence or extent of a hearing loss
5-3 and to provide aural rehabilitation services to a person with a
5-4 hearing loss if those services or procedures are scheduled in the
5-5 policy;
5-6 (6) [,] a licensed speech-language pathologist to
5-7 evaluate speech and language and to provide habilitative and
5-8 rehabilitative services to restore speech or language loss or to
5-9 correct a speech or language impairment if those services or
5-10 procedures are scheduled in the policy;
5-11 (7) [,] a licensed master social worker--advanced
5-12 clinical practitioner to provide the services that fall within the
5-13 scope of the license of such certified practitioner and which are
5-14 specified as services within the terms of the policy of insurance,
5-15 including the provision of direct, diagnostic, preventive, or
5-16 clinical services to individuals, families, and groups whose
5-17 functioning is threatened or affected by social or psychological
5-18 stress or health impairment, if those services or procedures are
5-19 scheduled in the policy;
5-20 (8) [,] a licensed dietitian including a provisional
5-21 licensed dietitian under a licensed dietitian's supervision to
5-22 provide the services that fall within the scope of the license of
5-23 that dietitian if those services are scheduled in the policy;
5-24 (9) [,] a licensed professional counselor to provide
5-25 the services that fall within the scope of the license of that
5-26 professional if those services are scheduled in the policy;
5-27 (10) [,] a licensed marriage and family therapist to
5-28 provide the services that fall within the scope of the license of
5-29 that professional if those services are scheduled in the policy;
5-30 (11) [,] a psychologist to perform the services or
5-31 procedures scheduled in the policy that fall within the scope of
5-32 the license of that psychologist;
5-33 (12) a licensed chemical dependency counselor to
5-34 perform the services or procedures scheduled in the policy that
5-35 fall within the scope of the license of that practitioner;
5-36 (13) an advanced practice nurse to provide the
5-37 services scheduled in the policy that fall within the scope of the
5-38 license of that practitioner;
5-39 (14) a physician assistant to provide the services
5-40 scheduled in the policy that fall within the scope of the license
5-41 of that practitioner;
5-42 (15) [,] a licensed hearing aid fitter and dispenser
5-43 to provide the services or procedures scheduled in the policy that
5-44 fall within the scope of the license of that practitioner;[,] or
5-45 (16) a licensed psychological associate to provide the
5-46 services that fall within the scope of the license of that
5-47 professional if those services are scheduled in the policy.
5-48 (b) The services of a licensed master social
5-49 worker--advanced clinical practitioner, licensed professional
5-50 counselor, or licensed marriage and family therapist that are
5-51 included in this Act may require a professional recommendation by a
5-52 doctor of medicine or doctor of osteopathy unless the health
5-53 insurance policy terms do not require such a recommendation.
5-54 (c) The payment or reimbursement by the insurance company,
5-55 association, or organization for [those] services or procedures in
5-56 accordance with the payment schedule or the payment provisions in
5-57 the policy shall not be denied because the same were performed by a
5-58 licensed doctor of podiatric medicine, a licensed doctor of
5-59 optometry, a licensed doctor of chiropractic, a licensed dentist,
5-60 an occupational therapist, a physical therapist, a licensed
5-61 audiologist, a licensed speech-language pathologist, a licensed
5-62 master social worker--advanced clinical practitioner, a licensed
5-63 dietitian, a licensed professional counselor, a licensed marriage
5-64 and family therapist, a psychologist, a licensed psychological
5-65 associate, a licensed chemical dependency counselor, an advanced
5-66 practice nurse, a physician assistant, or a licensed hearing aid
5-67 fitter and dispenser.
5-68 (d) There shall not be any classification, differentiation,
5-69 or other discrimination in the payment schedule or the payment
6-1 provisions in a health insurance policy, nor in the amount or
6-2 manner of payment or reimbursement thereunder, between scheduled
6-3 services or procedures when performed by a doctor of podiatric
6-4 medicine, a doctor of optometry, a doctor of chiropractic, a
6-5 licensed dentist, an occupational therapist, a physical therapist,
6-6 a licensed audiologist, a licensed speech-language pathologist, a
6-7 licensed master social worker--advanced clinical practitioner, a
6-8 licensed dietitian, a licensed professional counselor, a licensed
6-9 marriage and family therapist, a psychologist, a licensed
6-10 psychological associate, a licensed chemical dependency counselor,
6-11 an advanced practice nurse to provide the services scheduled in the
6-12 policy, a physician assistant to provide the services scheduled in
6-13 the policy, or a licensed hearing aid fitter and dispenser which
6-14 fall within the scope of that practitioner's [his] license or
6-15 certification and the same services or procedures when performed by
6-16 any other practitioner of the healing arts whose services or
6-17 procedures are covered by the policy. However, a health insurance
6-18 policy may provide for a different amount of payment or
6-19 reimbursement for scheduled services or procedures when performed
6-20 by an advanced practice nurse or physician assistant provided the
6-21 reimbursement methodology used to calculate the payment for the
6-22 service or procedure is the same methodology used to calculate the
6-23 payment when the service or procedure is provided by a physician.
6-24 (e) Any provision in a health insurance policy contrary to
6-25 or in conflict with the provisions of this article shall, to the
6-26 extent of the conflict, be void, but such invalidity shall not
6-27 affect the validity of the other provisions of this policy. Any
6-28 presently approved policy form containing any provision in conflict
6-29 with the requirements of this Act shall be brought into compliance
6-30 with this Act by the use of riders and endorsements which have been
6-31 approved by the commissioner [State Board of Insurance] or by the
6-32 filing of new or revised policy forms for approval by the
6-33 commissioner [State Board of Insurance].
6-34 SECTION 8. Section 3, Article 21.52, Insurance Code, as
6-35 amended by Chapter 429, Acts of the 74th Legislature, Regular
6-36 Session, 1995, and as reenacted and amended by Chapter 946, Acts of
6-37 the 75th Legislature, Regular Session, 1997, is repealed.
6-38 SECTION 9. This Act takes effect September 1, 1999.
6-39 SECTION 10. The importance of this legislation and the
6-40 crowded condition of the calendars in both houses create an
6-41 emergency and an imperative public necessity that the
6-42 constitutional rule requiring bills to be read on three several
6-43 days in each house be suspended, and this rule is hereby suspended.
6-44 * * * * *