86R4821 BEE-D
By: White H.B. No. 927
A BILL TO BE ENTITLED
AN ACT
relating to the practice of certain advanced practice registered
nurses in certain rural counties; authorizing a fee.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
ARTICLE 1. PRACTICE OF ADVANCED PRACTICE REGISTERED NURSES IN
CERTAIN RURAL COUNTIES
SECTION 1.001. Chapter 487, Government Code, is amended by
adding Subchapter S to read as follows:
SUBCHAPTER S. REQUEST TO AUTHORIZE PRACTICE OF ADVANCED PRACTICE
REGISTERED NURSES IN CERTAIN RURAL COUNTIES
Sec. 487.851. IDENTIFICATION OF HEALTH PROFESSIONAL
SHORTAGE AREAS. (a) Not later than October 1 of each year, the
office shall:
(1) identify the rural counties of this state that are
determined to be health professional shortage areas by the United
States Department of Health and Human Services; and
(2) provide a list of the counties identified under
Subdivision (1) to:
(A) each county judge in this state; and
(B) the Texas Board of Nursing.
(b) The department by rule shall establish the criteria for
a county to be identified as a rural county for the purposes of
Subsection (a).
Sec. 487.852. REQUEST FOR AUTHORIZATION OF PRACTICE OF
ADVANCED PRACTICE REGISTERED NURSES. Not later than December 1 of
each year, the county commissioners court of a county identified
under Section 487.851(a)(1) or of an adjacent county may direct the
county judge to submit to the Texas Board of Nursing a written
request for the board to authorize the practice in the county of
advanced practice registered nurses under Section 301.357,
Occupations Code.
SECTION 1.002. Section 301.002, Occupations Code, is
amended by amending Subdivision (2) and adding Subdivisions (6),
(7), (8), (9), and (10) 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, except with respect to an advanced practice registered
nurse authorized to practice under Section 301.357. 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 health care practitioner legally
authorized to prescribe the medication or treatment [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 which an advanced practice registered nurse is authorized to
sign prescription drug orders as provided by Subchapter B, Chapter
157, or Section 301.357;
(G) the performance of an act delegated by a
physician under Section 157.0512, 157.054, 157.058, or 157.059;
[and]
(H) the development of the nursing care plan; and
(I) the performance of an act by an advanced
practice registered nurse in accordance with Section 301.357.
(6) "Controlled substance" has the meaning assigned by
Section 481.002, Health and Safety Code.
(7) "Dangerous drug" has the meaning assigned by
Section 483.001, Health and Safety Code.
(8) "Device" has the meaning assigned by Section
551.003, and includes durable medical equipment.
(9) "Nonprescription drug" has the meaning assigned by
Section 551.003.
(10) "Prescribe or order a drug or device" has the
meaning assigned by Section 157.051.
SECTION 1.003. Section 301.152(b), Occupations Code, is
amended to read as follows:
(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 registered nurse
must have to prescribe or order a drug or device as delegated by a
physician under Section 157.0512 or 157.054 or as authorized by the
board under Section 301.357;
(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 or as authorized by
the board under Section 301.357 on the receipt of evidence of
completing the specialized education and training requirement
under Paragraph (A); and
(C) a system for issuing a prescription
authorization number to an advanced practice registered nurse
approved under Paragraph (B); and
(3) concurrently 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.
SECTION 1.004. Subchapter H, Chapter 301, Occupations Code,
is amended by adding Section 301.357 to read as follows:
Sec. 301.357. PRACTICE OF CERTAIN ADVANCED PRACTICE
REGISTERED NURSES IN CERTAIN RURAL COUNTIES. (a) The board shall
authorize the practice under this section of an advanced practice
registered nurse who:
(1) practices in a county:
(A) identified under Section 487.851(a)(1),
Government Code; and
(B) the county judge of which has submitted a
request under Section 486.852, Government Code;
(2) has been issued a prescription authorization
number as provided by Section 301.152(b); and
(3) applies for authorization under this section in
the manner prescribed by the board.
(b) The scope of practice of an advanced practice registered
nurse authorized to practice under this section includes:
(1) ordering, performing, and interpreting diagnostic
tests;
(2) formulating primary and differential medical
diagnoses and advanced assessments;
(3) treating actual and potential health problems;
(4) prescribing therapeutic and corrective measures,
including nutrition and diagnostic support services, home health
care, hospice care, physical therapy, and occupational therapy, and
delegating and assigning the performance of therapeutic and
corrective measures to assistive personnel;
(5) subject to Subsection (c), prescribing and
ordering drugs and devices, including controlled substances listed
in Schedules II, III, IV, and V, dangerous drugs, and
nonprescription drugs;
(6) providing referrals to health care agencies,
health care providers, and community resources;
(7) serving as the primary care provider of record;
and
(8) performing other acts that require education and
training consistent with professional standards and that are
commensurate with the advanced practice registered nurse's
education, licensure, and demonstrated competencies and
experience.
(c) An advanced practice registered nurse authorized to
practice under this section may prescribe and order controlled
substances listed in Schedule II only:
(1) in a hospital facility-based practice 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 and is
expected to remain in the hospital for a period of 24 hours or more;
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.
(d) The board by rule:
(1) shall prescribe the application process for
authorization to practice under this section;
(2) shall establish criteria to determine the county
in which an advanced practice registered nurse practices for
purposes of Subsection (a)(1); and
(3) may set a fee for an application for authorization
under this section in a reasonable amount that is sufficient to
cover the costs of administering this section.
(e) An authorization under this section remains in effect as
long as the advanced practice registered nurse practices in a
county described by Subsection (a)(1).
ARTICLE 2. CONFORMING AMENDMENTS
SECTION 2.001. Section 38.151(1), Education Code, is
amended to read as follows:
(1) "Advanced practice nurse" has the meaning assigned
to "advanced practice registered nurse" by Section 301.152,
Occupations Code.
SECTION 2.002. Section 671.001(b), 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) if applicable, 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, 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 2.003. Section 481.002(39), Health and Safety Code,
is amended to read as follows:
(39) "Practitioner" means:
(A) a physician, dentist, veterinarian,
podiatrist, scientific investigator, advanced practice registered
nurse, 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, advanced
practice registered nurse, 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 under Section 157.0511,
157.0512, or 157.054, Occupations Code.
SECTION 2.004. Section 481.073(a), Health and Safety Code,
is amended to read as follows:
(a) Only a practitioner defined by Section 481.002(39)(A)
and an agent designated in writing by the practitioner in
accordance with rules adopted by the board may communicate a
prescription by telephone. A pharmacy that receives a
telephonically communicated prescription shall promptly write the
prescription and file and retain the prescription in the manner
required by this subchapter. A practitioner who designates an
agent to communicate prescriptions shall maintain the written
designation of the agent in the practitioner's usual place of
business and shall make the designation available for inspection by
investigators for the Texas Medical Board, the State Board of
Dental Examiners, the State Board of Veterinary Medical Examiners,
the Texas Board of Nursing, the board, and the department. A
practitioner who designates a different agent shall designate that
agent in writing and maintain the designation in the same manner in
which the practitioner initially designated an agent under this
section.
SECTION 2.005. Section 481.074(d), Health and Safety Code,
is amended to read as follows:
(d) Except as specified in Subsections (e) and (f), the
board, by rule and in consultation with the Texas Medical Board and
the Texas Board of Nursing, shall establish the period after the
date on which the prescription is issued that a person may fill a
prescription for a controlled substance listed in Schedule II. A
person may not refill a prescription for a substance listed in
Schedule II.
SECTION 2.006. Section 481.076(c), Health and Safety Code,
is amended to read as follows:
(c) The board by rule shall design and implement a system
for submission of information to the board by electronic or other
means and for retrieval of information submitted to the board under
this section and Sections 481.074 and 481.075. The board shall use
automated information security techniques and devices to preclude
improper access to the information. The board shall submit the
system design to the director, [and] the Texas Medical Board, and
the Texas Board of Nursing for review and comment a reasonable time
before implementation of the system and shall comply with the
comments of those agencies unless it is unreasonable to do so.
SECTION 2.007. Sections 483.001(4) and (12), Health and
Safety Code, are amended to read as follows:
(4) "Designated agent" means:
(A) a licensed nurse, physician assistant,
pharmacist, or other individual designated by a practitioner to
communicate prescription drug orders to a pharmacist;
(B) a licensed nurse, physician assistant, or
pharmacist employed in a health care facility to whom the
practitioner communicates a prescription drug order; or
(C) an advanced practice [a] registered nurse or
physician assistant authorized by a practitioner to carry out a
prescription drug order for dangerous drugs under Subchapter B,
Chapter 157, Occupations Code, or an advanced practice registered
nurse authorized to practice under Section 301.357, Occupations
Code.
(12) "Practitioner" means:
(A) a person licensed by:
(i) the Texas Medical Board, State Board of
Dental Examiners, [Texas State Board of Podiatric Medical
Examiners,] Texas Optometry Board, Texas Board of Nursing, or State
Board of Veterinary Medical Examiners to prescribe and administer
dangerous drugs; or
(ii) the Texas Department of Licensing and
Regulation, with respect to podiatry, 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 under Section 157.0511,
157.0512, or 157.054, Occupations Code.
SECTION 2.008. Section 32.03141, Human Resources Code, is
amended 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, in
addition to other health care practitioners authorized by federal
law, the following persons may order and prescribe durable medical
equipment and supplies under the medical assistance program:
(1) an advanced practice registered nurse authorized
to practice under Section 301.357, Occupations Code; and
(2) 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 2.009. Section 843.312, Insurance Code, is amended
to read as follows:
Sec. 843.312. PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE
REGISTERED NURSES. (a) A health maintenance organization may not
refuse a request by a physician participating in the health
maintenance organization delivery network and a physician
assistant or advanced practice registered nurse who is authorized
by the physician to provide care under Subchapter B, Chapter 157,
Occupations Code, or an advanced practice registered nurse who is
authorized to practice under Section 301.357, Occupations Code, to
identify a physician assistant or advanced practice registered
nurse as a provider in the network.
(b) A health maintenance organization may refuse a request
under Subsection (a) if the physician assistant or advanced
practice registered nurse does not meet the quality of care
standards previously established by the health maintenance
organization for participation in the network by physician
assistants and advanced practice registered nurses.
SECTION 2.010. Section 1301.001(1-a), Insurance Code, is
amended to read as follows:
(1-a) "Health care provider" means a practitioner,
institutional provider, or other person or organization that
furnishes health care services and that is licensed or otherwise
authorized to practice in this state. The term includes a
pharmacist, [and] a pharmacy, and an advanced practice registered
nurse. The term does not include a physician.
SECTION 2.011. Section 1301.052, Insurance Code, is amended
to read as follows:
Sec. 1301.052. DESIGNATION OF ADVANCED PRACTICE REGISTERED
NURSE OR PHYSICIAN ASSISTANT AS PREFERRED PROVIDER. An insurer
offering a preferred provider benefit plan may not refuse a request
made by a physician participating as a preferred provider under the
plan and an advanced practice registered nurse or physician
assistant to have the advanced practice registered nurse or
physician assistant included as a preferred provider under the plan
if:
(1) the advanced practice registered nurse or
physician assistant is authorized by the physician to provide care
under Subchapter B, Chapter 157, Occupations Code, or the advanced
practice registered nurse is authorized to practice under Section
301.357, Occupations Code; and
(2) the advanced practice registered nurse or
physician assistant meets the quality of care standards previously
established by the insurer for participation in the plan by
advanced practice registered nurses and physician assistants.
SECTION 2.012. Section 1451.001(2), Insurance Code, is
amended to read as follows:
(2) "Advanced practice registered nurse" means an
individual licensed by the Texas Board of Nursing as a registered
nurse and licensed [recognized] by that board as an advanced
practice registered nurse.
SECTION 2.013. Section 1451.104(c), Insurance Code, is
amended to read as follows:
(c) Notwithstanding Subsection (a), a health insurance
policy may provide for a different amount of payment or
reimbursement for scheduled services or procedures performed by an
advanced practice registered nurse, nurse first assistant,
licensed surgical assistant, or physician assistant if the
methodology used to compute the amount is the same as the
methodology used to compute the amount of payment or reimbursement
when the services or procedures are provided by a physician.
SECTION 2.014. Section 1451.106, Insurance Code, is amended
to read as follows:
Sec. 1451.106. SELECTION OF ADVANCED PRACTICE REGISTERED
NURSE. An insured may select an advanced practice registered nurse
to provide the services scheduled in the health insurance policy
that are within the scope of the nurse's license.
SECTION 2.015. Section 1452.051(1), Insurance Code, is
amended to read as follows:
(1) "Advanced practice nurse" has the meaning assigned
to "advanced practice registered nurse" by Section 301.152,
Occupations Code.
SECTION 2.016. Sections 551.003(14) and (34), Occupations
Code, are amended to read as follows:
(14) "Designated agent" means:
(A) an individual, including a licensed nurse,
physician assistant, or pharmacist:
(i) who is designated by a practitioner and
authorized to communicate a prescription drug order to a
pharmacist; and
(ii) for whom the practitioner assumes
legal responsibility;
(B) a licensed nurse, physician assistant, or
pharmacist employed in a health care facility to whom a
practitioner communicates a prescription drug order; or
(C) a registered nurse or physician assistant
authorized by a practitioner to administer a prescription drug
order for a dangerous drug under Subchapter B, Chapter 157, or an
advanced practice registered nurse authorized to practice under
Section 301.357.
(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, advanced practice registered
nurse, 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,
advanced practice registered nurse, 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 under Section 157.0511,
157.0512, or 157.054.
SECTION 2.017. Section 563.053, Occupations Code, is
amended to read as follows:
Sec. 563.053. DISPENSING OF DANGEROUS DRUGS IN CERTAIN
RURAL AREAS. (a) In this section, "reimbursement for cost" means
an additional charge, separate from that imposed for the
physician's or advanced practice registered nurse's professional
services, that includes the cost of the drug product and all other
actual costs to the physician or advanced practice registered nurse
incidental to providing the dispensing service. The term does not
include a separate fee imposed for the act of dispensing the drug
itself.
(b) This section applies to an area located in a county with
a population of 5,000 or less, or in a municipality or an
unincorporated town with a population of less than 2,500, that is
within a 15-mile radius of the physician's or advanced practice
registered nurse's office and in which a pharmacy is not located.
This section does not apply to a municipality or an unincorporated
town that is adjacent to a municipality with a population of 2,500
or more.
(c) A physician who practices medicine or an advanced
practice registered nurse who is authorized to practice under
Section 301.357 and who practices advanced practice registered
nursing in an area described by Subsection (b) may:
(1) maintain a supply of dangerous drugs in the
physician's or advanced practice registered nurse's office to be
dispensed in the course of treating the physician's or advanced
practice registered nurse's patients; and
(2) be reimbursed for the cost of supplying those
drugs without obtaining a license under Chapter 558.
(d) A physician or advanced practice registered nurse who
dispenses dangerous drugs under Subsection (c) shall:
(1) comply with each labeling provision under this
subtitle applicable to that class of drugs; and
(2) oversee compliance with packaging and
recordkeeping provisions applicable to that class of drugs.
(e) A physician who desires to dispense dangerous drugs
under this section shall notify both the board and the Texas Medical
[State] Board [of Medical Examiners] that the physician practices
in an area described by Subsection (b). An advanced practice
registered nurse who desires to dispense dangerous drugs under this
section shall notify both the board and the Texas Board of Nursing
that the advanced practice registered nurse practices in an area
described by Subsection (b). The physician or advanced practice
registered nurse may continue to dispense dangerous drugs in the
area until the board determines, after notice and hearing, that the
physician or advanced practice registered nurse no longer practices
in an area described by Subsection (b).
SECTION 2.018. Section 605.002(14), Occupations Code, is
amended to read as follows:
(14) "Orthotics" means the science and practice of
measuring, designing, fabricating, assembling, fitting, adjusting,
or servicing an orthosis under an order from a licensed physician,
chiropractor, [or] podiatrist, or [an] advanced practice
registered nurse, or from an advanced practice registered nurse or
physician assistant acting under the delegation and supervision of
a licensed physician as provided by Subchapter B, Chapter 157, and
rules adopted by the Texas Medical Board, for the correction or
alleviation of a neuromuscular or musculoskeletal dysfunction,
disease, injury, or deformity.
SECTION 2.019. Section 605.2515, Occupations Code, is
amended to read as follows:
Sec. 605.2515. ADDITIONAL LICENSE: DEVICE MANUFACTURER. A
person licensed to practice orthotics or prosthetics who measures,
designs, fabricates, fits, assembles, adjusts, or services an
orthosis or a prosthesis under an order from a licensed physician,
chiropractor, [or] podiatrist, or [an] advanced practice
registered nurse, or from an advanced practice registered nurse or
physician assistant acting under the delegation and supervision of
a licensed physician as provided by Subchapter B, Chapter 157, and
rules adopted by the Texas Medical Board, for a specific patient is
exempt from licensing as a device manufacturer under Subchapter L,
Chapter 431, Health and Safety Code. A person licensed to practice
orthotics or prosthetics who fabricates or assembles an orthosis or
a prosthesis without an order from a licensed physician,
chiropractor, [or] podiatrist, or [an] advanced practice
registered nurse, or from an advanced practice registered nurse or
physician assistant acting under the delegation and supervision of
a licensed physician as provided by Subchapter B, Chapter 157, and
rules adopted by the Texas Medical Board, for a specific patient is
required to be licensed as a device manufacturer under Subchapter
L, Chapter 431, Health and Safety Code.
ARTICLE 3. TRANSITION; CONFLICT WITH OTHER LEGISLATION; EFFECTIVE
DATE
SECTION 3.001. (a) Notwithstanding the deadline provided
by Section 487.851, Government Code, as added by this Act, the
Office of Rural Affairs established in the Department of
Agriculture shall produce the initial list required under that
section not later than December 1, 2019. Notwithstanding the
deadline provided by Section 487.852, Government Code, as added by
this Act, a county judge may submit an initial request as provided
by that section not later than February 1, 2020.
(b) Not later than February 1, 2020, the Texas Board of
Nursing shall adopt the rules necessary to implement the changes in
law made by this Act.
SECTION 3.002. To the extent of any conflict, this Act
prevails over another Act of the 86th Legislature, Regular Session,
2019, relating to nonsubstantive additions to and corrections in
enacted codes.
SECTION 3.003. This Act takes effect September 1, 2019.