85R13070 EES-D     By: Price H.B. No. 3395       A BILL TO BE ENTITLED   AN ACT   relating to the authority of advanced practice registered nurses   practicing in certain areas.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:   ARTICLE 1.  INDEPENDENT PRACTICE AND PRESCRIPTIVE AUTHORITY FOR   ADVANCED PRACTICE REGISTERED NURSES PRACTICING IN CERTAIN AREAS          SECTION 1.001.  Section 301.002, Occupations Code, is   amended by amending Subdivision (2) and adding Subdivisions (6) and   (7) 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 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 prescribing and ordering of drugs and   devices by an advanced practice registered nurse as authorized by   the board under Section 301.357.                (6)  "Controlled substance" has the meaning assigned by   Section 157.051.                (7)  "Prescribe or order a drug or device" has the   meaning assigned by Section 157.051.          SECTION 1.002.  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 1.003.  Subchapter H, Chapter 301, Occupations Code,   is amended by adding Section 301.357 to read as follows:          Sec. 301.357.  INDEPENDENT PRACTICE BY AND PRESCRIBING AND   ORDERING AUTHORITY OF CERTAIN ADVANCED PRACTICE REGISTERED NURSES.     (a)  An advanced practice registered nurse may practice as a   licensed independent practitioner if the advanced practice   registered nurse is practicing in a county:                (1)  in which there are no practicing primary care   physicians; and                (2)  that:                      (A)  has been designated as a medically   underserved area under state or federal law; or                      (B)  contains a medically underserved population.          (b)  The board may authorize an advanced practice registered   nurse practicing in a county described by Subsection (a) to   prescribe and order drugs and devices, excluding controlled   substances, if the advanced practice registered nurse has been   issued a prescription authorization number under Section   301.152(b).   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.  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)  [a] an advanced practice 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 by a practitioner to carry out a prescription drug   order for dangerous drugs under other law.                (12)  "Practitioner" means:                      (A)  a person licensed by 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;                      (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 2.004.  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 prescribe and order drugs and devices 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 2.005.  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 provide care by the physician under other law, 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 2.006.  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 2.007.  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 provide care by the   physician under other law; 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 2.008.  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 2.009.  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 2.010.  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 2.011.  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 2.012.  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 by a practitioner to   administer a prescription drug order for a dangerous drug under   other law.                (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, 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 2.013.  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 prescribe and order   drugs and devices 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 2.014.  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 2.015.  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 AND EFFECTIVE DATE          SECTION 3.001.  Not later than February 1, 2018, the Texas   Board of Nursing shall adopt the rules necessary to implement the   changes in law made by this Act.          SECTION 3.002.  This Act takes effect September 1, 2017.