S.B. No. 406
AN ACT
relating to the practice of advanced practice registered nurses and
physician assistants and the delegation of prescriptive authority
by physicians to and the supervision by physicians of certain
advanced practice registered nurses and physician assistants.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. The heading to Subchapter B, Chapter 157,
Occupations Code, is amended to read as follows:
SUBCHAPTER B. DELEGATION TO ADVANCED PRACTICE REGISTERED NURSES
AND PHYSICIAN ASSISTANTS
SECTION 2. Section 157.051, Occupations Code, is amended to
read as follows:
Sec. 157.051. DEFINITIONS. In this subchapter:
(1) "Advanced practice registered nurse" has the
meaning assigned to that term by Section 301.152. The term includes
an advanced nurse practitioner and advanced practice nurse.
(2) ["Carrying out or signing a prescription drug
order" means completing a prescription drug order presigned by the
delegating physician, or the signing of a prescription by a
registered nurse or physician assistant.
[(2-a)] "Controlled substance" has the meaning
assigned to that term by Section 481.002, Health and Safety Code.
(3) [(2-b)] "Dangerous drug" has the meaning assigned
to that term by Section 483.001, Health and Safety Code.
(4) "Device" has the meaning assigned by Section
551.003, and includes durable medical equipment.
(5) "Health professional shortage area" means:
(A) an urban or rural area of this state that:
(i) is not required to conform to the
geographic boundaries of a political subdivision but is a rational
area for the delivery of health services;
(ii) the secretary of health and human
services determines has a health professional shortage; and
(iii) is not reasonably accessible to an
adequately served area;
(B) a population group that the secretary of
health and human services determines has a health professional
shortage; or
(C) a public or nonprofit private medical
facility or other facility that the secretary of health and human
services determines has a health professional shortage, as
described by 42 U.S.C. Section 254e(a)(1).
(6) "Hospital" means a facility that:
(A) is:
(i) a general hospital or a special
hospital, as those terms are defined by Section 241.003, Health and
Safety Code, including a hospital maintained or operated by the
state; or
(ii) a mental hospital licensed under
Chapter 577, Health and Safety Code; and
(B) has an organized medical staff.
(7) "Medication order" has the meanings assigned by
Section 551.003 of this code and Section 481.002, Health and Safety
Code.
(8) "Nonprescription drug" has the meaning assigned by
Section 551.003.
(9) [(3)] "Physician assistant" means a person who
holds a license issued under Chapter 204.
(10) "Physician group practice" means an entity
through which two or more physicians deliver health care to the
public through the practice of medicine on a regular basis and that
is:
(A) owned and operated by two or more physicians;
or
(B) a freestanding clinic, center, or office of a
nonprofit health organization certified by the board under Section
162.001(b) that complies with the requirements of Chapter 162.
(11) "Practice serving a medically underserved
population" means:
(A) a practice in a health professional shortage
area;
(B) a clinic designated as a rural health clinic
under 42 U.S.C. Section 1395x(aa);
(C) a public health clinic or a family planning
clinic under contract with the Health and Human Services Commission
or the Department of State Health Services;
(D) a clinic designated as a federally qualified
health center under 42 U.S.C. Section 1396d(l)(2)(B);
(E) a county, state, or federal correctional
facility;
(F) a practice:
(i) that either:
(a) is located in an area in which the
Department of State Health Services determines there is an
insufficient number of physicians providing services to eligible
clients of federally, state, or locally funded health care
programs; or
(b) is a practice that the Department
of State Health Services determines serves a disproportionate
number of clients eligible to participate in federally, state, or
locally funded health care programs; and
(ii) for which the Department of State
Health Services publishes notice of the department's determination
in the Texas Register and provides an opportunity for public
comment in the manner provided for a proposed rule under Chapter
2001, Government Code; or
(G) a practice at which a physician was
delegating prescriptive authority to an advanced practice
registered nurse or physician assistant on or before March 1, 2013,
based on the practice qualifying as a site serving a medically
underserved population.
(12) "Prescribe or order a drug or device" means
prescribing or ordering a drug or device, including the issuing of a
prescription drug order or a medication order.
(13) "Prescription drug" has the meaning assigned by
Section 551.003.
(14) "Prescriptive authority agreement" means an
agreement entered into by a physician and an advanced practice
registered nurse or physician assistant through which the physician
delegates to the advanced practice registered nurse or physician
assistant the act of prescribing or ordering a drug or device.
SECTION 3. Section 157.0511, Occupations Code, is amended
to read as follows:
Sec. 157.0511. DELEGATION OF PRESCRIBING AND ORDERING DRUGS
AND DEVICES [PRESCRIPTION DRUG ORDERS]. (a) A physician's
authority to delegate the prescribing or ordering of a drug or
device [carrying out or signing of a prescription drug order] under
this subchapter is limited to:
(1) nonprescription drugs;
(2) dangerous drugs; and
(3) [(2)] controlled substances to the extent
provided by Subsections [Subsection] (b) and (b-1).
(b) Except as provided by Subsection (b-1), a [A] physician
may delegate the prescribing or ordering of [carrying out or
signing of a prescription drug order for] a controlled substance
only if:
(1) the prescription is for a controlled substance
listed in Schedule III, IV, or V as established by the commissioner
of the Department of State Health Services [public health] under
Chapter 481, Health and Safety Code;
(2) the prescription, including a refill of the
prescription, is for a period not to exceed 90 days;
(3) with regard to the refill of a prescription, the
refill is authorized after consultation with the delegating
physician and the consultation is noted in the patient's chart; and
(4) with regard to a prescription for a child less than
two years of age, the prescription is made after consultation with
the delegating physician and the consultation is noted in the
patient's chart.
(b-1) A physician may delegate the prescribing or ordering
of a controlled substance listed in Schedule II as established by
the commissioner of the Department of State Health Services under
Chapter 481, Health and Safety Code, only:
(1) in a hospital facility-based practice under
Section 157.054, in accordance with policies approved by the
hospital's medical staff or a committee of the hospital's medical
staff as provided by the hospital bylaws to ensure patient safety,
and as part of the care provided to a patient who:
(A) has been admitted to the hospital for an
intended length of stay of 24 hours or greater; or
(B) is receiving services in the emergency
department of the hospital; or
(2) as part of the plan of care for the treatment of a
person who has executed a written certification of a terminal
illness, has elected to receive hospice care, and is receiving
hospice treatment from a qualified hospice provider.
(b-2) The board shall adopt rules that require a physician
who delegates the prescribing or ordering of a drug or device
[carrying out or signing of a prescription drug order under this
subchapter] to register with the board the name and license number
of the physician assistant or advanced practice registered nurse to
whom a delegation is made. The board may develop and use an
electronic online delegation registration process for registration
under this subsection.
(c) This subchapter does not modify the authority granted by
law for a licensed registered nurse or physician assistant to
administer or provide a medication, including a controlled
substance listed in Schedule II as established by the commissioner
of the Department of State Health Services [public health] under
Chapter 481, Health and Safety Code, that is authorized by a
physician under a physician's order, standing medical order,
standing delegation order, or protocol.
SECTION 4. Subchapter B, Chapter 157, Occupations Code, is
amended by adding Sections 157.0512, 157.0513, and 157.0514 to read
as follows:
Sec. 157.0512. PRESCRIPTIVE AUTHORITY AGREEMENT. (a) A
physician may delegate to an advanced practice registered nurse or
physician assistant, acting under adequate physician supervision,
the act of prescribing or ordering a drug or device as authorized
through a prescriptive authority agreement between the physician
and the advanced practice registered nurse or physician assistant,
as applicable.
(b) A physician and an advanced practice registered nurse or
physician assistant are eligible to enter into or be parties to a
prescriptive authority agreement only if:
(1) if applicable, the Texas Board of Nursing has
approved the advanced practice registered nurse's authority to
prescribe or order a drug or device as authorized under this
subchapter;
(2) the advanced practice registered nurse or
physician assistant:
(A) holds an active license to practice in this
state as an advanced practice registered nurse or physician
assistant, as applicable, and is in good standing in this state; and
(B) is not currently prohibited by the Texas
Board of Nursing or the Texas Physician Assistant Board, as
applicable, from executing a prescriptive authority agreement; and
(3) before executing the prescriptive authority
agreement, the physician and the advanced practice registered nurse
or physician assistant disclose to the other prospective party to
the agreement any prior disciplinary action by the board, the Texas
Board of Nursing, or the Texas Physician Assistant Board, as
applicable.
(c) Except as provided by Subsection (d), the combined
number of advanced practice registered nurses and physician
assistants with whom a physician may enter into a prescriptive
authority agreement may not exceed seven advanced practice
registered nurses and physician assistants or the full-time
equivalent of seven advanced practice registered nurses and
physician assistants.
(d) Subsection (c) does not apply to a prescriptive
authority agreement if the prescriptive authority is being
exercised in:
(1) a practice serving a medically underserved
population; or
(2) a facility-based practice in a hospital under
Section 157.054.
(e) A prescriptive authority agreement must, at a minimum:
(1) be in writing and signed and dated by the parties
to the agreement;
(2) state the name, address, and all professional
license numbers of the parties to the agreement;
(3) state the nature of the practice, practice
locations, or practice settings;
(4) identify the types or categories of drugs or
devices that may be prescribed or the types or categories of drugs
or devices that may not be prescribed;
(5) provide a general plan for addressing consultation
and referral;
(6) provide a plan for addressing patient emergencies;
(7) state the general process for communication and
the sharing of information between the physician and the advanced
practice registered nurse or physician assistant to whom the
physician has delegated prescriptive authority related to the care
and treatment of patients;
(8) if alternate physician supervision is to be
utilized, designate one or more alternate physicians who may:
(A) provide appropriate supervision on a
temporary basis in accordance with the requirements established by
the prescriptive authority agreement and the requirements of this
subchapter; and
(B) participate in the prescriptive authority
quality assurance and improvement plan meetings required under this
section; and
(9) describe a prescriptive authority quality
assurance and improvement plan and specify methods for documenting
the implementation of the plan that includes the following:
(A) chart review, with the number of charts to be
reviewed determined by the physician and advanced practice
registered nurse or physician assistant; and
(B) periodic face-to-face meetings between the
advanced practice registered nurse or physician assistant and the
physician at a location determined by the physician and the
advanced practice registered nurse or physician assistant.
(f) The periodic face-to-face meetings described by
Subsection (e)(9)(B) must:
(1) include:
(A) the sharing of information relating to
patient treatment and care, needed changes in patient care plans,
and issues relating to referrals; and
(B) discussion of patient care improvement; and
(2) be documented and occur:
(A) except as provided by Paragraph (B):
(i) at least monthly until the third
anniversary of the date the agreement is executed; and
(ii) at least quarterly after the third
anniversary of the date the agreement is executed, with monthly
meetings held between the quarterly meetings by means of a remote
electronic communications system, including videoconferencing
technology or the Internet; or
(B) if during the seven years preceding the date
the agreement is executed the advanced practice registered nurse or
physician assistant for at least five years was in a practice that
included the exercise of prescriptive authority with required
physician supervision:
(i) at least monthly until the first
anniversary of the date the agreement is executed; and
(ii) at least quarterly after the first
anniversary of the date the agreement is executed, with monthly
meetings held between the quarterly meetings by means of a remote
electronic communications system, including videoconferencing
technology or the Internet.
(g) The prescriptive authority agreement may include other
provisions agreed to by the physician and advanced practice
registered nurse or physician assistant.
(h) If the parties to the prescriptive authority agreement
practice in a physician group practice, the physician may appoint
one or more alternate supervising physicians designated under
Subsection (e)(8), if any, to conduct and document the quality
assurance meetings in accordance with the requirements of this
subchapter.
(i) The prescriptive authority agreement need not describe
the exact steps that an advanced practice registered nurse or
physician assistant must take with respect to each specific
condition, disease, or symptom.
(j) A physician, advanced practice registered nurse, or
physician assistant who is a party to a prescriptive authority
agreement must retain a copy of the agreement until the second
anniversary of the date the agreement is terminated.
(k) A party to a prescriptive authority agreement may not by
contract waive, void, or nullify any provision of this section or
Section 157.0513.
(l) In the event that a party to a prescriptive authority
agreement is notified that the individual has become the subject of
an investigation by the board, the Texas Board of Nursing, or the
Texas Physician Assistant Board, the individual shall immediately
notify the other party to the prescriptive authority agreement.
(m) The prescriptive authority agreement and any amendments
must be reviewed at least annually, dated, and signed by the parties
to the agreement. The prescriptive authority agreement and any
amendments must be made available to the board, the Texas Board of
Nursing, or the Texas Physician Assistant Board not later than the
third business day after the date of receipt of request, if any.
(n) The prescriptive authority agreement should promote the
exercise of professional judgment by the advanced practice
registered nurse or physician assistant commensurate with the
advanced practice registered nurse's or physician assistant's
education and experience and the relationship between the advanced
practice registered nurse or physician assistant and the physician.
(o) This section shall be liberally construed to allow the
use of prescriptive authority agreements to safely and effectively
utilize the skills and services of advanced practice registered
nurses and physician assistants.
(p) The board may not adopt rules pertaining to the elements
of a prescriptive authority agreement that would impose
requirements in addition to the requirements under this section.
The board may adopt other rules relating to physician delegation
under this chapter.
(q) The board, the Texas Board of Nursing, and the Texas
Physician Assistant Board shall jointly develop responses to
frequently asked questions relating to prescriptive authority
agreements not later than January 1, 2014. This subsection expires
January 1, 2015.
Sec. 157.0513. PRESCRIPTIVE AUTHORITY AGREEMENT:
INFORMATION. (a) The board, the Texas Board of Nursing, and the
Texas Physician Assistant Board shall jointly develop a process:
(1) to exchange information regarding the names,
locations, and license numbers of each physician, advanced practice
registered nurse, and physician assistant who has entered into a
prescriptive authority agreement;
(2) by which each board shall immediately notify the
other boards when a license holder of the board becomes the subject
of an investigation involving the delegation and supervision of
prescriptive authority, as well as the final disposition of any
such investigation; and
(3) by which each board shall maintain and share a list
of the board's license holders who have been subject to a final
adverse disciplinary action for an act involving the delegation and
supervision of prescriptive authority.
(b) If the board, the Texas Board of Nursing, or the Texas
Physician Assistant Board receives a notice under Subsection
(a)(2), the board that received notice may open an investigation
against a license holder of the board who is a party to a
prescriptive authority agreement with the license holder who is
under investigation by the board that provided notice under
Subsection (a)(2).
(c) The board shall maintain and make available to the
public a searchable online list of physicians, advanced practice
registered nurses, and physician assistants who have entered into a
prescriptive authority agreement authorized under Section 157.0512
and identify the physician, advanced practice registered nurse, or
physician assistant with whom each physician, advanced practice
registered nurse, and physician assistant has entered into a
prescriptive authority agreement.
(d) The board shall collaborate with the Texas Board of
Nursing and the Texas Physician Assistant Board to maintain and
make available to the public a list of physicians, advanced
practice registered nurses, and physician assistants who are
prohibited from entering into or practicing under a prescriptive
authority agreement.
Sec. 157.0514. PRESCRIPTIVE AUTHORITY AGREEMENT:
INSPECTIONS. If the board receives a notice under Section
157.0513(a)(2), the board or an authorized board representative may
enter, with reasonable notice and at a reasonable time, unless the
notice would jeopardize an investigation, a site where a party to a
prescriptive authority agreement practices to inspect and audit any
records or activities relating to the implementation and operation
of the agreement. To the extent reasonably possible, the board and
the board's authorized representative shall conduct any inspection
or audit under this section in a manner that minimizes disruption to
the delivery of patient care.
SECTION 5. Section 157.054, Occupations Code, is amended by
amending Subsections (a), (b), and (c) and adding Subsections (a-1)
and (b-1) to read as follows:
(a) One or more physicians [A physician] licensed by the
board may delegate, to one or more physician assistants or advanced
practice registered nurses acting under adequate physician
supervision whose practice is facility-based at a [licensed]
hospital or licensed long-term care facility, the administration or
provision of a drug and the prescribing or ordering of a drug or
device [carrying out or signing of a prescription drug order] if
each of the delegating physicians [physician] is:
(1) the medical director or chief of medical staff of
the facility in which the physician assistant or advanced practice
registered nurse practices;
(2) the chair of the facility's credentialing
committee;
(3) a department chair of a facility department in
which the physician assistant or advanced practice registered nurse
practices; or
(4) a physician who consents to the request of the
medical director or chief of medical staff to delegate the
prescribing or ordering of a drug or device [carrying out or signing
of a prescription drug order] at the facility in which the physician
assistant or advanced practice registered nurse practices.
(a-1) The limits on the number of advanced practice
registered nurses or physician assistants to whom a physician may
delegate under Section 157.0512 do not apply to a physician under
Subsection (a) whose practice is facility-based under this section,
provided that the physician is not delegating in a freestanding
clinic, center, or practice of the facility.
(b) A physician's authority to delegate under Subsection
(a) is limited as follows:
(1) the delegation must be made under a physician's
order, standing medical order, standing delegation order, or
another order or protocol developed in accordance with policies
approved by the facility's medical staff or a committee of the
facility's medical staff as provided by the facility bylaws;
(2) the delegation must occur in the facility in which
the physician is the medical director, the chief of medical staff,
the chair of the credentialing committee, [or] a department chair,
or a physician who consents to delegate under Subsection (a)(4);
(3) the delegation may not permit the prescribing or
ordering of a drug or device [carrying out or signing of
prescription drug orders] for the care or treatment of the patients
of any other physician without the prior consent of that physician;
and
(4) delegation in a long-term care facility must be by
the medical director and is limited to the prescribing or ordering
of a drug or device [carrying out and signing of prescription drug
orders] to not more than seven [four] advanced practice registered
nurses or physician assistants or their full-time equivalents.[;
and]
(b-1) A facility-based [(5) a] physician may not delegate at
more than one [licensed] hospital or more than two long-term care
facilities under this section unless approved by the board. The
facility-based physician may not be prohibited from delegating the
prescribing or ordering of drugs or devices under Section 157.0512
at other practice locations, including hospitals or long-term care
facilities, provided that the delegation at those locations
complies with all the requirements of Section 157.0512.
(c) Physician supervision of the prescribing or ordering of
a drug or device [carrying out and signing of prescription drug
orders] must conform to what a reasonable, prudent physician would
find consistent with sound medical judgment but may vary with the
education and experience of the particular advanced practice
registered nurse or physician assistant. A physician shall provide
continuous supervision, but the constant physical presence of the
physician is not required.
SECTION 6. Section 157.055, Occupations Code, is amended to
read as follows:
Sec. 157.055. ORDERS AND PROTOCOLS. A protocol or other
order shall be defined in a manner that promotes the exercise of
professional judgment by the advanced practice registered nurse and
physician assistant commensurate with the education and experience
of that person. Under this section, an order or protocol used by a
reasonable and prudent physician exercising sound medical
judgment:
(1) is not required to describe the exact steps that an
advanced practice registered nurse or a physician assistant must
take with respect to each specific condition, disease, or symptom;
and
(2) may state the types or categories of medications
that may be prescribed or the types or categories of medications
that may not be prescribed.
SECTION 7. Section 157.057, Occupations Code, is amended to
read as follows:
Sec. 157.057. ADDITIONAL IMPLEMENTATION METHODS. The board
may adopt additional methods to implement:
(1) a physician's prescription; or
(2) the delegation of prescriptive authority [the
signing of a prescription under a physician's order, standing
medical order, standing delegation order, or other order or
protocol].
SECTION 8. Subsections (b), (d), (e), (f), and (j), Section
157.059, Occupations Code, are amended to read as follows:
(b) A physician may delegate to a physician assistant
offering obstetrical services and certified by the board as
specializing in obstetrics or an advanced practice registered nurse
recognized by the Texas Board of Nursing as a nurse midwife the act
of administering or providing controlled substances to the
physician assistant's or nurse midwife's clients during intrapartum
and immediate postpartum care.
(d) The delegation of authority to administer or provide
controlled substances under Subsection (b) must be under a
physician's order, medical order, standing delegation order,
prescriptive authority agreement, or protocol that requires
adequate and documented availability for access to medical care.
(e) The physician's orders, medical orders, standing
delegation orders, prescriptive authority agreements, or protocols
must require the reporting of or monitoring of each client's
progress, including complications of pregnancy and delivery and the
administration and provision of controlled substances by the nurse
midwife or physician assistant to the clients of the nurse midwife
or physician assistant.
(f) The authority of a physician to delegate under this
section is limited to:
(1) seven [four] nurse midwives or physician
assistants or their full-time equivalents; and
(2) the designated facility at which the nurse midwife
or physician assistant provides care.
(j) This section does not limit the authority of a physician
to delegate the prescribing or ordering of [carrying out or signing
of a prescription drug order involving] a controlled substance
under this subchapter.
SECTION 9. Section 157.060, Occupations Code, is amended to
read as follows:
Sec. 157.060. PHYSICIAN LIABILITY FOR DELEGATED ACT.
Unless the physician has reason to believe the physician assistant
or advanced practice registered nurse lacked the competency to
perform the act, a physician is not liable for an act of a physician
assistant or advanced practice registered nurse solely because the
physician signed a standing medical order, a standing delegation
order, or another order or protocol, or entered into a prescriptive
authority agreement, authorizing the physician assistant or
advanced practice registered nurse to administer, provide,
prescribe, or order a drug or device [carry out, or sign a
prescription drug order].
SECTION 10. Section 156.056, Occupations Code, is amended
to read as follows:
Sec. 156.056. CERTAIN VOLUNTEER SERVICES. (a) In this
section, "practice [site] serving a medically underserved
population" has the meaning assigned by Section 157.051 [157.052].
(b) The board by rule shall permit a license holder to
complete half of any informal continuing medical education hours
required under this subchapter by providing volunteer medical
services at a practice [site] serving a medically underserved
population other than a site that is a primary practice site of the
license holder.
SECTION 11. Subchapter C, Chapter 204, Occupations Code, is
amended by adding Section 204.1025 to read as follows:
Sec. 204.1025. DUTIES REGARDING PRESCRIPTIVE AUTHORITY
AGREEMENTS. The physician assistant board shall in conjunction
with the Texas Medical Board and the Texas Board of Nursing perform
the functions and duties relating to prescriptive authority
agreements assigned to the physician assistant board in Sections
157.0512 and 157.0513.
SECTION 12. Section 204.1565, Occupations Code, is amended
to read as follows:
Sec. 204.1565. INFORMAL CONTINUING MEDICAL EDUCATION.
(a) In this section, "practice [site] serving a medically
underserved population" has the meaning assigned by Section 157.051
[157.052].
(b) The physician assistant board by rule shall permit a
license holder to complete half of any informal continuing medical
education hours required to renew a license under this chapter by
providing volunteer medical services at a practice [site] serving a
medically underserved population, other than a site that is a
primary practice site of the license holder.
SECTION 13. Subsection (b), Section 204.202, Occupations
Code, is amended to read as follows:
(b) Medical services provided by a physician assistant may
include:
(1) obtaining patient histories and performing
physical examinations;
(2) ordering or performing diagnostic and therapeutic
procedures;
(3) formulating a working diagnosis;
(4) developing and implementing a treatment plan;
(5) monitoring the effectiveness of therapeutic
interventions;
(6) assisting at surgery;
(7) offering counseling and education to meet patient
needs;
(8) requesting, receiving, and signing for the receipt
of pharmaceutical sample prescription medications and distributing
the samples to patients in a specific practice setting in which the
physician assistant is authorized to prescribe pharmaceutical
medications and sign prescription drug orders as provided by
Section 157.0512 or [157.052, 157.053,] 157.054[, 157.0541, or
157.0542 or as otherwise authorized by physician assistant board
rule];
(9) prescribing or ordering a drug or device [signing
or completing a prescription] as provided by Subchapter B, Chapter
157; and
(10) making appropriate referrals.
SECTION 14. Section 204.204, Occupations Code, is amended
by adding Subsection (c) to read as follows:
(c) The number of physician assistants a physician may
supervise in a practice setting may not be less than the number of
physician assistants to whom a physician may delegate the authority
to prescribe or order a drug or device in that practice setting
under Subchapter B, Chapter 157.
SECTION 15. Subdivision (2), Section 301.002, Occupations
Code, is amended to read as follows:
(2) "Professional nursing" means the performance of an
act that requires substantial specialized judgment and skill, the
proper performance of which is based on knowledge and application
of the principles of biological, physical, and social science as
acquired by a completed course in an approved school of
professional nursing. The term does not include acts of medical
diagnosis or the prescription of therapeutic or corrective
measures. Professional nursing involves:
(A) the observation, assessment, intervention,
evaluation, rehabilitation, care and counsel, or health teachings
of a person who is ill, injured, infirm, or experiencing a change in
normal health processes;
(B) the maintenance of health or prevention of
illness;
(C) the administration of a medication or
treatment as ordered by a physician, podiatrist, or dentist;
(D) the supervision or teaching of nursing;
(E) the administration, supervision, and
evaluation of nursing practices, policies, and procedures;
(F) the requesting, receiving, signing for, and
distribution of prescription drug samples to patients at practices
at [sites in] which an advanced practice [a] registered nurse is
authorized to sign prescription drug orders as provided by
Subchapter B, Chapter 157;
(G) the performance of an act delegated by a
physician under Section 157.0512 [157.052, 157.053], 157.054,
[157.0541, 157.0542,] 157.058, or 157.059; and
(H) the development of the nursing care plan.
SECTION 16. Section 301.005, Occupations Code, is amended
to read as follows:
Sec. 301.005. REFERENCE IN OTHER LAW. (a) A reference in
any other law to the former Board of Nurse Examiners means the Texas
Board of Nursing.
(b) A reference in any other law to an "advanced nurse
practitioner" or "advanced practice nurse" means an advanced
practice registered nurse.
SECTION 17. Section 301.152, Occupations Code, is amended
to read as follows:
Sec. 301.152. RULES REGARDING SPECIALIZED TRAINING.
(a) In this section, "advanced practice registered nurse" means a
registered nurse licensed [approved] by the board to practice as an
advanced practice registered nurse on the basis of completion of an
advanced educational program. The term includes a nurse
practitioner, nurse midwife, nurse anesthetist, and clinical nurse
specialist. The term is synonymous with "advanced nurse
practitioner" and "advanced practice nurse."
(b) The board shall adopt rules to:
(1) license a registered nurse as an advanced practice
registered nurse;
(2) establish:
(A) any specialized education or training,
including pharmacology, that an advanced practice [a] registered
nurse must have to prescribe or order a drug or device as delegated
by a physician [carry out a prescription drug order] under Section
157.0512 or 157.054 [157.052]; [and]
(B) a system for approving an advanced practice
registered nurse to prescribe or order a drug or device as delegated
by a physician under Section 157.0512 or 157.054 on the receipt of
[assigning an identification number to a registered nurse who
provides the board with] evidence of completing the specialized
education and training requirement under Paragraph (A)
[Subdivision (1)(A)]; and
(C) a system for issuing a prescription
authorization number to an advanced practice registered nurse
approved under Paragraph (B) [(2) approve a registered nurse as an
advanced practice nurse]; and
(3) concurrently [initially approve and biennially]
renew any license or approval granted to an advanced practice
registered nurse under this subsection and a license renewed by the
advanced practice registered nurse under Section 301.301 [an
advanced practice nurse's authority to carry out or sign a
prescription drug order under Chapter 157].
(c) At a minimum, the rules adopted under Subsection (b)(2)
[(b)(3)] must:
(1) require completion of pharmacology and related
pathophysiology [pathology] education for initial approval; and
(2) require continuing education in clinical
pharmacology and related pathophysiology [pathology] in addition
to any continuing education otherwise required under Section
301.303[; and
[(3) provide for the issuance of a prescription
authorization number to an advanced practice nurse approved under
this section].
(d) The signature of an advanced practice registered nurse
attesting to the provision of a legally authorized service by the
advanced practice registered nurse satisfies any documentation
requirement for that service established by a state agency.
SECTION 18. Subchapter D, Chapter 301, Occupations Code, is
amended by adding Section 301.168 to read as follows:
Sec. 301.168. DUTIES REGARDING PRESCRIPTIVE AUTHORITY
AGREEMENTS. The board shall in conjunction with the Texas Medical
Board and the Texas Physician Assistant Board perform the functions
and duties relating to prescriptive authority agreements assigned
to the board in Sections 157.0512 and 157.0513.
SECTION 19. Subdivisions (34) and (45), Section 551.003,
Occupations Code, are amended to read as follows:
(34) "Practitioner" means:
(A) a person licensed or registered to prescribe,
distribute, administer, or dispense a prescription drug or device
in the course of professional practice in this state, including a
physician, dentist, podiatrist, or veterinarian but excluding a
person licensed under this subtitle;
(B) a person licensed by another state, Canada,
or the United Mexican States in a health field in which, under the
law of this state, a license holder in this state may legally
prescribe a dangerous drug;
(C) a person practicing in another state and
licensed by another state as a physician, dentist, veterinarian, or
podiatrist, who has a current federal Drug Enforcement
Administration registration number and who may legally prescribe a
Schedule II, III, IV, or V controlled substance, as specified under
Chapter 481, Health and Safety Code, in that other state; or
(D) an advanced practice registered nurse or
physician assistant to whom a physician has delegated the authority
to prescribe or order a drug or device [carry out or sign
prescription drug orders] under Section 157.0511, 157.0512
[157.052, 157.053], or 157.054[, 157.0541, or 157.0542].
(45) "Written protocol" means a physician's order,
standing medical order, standing delegation order, or other order
or protocol as defined by rule of the Texas Medical [State] Board
[of Medical Examiners] under Subtitle B.
SECTION 20. Subsection (a), Section 533.005, Government
Code, is amended to read as follows:
(a) A contract between a managed care organization and the
commission for the organization to provide health care services to
recipients must contain:
(1) procedures to ensure accountability to the state
for the provision of health care services, including procedures for
financial reporting, quality assurance, utilization review, and
assurance of contract and subcontract compliance;
(2) capitation rates that ensure the cost-effective
provision of quality health care;
(3) a requirement that the managed care organization
provide ready access to a person who assists recipients in
resolving issues relating to enrollment, plan administration,
education and training, access to services, and grievance
procedures;
(4) a requirement that the managed care organization
provide ready access to a person who assists providers in resolving
issues relating to payment, plan administration, education and
training, and grievance procedures;
(5) a requirement that the managed care organization
provide information and referral about the availability of
educational, social, and other community services that could
benefit a recipient;
(6) procedures for recipient outreach and education;
(7) a requirement that the managed care organization
make payment to a physician or provider for health care services
rendered to a recipient under a managed care plan not later than the
45th day after the date a claim for payment is received with
documentation reasonably necessary for the managed care
organization to process the claim, or within a period, not to exceed
60 days, specified by a written agreement between the physician or
provider and the managed care organization;
(8) a requirement that the commission, on the date of a
recipient's enrollment in a managed care plan issued by the managed
care organization, inform the organization of the recipient's
Medicaid certification date;
(9) a requirement that the managed care organization
comply with Section 533.006 as a condition of contract retention
and renewal;
(10) a requirement that the managed care organization
provide the information required by Section 533.012 and otherwise
comply and cooperate with the commission's office of inspector
general and the office of the attorney general;
(11) a requirement that the managed care
organization's usages of out-of-network providers or groups of
out-of-network providers may not exceed limits for those usages
relating to total inpatient admissions, total outpatient services,
and emergency room admissions determined by the commission;
(12) if the commission finds that a managed care
organization has violated Subdivision (11), a requirement that the
managed care organization reimburse an out-of-network provider for
health care services at a rate that is equal to the allowable rate
for those services, as determined under Sections 32.028 and
32.0281, Human Resources Code;
(13) a requirement that, notwithstanding any other
law, including Sections 843.312 and 1301.052, Insurance Code, the
organization:
(A) use advanced practice registered nurses and
physician assistants in addition to physicians as primary care
providers to increase the availability of primary care providers in
the organization's provider network; and
(B) treat advanced practice registered nurses
and physician assistants in the same manner as primary care
physicians with regard to:
(i) selection and assignment as primary
care providers;
(ii) inclusion as primary care providers in
the organization's provider network; and
(iii) inclusion as primary care providers
in any provider network directory maintained by the organization;
(14) a requirement that the managed care organization
reimburse a federally qualified health center or rural health
clinic for health care services provided to a recipient outside of
regular business hours, including on a weekend day or holiday, at a
rate that is equal to the allowable rate for those services as
determined under Section 32.028, Human Resources Code, if the
recipient does not have a referral from the recipient's primary
care physician;
(15) a requirement that the managed care organization
develop, implement, and maintain a system for tracking and
resolving all provider appeals related to claims payment, including
a process that will require:
(A) a tracking mechanism to document the status
and final disposition of each provider's claims payment appeal;
(B) the contracting with physicians who are not
network providers and who are of the same or related specialty as
the appealing physician to resolve claims disputes related to
denial on the basis of medical necessity that remain unresolved
subsequent to a provider appeal; and
(C) the determination of the physician resolving
the dispute to be binding on the managed care organization and
provider;
(16) a requirement that a medical director who is
authorized to make medical necessity determinations is available to
the region where the managed care organization provides health care
services;
(17) a requirement that the managed care organization
ensure that a medical director and patient care coordinators and
provider and recipient support services personnel are located in
the South Texas service region, if the managed care organization
provides a managed care plan in that region;
(18) a requirement that the managed care organization
provide special programs and materials for recipients with limited
English proficiency or low literacy skills;
(19) a requirement that the managed care organization
develop and establish a process for responding to provider appeals
in the region where the organization provides health care services;
(20) a requirement that the managed care organization
develop and submit to the commission, before the organization
begins to provide health care services to recipients, a
comprehensive plan that describes how the organization's provider
network will provide recipients sufficient access to:
(A) preventive care;
(B) primary care;
(C) specialty care;
(D) after-hours urgent care; and
(E) chronic care;
(21) a requirement that the managed care organization
demonstrate to the commission, before the organization begins to
provide health care services to recipients, that:
(A) the organization's provider network has the
capacity to serve the number of recipients expected to enroll in a
managed care plan offered by the organization;
(B) the organization's provider network
includes:
(i) a sufficient number of primary care
providers;
(ii) a sufficient variety of provider
types; and
(iii) providers located throughout the
region where the organization will provide health care services;
and
(C) health care services will be accessible to
recipients through the organization's provider network to a
comparable extent that health care services would be available to
recipients under a fee-for-service or primary care case management
model of Medicaid managed care;
(22) a requirement that the managed care organization
develop a monitoring program for measuring the quality of the
health care services provided by the organization's provider
network that:
(A) incorporates the National Committee for
Quality Assurance's Healthcare Effectiveness Data and Information
Set (HEDIS) measures;
(B) focuses on measuring outcomes; and
(C) includes the collection and analysis of
clinical data relating to prenatal care, preventive care, mental
health care, and the treatment of acute and chronic health
conditions and substance abuse;
(23) subject to Subsection (a-1), a requirement that
the managed care organization develop, implement, and maintain an
outpatient pharmacy benefit plan for its enrolled recipients:
(A) that exclusively employs the vendor drug
program formulary and preserves the state's ability to reduce
waste, fraud, and abuse under the Medicaid program;
(B) that adheres to the applicable preferred drug
list adopted by the commission under Section 531.072;
(C) that includes the prior authorization
procedures and requirements prescribed by or implemented under
Sections 531.073(b), (c), and (g) for the vendor drug program;
(D) for purposes of which the managed care
organization:
(i) may not negotiate or collect rebates
associated with pharmacy products on the vendor drug program
formulary; and
(ii) may not receive drug rebate or pricing
information that is confidential under Section 531.071;
(E) that complies with the prohibition under
Section 531.089;
(F) under which the managed care organization may
not prohibit, limit, or interfere with a recipient's selection of a
pharmacy or pharmacist of the recipient's choice for the provision
of pharmaceutical services under the plan through the imposition of
different copayments;
(G) that allows the managed care organization or
any subcontracted pharmacy benefit manager to contract with a
pharmacist or pharmacy providers separately for specialty pharmacy
services, except that:
(i) the managed care organization and
pharmacy benefit manager are prohibited from allowing exclusive
contracts with a specialty pharmacy owned wholly or partly by the
pharmacy benefit manager responsible for the administration of the
pharmacy benefit program; and
(ii) the managed care organization and
pharmacy benefit manager must adopt policies and procedures for
reclassifying prescription drugs from retail to specialty drugs,
and those policies and procedures must be consistent with rules
adopted by the executive commissioner and include notice to network
pharmacy providers from the managed care organization;
(H) under which the managed care organization may
not prevent a pharmacy or pharmacist from participating as a
provider if the pharmacy or pharmacist agrees to comply with the
financial terms and conditions of the contract as well as other
reasonable administrative and professional terms and conditions of
the contract;
(I) under which the managed care organization may
include mail-order pharmacies in its networks, but may not require
enrolled recipients to use those pharmacies, and may not charge an
enrolled recipient who opts to use this service a fee, including
postage and handling fees; and
(J) under which the managed care organization or
pharmacy benefit manager, as applicable, must pay claims in
accordance with Section 843.339, Insurance Code; and
(24) a requirement that the managed care organization
and any entity with which the managed care organization contracts
for the performance of services under a managed care plan disclose,
at no cost, to the commission and, on request, the office of the
attorney general all discounts, incentives, rebates, fees, free
goods, bundling arrangements, and other agreements affecting the
net cost of goods or services provided under the plan.
SECTION 21. Subsection (b), Section 671.001, Government
Code, is amended to read as follows:
(b) The pilot program must provide for the following:
(1) a licensed advanced practice registered nurse as
defined by Section 301.152, Occupations Code, or a licensed
physician assistant as described by Chapter 204, Occupations Code,
who is employed by the state or whose services are acquired by
contract, who will be located at a state office complex;
(2) a licensed physician, who is employed by a state
governmental entity for purposes other than the pilot program or
whose services are acquired by contract, who will delegate to and
supervise the advanced practice registered nurse or physician
assistant under a prescriptive authority agreement under Chapter
157 [perform all supervisory functions described by Section
157.052(e)], Occupations Code;
(3) appropriate office space and equipment for the
advanced practice registered nurse or physician assistant to
provide basic medical care to employees at the state office complex
where the nurse or physician assistant is located; and
(4) professional liability insurance covering
services provided by the advanced practice registered nurse or the
physician assistant.
SECTION 22. Subchapter D, Chapter 62, Health and Safety
Code, is amended by adding Section 62.1551 to read as follows:
Sec. 62.1551. INCLUSION OF CERTAIN HEALTH CARE PROVIDERS IN
PROVIDER NETWORKS. Notwithstanding any other law, including
Sections 843.312 and 1301.052, Insurance Code, the executive
commissioner of the commission shall adopt rules to require a
managed care organization or other entity to ensure that advanced
practice registered nurses and physician assistants are available
as primary care providers in the organization's or entity's
provider network. The rules must require advanced practice
registered nurses and physician assistants to be treated in the
same manner as primary care physicians with regard to:
(1) selection and assignment as primary care
providers;
(2) inclusion as primary care providers in the
provider network; and
(3) inclusion as primary care providers in any
provider network directory maintained by the organization or
entity.
SECTION 23. Subdivision (39), Section 481.002, Health and
Safety Code, is amended to read as follows:
(39) "Practitioner" means:
(A) a physician, dentist, veterinarian,
podiatrist, scientific investigator, or other person licensed,
registered, or otherwise permitted to distribute, dispense,
analyze, conduct research with respect to, or administer a
controlled substance in the course of professional practice or
research in this state;
(B) a pharmacy, hospital, or other institution
licensed, registered, or otherwise permitted to distribute,
dispense, conduct research with respect to, or administer a
controlled substance in the course of professional practice or
research in this state;
(C) a person practicing in and licensed by
another state as a physician, dentist, veterinarian, or podiatrist,
having a current Federal Drug Enforcement Administration
registration number, who may legally prescribe Schedule II, III,
IV, or V controlled substances in that state; or
(D) an advanced practice registered nurse or
physician assistant to whom a physician has delegated the authority
to prescribe or order a drug or device [carry out or sign
prescription drug orders] under Section 157.0511, 157.0512
[157.052, 157.053], or 157.054, [157.0541, or 157.0542,]
Occupations Code.
SECTION 24. Subdivision (12), Section 483.001, Health and
Safety Code, is amended to read as follows:
(12) "Practitioner" means [a person licensed]:
(A) a person licensed by the Texas [State Board
of] Medical Board [Examiners], State Board of Dental Examiners,
Texas State Board of Podiatric Medical Examiners, Texas Optometry
Board, or State Board of Veterinary Medical Examiners to prescribe
and administer dangerous drugs;
(B) a person licensed by another state in a
health field in which, under the laws of this state, a licensee may
legally prescribe dangerous drugs;
(C) a person licensed in Canada or Mexico in a
health field in which, under the laws of this state, a licensee may
legally prescribe dangerous drugs; or
(D) an advanced practice registered nurse or
physician assistant to whom a physician has delegated the authority
to prescribe or order a drug or device [carry out or sign
prescription drug orders] under Section 157.0511, 157.0512
[157.052, 157.053], or 157.054, [157.0541, or 157.0542,]
Occupations Code.
SECTION 25. Section 32.024, Human Resources Code, is
amended by adding Subsection (gg) to read as follows:
(gg) Notwithstanding any other law, including Sections
843.312 and 1301.052, Insurance Code, the department shall ensure
that advanced practice registered nurses and physician assistants
may be selected by and assigned to recipients of medical assistance
as the primary care providers of those recipients. The department
must require that advanced practice registered nurses and physician
assistants be treated in the same manner as primary care physicians
with regard to:
(1) selection and assignment as primary care
providers; and
(2) inclusion as primary care providers in any
directory of providers of medical assistance maintained by the
department.
SECTION 26. Subchapter B, Chapter 32, Human Resources Code,
is amended by adding Section 32.03141 to read as follows:
Sec. 32.03141. AUTHORITY OF ADVANCED PRACTICE REGISTERED
NURSES AND PHYSICIAN ASSISTANTS REGARDING DURABLE MEDICAL
EQUIPMENT AND SUPPLIES. To the extent allowed by federal law, an
advanced practice registered nurse or physician assistant acting
under adequate physician supervision and to whom a physician has
delegated the authority to prescribe and order drugs and devices
under Chapter 157, Occupations Code, may order and prescribe
durable medical equipment and supplies under the medical assistance
program.
SECTION 27. Sections 157.052, 157.053, 157.0541, and
157.0542, Occupations Code, are repealed.
SECTION 28. The calculation under Chapter 157, Occupations
Code, as amended by this Act, of the amount of time an advanced
practice registered nurse or physician assistant has practiced
under the delegated prescriptive authority of a physician under a
prescriptive authority agreement shall include the amount of time
the advanced practice registered nurse or physician assistant
practiced under the delegated prescriptive authority of that
physician before the effective date of this Act.
SECTION 29. Not later than November 1, 2013, the Texas
Medical Board, the Texas Board of Nursing, and the Texas Physician
Assistant Board shall adopt the rules necessary to implement the
changes in law made by this Act.
SECTION 30. This Act takes effect November 1, 2013.
______________________________ ______________________________
President of the Senate Speaker of the House
I hereby certify that S.B. No. 406 passed the Senate on
March 13, 2013, by the following vote: Yeas 31, Nays 0; and that
the Senate concurred in House amendment on May 17, 2013, by the
following vote: Yeas 31, Nays 0.
______________________________
Secretary of the Senate
I hereby certify that S.B. No. 406 passed the House, with
amendment, on May 15, 2013, by the following vote: Yeas 146,
Nays 0, two present not voting.
______________________________
Chief Clerk of the House
Approved:
______________________________
Date
______________________________
Governor