SUBCHAPTER A. GENERAL

The Texas Medical Board (Board) adopts the repeal of current Chapter 161, concerning General Provisions, §§161.1 - 161.7, §161.10 and §161.11. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7710). The repeals will not be republished.

The Board also adopts new Chapter 161, concerning Physician Licensure. This includes new Subchapter A, concerning Pre-Licensure Criminal History Evaluations, §161.1; Subchapter B, concerning General Licensure Requirements, §§161.5 - 161.7; Subchapter C, concerning U.S. and Canadian Medical Graduates, §161.10; Subchapter D, concerning Foreign Medical Graduates, §§161.15 - §161.17; Subchapter E, concerning Licensure For Military Service Members, Veterans, and Spouses, §161.20; Subchapter F, concerning Application Procedure, §161.25; Subchapter G, concerning Registration of License, §161.30 and §161.31; Subchapter H, concerning Continuing Medical Education Requirements for License Renewal, §161.35; Subchapter I, concerning Full Medical License, §161.40; Subchapter J, concerning Limited Licenses, §§161.45 - 161.47; Subchapter K, concerning Temporary Licenses, §§161.50 - 161.52; Subchapter L, concerning Physician-In-Training Permits, §§161.55 - 161.58; Subchapter M, concerning Fellowship Program Approval, §161.65; and Subchapter N, concerning Emergency Practice Authorization, §§161.70 - 161.73. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7710). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 161 is more efficient than proposing multiple amendments to make the required changes.

The adopted new subchapters and sections are as follows:

SUBCHAPTER A. PRE-LICENSURE CRIMINAL HISTORY EVALUATIONS.

New §161.1, Pre-Licensure Criminal History Evaluation, describes the process for a potential applicant to obtain a criminal history evaluation letter to determine potential ineligibility for a license.

SUBCHAPTER B. GENERAL LICENSURE REQUIREMENTS.

New §161.5, Definitions, defines terms used throughout new Chapter 161.

New §161.6, General Requirements for Licensure, outlines the general requirements for licensure for a Texas medical license.

New §161.7, Examination Requirements, outlines the examinations required for licensure, in accordance with Sections 155.051, 155.0511 and 155.054 of the Medical Practice Act ("the Act").

SUBCHAPTER C. U.S. AND CANADIAN MEDICAL GRADUATES.

New §161.10, Specific Requirements for U.S. and Canadian Medical School Graduates, explains that all U.S. and Canadian medical school graduates must the requirements set forth in Section 155.003 of the Act for licensure.

SUBCHAPTER D. FOREIGN MEDICAL GRADUATES.

New §161.15, Specific Requirements for Foreign Medical Graduates, sets forth specific licensure requirements for Foreign Medical Graduates from substantially equivalent medical schools.

New §161.16, Foreign Medical Graduates of a Medical School That Is Not Substantially Equivalent, sets forth specific licensure requirements for Foreign Medical Graduates from non-substantially equivalent medical schools.

New §161.17, Other Foreign Medical Graduates, explains how Foreign Medical Graduates of a medical school who are not substantially equivalent and do not meet the criteria in §161.15 and §161.16 of this chapter can demonstrate substantial equivalence.

SUBCHAPTER E. LICENSURE FOR MILITARY SERVICE MEMBERS, VETERANS AND SPOUSES.

New §161.20, Alternative License Procedures for Military Service Members, Military Veterans, and Military Spouses, describes the licensure process for military service members, veterans, and spouses.

SUBCHAPTER F. APPLICATION PROCEDURE.

New §161.25, Procedural Rules for Licensure Applicants, explains the sections of the Act that apply to how licensure applications are processed.

SUBCHAPTER G. REGISTRATION OF LICENSE.

New §161.30, Registration and Renewal, explains the registration and renewal process for a physician license.

New §161.31, Exceptions from Certain Renewal Requirements, explains the exceptions from certain renewal requirements for Texas-licensed military service members, retired physicians, and voluntary charity care physicians.

SUBCHAPTER H. CONTINUING MEDICAL EDUCATION REQUIREMENTS FOR LICENSE RENEWAL.

New §161.35, Continuing Medical Education (CME) Requirements for License Renewal, explains the continuing medical education requirements physicians must meet for license renewal. It also explains how to correct any deficiencies in CME requirements and how CME may be carried forward between licensure renewals.

SUBCHAPTER I. FULL MEDICAL LICENSE.

New §161.40, Medical License, explains that all physicians practicing in Texas, with limited named exceptions, must hold a full Texas medical license.

SUBCHAPTER J. LIMITED LICENSES.

New §161.45. Conceded Eminence License, explains the requirements and process for seeking a conceded eminence license.

New §161.46, Administrative Medicine License, explains the requirements and process for seeking an administrative medicine license. It also explains the limitations of that type of license.

New §161.47, Military Volunteer License, explains the requirements and process for seeking a military volunteer license.

SUBCHAPTER K. TEMPORARY LICENSES.

New §161.48. Provisional License, explains the requirements for a provisional license.

New §161.50, Regular Temporary License, explains the purpose of the regular temporary license.

New §161.51, Faculty Temporary License, explains the requirements and application process for a Faculty Temporary License.

New §161.52, Visiting Physician Temporary Permit, explains the purpose, requirements, and application process for a Visiting Physician Temporary Permit. It also explains the limitations of such a permit.

SUBCHAPTER L. PHYSICIAN-IN-TRAINING PERMITS.

New §161.55, Physician-In-Training Permit (PIT), explains the purpose, requirements, and application process for PIT permits. It also explains the limitations of such a permit.

New §161.56, Rotator PIT Permits, explains the purpose, requirements, and application process for Rotator PIT permits.

New §161.57, Duties of Permit Holders to Report, explains the reporting obligations of the permit holder to the board and the time period to make a required report.

New §161.58, Duties of Program Directors to Report, explains the reporting obligations of the training program directors to the board and the time period to make a required report.

SUBCHAPTER M. FELLOWSHIP PROGRAM APPROVAL.

New §161.65, Process for Board-Approval of Fellowships, explains the requirements and application process for board approval of fellowships.

SUBCHAPTER N. EMERGENCY PRACTICE AUTHORIZATION.

New §161.70, Emergency Practice Authorization (EPA), explains when certain licensure requirements can be waived by the board in event of a disaster or emergency.

New §161.71, Emergency Practice Authorization (EPA) Requirements and Procedures for Healthcare Professionals, explains the purpose, requirements, and authorization process for healthcare professionals not licensed in Texas to practice in Texas during a disaster or emergency.

New §161.72, Board Regulation of Emergency Practice Authorization, explains the board's authority and jurisdiction over individuals practicing under an Emergency Practice Authorization.

New §161.73, Confidentiality, explains that confidentiality under §164.007 (c) of the Act applies to all board files, information, or investigative materials for healthcare providers practicing in Texas under an Emergency Practice Authorization.

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 161.

The Board received two comments regarding the proposed new rules. A summary of the comments and the Board responses is as follows:

Commenter No. 1: Garanflo & Meyer Consulting

Section 161.5

The commenter suggested the board should add language regarding the Committee on Accreditation of Canadian Medical Schools (CACMS).

Board Response - The Board agrees and adopts the non-substantive change to the section as requested.

Section 161.6

The commenter suggested that the board should add standard language allowing for substitute documents where exhaustive efforts on the PIT applicant's part to secure the required documents.

Board Response - The Board agrees and adopts the non-substantive change to the section as requested.

§161.7

The commenter inquired about the impact of this rule on applicants for licensure.

Board Response - The rule allows certain out of state applicants who are licensed for a specified period of time and ultimately passed the required examination to be considered eligible to be licensed in Texas.

Section 161.15

The commenter inquired about the impact of this rule on applicants for licensure.

Board Response - The rule allows certain foreign applicants to be considered eligible to be licensed based on postgraduate training or alternatively if they are eligible for obtaining specialty board certification, board eligibility is allowed with recognized acceptable post graduate training.

Section 161.16

The commenter inquired about the impact of this rule on applicants for licensure.

Board Response - The rule allows more flexibility for certain foreign applicants to be considered eligible to be licensed based on proof of alternate showing of medical competence and knowledge. This includes more focus on post-medical school experience, including the post graduate advanced training and competency development, rather than overemphasizing the underlying medical school attended. The rule allows certain foreign applicants to be considered eligible to be licensed based on proof of appropriate postgraduate training; being eligible for specialty board certification, which is verified by having recognized acceptable post graduate training; or showing licensure and training by significant practice time in another state.

Section 161.17

The commenter inquired about the impact of this rule on applicants for licensure.

Board Response - The rule allows more flexibility for certain foreign applicants to be considered eligible to be licensed based on proof of alternate showing of medical competence and knowledge. This includes more focus on post medical school experience, including post graduate advanced training and competency development rather than overemphasizing the underlying medical school attended.

Section 161.45

The commenter made an inquiry about the wording in the statute and rule.

Board Response - The rule clarifies an examination must be taken; this avoids a potential applicant from seeking licensure without ever attempting an examination and then claiming they have not failed an examination. Although the rule is a restatement of the statute, it is in the affirmative form, so that to clarify "to have not failed an examination" indicates or implies the passage of an examination. The rule as written uses affirmative language while the statute is stated in the negative, but there is no conflict.

Commenter No. 2: Texas Medical Association (TMA)

Section 161.1

The TMA recommended the Board amend the rule by adding a provision that ensures the board will respond to an individual who provides all requested information within one year.

Board Response - The Board declines to make this change as the rule as written provides that the board will notify the requestor of the determination.

Section 161.7

The TMA requested that the Board provide the procedural requirements it will enforce, related to licensure requirements, in the rule.

Board Response - The Board declines to implement this request as the rule references the relevant statutes related to licensing. The language in the statute is unambiguous and repeating statutory language in a rule is unnecessary.

The TMA expressed concerns over exam attempts and asked the Board to clarify proposed Section 161.7 by adding language regarding examination attempts.

Board Response - The Board agrees and adopts the non-substantive change to the section as requested.

The TMA requested clarification regarding the elimination of specific references to the Clinical Skills (CS) component of the USMLE Step 2 exam and the osteopathic version, the COMLEX Level 2 Performance Evaluation (PE), and inquired if TMB will no longer require applicants to report the outcomes for this test component.

Board Response - The Board declines to implement this request as the language in the statute is clear i.e., the results of all testing are reported and evaluated. Elimination or discontinuation of a portion of an exam by the testing entity does not otherwise negate an applicant's historical testing results submitted for a licensure determination.

Section 161.15

The TMA inquired whether the Board still intends to require applicants who graduate from a foreign medical school and have board certification to have successfully completed two years of graduate medical training approved by the board in the United States or Canada.

Board Response - The inclusion of board certification in lieu or two years training is specifically recognized because in order to obtain certification by these boards the applicant must meet the post graduate training standards that are equivalent to those of US and Canadian school graduates. This rule sets forth a pathway to licensure that demands an equivalent knowledge and training level of certain foreign applicants.

The TMA noted omitted language relating to the ability to communicate in English and whether or not such is still a requirement for licensure or will be demonstrated through other means.

Board Response - The Board declines to make any change in response to this comment. The English proficiency of an applicant is demonstrated by passage of licensure and jurisprudence examinations because these examinations are only given in English.

Section 161.16

The TMA requests that the Board pause implementation of proposed Section 161.16 until the completion of the Draft Guidance Document from the Advisory Commission on Additional Licensing Models.

Board Response - The Board declines to pause implementation. The Foreign Credential Service of America (FSCA) has historically been used and recognized by TMB as providing sufficient proof of adequate training of foreign applicants equivalent to domestic training. The other standards in this rule focus on the demonstrate of adequate competence to practice in this state, such as post graduate training that leads to eligibility for board certification, and licensure in another state for five years without any disciplinary action. This rule allows a pathway to increase the physician population without any diminution of standards and safety.

Section 161.20

The TMA seeks clarification from the Board as to whether: (1) it intends to remove these privileges from military service members and their spouses or (2) if these privileges will be explained in a board-approved form for licensing a military service member or the spouse of a military service member.

Board Response - The Board declines to make changes in response to this comment, as the expedited processing is already mandated under Chapter 55 of the Occupations Code and a rule is unnecessary and redundant. Additionally, Chapter 55 allows for discretion in determining competence, and "additional documentation" includes alternative demonstrations of competency and provides greatest flexibility to the agency.

Section 161.30

TMA recommended that the proposed rule mention the requirements of the criminal record check located in Section 156.0015 of the Texas Occupations Code, which provides that, in addition to the general registration requirements, a license holder "shall submit to the board with the registration permit renewal application a complete set of fingerprints."

Board Response - The Board declines to make the requested changes. The criminal record check is required by statute, and therefore a rule is unnecessary.

Section 161.31

TMA asked if the proposed rule separates voluntary charity care from retired physician status such that a physician will no longer be forced to retire in order to practice voluntary charity care and will not have to pay licensure fees. They requested confirmation that non-retired physicians who provide voluntary charity care are not required to pay the biennial registration fee.

Board Response - The Board confirms that the rule does not distinguish based on active or retired status.

Section 161.46

TMA asked if the proposed rule language changes the scope of an administrative medicine license and any potential impact on enforcement or the scope of an administrative medicine license.

Board Response - The rule does not change the scope of an administrative license. The rule clarifies the long-standing interpretation of the scope of administrative medicine and comports with language used in disciplinary orders regarding administrative medicine.

Section 161.51

TMA noted the rule changed the notice period for an application for a faculty temporary license (FTL) from 30 days to 45 days when the corresponding statute has no time such requirement.

Board Response - The increase to 45 days is to ensure all involved parties have adequate time to provide information and process these license types so as to avoid delays in licensing and having faculty for training new physicians.

TMA recommended adding language requiring a recommendation from the applying institution's chief administrative officer and president in order to claim their time spent teaching towards their approved postgraduate residency program requirements.

Board Response - The Board declines making the requested changes to the rule. The language requested and the limitations of the Faculty Temporary License (FTL) and the credit towards post graduate training are set out in the statute, and therefore a rule is unnecessary.

Section 161.55

TMA recommended that the Board amend subsection (h) by striking "supervised" and inserting, "under the supervision of a physician" between "medicine" and "that" to read as follows: (h) A PIT permit holder is restricted to the supervised practice of medicine under the supervision of a physician that is part of and approved by the training program and does not allow for the practice of medicine outside of the approved program.

Board Response - The Board declines to make this change as the language is unnecessary because Texas law does not allow supervision of medical acts by anyone other than a physician.

Section 161.57

TMA requested that the Board change the phrase "affects" to "which has impaired or impairs" in paragraph (6) of proposed Section 161.57.

Board Response - The Board agrees and adopts the non-substantive change to the section as requested.

Section 161.71

TMA recommended adding language to subsections (a) and (b) relating to qualifying events for an emergency license.

Board Response - The Board declines to make the requested changes as the rule adequately describes the potential triggering events that would allow for initiation of Emergency Practice Authorization. Additionally, as proposed the TMA language would cause an emergency license to end immediately upon the emergency declaration ending and provides for no wind down period or transfer of care.

Section 161.73

TMA commented that the proposed rule's reference to "all board files, information" is much broader than what is contemplated by the statute and recommends changing the rule to the wording in the statute.

Board Response - The Board declines to make the requested changes. The rule cites to §164.007(c) of the Texas Occupations Code and does not broaden the scope of confidentiality applied to a physician acting under an Emergency Practice Authorization (EPA). The rule provides the same confidentiality protections to EPA files, including enforcement and licensure, that applies to all physician files.

SUBCHAPTER A. PRE-LICENSURE CRIMINAL HISTORY EVALUATIONS

The Texas Medical Board (Board) adopts the repeal of current Chapter 162, concerning Supervision of Medical Students, §162.1 and §162.2. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7720). The repeals will not be republished.

The Board also adopts new Chapter 162, concerning Physician Profiles, §§162.1 - 162.3. The new sections are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7720). The rules will not be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, the repeal of Chapter 162 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §162.1, Profile Contents, provides a description of the content of a physician's public profile.

New §162.2, Profile Updates, provides a description of mandatory updates required to be reported by a physician to the board.

New §162.3, Profile Disputes, explains the process by which a physician may dispute their public profile information.

COMMENTS:

The Board received one comment from Texas Medical Association (TMA) regarding the repeal of current Chapter 162. A summary of the comment and the Board response is as follows:

§§162.1-162.2

TMA is opposed to the repeal of these rules, concerning the requirements for physicians who supervise medical students and student physician assistants, including students who are not enrolled in a Texas medical school or as a visiting medical student with a Texas medical school. They believe that the rules help preserve clinical training sites and medical student preceptorship opportunities for Texas medical students with community-based physicians. TMA expressed concern about potential violations of §61.306 of the Texas Education Code by certain foreign medical schools.

Board Response - The Board declines to retain the repealed rules as urged by TMA. The accreditation and authority to operate as a medical school is outside the regulation of the Board. Additionally, the Board does not regulate the activities of a medical student. The repealed rules are unnecessary because supervision and delegation by any physician in Texas is fully addressed by other statutes and rules, including Chapter 157 of the Texas Occupations Code and board rules related to supervision and delegation. The allowance and ability for the student opportunities as outlined by TMA are not affected in any manner by repeal of these rules. Physicians still remain responsible for any delegated act and that delegation includes ensuring appropriate qualification and supervision. If any concerns over the activity of a medical student occur, the existing complaint process is adequate to respond to any issues of both the student and the supervising physician.

The Board received no comments regarding the new rules.

The Texas Medical Board (Board) adopts the repeal of current Chapter 163, concerning Licensure, §§163.1 - 163.6, 163.8 - 163.11 and 163.13. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7722-7723). The repeals will not be republished.

The Board also adopts new Chapter 163, concerning Medical Records. This includes new Subchapter A, concerning General Documentation Provisions, §§163.1 - 163.5; and Subchapter B, concerning Abortion Documentation, §§163.10 - 163.13. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7723-7726). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 163 is more efficient than proposing multiple amendments to make the required changes.

The adopted new subchapters and sections are as follows:

SUBCHAPTER A. GENERAL PROVISIONS.

New §163.1, Medical Records, describes the necessary content of a medical record and the appropriate method for documenting each patient encounter.

New §163.2, Medical Record Retention, explains providers responsible for retaining medical records and the amount of time those providers must retain medical records.

New §163.3, Requests for Medical Records, explains a provider's responsibility for providing medical records to patients upon request. It also explains allowable charges for responding to requests for medical records or diagnostic imaging.

New §163.4, Physician Responsibilities when Leaving a Practice, explains a provider must provide notice to patients when they leave, retire, or terminate a practice.

New §163.5, Appointment of Record Custodian of a Physician's Records, explains who the appropriate records custodian is of medical records in certain situations. It also explains the process by which a records custodian is appointed and outlines the custodian's responsibilities.

SUBCHAPTER B. ABORTION DOCUMENTATION.

New §163.10, Definitions, describes the specific definitions for certain terms used in this subchapter.

New §163.11, Required Form Regarding an Abortion on an Unemancipated Minor, details the required disclosure and consent form to be completed when performing an abortion or related procedure on an unemancipated minor.

New §163.12, Abortion Ban Exception Performance and Documentation, explains that physicians need to comply with all applicable laws, rules, and court opinions related to abortion and its exceptions in Texas. The rules also provide the minimum required information that must be included in the medical record.

New §163.13, Complaints Regarding Abortions Performed, explains the procedures that the Board will utilize in the event a complaint is received. The rule also explains the limitation of any Board decision and that possible criminal or civil action under the law is separate and independent of any Board decision.

COMMENTS:

The Board received one comment regarding the repeal of current Chapter 163 from the Texas Medical Association (TMA). A summary of the comment and the Board response is as follows:

§163.11

TMA recommended that the contents of the repealed rule be retained despite issues for physicians who took a break from practice for health, family, or professional reasons, as there are remedies for mitigating an inability to meet the requirement.

Board Response - The Board declines to retain the repealed language as the language is overly restrictive and was found to create barriers to licensure. The counting of one year of the last two and then narrowing further by 20 hours per week for 40 weeks created hypertechnical counting. The Board has adopted non-substantive changes to the new licensure rules to address the issue of practice remediation.

The Board received three comments regarding the new rules. A summary of the comments and the Board responses is as follows:

Commenter 1: Texas Medical Association (TMA)

§163.1

TMA requested that the Board add language regarding the documentation of checking the Prescription Monitoring Program (PMP). They asked for inclusion of the language to "to the extent applicable" regarding the documentation of a review of the patient's PMP prescribing history.

Board Response - The Board agrees and adopts the non-substantive change to the section as requested.

§163.4

TMA requests that the Board retain a 30-day timeframe rather than the use of "immediately" with regard to a physician's responsibilities when leaving a practice in the event of a license surrender or revocation. TMA argues this is less definite, and having a specific deadline will aid physicians in complying with this rule.

Board Response - The Board declines to make the requested change. The rationale for "immediate" is so patients do not have to wait 30 days to get notice of the potential loss of a physician's care, thereby impacting the continuity of care when finding subsequent care may take some time. Accordingly, patients need notice very quickly.

§163.11

TMA requested additional language be added to the abortion consent form for an unemancipated minor to reflect the exception for a "medical emergency." TMA had concerns that the rule, as written, might cause confusion regarding situations involving a medical emergency.

Board Response - The Board declines to make the requested change as TMA's suggested language relating to exception/medical emergency is found in other law that is applicable to patients and adding such language here is unnecessary. Physicians are already required to comply with all applicable laws pertaining to abortions.

Commenter No. 2: Texas Hospital Association (THA)

§163.11

THA expressed similar concerns as TMA with regard to the exception to abortion in the case of a "medical emergency." THA requested additional language be added to the abortion consent form for an unemancipated minor and asserts that the rule, as written, might cause confusion regarding situations involving a medical emergency.

Board Response - The Board declines to make the requested change as TMA's and THA's suggested language relating to exception/medical emergency is found in other law that is applicable to patients and adding such language here is unnecessary. Physicians are already required to comply with all applicable laws pertaining to abortions.

Commenter 3: Texas Council of Community Centers (TCCC)

§163.1

TCCC inquired about the documentation requirements for checking of the Prescription Monitoring Program (PMP). The concern was similar to that expressed by TMA. They sought some clarification "to the extent applicable" regarding the documentation of a review of the patient's PMP prescribing history.

Board Response - The Board addressed the concern by adopting the non-substantive change to the section as requested by TMA.

SUBCHAPTER A. GENERAL DOCUMENTATION PROVISIONS

The Texas Medical Board (Board) adopts the repeal of current Chapter 164, concerning Physician Advertising, §§164.1 - 164.6. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7726). The repeals will not be republished.

The Board also adopts new Chapter 164, concerning Physician Advertising, §§164.1 - 164.4. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7726). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, the repeal of Chapter 164 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §164.1, Definitions, gives definitions of terms used in this chapter.

New §164.2, Physician Responsibilities, explains the physician's responsibilities as to form and content of advertisement of the practice of medicine.

New §164.3, Prohibited Acts or Omissions in Advertising, describes what is permissible or prohibited in advertising by physicians.

New §164.4, Advertising Board Certification, explains the permissible use of the term "board certified" in advertising. The new section also details the process for a physician or physician-based certifying organization to apply for recognition to advertise as "board certified."

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 164.

The Board received comments from an individual and five organizations regarding the proposed new rules. A summary of the comments and the Board responses is as follows:

Commenter No. 1: Individual

§§164.1-164.4

The commenter asserted that the revised rules allow physicians to act in bad faith and deceptively advertise by removing some of the language found in the current rules. They also noted the revised rule makes it harder to enforce a violation. The commenter found the addition of the $200 renewal fee in §164.4 to be offensive, as there are already fees related to board certification.

Board Response - The Board declines to make changes in response to this comment. This rule clarifies the level of transparency needed in advertising and is consistent with existing law that prohibits false and deceptive advertising. The rule as written does not impact the board's enforcement of deceptive advertising. Additionally, the fee is unchanged from the existing fee that has been in place for a number of years.

Commenter No. 2: Association of American Physicians and Surgeons

§164.4

AAPS expressed concern that §164.4 is overly broad because it summarily disallows physicians to state they are certified if they are not certified by one of the three certification entities mentioned explicitly in the rule and that the proposed rule is not within the spirit of existing statute Tex. Occ. Code, §153.002

Board Response - The Board declines to make changes in response to this comment. The rules allow for other boards' recognition for advertising as board certified; currently at least 14 certifying boards are recognized by TMB. Additionally, board certification is not required for licensure or to practice in Texas.

Comment No. 3: Texas Association of Nurse Anesthetists (TxANA)

§164.3

TxANA commented that the requirement to disclose supervision in advertising is an overreach which will discourage physicians from delegating to CRNAs and other advanced practice providers.

Board Response - The Board declines to make changes in response to this comment. The rules as written are intended to increase transparency for patients to ensure they know who is delegating to a non-physician that is seeing that patient.

Comment No. 4: Texas Nurse Practitioners (TNP)

§164.3

TNP commented that the requirement for physicians to disclose in their advertising supervision of or delegation to non- physicians at locations other than primary practice will discourage delegation to nurse practitioners and increase delegation costs.

Board Response - The Board declines to make changes in response to this comment. The rules as written are intended to increase transparency for patients to ensure they know there is physician oversight and who is responsible for delegating their care.

Comment No. 5: National Board of Physicians and Surgeons (NBPAS)

§164.4

The president and 59 members of the NBPAS commented that the new rule does not update or modernize the provision on advertising as Board Certified; requires Maintenance of Certification (MOC) programs that are costly and do not prove competence; somehow worsens physician shortages; drives physicians into retirement or out of the state; and delays patient preventative care.

Board Response - The Board declines to make changes in response to the comments. The rules allow for other boards' recognition for advertising as board certified; currently at least 14 certifying boards are recognized by TMB. Additionally, board certification is not required for licensure or to practice in Texas.

Comment No. 6: Texas Medical Association (TMA)

§164.1

TMA commented that they had concerns that the phrase "or practice generally" added to new §164.1 is open-ended and should be removed from the definition of "testimonial."

Board Response - The Board declines to make changes in response to this comment. The inclusion of this term is consistent with other terms such as "services" or "treatments" and allows for greater transparency and information for patients.

The new rules are adopted under the authority of the Texas Occupations Code, §153.001, which provides authority for the Board to recommend and adopt rules and bylaws as necessary to: govern its own proceedings, perform its duties, regulate the practice of medicine, and enforce Subtitle B of Title 3 of the Texas Occupations Code. The new rules are also adopted in accordance with the requirements of Texas Occupations Code, §101.201. The new rules are also adopted in accordance with the requirements of Texas Government Code, §2001.039, which requires a state agency to review and consider its rules for readoption, readoption with amendments, or repeal every four years. No other statutes, articles or codes are affected by this adoption.

§164.1.Definitions.

The following words and terms, when used in this chapter, shall have the following meanings, unless the contents clearly indicate otherwise.

(1) Advertising and advertisement--Any communication designed to attract attention to the practice of a physician.

(2) Testimonial--Statement about a physician's competence, services, treatments, or practice generally. Also includes expressions of appreciation or esteem, a character reference, or a statement of benefits received. §164.2.Physician Responsibilities.

(a) Every physician is:

(1) responsible for the form and content of any advertisement for their individual practice or group practice; and

(2) deemed to have reviewed and approved any and all advertisements.

(b) Patients must consent prior to any use of photographs or other representations in any advertising by a physician, practice, or entity.

(c) A recording or copy of any advertisement shall be retained by the physician for a period of two years from the last date of communication. §164.3.Prohibited Acts or Omissions in Advertising.

(a) Advertising regarding the practice of medicine, professional credentials, and qualifications is permissible. However, the information provided in the advertisement cannot be false, deceptive, or misleading.

(b) In addition to those items listed in §101.201 of the Texas Occupations Code, the following are also deemed false, deceptive, or misleading advertising:

(1) using the term "board eligible," "board qualified," or any similar language calculated to convey the same meaning as "board certified;"

(2) offering a permanent cure for an incurable disease, sickness, and/or illness;

(3) providing a testimonial without:

(A) a disclaimer or warning as to the credentials of the person making the testimonial; and

(B) a disclosure of compensation provided in exchange for the testimonial;

(4) failing to explicitly identify individuals as models or actors instead of actual patients;

(5) providing untruthful or deceptive claims regarding costs and fees, including claims of free service if a third-party is billed;

(6) claiming a unique or exclusive skill without substantiation and basis for such claim;

(7) failing to disclose that the advertisement, article, or infomercial is a "paid for" presentation; or

(8) failing to disclose medical directorship, supervision of, or delegation to non-physicians at a location that is not the physician's primary practice location and where care is delivered pursuant to standing orders and protocols. §164.4.Advertising Board Certification.

(a) The use of the term "board certified" may be used by a physician if they are currently certified by a member board of:

(1) the American Board of Medical Specialties (ABMS);

(2) the American Osteopathic Association Bureau of Osteopathic Specialists (BOS);

(3) the American Board of Oral and Maxillofacial Surgery; or

(4) other certifying board certification as approved by the board under subsection (b) of this section.

(b) Physician-based certifying organizations seeking approval on behalf of their members to advertise other board certification not listed in subsection (a) of this section, must:

(1) submit a completed board application that is valid for one year; and

(2) submit payment of a $200.00 application fee; and

(3) submit documentation that the certifying entity/board:

(A) has certification requirements that are substantially equivalent to the requirements of the ABMS or BOS; and

(B) requires members to complete an examination that has been psychometrically evaluated for validation and has been administered by a testing organization that tests knowledge and skills in the specialty or subspecialty;

(C) requires members successfully completed postgraduate training accredited by ACGME or AOA, with training in the specialty or subspecialty;

(D) utilizes appropriate peer-review processes;

(E) has a total membership of at least 100 duly licensed members, fellows, diplomates, or certificate holders from at least one-third of the states; and

(F) is tax exempt under the Internal Revenue Code pursuant to §501(c) with a permanent headquarters and staff.

(c) A certifying organization approved by the board under subsection (b) of this section must be reviewed every five years from the date of initial approval. As part of this review, the certifying organization must:

(1) submit payment of the $200.00 renewal fee, and

(2) submit to the board information of any substantive changes in the certifying organization's requirements for diplomates since the certifying board was last reviewed by the board.

Filed with the Office of the Secretary of State on December 20, 2024.

TRD-202406191

Scott Freshour

General Counsel

Texas Medical Board

Effective date: January 9, 2025

Proposal publication date: September 27, 2024

For further information, please call: (512) 305-7030

The Texas Medical Board (Board) adopts the repeal of current Chapter 169, concerning Authority of Physicians to Supply Drugs, §§169.1 - 169.8. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7732). The repeals will not be republished.

The Board also adopts new Chapter 169, concerning Delegation. This includes new Subchapter A, concerning Definitions and General Provisions, §169.1 and §169.2; Subchapter B, concerning Physician Assistants and Advanced Practice Registered Nurses, §169.5; Subchapter C, concerning Emergency Medical Services, §§169.10 - 169.15; Subchapter D, concerning Pharmacists, §169.20; and Subchapter E, concerning Other Delegated Acts, §§169.25 - 169.28. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7732). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 169 is more efficient than proposing multiple amendments to make the required changes.

The adopted new subchapters and section are as follows:

SUBCHAPTER A. DEFINITIONS AND GENERAL PROVISIONS.

New §169.1, Definitions, explains words and terms used in new Chapter 169.

New §169.2, General Responsibilities of Delegating Physician, explains what is required of a physician delegating any medical act.

SUBCHAPTER B. PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE REGISTERED NURSES.

New §169.5, Delegation to a Physician Assistant or Advanced Practice Registered Nurse, explains requirements for a physician delegating medical acts to a physician assistant or an advanced practice registered nurse.

SUBCHAPTER C. EMERGENCY MEDICAL SERVICES.

New §169.10, Definitions, explains the resources for definitions of words and terms used in Subchapter C of new Chapter 169, as applied to physician supervision of emergency medical service (EMS) personnel.

New §169.11, Medical Supervision, explains the statutory authority physicians providing medical control and medical supervision of EMS providers must adhere to.

New §169.12, Medical Director Qualifications, explains the requirements for a physician to be a medical director of EMS services.

New §169.13, Medical Director Responsibilities, explains the responsibilities of a physician acting as medical director of EMS services.

New §169.14, Limits on Off-Line Medical Control, explains the limit on the number of EMS providers an off-line medical director may supervise.

New §169.15, Other Physician Presence at Medical Emergency, explains how care should be provided by another physician, other than an EMS medical director, at the scene of an emergency.

SUBCHAPTER D. PHARMACISTS.

New §169.20, General Standards, explains the general standards expected when a physician delegates to a licensed pharmacist in Texas. Drug therapy management, immunizations, and vaccinations may be authorized by the physician to be performed by the pharmacist under an order, standing medical order, standing delegation order, or protocol.

SUBCHAPTER E. OTHER DELEGATED ACTS.

New §169.25, Other Delegation, explains that delegation is required for non-surgical cosmetic procedures and other medical practices involving administration of other substances for human consumption.

New §169.26, General Standards, explains the responsibilities relating to the delegating physician for other medical procedures.

New §169.27, Physician Responsibilities related to Written Order, explains minimum requirements for orders provided to a non-physician performing delegated acts involving administration of substances for human consumption.

New §169.28, Notice and Identification Provisions, explains notice and identification requirements when performing these other delegated acts.

COMMENTS:

The Board received no comments regarding the repeal of current chapter 169.

The Board received five comments regarding the new rules. A summary of the comments and the Board responses is as follows:

Commenter 1: Texas Association of Nurse Anesthetists (TxANA)

§169.2

TxANA asserted the rule conflicts with a statute related to protocols and orders that may be issued by a delegating physician.

Board Response - The Board declines to make changes in response to this comment. The rule does not conflict with state law in any manner. The rule ensures the content of the issued orders and protocols are clear enough to allow use of professional judgment and training of the person delegated to, but it is not unfettered judgment. The statute states the protocol is "not required to describe exact steps," but that does not preclude a level of specificity a physician believes is appropriate based on the training, knowledge, and experience of a delegate. The text of the rule itself recognizes the inherent flexibility, where it states: Delegation must be through written protocols or prescriptive authority agreements depending on the type of delegate and the medical acts being delegated. An order or protocol can and should describe steps in some fashion. Further the comment ignores that physicians may delegate to other practitioners and not just advanced registered nurse practitioners (APRNs) and physician assistants (PAs).

§169.27

TxANA asserted the rule requires a description of the "appropriate care," which conflicts with a statute related to protocols and orders issued by a delegating physician to Certified Registered Nurse Anesthetists.

Board Response - The Board declines to make changes in response to this comment. This subchapter is for "other delegated acts" related to business models being utilized now and that might develop. But it is not related to the providing of anesthesia by CRNAs, which is specifically addressed in §157.058 of the Occupations Code. This rule is directed specifically at delegation and the role of a delegating physician at facilities other than medical practices that often times do not have trained medical professionals performing certain delegated tasks, but the delegating physician and delegates are still required to meet the standards of Chapter 157 of the Occupations Code when performing delegated acts. Even if construed to be applicable to all delegates, the standards for CRNAs are unchanged. The purpose of delegation is to provide guidance on appropriate care, which is flexible and is "liberally construed" depending on training, knowledge, and experience as well as services being provided at these facilities. Nowhere does this rule say anything about exact doses, drugs, etc. because in these settings the CRNA would not be performing anesthesia services, but rather would be acting in their more general capacity as an APRN.

Commenter 2 - Texas Nurse Practitioners (TNP)

§169.2

TNP opposed §169.2, claiming the rule violates the Act and discourages delegation to APRNs and/or limits the use of APRNs and CRNAs. This is the same assertion as the TxANA comment.

Board response - The Board declines to make changes in response to this comment. This rule does not conflict with the statute in any manner. The rule ensures the content of the issued orders and protocols are clear enough to allow use of professional judgment and training of the person delegated to, but it is not unfettered judgment. The statute states the protocol is "not required to describe exact steps" but that does not preclude a level of specificity a physician believes is appropriate based on the training, knowledge, and experience of a delegate. The text of the rule itself recognizes the inherent flexibility, where it states: Delegation must be through written protocols or prescriptive authority agreements depending on the type of delegate and the medical acts being delegated. An order or protocol can and should describe steps in some fashion. Further the comment ignores that physicians may delegate to other practitioners and not just advanced registered nurse practitioners (APRNs) and physician assistants (PAs).

Commenter No. 3: Texas Medical Association

§169.10

TMA requested clarification of the term "medical direction" related to EMS services.

Board Response - The Board declines to clarify the term "medical direction" in the context of EMS services, as it is a commonly understood term by practitioners.

§169.25

TMA requested clarification on whether the rule applies to IV therapy.

Board Response - The Board's purpose in adopting Subchapter E is to expand delegation and supervision consistent with and in response to not only medical spas, but also other types of practices and expanded medical services that require physician delegation and supervision. This expansion accommodates new business models but continues to maintain standards under Chapter 157 of the Texas Occupations Code related to delegation generally. The Board is also aware of potential legislation forthcoming in this area and plans to consider further revisions to this section at a later date, if necessary.

§169.26

TMA expressed concerns about the emergency consultation provision, opining that the new rule lessens requirements by permitting an emergency consultation to be provided by an APRN or PA in addition to a supervising physician, rather than mandating that the physician provide the emergency consultation.

Board Response - The Board declines to make changes in response to this comment. The Board did not include a specific requirement that emergency consultation be provided by a physician so as to create flexibility with accountability because an adverse event by nature is not planned. This rule is similar to a call coverage arrangement where a physician can be called directly or by a delegate if an emergency arises, but the PA or APRN is available in the event the physician is not available for some reason in an emergency. This language ensures there will be someone available to respond in an emergency.

Commenter 4: Texas Health and Human Services - Department of State Health Services (DSHS)/Health and Human Services Commission (HHSC)

§169.12

DSHS/HHSC requested addition of the term "Chief Medical Officer" to the title of this rule.

Board Response - The Board agrees and adopts the non-substantive change to the section as requested.

§169.13

DSHS/HHSC asked to add the term "guidelines" where rules referred to standing orders and protocols.

Board Response - The Board agrees and adopts the non-substantive revision as requested in multiple places in this rule.

DSHS/HHSC requested to add a requirement that the Medical Director establish protocols, standing orders, and/or guidelines documenting no patient found or cancelled by dispatch. Further, DSHS/HHSC requested additional language providing that direct medical control must be provided by a physician and cannot be delegated to anyone who is not a physician licensed in Texas.

Board Response - The Board TMB declines to add this language. This information will be part of the medical records and dispatch logs, so it is unnecessary. TMB further declines to add language specifying that direct control must only be provided by a licensed physician. Texas law already requires a physician to be licensed to practice medicine in Texas including delegation related to EMS. Further rules are unnecessary.

Commenter 5: Texas Society of Anesthesiologists (TSA)

§169.13

TSA requested to add a provision requiring the medical director to implement and provide oversight of a continuous quality improvement plan for patient care, and a credentialing process for all EMS providers acting under the supervision of the medical director.

Board Response - The Board declines making any changes in response to this comment. The requested change goes beyond the authority of the Board. DSHS/HHSC licenses EMS providers. The requested change would be part of the overall EMS plans submitted as part of the licensure process. Further, any credentialing process would be submitted as part of the licensure process. TMB has no authority to oversee or direct EMS operational standards and plans.

§169.15

TSA requested to add language to subsection (a) requiring that documentation of the on-scene physician providing care be added to this section. TSA also requested language requiring that if that physician directs EMS providers to act outside the approved protocol, the on-scene physician assumes responsibility for the care of that patient and must accompany the patient with the EMS agency to the appropriate receiving facility. TSA further requested to add "if possible" to subsection (b), requiring the on-scene physician and medical director to communicate and coordinate care as appropriate under the circumstances.

Board Response - The Board agrees to add the non-substantive amendment requiring proper documentation of the presence of the on-scene physician providing care to the patient in subsection (a). The Board also agrees to add the qualifier "if possible" to subsection (b). This language clarifies what the proposed rules already required in terms of appropriate documentation of care and on-scene response.

§169.20

TSA requested that "for the" be added to paragraph (b)(3) to improve the clarity of the sentence. TSA further requested that the term "periodic" in subparagraph (c)(3)(D) be defined or clarified as to how often the review of written protocols for drug therapy management, immunizations, and vaccinations are required.

Board Response - The Board agrees and added the requested language to paragraph (b)(3). The Board declines to add language setting forth specific parameters on the required frequency of the reviews in subparagraph (c)(3)(D), as it is unnecessary and a delegating physician must establish appropriate frequency according to the circumstances applicable to the physician and pharmacist procedures.

§169.25

TSA asked to change "can" to "may" in paragraph (a) regarding delegation and supervision of medical acts.

Board Response - The Board declines to make changes in response to this comment as the statute authorizing delegation and supervision uses the term "can."

§169.26

TSA asked to delete "either/or" in subsection (b). TSA further asked for language clarifying that the practitioner-patient relationship be established via a one-on-one visit in person or via telehealth in subparagraph (c)(1) Finally, TSA asked to clarify how the identity and title of the individual performing the delegated act must be disclosed, asking for language requiring individuals to wear photo ID badges containing certain information.

Board Response - The Board declines to make any changes in response to this comment, as the requested changes are unnecessary. Statute permits practitioner-patient relationships to be established via in person or telemedicine visits and requires health care practitioners to be clearly identified to patients.

SUBCHAPTER A. DEFINITIONS AND GENERAL PROVISIONS.

New §169.1, Definitions

New §169.2, General Responsibilities of Delegating Physician

SUBCHAPTER B. PHYSICIAN ASSISTANTS AND ADVANCED PRACTICE REGISTERED NURSES.

New §169.5, Delegation to a Physician Assistant or Advanced Practice Registered Nurse

SUBCHAPTER C. EMERGENCY MEDICAL SERVICES.

New §169.10, Definitions

New §169.11, Medical Supervision

New §169.12, Medical Director Qualifications

New §169.13, Medical Director Responsibilities

New §169.14, Limits on Off-Line Medical Control

New §169.15, Other Physician Presence at Medical Emergency

SUBCHAPTER D. PHARMACISTS.

New §169.20, General Standards

SUBCHAPTER E. OTHER DELEGATED ACTS.

New §169.25, Other Delegation

New §169.26, General Standards

New §169.27, Physician Responsibilities related to Written Order

New §169.28, Notice and Identification Provisions

SUBCHAPTER A. DEFINITIONS AND GENERAL PROVISIONS

The Texas Medical Board (Board) adopts the repeal of current Chapter 170, concerning Prescription of Controlled Substances. This includes Subchapter A, concerning Pain Management, §§170.1 - 170.3; Subchapter B, concerning Utilization of Opioid Antagonists, §§170.4 - 170.8; Subchapter C, concerning Prescription Monitoring Program Check, §170.9; and Subchapter D, concerning Electronic Prescribing of Controlled Substances, §170.10. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7738). The repeals will not be republished.

The Board also adopts new Chapter 170, concerning Standards for Use of Investigational Agents. This includes new Subchapter A, concerning Standards for Use of Investigational Drugs, Biological Products, or Devices, §170.1, and Subchapter B, concerning Investigational Stem Cell Treatments for Patients with Certain Severe Chronic Diseases or Terminal Illnesses, §170.5 and §170.6. The new sections are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7739). The rules will not be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 170 is more efficient than proposing multiple amendments to make the required changes.

The adopted new subchapters and sections are as follows:

SUBCHAPTER A. STANDARDS FOR USE OF INVESTIGATIONAL DRUGS, BIOLOGICAL PRODUCTS, OR DEVICES.

New §170.1, General Standards for Use of Investigational Agents, explains the standards required of a physician who administers or provides for the use of investigational agents, drugs, biological products, or devices.

SUBCHAPTER B. INVESTIGATIONAL STEM CELL TREATMENTS FOR PATIENTS WITH CERTAIN SEVERE CHRONIC DISEASES OR TERMINAL ILLNESSES.

New §170.5, General Standards for the Use of Investigational Stem Cell Treatments for Patients with Severe Chronic Diseases or Terminal Illnesses, explains the standard required of a physician who administers or provides for the use of Investigational Stem Cell treatments in patients.

New §170.6, Annual Reporting of Clinical Trial of Investigational Stem Cell Treatments, outlines reports required to be submitted to the board by IRBs overseeing clinical trials of investigational stem cell treatments.

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 170.

The Board received one comment from the Texas Medical Association (TMA). A summary of the comment and the Board response is as follows:

§170.1

TMA recommended including language found in existing rule (§198.3(f)) that states a physician does not commit a violation of the Medical Practice Act (unprofessional conduct or standard of care violation) solely on the basis of providing an investigational agent unless done in violation of the rule.

Board Response - The Board declines to make any changes in response to this comment. Sections 489.054 and 489.151 of the Health and Safety Code provide specific protections for the physician. Therefore, a rule is unnecessary.

SUBCHAPTER A. PAIN MANAGEMENT

SUBCHAPTER A. STANDARDS FOR USE OF INVESTIGATIONAL DRUGS, BIOLOGICAL PRODUCTS, OR DEVICES.

The Texas Medical Board (Board) adopts the repeal of current Chapter 171, concerning Postgraduate Training Permits, §§171.1 - 171.6. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7741). The repeals will not be republished.

The Board also adopts new Chapter 171, concerning Complementary and Alternative Medicine Standards, §171.1 and §171.2. The new sections are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7741). The rules will not be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 171 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §171.1, Definitions, defines terms used in the chapter.

New §171.2, Required Consent and Disclosure, details the required written consent and disclosure form required prior to the patient's treatment by the physician using complementary or alternative medicine.

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 171.

The Board received one comment from the Texas Medical Association (TMA). A summary of the comment and the Board response is as follows:

TMA would like language in current rule to be carried over to the proposed rules - "A licensed physician shall not be found guilty of unprofessional conduct or be found to have committed professional failure to practice medicine in an acceptable manner solely on the basis of administering or providing an investigational drug, biological product, or device, unless it can be demonstrated that such use does not comply with this section

Board Response - The Board declines to make any changes in response to this comment. The recommendation is unnecessary because finding a violation must be due to failure to comply with a law or rule.

The Texas Medical Board (Board) adopts the repeal of current Chapter 172, concerning Temporary and Limited Licenses. This includes Subchapter A, concerning General Provisions and Definitions, §172.1 and §172.2; Subchapter B, concerning Temporary Licenses, §§172.3 - 172.11; Subchapter C, concerning Limited Licenses, §§172.12, 172.13, 172.15 - 172.19; Subchapter D, concerning Disaster Emergency Rule, §172.20 and §172.21. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7743). The repeals will not be republished.

The Board also adopts new Chapter 172, concerning Pain Management Clinics, §§172.1 - 172.5. The new sections are being adopted with changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7745). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 172 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §172.1, Definitions, defines the various forms of pain that implicates need of Pain Management Clinic Registration.

New §172.2, Gold Designated Practice, explains the eligibility criteria and application process for the Gold Practice designation.

New §172.3, Certification of a Pain Management Clinic, explains which clinics must register as a Pain Management Clinic and the procedures and information needed for processing certificate applications.

New §172.4, Minimum Operational Standards, explains minimum standards for any physician treating a pain patient.

New §172.5, Audits, Inspections, and Investigations, explains the board's regulatory actions of audits, inspections, and investigations. It details the information requested and the process followed by the board during these actions.

COMMENTS:

The Board received one comment regarding the repeal of current Chapter 172.

§172.6

Denise Meyer of Garanflo & Meyer Consulting requested confirmation that the Board consulted with stakeholders regarding the elimination of the Visiting Professor Temporary License in repealed §172.6.

Board Response - The Board has discussed the elimination of this license type by repeal with stakeholders.

The Board received one comment from the Texas Society of Anesthesiologists (TSA) regarding the new rules. A summary of the comment and the Board response are as follows:

§172.1

TSA recommended removing the phrases "post-surgical" and "post-procedure" from the definition of acute pain in paragraph (1). They stated these types of pain are, by definition, acute pain. Additionally, post-surgical and post-procedure pain is adequately described in paragraph (3).

Board Response - The Board agrees and deleted the phrase "or post-surgical, post-procedure," from the definition in paragraph (1).

SUBCHAPTER A. GENERAL PROVISIONS AND DEFINITIONS

The Texas Medical Board (Board) adopts the repeal of current Chapter 173, concerning Physician Profiles, §§173.1 - 173.5, and §173.7. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7748). The repeals will not be republished.

The Board also adopts new Chapter 173, concerning Office-Based Anesthesia Services, §§173.1 - 173.5. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7748). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 173 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §173.1, General Definitions, defines terms used in new Chapter 173.

New §173.2, Standards for Anesthesia Services, explains the standards and minimum equipment requirements when providing anesthesia services in an outpatient setting.

New §173.3, Specific Requirements Based on Level of Anesthesia Provided, explains the additional standards applicable to outpatient settings based upon the level of anesthesia being provided in Level I, Level II, Level III, and Level IV anesthesia services.

New §173.4, Registration, explains the process in which a physician providing anesthesia services or performing a procedure for anesthesia services are provided in an outpatient setting (excluding Level I services) must register with the board.

New §173.5, Inspections, explains that the board may conduct inspections for the purpose of enforcing Office-Based Anesthesia rules.

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 173.

The Board received comments from five organizations and 37 individuals regarding the proposed new rules. Certain non-substantive changes are adopted based upon the comments, which include minor typographical corrections and renumbering as required. A summary of the comments and the Board responses is as follows:

Commenter 1: Texas Society of Anesthesiologists (TSA)

§173.1

TSA requested adding a new definition recognizing a "certified anesthesiologist assistant" with certain educational requirements.

Board Response - The Board declines to make this change, as the Medical Practice Act currently provides no authority to recognize such a designation or set educational standards for this profession.

TSA objected to the use of the acronym "CRNA" in §173.1 and throughout the rule, stating that using the acronym for "certified registered nurse anesthetists" risks confusion.

Board Response - The Board declines to make this change as the acronym is well understood in the health care community.

TSA requested that the rules require a medical director and specific training and other requirements for a medical director depending on the level of anesthesia performed.

Board Response - The Board declines to adopt the rules with this change. The request seeks to limit the physicians who may undertake OBA. This would exceed TMB authority by adding "specialization training" that is not required to obtain either a license or an OBA certificate. Any physician practicing OBA is expected to meet the standard of care in such a setting. TMB does not issues licenses limited to any particular specialty.

TSA requested that the definition for "hypnotics" have added language to reflect that such drugs alter consciousness. Further TSA requested adding the phrase "and any other dangerous or scheduled drug that alters consciousness" so as to indicate that the listed drugs are not a comprehensive list.

Board Response - The Board adopts the definition with the non-substantive change clarifying that hypnotics are a class of drugs that alter consciousness. The Board declines to include language further stating that the list is not comprehensive, as the language already contains the term "such as" and therefore such language is unnecessary.

TSA requested several non-substantive changes to different definitions under §173.1 related to levels of sedation and anesthesia. These changes requested use current terminology and have clearer descriptions of each of the terms. This request also included adding Perioperative Resuscitation and Life Support Certificate (PeRLS) recognizing the certificate offered by the American Society of Anesthesiologists as an optional requirement for physicians providing certain anesthesia service levels.

Board Response - The Board agrees and adopts the rules under §173.1 with non-substantive changes so that the definitional language has improved clarity and accuracy. The non-substantive changes include the use American Society of Anesthesiologist's (ASA) definitions, and other widely used and recognized terminology modifications. The additions also required deletion of the older terminology previously used.

§173.2

TSA recommended adding "or delegating" to subsection (a).

Board Response - The Board adopts the section with the non-substantive change to better clarify the scope of the rules' application including recognition of allowable delegation.

TSA requested that the term "certified anesthesiologist assistants" be added to paragraph (a)(1).

Board Response - The Board declines to adopt the rules with this change. The Medical Practice Act currently provides no authority to recognize such a designation.

TSA requested that the rules require a specific anesthesia consent form adopted by the Texas Medical Disclosure Panel under paragraph (a)(4).

Board Response - The Board declines to adopt the rules with this change at this time. The reference to state law is sufficient.

TSA recommended adding the new definitions for "deep sedation" and "general anesthesia" to subsection (b) and to clarify that O2 analyzers are only utilized in general anesthesia using a closed circuit. TSA further requested that the term "algorithm" be used rather than "measures."

Board Response - The Board adopts the rules with the non-substantive change improving the accuracy of the language.

§173.3, Specific Requirements Based on Level of Anesthesia Provided

TSA recommended adding to paragraph (2) a reference to the PeRLS certification offered by ASA and eliminating the term "pre-measured doses" related to first-line cardiac medications. TSA explained that the term is no longer accurate, asserting that such medications are now distributed in vials with labelled concentration and volume on the packaging. TSA also requested adding the phrase "to treat local anesthetic systemic toxicity" related to when the stocking of lipid emulsion is required for Level II services.

Board Response - The Board agrees the PeRLS certification will be an appropriate training option, and that eliminating the term "pre-measured doses" and tying the stocking of lipid emulsion to the treatment of LAST will improve the clarity of the rule. The Board adopts the rules with those non-substantive changes.

TSA requested adding to subparagraph (3)(A) (Level III services) the requirement that a medical director provide oversight, and that the physician who participated in the procedure possess airway expertise determined appropriate by the Medical Director for the level of sedation provided, and that additional personnel have ACLS, PALs, or PeRLS certification rather than BLS. Finally, TSA recommended adding recognition of PeRLS certification for physicians.

Board Response - The Board agrees that adding PeRLS certification as an option will improve the rule and is a non-substantive change. The Board declines to adopt the rules with the remaining changes requested at this time. State law standards are sufficient. This would exceed TMB authority by adding "specialization training" that is not required to obtain either a license or an OBA certificate. Any physician practicing OBA is expected to meet the standard of care in such a setting. TMB does not issue licenses limited to any particular specialty.

TSA requested language adding to subparagraph (3)(B) the requirement of maintaining a backup cylinder of oxygen and adding the requirement of maintaining lipid emulsion for Level III services.

Board Response - The Board declines to require the stocking of lipid emulsion for Level III services. The Board agrees that requiring a backup cylinder of oxygen will be a non-substantive change that will improve the rule.

TSA recommends changing the term "feed" to "access" under subparagraph (3)(C) to align with current medical terminology, and remove the term "working" as it is an inaccurate term in the context of the rule.

Board Response - The Board agrees and adopts the rule with the non-substantive change.

TSA requests that additional language be added to paragraph (4) (Level IV services) the requirement that a medical director provide oversight, that the physician who participated in the procedure possess airway expertise determined appropriate by the Medical Director for the level of sedation provided. TSA further requested that the stocking of lipid emulsion be required for Level IV services. Finally, TSA requested that language be added requiring the stocking of a backup cylinder of oxygen be required.

Board Response - The Board declines to adopt changes requiring additional training as state law standards are sufficient. This would exceed TMB authority by adding "specialization training" that is not required to obtain either a license or an OBA certificate. Any physician practicing OBA is expected to meet the standard of care in such a setting. TMB does not issue licenses limited to any particular specialty. The Board agrees that requiring a backup cylinder of oxygen for Level IV service will be a non-substantive amendment improving the rule.

TSA requested an additional rule section requiring practices to report adverse events to TMB, suggesting it be placed at §173.6.

Board Response - The Board declines to adopt the rules with this change. Such reporting would create an unnecessary administrative burden. The Board is able to appropriately monitor OBA practices through the audit and complaint processes, which include the ability to obtain relevant documents.

Comment No. 2: Texas Association of Nurse Anesthetists (TxANA)

§173.2

TxANA opposed proposed subsection (a). TxANA claimed that the reference to Chapter 157 of Texas Occupations Code improperly limits CRNA discretion as allowed by §157.058 of Texas Occupations Code, stating that the language requires supervision of CRNAs. TxANA further opined that the reference to §157.058 "expands applicability" of the OBA rules from "anesthesia services that are administered within two hours before an outpatient procedure to all anesthesia services," claiming this will require an "on-site physician when any medication is administered, regardless of whether it is anesthesia for a physician-provided service." TxANA claims that the rule will create market barriers to participation by CRNAs and reduce market competition.

Board Response - The rules do not change to the state law requirements for physicians with respect to delegation in an office-based anesthesia (OBA) practice or CRNA scope of practice in an OBA setting. The duties and scope of a CRNA to administer an anesthesia-service applies in the same manner in any setting and the timing of such services which depend on the variable factors does not change those responsibilities. The new rules under Chapter 173 represent no change from how the repealed rules governing OBA applied to the permitted scope of a CRNA in an OBA setting. But nowhere does this rule say anything to limit CRNA and fully comports with §157.058 of the Occupations Code.

Commenter 3: Texas Medical Association (TMA)

§173.5

TMA requested that language be added to §173.5 so that a five-day notice period is required prior to the Board conducting inspections of OBA practices.

Board Response - The Board declines to add language providing the five-day notice period, as the five-day notice period is provided for in statute. Such language is therefore unnecessary in the rule.

Commenter 4: American Society of Ketamine Physicians, Psychotherapists, & Practitioners (ASKP3)

§173.1

ASKP3 stated that it is a professional association of physicians and other practitioners advocating for sensible regulation of low dose ketamine as a psychotropic agent (as a recognized off-label use) in treatment of PTSD, drug resistant depression and several other mental health conditions.

ASKP3 opined there is a lack of clarity in how the rules apply to the administration of low-dose ketamine as a psychotropic agent as opposed to an anesthetic agent. ASKP3 requested that the use of ketamine as a psychotropic agent (and not as an anesthetic agent), be regulated under a separate section or chapter of the rules, to standardize the administration of low-dose ketamine practices and ensure patient safety.

Board Response - The Board declines to adopt the rules with the proposed change at this time. The rules as written address ketamine as an anesthetic agent. The emerging therapeutic uses at low doses, not for purposes of anesthesia, will need further review. The Board will be undertaking a comprehensive review of this application in the coming year.

Comment No. 5: Texans for Greater Mental Health (T4GMH)

T4GMH expressed support for dedicating a separate chapter to the regulation of psychotropic ketamine therapy, to standardize the administration of low-dose ketamine practices and ensure patient safety.

Board Response - The Board declines to adopt the rules with the proposed change at this time. The rules as written address ketamine as an anesthetic agent. The emerging therapeutic uses at low doses, not for purposes of anesthesia, will need further review. The Board will be undertaking a comprehensive review of this application in the coming year.

Individual Comments

Approximately 37 individuals submitted a comment regarding low-dose ketamine therapy, expressing concerns that the proposed rules may limit their access.

Board Response - The Board declines to adopt the rules with the proposed change at this time. The rules as written address ketamine as an anesthetic agent. The emerging therapeutic uses at low doses, not for purposes of anesthesia, will need further review. The Board will be undertaking a comprehensive review of this application in the coming year.

The Texas Medical Board (Board) adopts the repeal of current Chapter 174 concerning Telemedicine. This includes Subchapter A, concerning Telemedicine, §§174.1 - 174.8; and Subchapter B, concerning Mental Health Services, §174.9. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7752). The repeals will not be republished.

The Board also adopts new Chapter 174, concerning Business Organizations. This includes new Subchapter A, concerning Non-Profit Health Organizations, §174.1 and 174.2; Subchapter B, concerning Jointly Owned Entities, §174.5; and Subchapter C, concerning Physician Call Coverage Arrangements, §174.10. The new sections are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7753). The rules will not be republished.

The Board has determined that due to the extensive reorganization of Chapters 160 - 200, repeal of Chapter 174 is more efficient than proposing multiple amendments to make the required changes.

The adopted new subchapters and sections are as follows:

SUBCHAPTER A. NON-PROFIT HEALTH ORGANIZATIONS.

New §174.1, Definitions, gives definitions for terms used in new Chapter 174.

New §174.2, Certification of a Non-Profit Health Organization, describes the process of certification of a Non-Profit Health Organization.

SUBCHAPTER B. JOINTLY OWNED ENTITIES.

New Section 174.5. Joint Ownership, provides the requirements for the Physician and Physician Assistant's joint ownership in compliance with Chapter 301, Texas Business Organizations Code.

SUBCHAPTER C. CALL COVERAGE AGREEMENTS.

New Section 174.10. Call Coverage Agreement Minimum Requirements, sets forth minimum requirements for a physician to follow regarding a call coverage agreement for another physician.

COMMENTS:

The Board received one comment from the Texas Medical Association (TMA) regarding the proposed new rules. A summary of the comments and the Board responses is as follows

§174.2

TMA expressed opposition to the removal of certain provisions related to non-profit health organizations that exist in the repealed rules and further inquire whether such information is elsewhere in the new proposed rules. They specifically requested that the Board include language in rule §174.2(a) and (b) stating "the health organization is not established or organized or operated in contravention to or with the intent to circumvent any of the provisions of the Act."

Board Response - The Board declines to make changes to the rule in response to this comment. The identified provisions removed are specifically delineated in statute and are unnecessary to duplicate in the rule. The rule as proposed does not alter or change any processes concerning non-profit health organizations. Any complaints are received and evaluated using standard procedures applied to all TMB complaints. The inclusion of language concerning "contravention of any provision of the act" is unnecessary because that authority is already in statute.

SUBCHAPTER A. TELEMEDICINE

SUBCHAPTER A. NON-PROFIT HEALTH ORGANIZATIONS

The Texas Medical Board (Board) adopts the repeal of current Chapter 175, concerning Fees and Penalties, §§175.1 - 175.5. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7755). The repeal will not be republished.

The Board also adopts new Chapter 175, concerning Telemedicine, §§175.1- 175.3. Section 175.1 and §175.2 are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7755), and will not be republished. Section 175.3 is being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7755), and will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 175 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §175.1. License Required, explains that a physician practicing telemedicine in Texas must hold a full Texas medical license, with some limited exceptions.

New §175.2. Telemedicine Services, explains that telemedicine services must be performed in compliance with the Medical Practice Act and Chapter 111 of the Texas Occupations Code.

New §175.3. Requirements for a Valid Prescription, explains the requirements for a valid prescription using telemedicine. It also explains the requirements for prescribing for chronic pain using telemedicine.

COMMENTS:

The Board received two comments regarding the proposed new rules.

Commenter 1: Texas Council of Community Centers (TCCC)

§175.3

TCCC recommended further clarification of when a doctor may prescribe on behalf of a supervised/delegated advanced practice nurse or physician assistant. They suggested language that under the telemedicine statute (§111.006 of the Texas Occupations Code), a valid prescription requires either the establishment of a physician-patient relationship or the evaluation of the patient by another provider under delegation.

Board Response - TMB declines to make changes in response to this comment. The issuing of a prescription by telemedicine is subject to all applicable laws and regulations, including statutory provisions regarding prescriptive delegation under Chapter 157 of the Occupations Code.

Commenter 2: Garanflo and Meyer Consulting

§175.3

The commenter requested to add back into the rule language in repealed rule §172.12(f) regarding exceptions to licensure for certain telemedicine practices.

Board Response - The Board declines to make changes in response to the comment. The exceptions are found in §151.056 of the Texas Occupations Code and therefore a rule is unnecessary.

The Texas Medical Board (Board) adopts the repeal of current Chapter 177, concerning Business Organizations and Agreements. This includes Subchapter A, concerning Definitions, §177.1, Subchapter B, concerning Non-Profit Health Organizations, §§177.2 - 177.13, Subchapter C, concerning Jointly Owned Entities, §§177.14 - 177.16, Subchapter D, concerning Employment of Physicians, §177.17, Subchapter E, concerning Physician Call Coverage Medical Services, §177.18 and §177.20. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7758). The repeals will not be republished.

The Board also adopts new Chapter 177, concerning Complaints and Investigations. This includes new Subchapter A, concerning Complaints, §§177.1 - 177.3; Subchapter B, concerning Investigative Process, §§177.10 - 177.13, and Subchapter C, concerning Expert Panel Review, §177.20 and §177.21. The new sections are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7758). The rules will not be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 177 is more efficient than proposing multiple amendments to make the required changes.

The adopted new subchapters and sections are as follows:

SUBCHAPTER A. COMPLAINTS.

New §177.1, Definitions, explains the meaning of several terms as used in new Chapter 177.

New §177.2, Mandatory Complaint Notification, requires the posting of a notice of how to file a complaint and explains to whom the requirement applies.

New §177.3, Complaint Initiation, explains how to file a complaint and what information a complaint must contain.

SUBCHAPTER B. INVESTIGATIVE PROCESS.

New §177.10, Preliminary Investigation, explains how a preliminary investigation is to be conducted and how it is utilized by the board.

New §177.11, Official Investigation, how an official investigation is to be conducted and how it is utilized by the board.

New §177.12, Appeal of Dismissal, explains the process for a complainant to appeal the dismissal of a complaint and the possible outcomes of a complainant's appeal.

New §177.13, Probable Cause Guidelines for Requiring Mental or Physical Examination, explains the process for the board to order a mental or physical examination of a licensee if there is cause for concern regarding the fitness of the licensee to practice the regulated profession.

SUBCHAPTER C. EXPERT PANEL REVIEW.

New §177.20, Qualifications, explains the general qualifications necessary to act as an expert reviewer for the board.

New §177.21, Expert Reviewer Selection and Report, explains the selection and assignment process for assigning expert reviewers and duties if assigned as an expert reviewer.

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 177.

The Board received three comments regarding the proposed new rules. A summary of the comments and the Board responses are as follows:

Commenter 1: Texas Association of Nurse Anesthetists (TxANA)

§177.2

TxANA asserted the requirement to post public notifications on how to file complaints with the board at "any location where physician supervision or delegation is required" is intended to limit or discourage delegation. They said it would directly regulate NPs who own their own practice and receive delegation from an off-site physician. They claimed it is another way to discourage physicians who would otherwise delegate, resulting in higher prices for services.

Board response - The Board declines to make any changes in response to this comment. The requirement for posting notices of how to file a complaint concerning a physician with TMB is statutory and has been in place for over a decade. The rule simply recognizes that medical services can be provided at a number of locations/facilities other than a physicians' office. No matter the location, these are still medical acts, and patients need to be informed as to who delegated the act to the provider and where to complain if issues arise. This is intended to maintain patients' protection, patients' right to an informed decision, and transparency. The new rule does not change or alter physician delegation in any manner.

Commenter 2: Texas Nurse Practitioners (TNP)

§177.2

TNP listed the same comments as TxANA regarding the requirement to post public notifications on how to file a complaint with the board at "any location where physician supervision or delegation is required.

Board response - The Board declines to make any changes in response to this comment. The requirement for posting notices of how to file a complaint concerning a physician with TMB is statutory and has been in place for over a decade. The rule simply recognizes that medical services can be provided at a number of locations/facilities other than a physicians' office. No matter the location, these are still medical acts, and patients need to be informed as to who delegated the act to the provider and where to complain if issues arise. This is intended to maintain patients' protection, patients' right to an informed decision, and transparency. The new rule does not change or alter physician delegation in any manner.

Commenter 3: Texas Medical Association (TMA)

§177.21

TMA is opposed to the new language that would allow an expert reviewer to be "of the same or similar specialty for the area of practice that is the basis of the complaint." They recommend that only a physician with the same specialty is qualified to conduct an expert review related to a complaint. In the alternative, they recommend the board revert back to the language in repealed §182.8.

Board Response - The Board disagrees and declines to make any changes in response to this comment. The rule as written is consistent with statute and allows flexibility in the event of difficulty obtaining certain highly specialized practitioners. Also, several specialties have crossover areas of care which is recognized by the rule as proposed. This ensures the Board has sufficient qualified reviewers to carry out these required reviews.

SUBCHAPTER A. DEFINITIONS

SUBCHAPTER A. COMPLAINTS

The Texas Medical Board (Board) adopts the repeal of current Chapter 179, concerning Investigations, §§179.1 - 179.8. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7764). The repeals will not be republished.

The Board also adopts new Chapter 179, concerning Procedural Rules. This includes new Subchapter A, concerning Definitions, §179.1; Subchapter B, concerning Reporting Requirements, §179.5; Subchapter C, concerning Pre-Settlement Conference Resolution Process, §179.10; Subchapter D, concerning Informal Settlement Conference, §179.15 and §179.16; Subchapter E, concerning Contested Case Procedure §179.20; Subchapter F, concerning Temporary Suspension or Restriction Proceedings, §179.25 and §179.26; Subchapter G, concerning Suspension by Operation of Law, §179.30; Subchapter H, concerning Cease and Desist Orders, §179.35; Subchapter I, concerning Out-of-Network Billing, §179.40. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7764). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 179 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

SUBCHAPTER A. DEFINITIONS.

New §179.1, Definitions, explains the meaning of certain specific terms as used in new Chapter 179.

SUBCHAPTER B. REPORTING REQUIREMENTS.

New §179.5, Reports to Outside Entities, explains the board's mandatory reporting related to board actions.

SUBCHAPTER C. PRE-SETTLEMENT CONFERENCE RESOLUTION PROCESS.

New §179.10, Quality Assurance Panel, explains the process utilized by the board for potential disposition of certain complaints prior to the convening of an Informal Settlement Conference (ISC).

SUBCHAPTER D. INFORMAL SETTLEMENT CONFERENCE.

New §179.15, Informal Settlement Conference (ISC) Notice, explains the content of the notice of the ISC to a licensee. It also explains a licensee's ability to submit information for consideration at the ISC, request for recordation of the ISC, and a request for continuance of the ISC.

New §179.16, Conduct of the Informal Settlement Conference (ISC), explains how an ISC will generally be conducted and possible complaint resolutions that may be offered at an ISC.

SUBCHAPTER E. CONTESTED CASE PROCEDURE.

New §179.20, Notice of Oral Argument, explains the opportunity for a licensee to attend and provide oral argument to the board concerning a proposal for decision after a State Office of Administrative Hearings (SOAH) contested case hearing.

SUBCHAPTER F. TEMPORARY SUSPENSION OR RESTRICTION PROCEEDINGS.

New §179.25, Temporary Suspension or Restriction Hearing Without Notice, explains the process followed by the board if the board has reason to believe a licensee is a "continuing threat."

A disciplinary hearing will be held as soon as practicable in accordance with §164.059 of the Act or §164.0595 of the Act.

§179.26, Temporary Suspension or Restriction Hearing With Notice, explains the process followed by the board regarding examining witnesses, closing arguments, panel deliberation and announcement of the panel's decision. Evidence is considered under a relaxed standard described in §2001.081 of the Texas Government Code.

SUBCHAPTER G. SUSPENSION BY OPERATION OF LAW.

New §179.30, Automatic Suspensions Based upon Felony Conviction, explains what the board considers to be initial and final criminal convictions. It also details how initial and final convictions may be handled by the board.

SUBCHAPTER H. CEASE AND DESIST ORDERS.

New §179.35, Cease and Desist Orders, explains the process utilized by the board to consider the unlicensed practice of a regulated profession.

SUBCHAPTER I. OUT-OF-NETWORK BILLING.

New §179.40, Out-of-Network Billing, explains how the board investigates complaints of bad faith participation and other consumer complaints in out-of-network billing cases.

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 179.

The Board received one comment from the Texas Medical Association (TMA) on the new rules. A summary of the comment and the Board responses is as follows:

§179.20

TMA stated that the rule does not provide a clear overview of the procedure for contested cases. They suggested adding references to and outlining the contested case and appeal provisions in Occupations Code, §§ 164.005, 164.006, 164.007, 164.0071, 164.0072, 164.008, 164.009, and Government Code, Chapter 2001. Additionally, they stated that the phrase "proposal for decision" is not defined, so it is not clear to readers what is meant.

Board Response - For the sake of clarity, the Board has inserted the phrase "After the issuance of a proposal for decision by the State Office of Administrative Hearings (SOAH)" at the beginning of the sentence. This makes clear what the rule is referring to. However, the Board declines to add in the statutory references listed by TMA, as the statute is clear.

SUBCHAPTER A. DEFINITIONS.

The Texas Medical Board (Board) adopts the repeal of current Chapter 180, concerning Texas Physician Health Program, §§180.1 - 180.4. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7770). The repeals will not be republished.

The Board adopts new Chapter 180, concerning Disciplinary Guidelines. This includes new Subchapter A, concerning Violation Guidelines, §180.1; and Subchapter B, concerning Sanction Guidelines, §180.5. The new sections are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7770). The rules will not be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapters 180 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

SUBCHAPTER A. VIOLATION GUIDELINES.

New §180.1, Violation Guidelines, outlines the acts, practices and conduct that are violations of the Medical Practice Act.

SUBCHAPTER B. SANCTION GUIDELINES.

New §180.5, Sanction Guidelines, provide guidance on assessing remedial action or sanctions for violations of the Medical Practice Act.

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 180.

The Board received one comment from the Texas Council of Community Centers on the new rules. A summary of the comment and the Board responses are as follows:

§180.1(3)(F)

Texas Council of Community Centers asked if this subparagraph is intended to make physicians responsible for all billing statements sent on their behalf, e.g., by their employers. They recommended clarifying that a physician is not held accountable for billing processes conducted by their employer.

Board Response - The Board declines to make any changes in response to this comment. Physicians are responsible for all billing done under their taxpayer identification number and/or national provider identification (NPI).

SUBCHAPTER A. VIOLATION GUIDELINES

The Texas Medical Board (Board) adopts the repeal of current Chapter 181, concerning Contact Lens Prescriptions, §§181.1 - 181.7. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7773). The repeals will not be republished.

The Board also adopts new Chapter 181, concerning Compliance Program, §§181.1 - 181.8. The new sections are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7773). The rules will not be republished.

The Board has determined that due to the extensive reorganization of Chapters 160 - 200, repeal of Chapter 181 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §181.1, Definitions, defines terms used in new Chapter 181.

New §181.2, General Compliance Standards, explains the general compliance requirements for licensees subject to board action.

New §181.3, Compliance Process, describes the compliance process, including the initial meeting with the compliance officer and ongoing compliance reviews.

New §181.4, Determination of Non-Compliance, describes conduct considered by the board to be non-compliant with the terms or conditions of a non-disciplinary or disciplinary action.

New §181.5, Enforcement Process for Violations, identifies non-compliance by a compliance officer. It also describes the proper timeframe of ISC notification to the licensee, as well as information the board must receive from the licensee prior to the ISC.

New §181.6, Modification and Termination Process for Disciplinary Orders, explains the process to follow for licensees under disciplinary orders when seeking to modify or terminate the order.

New §181.7, Automatic Termination of a Disciplinary Order, explains the condition or terms that allow for an automatic termination of a licensee's disciplinary order.

New §181.8, Recommendation for Competency Assessment, explains the process followed when a third-party monitor for the board believes a licensee poses a continuing threat.

COMMENTS:

The Board received no comments regarding the repeal of current Chapter 181.

The Board received one comment from the Texas Medical Association (TMA) on the new rules. A summary of the comment and the Board responses is as follows:

§181.1

TMA did not recommend any changes to this section, but instead asked for clarification of qualifications for "monitoring physicians" as the term is used in the rule.

Board Response - The Board declines to make any changes in response to this comment. The monitoring physician selection is an internal board process and fully explained to a licensee when the licensee and compliance staff meet. As it is an internal process, the Board declines to include it in the rule.

The new rules are adopted under the authority of the Texas Occupations Code, §153.001, which provides authority for the Board to recommend and adopt rules and bylaws as necessary to: govern its own proceedings, perform its duties, regulate the practice of medicine, and enforce Subtitle B of Title 3 of the Texas Occupations Code. The new rules are adopted in accordance with Chapter 164 of the Texas Occupations Code, concerning Disciplinary Actions and Procedures. The new rules are also adopted in accordance with the requirements of Texas Government Code, §2001.039, which requires a state agency to review and consider its rules for readoption, readoption with amendments, or repeal every four years. No other statutes, articles or codes are affected by this adoption.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on December 20, 2024.

TRD-202406253

Scott Freshour

General Counsel

Texas Medical Board

Effective date: January 9, 2025

Proposal publication date: September 27, 2024

For further information, please call: (512) 305-7030

The Texas Medical Board (Board) adopts the repeal of current Chapter 182, concerning Use of Experts, §182.1, §182.3, §182.5, and §182.8. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7776). The repeals will not be republished.

The Board also adopts new Chapter 182, concerning Texas Physician Health Program, §§182.1 - 182.4. The new sections are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7776). The rules will not be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 182 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §182.1, Definitions, defines terms used in new Chapter 182.

New §182.2, Governing Board and Physician Health and Rehabilitation Advisory Committee Standards, explains the process of appointment of the Governing Board and Physician Health and Rehabilitation Advisory Committee. It also details the grounds for removal of members and conflicts of interest for members.

New §182.3, Operation of the Program, details how the Texas Physician Health Program (PHP) operates, including referrals to the program, agreements with participants, and drug and alcohol testing of participants. It also explains the Case Advisory Panel of the PHP.

New §182.4, Authority for the Program to Accept Gifts, Grants, and Donations, describes the process for acceptance of gifts, grants, and donations to the Governing Board.

No comments were received regarding the repeal or new rules.

The Texas Medical Board (Board) adopts the repeal of current Chapter 183, concerning Acupuncture, §§183.1 - 183.27. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7779). The repeals will not be republished.

The Board also adopts new Chapter 183, concerning Physician Assistants. This includes new Subchapter A, concerning Physician Assistant Board, §§183.1 - 183.5; Subchapter B, concerning Licensing and Registration, §§183.10 - 183.17; Subchapter C, concerning Practice Requirements, §183.20, and §183.21; and Subchapter D, concerning Board Processes and Procedures, §183.25. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7779). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, the repeal of Chapter 183 is more efficient than proposing multiple amendments to make the required changes.

SUBCHAPTER A. PHYSICIAN ASSISTANT BOARD.

New §183.1, Definitions, defines terms used in new Chapter 183.

New §183.2, Functions and Duties, explains the functions and duties of the Physician Assistant Board and its members.

New §183.3, Meetings, explains how often the board meets, how board and committee meetings are conducted, and the voting process at meetings.

New §183.4, Standing Committees, explains the function of the two Standing Committees, Disciplinary Committee and Licensure Committee of the board.

New §183.5, Officers of the Board, explains the duties of the presiding officer and secretary of the board, as well as appointment and succession of officers.

SUBCHAPTER B. LICENSING AND REGISTRATION.

New §183.10, General Requirements for Licensure, outlines the general standards for licensure for a Physicians Assistants license cited in §§204.152 and 204.153 of the Act and submission of relevant documentation.

New §183.11, Current Clinical Practice, outlines the requirements of a physician assistant relating to professional or work history evaluations and demonstration that the physician assistant has worked as a physician assistant in the preceding five years from the date of application. Alternatively, the section describes several options if an applicant cannot demonstrate current clinical practice as a physician assistant within the last three years from the date of application.

New §183.12, Temporary Licenses, explains the requirements and process for an applicant to obtain a temporary physician assistants license as cited in §205.155 of the Act.

New §183.13, Procedural Rules for Licensure Applicants, outlines the general requirements and processing of the application to obtain a physician assistants license. This section also describes the options offered by the Executive Director to the applicant if there is an issue with the application.

New §183.14, Relicensure, explains the requirements for a license holder who retired or surrendered their license and seek to be re-licensed.

New §183.15, License Registration and Renewal, outlines the general requirements for license registration and renewal for a Texas physician assistants license.

New §183.16, Biennial Continuing Medical Education (CME) Requirements, explains the registration renewal requirements regarding the Physicians Assistants biennial continuing medical education.

New §183.17, Inactive License, explains the number of years that the license is automatically canceled after being placed on inactive status for 3 years. This section also describes the process for relicensure, which is required for activation of a canceled license.

SUBCHAPTER C. PRACTICE REQUIREMENTS.

New §183.20, On-Going Reporting Requirements, states that a license holder must report any event listed in §162.2(b)(1) through (7) of this title to the board within 10 days after the event.

New §183.21, Training and Registration Requirements for Physician Assistants Performing Radiologic Procedures, outlines specific requirements for physician assistants in performing radiologic procedures when delegated in compliance with requirements of §157.001 of the Medical Practice Act.

NEW SUBCHAPTER D. BOARD PROCESSES AND PROCEDURES.

New §183.25, Procedural Rules, explains the applicable rules applied to complaints and investigations, disciplinary guidelines and sanctions, and compliance in accordance with §204.312 of the Act for physician assistants.

No comments were received regarding the repeal or new rules.

SUBCHAPTER A. PHYSICIAN ASSISTANT BOARD

The Texas Medical Board (Board) adopts the repeal of current Chapter 184, concerning Surgical Assistants §§184.1 - 184.9 and §§184.12 - 184.26. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7785). The repeals will not be republished.

The Board also adopts new Chapter 184, concerning Acupuncture. This includes new Subchapter A, concerning Acupuncture Board, §§184.1 - 184.4, Subchapter B, concerning Licensing and Registration, §§184.10 - 184.19, Subchapter C, concerning Practice Requirements, §§184.25 - 184.27, Subchapter D, concerning Board Processes and Procedures, §184.30; and Subchapter E, concerning Acudetox Specialists, §§184.35 - 184.37. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7785). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 184 is more efficient than proposing multiple amendments to make the required changes.

The adopted new subchapters and sections are as follows:

SUBCHAPTER A. ACUPUNCTURE BOARD.

New §184.1, Definitions, defines terms used in new Chapter 184.

New §184.2, Functions and Duties, explains the functions and duties of the Board and its members.

New §184.3, Meetings, explains how Board and Committee meetings are conducted.

New §184.4, Standing Committees, explains the function of the three Standing Committees of the Board.

SUBCHAPTER B. LICENSING AND REGISTRATION.

New §184.10, General Requirements for Licensure, outlines the general standards for licensure for a Texas acupuncture license.

New §184.11, Current Clinical Practice, outlines the professional or work history information applicants must provide for review when seeking a license.

New §184.12, Temporary Licenses, explains the standards required when a temporary license may be issued and the purpose of the license.

New §184.13, Examinations and Attempt Limits, outlines the applicants' requirements to take and pass the examination for licensure eligibility.

New §18414, Procedural Rules for Licensure Applicants, explains the procedural rules for Applicants in accordance with §205.202 of the Act.

New §184.15, Relicensure, explains the requirements for a license holder who retired or surrendered their license and is seeking to be re-licensed.

New §184.16, License Registration and Renewal, explains the registration and renewal process of an acupuncture license.

New §184.17, Biennial Continuing Acupuncture Education (CAE) Requirements, explains the requirements of a license holder, as part of registration renewal with regard to biennial continuing Acupuncture education.

New §184.18, Approval of Continuing Education Courses and Providers, explains the purpose, requirements, and process for approval of continuing education courses and providers.

New §184.19, Inactive License, explains the number of years that the license is automatically canceled after being placed on inactive status for 3 years. The process for relicensure is required for activation of a canceled license.

SUBCHAPTER C. PRACTICE REQUIREMENTS.

New §184.25, Patient Records, outlines the general requirements for keeping and maintaining adequate patient records, including retention periods.

New §184.26, On-Going Reporting Requirements, states that a license holder must report any event listed in §162.2(b)(1) through (7) of this title to the board within 10 days after the event.

New §184.27, Acupuncture Advertising, describes what type of acupuncture advertising is or is not considered to be permissible or prohibited.

SUBCHAPTER D. BOARD PROCESSES AND PROCEDURES.

New §184.30, Procedural Rules, explains the applicable rules applied to complaints and investigations, disciplinary guidelines and sanctions, and compliance in accordance with §205.351 of the Act.

SUBCHAPTER E, ACUDETOX SPECIALISTS.

New §184.35, Definitions, defines the term, Auricular Acudetox.

New §184.36, Acudetox Certification, outlines the general requirements and process for certification to perform acudetox, including acupuncture certificate renewal.

New §184.37, Other Requirements Related to Acudetox Practice, states that Certificate-holders must keep a current mailing and practice address on file with the board and that a change of address must be reported to the board within 10 days. Also, this section states that Certificate-holders use of titles is restricted to Certified Acudetox Specialist" or "C.A.S." and that failure to comply with Acudetox rules may result in loss of certification.

No comments were received regarding the repeal or new rules.

SUBCHAPTER A. ACUPUNCTURE BOARD

The Texas Medical Board (Board) adopts the repeal of current Chapter 185, concerning Physician Assistants, §§185.1 - 185.33. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7794). The repeals will not be republished.

The Board also adopts new Chapter 185, concerning Surgical Assistants, §§185.1 - 185.11. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7794). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 185 is more efficient than proposing multiple amendments to make the required changes.

The adopted new sections are as follows:

New §185.1, Definitions, defines terms used in new Chapter 185.

New §185.2, Meetings, explains how Advisory Committee meetings are conducted in compliance with §206.058 of the Act.

New §185.3, General Requirements for Licensure, outlines the general requirements for licensure for a Surgical Assistants license in accordance with §§206.202 and 206.203 of the Act including but not limited to, application form, and specific documentation.

New §185.4, Education Requirements, outlines the applicant's completion of specific education requirements for Surgical Assistants for licensure.

New §185.5, Examinations, describe the organizations that will accept a passing score for the purpose of obtaining a Surgical Assistants license.

New §185.6, Procedural Rules for Licensure Applicants, outlines the process of review of the licensee's application by the Executive Director and the options that may be offered in accordance with §206.209 of the Act.

New §185.7, Temporary Licenses, explains the requirements and process to obtain a temporary Surgical Assistants license in accordance with §206.206 of the Act.

New §185.8, License Registration and Renewal, outlines the general requirements for license registration and renewal of a Texas Surgical Assistants license.

New §185.9, Biennial Continuing Education (CE) Requirements, explains the requirements of a license holder, including their completion of formal course hours by an accredited organization or school and exemptions for CE requirements regarding the Surgical Assistants biennial continuing medical education.

New §185.10, Relicensure, describes the requirements by which a licensee who has retired or surrendered their license and seeks to be re-licensed.

New §185.11, Procedural Rules, explains the applicable rules applied to complaints and investigations, disciplinary guidelines and sanctions, and compliance in accordance with §206.313 of the Act.

No comments were received regarding the repeal or new rules.

The Texas Medical Board (Board) adopts the repeal of current Chapter 186, concerning Respiratory Care Practitioners §§186.1 - 186.14 and §§186.16 - 186.30. The repeals are being adopted without changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7798). The repeals will not be republished.

The Board also adopts new Chapter 186, concerning Medical Radiologic Technology. This includes new Subchapter A, concerning Texas Board of Medical Radiologic Technology, §§186.1 - 186.4; Subchapter B, concerning Medical Radiologic Technologist Certification, Registration, and Practice Requirements, §§186.10 - 186.21; Subchapter C, concerning Non-Certified Technician Registration and Practice Requirements, §§186.25 - 186.32; Subchapter D, concerning Hardship Exemptions §186.40 and §186.41; Subchapter E, concerning Education Programs and Instructor Requirements, §186.45; and Subchapter F, concerning, Procedural Rules, §186.50 and §186.51. The new sections are being adopted with non-substantive changes to the proposal as published in the September 27, 2024, issue of the Texas Register (49 TexReg 7798). The rules will be republished.

The Board has determined that due to the extensive reorganization of Chapters 160-200, repeal of Chapter 186 is more efficient than proposing multiple amendments to make the required changes.

The adopted new subchapters and sections are as follows:

SUBCHAPTER A. TEXAS BOARD OF MEDICAL RADIOLOGIC TECHNOLOGY.

New §186.1, Definitions, defines words and terms used in new Chapter 186.

New §186.2, Functions and Duties, explains the functions and duties of the Board and its members.

New §186.3, Meetings, explains how Board meetings are conducted.

New §186.4, Standing Committees, identifies and describes the function of the three standing committees of the board, the Disciplinary Committee, Licensure Committee, and Education Committee.

SUBCHAPTER B. MEDICAL RADIOLOGIC TECHNOLOGIST CERTIFICATION, REGISTRATION, AND PRACTICE REQUIREMENTS.

New §186.10. General Requirements for Certification, outlines the general requirements for an MRT certification.

New §186.11, Requirements for a Radiologist Assistant Certificate, outlines the requirements for certification as a Radiologist Assistant.

New §186.12, Requirements for a General Medical Radiologic Technologist Certificate, outlines the general requirements for certification as a Medical Radiologic Technologist.

New §186.13, Requirements for a Limited Medical Radiologic Technologist Certificate, outlines the limited requirements for certification as a Medical Radiologic Technologist.

New §186.14, Current Clinical Practice, outlines the submission of an applicant's professional or work history information for board review when seeking certification.

New §186.15, Temporary Certificates, explains the requirements and process to obtain a temporary Medical Radiologic Technology Certificate.

New §186.16, Procedural Rules for Certificate Applicants, outlines the general requirements for Applicants to obtain a Medical Radiologic Technology certification.

New §186.17, Recertification, outlines the requirements for a certificate holder who has retired or who has surrendered their certificate and is seeking reissuance of a certificate.

New §186.18, Certificate Registration and Renewal, outlines the general requirements of certificate registration and renewal.

New §186.19, Biennial Continuing Education (CE) Requirements, explains the requirements regarding the Medical Radiologic Technology biennial continuing medical education.

New §186.20, Scope of Practice, describes the dangerous and hazardous procedures that may be performed as are specified in §601.056 of the Act.

New §186.21, Professional Identification, explains the type of certification which must be displayed at all times when performing procedures.

SUBCHAPTER C. NON-CERTIFIED TECHNICIAN REGISTRATION AND PRACTICE REQUIREMENTS.

New §186.25, Non-Certified Technicians (NCTs), outlines specific documentation and payment of fee requirements that an NCT must provide in order to qualify for a NCT certification.

New §186.26, Education Standards for Non-Certified Technician (NCT), outlines specific educational standards as an applicant for NCT licensure.

New §186.27, Procedural Rules for Non-Certified Technician (NCT) Applicants, outlines the general requirements for an applicant to obtain an NCT certification.

New §186.28, Renewal of Non-Certified Technician (NCT) Registration, outlines the general requirements for NCT registration renewal.

New §186.29, Biennial Non-Certified Technician (NCT) Continuing Education (CE) Requirements, explains the requirements regarding the NCT's biennial continuing education.

New §186.30, Reissuance of Registration for Non-Certified Technicians (NCTs), outlines the requirements for an NCT who has retired or who has surrendered their registration and is seeking to be reissued registration.

New §186.31, Limited Practice of Non-Certified Technicians (NCTs), explains the parameters an NCT may not perform regarding a dangerous or hazardous procedure as defined by §186.12 of this subtitle.

New §186.32, Professional Identification, states the requirement that an NCT must display identification certification at all times when performing procedures.

SUBCHAPTER D. HARDSHIP EXEMPTIONS.

New §186.40, Hardship Exemptions, explains the hardship exemption qualifications that a practitioner or hospital may qualify for if it meets specific outlined criteria.

New §186.41, Bone Densitometry Exemption, describes the specific performance criteria for the practitioner, registered nurse, physician assistant, certificate holder, or a certified densitometry technologist regarding bone density using x-radiation.

SUBCHAPTER E. EDUCATION PROGRAMS AND INSTRUCTOR REQUIREMENTS.

New §186.45, Education Programs and Instructor Requirements, outlines the requirements of education programs and instructors to be accredited for LMRT and NCT certification.

SUBCHAPTER F. PROCEDURAL RULES.

New §186.50, Procedural Rules, Procedural Rules, explains the applicable rules applied to complaints and investigations, disciplinary guidelines and sanctions, and compliance in accordance with §601.311 of the Act.

New §186.51, On-Going Reporting Requirements, explains that a certificate holder or NCT must report any event listed in §162.2(b)(1) through (7) of this title within 10 days after the event.

No comments were received regarding the repeal or new rules.

SUBCHAPTER A. TEXAS BOARD OF MEDICAL RADIOLOGIC TECHNOLOGY