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  83R24733 EES-F
 
  By: Nelson, et al. S.B. No. 406
 
  (Kolkhorst, Coleman, Orr, Naishtat, Guerra, et al.)
 
  Substitute the following for S.B. No. 406:  No.
 
 
 
A BILL TO BE ENTITLED
 
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.  Sections 157.059(b), (d), (e), (f), and (j),
  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.  Section 204.202(b), 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.  Section 301.002(2), 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.  Sections 551.003(34) and (45), 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.  Section 533.005(a), 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.  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)  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.  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, 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.  Section 483.001(12), 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.