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SECOND REGULAR SESSION
HOUSE BILL NO. 1650
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE OVERCAST .
4216H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal sections 334.035 and 334.036, RSMo, and to enact in lieu thereof three new
sections relating to assistant physicians.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 334.035 and 334.036, RSMo, are repealed and three new sections
2 enacted in lieu thereof, to be known as sections 334.035, 334.036, and 334.039, to read as
3 follows:
334.035. Except as otherwise provided in [ section ] sections 334.036 and 334.039 ,
2 every applicant for a permanent license as a physician and surgeon shall provide the board
3 with satisfactory evidence of having successfully completed such postgraduate training in
4 hospitals or medical or osteopathic colleges as the board may prescribe by rule.
334.036. 1. For purposes of this section, the following terms shall mean:
2 (1) "Assistant physician", any graduate of a medical school accredited by the Liaison
3 Committee on Medical Education, the Commission on Osteopathic College Accreditation, or
4 an or ganization accredited by the Educational Commission for Foreign Medical Graduates
5 who:
6 (a) Is a resident and citizen of the United States or is a legal resident alien;
7 (b) Has successfully completed Step 2 or 3 of the United States Medical Licensing
8 Examination or the equivalent of such step of any other board-approved medical licensing
9 examination within the three-year period immediately preceding application for licensure as
10 an assistant physician[ , or within three years after graduation from a medical college or
11 osteopathic medical college, whichever is later ];
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
12 (c) Has not completed an approved postgraduate residency and has successfully
13 completed Step 2 or 3 of the United States Medical Licensing Examination or the equivalent
14 of such step of any other board-approved medical licensing examination within the
15 immediately preceding three-year period [ unless when such three-year anniversary occurred
16 he or she was serving as a resident physician in an accredited residency in the United States
17 and continued to do so within thirty days prior to application for licensure as an assistant
18 physician ]; and
19 (d) Has proficiency in the English language.
20
21 Any graduate of a medical school who could have applied for licensure and complied with the
22 provisions of this subdivision at any time between August 28, 2014, and August 28, 2017,
23 may apply for licensure and shall be deemed in compliance with the provisions of this
24 subdivision;
25 (2) "Assistant physician collaborative practice arrangement", an agreement between a
26 physician and an assistant physician that meets the requirements of this section and section
27 334.037.
28 2. (1) (a) An assistant physician collaborative practice arrangement shall limit the
29 assistant physician to providing only primary care services and only in :
30 a. Medically underserved rural or urban areas of this state ; or
31 b. A federally qualified health center , as defined under 42 U.S.C. Section 1395x,
32 located in any ar ea of this state.
33 (b) The prov isions of this subdivision shall not apply to an assistant physician
34 r eceiving postgraduate training under an authorized pr eceptor under subdivision (3) of
35 subsection 2 of section 334.039 .
36 (2) For a physician-assistant physician team working in a rural health clinic under the
37 federal Rural Health Clinic Services Act, P .L. 95-210, as amended , or in a federally
38 qualified health center as defined under 42 U.S.C. Section 1395x :
39 (a) An assistant physician shall be considered a physician assistant for purposes of
40 regulations of the Centers for Medicare and Medicaid Services (CMS); and
41 (b) No supervision requirements in addition to the minimum federal law shall be
42 required.
43 3. (1) For purposes of this section, the licensure of assistant physicians shall take
44 place within processes established by rules of the state board of registration for the healing
45 arts. The board of healing arts is authorized to establish rules under chapter 536 establishing
46 licensure and renewal procedures, supervision, collaborative practice arrangements, fees, and
47 addressing such other matters as are necessary to protect the public and discipline the
48 profession. No licensure fee for an assistant physician shall exceed the amount of any
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49 licensure fee for a physician assistant. An application for licensure may be denied or the
50 licensure of an assistant physician may be suspended or revoked by the board in the same
51 manner and for violation of the standards as set forth by section 334.100, or such other
52 standards of conduct set by the board by rule. No rule or regulation shall require an assistant
53 physician to complete more hours of continuing medical education than that of a licensed
54 physician.
55 (2) Any rule or portion of a rule, as that term is defined in section 536.010, that is
56 created under the authority delegated in this section shall become ef fective only if it complies
57 with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028.
58 This section and chapter 536 are nonseverable and if any of the powers vested with the
59 general assembly under chapter 536 to review , to delay the ef fective date, or to disapprove
60 and annul a rule are subsequently held unconstitutional, then the grant of rulemaking
61 authority and any rule proposed or adopted after August 28, 2014, shall be invalid and void.
62 (3) Any rules or regulations regarding assistant physicians in ef fect as of the ef fective
63 date of this section that conflict with the provisions of this section and section 334.037 shall
64 be null and void as of the ef fective date of this section.
65 4. An assistant physician shall clearly identify himself or herself as an assistant
66 physician and shall be permitted to use the terms "doctor", "Dr .", or "doc". No assistant
67 physician shall practice or attempt to practice without an assistant physician collaborative
68 practice arrangement, except as otherwise provided in this section and in an emer gency
69 situation.
70 5. The collaborating physician is responsible at all times for the oversight of the
71 activities of and accepts responsibility for primary care services rendered by the assistant
72 physician.
73 6. The provisions of section 334.037 shall apply to all assistant physician
74 collaborative practice arrangements. Any renewal of licensure under this section shall
75 include verification of actual practice under a collaborative practice arrangement in
76 accordance with this subsection during the immediately preceding licensure period.
77 7. Each health carrier or health benefit plan that of fers or issues health benefit plans
78 that are delivered, issued for delivery , continued, or renewed in this state shall reimburse an
79 assistant physician for the diagnosis, consultation, or treatment of an insured or enrollee on
80 the same basis that the health carrier or health benefit plan covers the service when it is
81 delivered by another comparable mid-level health care provider including, but not limited to,
82 a physician assistant or a certified nurse practitioner .
83 8. The department of commer ce and insurance shall enforce the pro visions of
84 this section.
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334.039. 1. An assistant physician with a license in good standing shall be
2 eligible to become a licensed physician if the assistant physician meets the r equir ements
3 of subsection 2 of this section or the r equir ements of subsection 4 of this section.
4 2. An assistant physician with a license in good standing shall be eligible to
5 become a licensed physician under this subsection if the assistant physician has not been
6 the subject of any disciplinary action and has:
7 (1) Completed Step 3 of the United States Medical Licensing Examination or the
8 equivalent of such step of any board-approv ed medical licensing examination in fewer
9 than thr ee attempts and within a seven-year period of completing Steps 1 and 2 of the
10 United States Medical Licensing Examination;
11 (2) Completed sixty months of cumulative, full-time, hands-on, active
1 2 collaborative practice. The sixty-month period shall begin on the date the assistant
13 physician enter ed into a collaborative practice arrangement and began practicing. Any
14 time the assistant physician was not working within a collaborative practice
1 5 arrangement with a collaborating physician shall not count toward the sixty-month
16 r equir ement;
17 (3) Completed the following postgraduate training under a prece ptor within the
18 sixty-month req uirement under subdivision (2) of this subsection:
19 (a) One hundred twenty hours fr om each of the following five requ ired core
20 categories, for a total of six hundr ed hours of core categories:
21 a. Family medicine;
22 b. Pediatrics;
23 c. Inpatient or outpatient psychiatry;
24 d. Internal medicine; and
25 e. Gynecology; and
26 (b) One hundr ed twenty hours fr om seven of the following elective categories,
27 for a total of eight hundre d forty hours of elective categories:
28 a. Primary car e;
29 b. Emergency medicine;
30 c. Urgent car e;
31 d. Dermatology;
32 e. Geriatrics;
33 f. Sports medicine;
34 g. W ound car e;
35 h. Imaging;
36 i. Urolo gy;
37 j. Nephr ology;
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38 k. Endocrinology;
39 l. Cardiology;
40 m. Surgery;
41 n. Pulmonology;
42 o. Rheumatology;
43 p. Obstetrics;
44 q. Family medicine;
45 r . Neur ology;
46 s. Addiction medicine;
47 t. Pain management;
48 u. V ascular medicine;
49 v . Gastr oenterolog y; or
50 w . Infectious diseases.
51
52 The postgraduate training re quir ed under this subdivision shall consist of on-the-job,
53 hands-on training, including performing medical proced ures, and shall not consist of
54 mer ely observing. The postgraduate training requ ired under this subdivision may be
55 completed at any time during the applicant's licensur e as an assistant physician as long
56 as it is completed during the time frame the applicant is working within a collaborative
57 practice arrangement with a collaborating physician;
58 (4) Completed at least one hundr ed hours of continuing medical education every
59 two years; and
60 (5) Submitted to the board letters of recomme ndation fr om:
61 (a) The physician who served as the assistant physician's collaborating physician
62 for the collaborative practice requ irem ent; and
63 (b) One other physician who has a license in good standing fr om this state.
64 3. The following pro visions shall apply to assistant physicians completing the
65 r equir ements of subsection 2 of this section:
66 (1) All postgraduate training under subdivision (3) of subsection 2 of this section
67 shall be completed under the supervision of a precep tor who is:
68 (a) Accredi ted by the Accr editation Council for Graduate Medical Education;
69 (b) A physician practicing under a pr ogram or community clinic affiliated with
70 the Accred itation Council for Graduate Medical Education; or
71 (c) An independent physician who is board certified in the particular discipline
72 or postgraduate category that the assistant physician is studying;
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73 (2) The postgraduate training may be administer ed by the collaborating
74 physician if the collaborating physician satisfies paragraph (a), (b), or (c) of subdivision
75 (1) of this subsection;
76 (3) Assistant physicians shall obtain medical malpractice liability insurance
77 during their postgraduate training;
78 (4) Assistant physicians shall complete a final res earch rep ort, which shall be
79 appr oved by the pr eceptor , for each category chosen under subdivision (3) of subsection
80 2 of this section. The assistant physician shall ret ain all r esear ch re ports for five years;
81 (5) During assistant physicians' postgraduate training period, collaborating
82 physicians shall still oversee the assistant physicians while they ar e practicing but not in
83 postgraduate training. Postgraduate training shall not pause the sixty-month
8 4 collaborative practice r equir ement under subdivision (2) of subsection 2 of this
85 section; and
86 (6) In order to meet the sixty-month collaborative practice requ irem ent of
87 subdivision (2) of subsection 2 of this section, an assistant physician shall pre sent
88 bimonthly didactic training r eports to the collaborating physician during the sixty-
89 month period. The repo rts may consist of the workup of a curr ent case of the assistant
90 physician or a subject re levant to the clinical practice. The collaborating physician shall
91 keep the didactic training r eports on file during the sixty-month period.
92 4. (1) An assistant physician with a license in good standing shall be eligible to
93 become a licensed physician under this subsection if the assistant physician has:
94 (a) Completed Step 3 of the United States Medical Licensing Examination;
95 (b) Completed sixty months of cumulative, full-time, hands-on, active
9 6 collaborative practice. The sixty-month period shall begin on the date the assistant
97 physician enter ed into a collaborative practice arrangement and began practicing. Any
98 time the assistant physician was not working within a collaborative practice
9 9 arrangement with a collaborating physician shall not count toward the sixty-month
100 r equir ement;
101 (c) Completed at least one hundr ed hours of continuing medical education every
102 two years; and
103 (d) Submitted to the board letters of recomm endation fr om:
104 a. The physician who served as the assistant physician's collaborating physician
105 for the collaborative practice requ irem ent; and
106 b. One other physician who has a license in good standing fr om this state.
107 (2) The pr ovisions of this subsection shall expir e on August 28, 2031.
108 5. Upon completion of the r equir ements of subsection 2 of this section or the
109 r equir ements of subsection 4 of this section, the assistant physician shall be eligible for
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110 licensur e as a physician with the state of Missouri and eligible to sit for board
111 certification or any other appr opriate advanced fellowships or certifications.
112 6. Any assistant physician obtaining licensur e as a physician under this section
113 shall be fully licensed as a physician and shall be subject to all statutes and reg ulations
114 pertaining to physicians.
✔
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